Intervention

BOOK REVIEW
Year
: 2018  |  Volume : 16  |  Issue : 1  |  Page : 59--60

Borderlands of Mental Health: Explorations in medical anthropology, psychiatric epidemiology, and health systems research in Afghanistan and Burundi by Peter Ventevogel, PhD thesis. Geneva: Peter Ventevogel: 2016 (374 pages) ISBN: 978-90-9029910-5


Devon E Hinton 
 MD, PhD, Professor of Psychiatry, Harvard University, Massachusetts General Hospital, Harvard Medical School

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How to cite this article:
Hinton DE. Borderlands of Mental Health: Explorations in medical anthropology, psychiatric epidemiology, and health systems research in Afghanistan and Burundi by Peter Ventevogel, PhD thesis. Geneva: Peter Ventevogel: 2016 (374 pages) ISBN: 978-90-9029910-5.Intervention 2018;16:59-60


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Hinton DE. Borderlands of Mental Health: Explorations in medical anthropology, psychiatric epidemiology, and health systems research in Afghanistan and Burundi by Peter Ventevogel, PhD thesis. Geneva: Peter Ventevogel: 2016 (374 pages) ISBN: 978-90-9029910-5. Intervention [serial online] 2018 [cited 2020 Aug 3 ];16:59-60
Available from: http://www.interventionjournal.org/text.asp?2018/16/1/59/228775


Full Text



This volume illuminates how evaluation and service delivery can be done in locations of complex humanitarian emergencies in a contextually and culturally sensitive way. Peter Ventevogel, MD, PhD, is both a psychiatrist and anthropologist, and thus brings a dual expertise to this important and informative volume. The book is based on his thesis work. Chapters are original to this volume, or taken from previous studies in which there are multiple co-authors. The focus is on Afghanistan and Burundi, which the author characterises as locations of complex humanitarian emergencies: low income settings beset by long periods of conflict and compounded by ecological and sociopolitical fragility. In the opening chapter, he provides a valuable review of the literature on global mental health, and the history of the development of complex humanitarian emergencies in Afghanistan and Burundi. The volume is divided into three sections: how to profile local perspectives on mental health and healing; how to measure mental health; and how to set up functional systems to address mental health and psychosocial problems.

 Local perspectives on mental health



The first section, Chapters 2–5, is on local perspectives of mental health and healing. Chapter 2 describes a study in Burundi that surveys local ideas about problems resulting from war and about psychosocial and mental problems related to war. The problems most often mentioned were poverty, deaths due to fighting, and orphans and widows. The psychosocial and mental problems most mentioned were ‘depression’ (akabonge), ‘much fear’ (ubwoba bwinshi) and guhahamuka (a trauma syndrome that has been extensively studied). Grief and mourning (page 60) were also mentioned in the study.

Chapter 3 examines local syndromes of illness in four African communities, based on focus group discussions and key informants. A complex local nosology is outlined, which includes syndromes and syndrome related symptoms, causes and favoured treatments, for example, with local healers. The chapter divides syndromes into those that involve behavioural disturbances and violence, and those marked by sadness and social isolation. In terms of local ideas of causation, supernatural causes are shown to be prominent, as well as losses, such as of property and/or loved ones.

In Chapter 4, Burundian divinatory healing is discussed. This chapter revisits the role of local traditional healers in treating distress, and thereby again emphasises the prominence of spirit-related beliefs in ideas of disorder and treatment. The complex system of spirits is described: there are three main groups–the spirit of the dead, spirits in nature and nameless wandering spirits. Possession and sorcery, such as sending objects into a person, are also shown to be prominent illness types. Two healing cults are described, one involving possession by spirits (Kubandwa) with continued bouts of periodic possession, and the other is a healing cult that has recently emerged, called Gucekera and involves exorcism.

Child mental health and resilience in Afghanistan are profiled in Chapter 5. For example, the major local problem of death by self-immolation is discussed, with girls ages 12–16 at especially high risk. Also discussed are such local problems as forced early marriage and violence against children. Possible service models, for example, the Intervention Pyramid (Inter-Agency Standing Committee (IASC), 2007), are reviewed and, in fact, the Pyramid is used to outline potential interventions.

 Measuring mental health



Section 2, on how to measure mental health, begins with Chapter 6. This chapter describes a general population study in Eastern Afghanistan using the Harvard Trauma Questionnaire (HTQ) to assess posttraumatic stress disorder (PTSD) and the Hopkins Symptom Checklist (HSCL) to assess depression and general anxiety, as well as a questionnaire to assess resources for emotional support. High rates of trauma exposure were found: 43.7% experienced between 8 and 10 trauma events in the last 10 years. High rates of psychopathology were found: PTSD, 20.4%. Odds ratios (ORs) were found to be higher for women: PTSD, OR 5.8. A large percentage, 98%, said that Allah was the main resource of emotional support when feeling sad, worried, or tense.

Chapter 7 describes a survey in a primary clinic in Eastern Afghanistan that used the HSCL-25 and the Self Reporting Questionnaire-20 (SRQ-20). These were compared with a gold standard, semi-structured psychiatric interview. For women, the HSCL optimal cut-off was 2.25, for men, 1.50. (The developers of the HSCL give the standard cut-off as 1.75.)

Chapter 8 reports on the validation of the Kirundi versions of brief self-rating scales for common mental disorders among children in Burundi. Validity is shown for the DSRS (Depression Self-Rating Scale) and CPSS (Child PTSD Symptom Scale), with higher cut-off scores suggested, but some questions are raised about the use of the SCARED-41 (Screen for Children Anxiety Related Emotional Disorders, 41 items version).

 Creating functional systems



Section 3 examines how to set up functional systems to address mental health and psychosocial issues and begins with Chapter 9. This chapter reports on a pilot project aiming to strengthen community care and resilience, focusing on women. It includes: community psychoeducation, how to cope, in health facilities, mosques, and houses of community leaders; workshops for village volunteers and community health workers on topics such as drug abuse and domestic violence; and support groups on various topics such as ‘worrying too much’ and ‘feelings of sadness’.

Chapter 10 discusses the experience of the nongovernmental organisation HealthNet TPO in setting up mental health services and psychosocial support services in Burundi, starting in 2000 and continuing for another 8 years. Major lessons include the need to help develop the general health care system and strengthen community systems.

Chapter 11 discusses the integration of mental health into primary care in low income countries and the need to avoid medicalisation. This review is done with the experience of the World Health Organization’s mental health Gap Action Plan (mhGAP) particularly emphasised. Suggestions are given as to how to avoid a narrow biomedical approach.

In Chapter 12, the conclusion and implications are discussed. Key issues are reviewed, such as the need to assess local distress forms and to track them across treatment, and the need to determine the cut-off for a measure in a particular cultural group (and each gender, as one chapter demonstrated). Possible means of intervention are discussed, including a balance of facility based and community based interventions, and the need to avoid excessive medicalisation that leads to ignoring local sources of distress.

As this review shows, the book presents a complex and multi-faceted view of mental health in general, and in Afghanistan and Burundi, in particular. These perspectives include anthropology, psychology, instrument validity, primary care, community resources, community survey, traditional healers, local needs assessment and idioms of distress, among others. For these reasons, this volume expertly demonstrates how contextually and culturally sensitive evaluation and service delivery can be done in locations of complex humanitarian emergencies, focusing on examples from Afghanistan and Burundi. This volume should have broad influence.[1]

References

1Inter-Agency Standing Committee (IASC). (2007). IASC Guidelines on Mental health and Psychosocial support in emergency settings. Geneva: IASC.