War Child Holland

While multiple studies have found that children affected by war are at increased risk for a range of mental health problems, little research has investigated how mental health problems are perceived locally. In this study we used a previously developed rapid ethnographic assessment method to explore local perceptions of mental health problems among children and adults from the Acholi ethnic group displaced by the war in northern Uganda. We conducted 45 free list interviews and 57 key informant interviews. The rapid assessment approach appears to have worked well for interviewing caretakers and children aged 10—17 years. We describe several locally defined syndromes: two tam/par/kumu (depression and dysthymia-like syndromes), ma lwor (a mixed anxiety and depression-like syndrome), and a category of conduct problems referred to as kwo maraco/gin lugero. The descriptions of these local syndromes were similar to western mood, anxiety and conduct disorders, but included culturespecific elements.

choice of treatments for investigation deserves comment. It is not clear why the authors have targeted depression in treatment, when the clinical picture in the participants appears to be one of mixed anxiety and depression caused by traumatic stress. The symptoms listed under “anxiety-like syndromes” are consistent with fear-related stress symptoms; evidence suggests that depression in such cases is often secondary to chronic anxiety/fear caused by exposure to unpredictable and uncontrollable stressors. 2 This implies that treatment should focus on anxiety/fear as the causal process. Fear-reducing behavioral interventions (eg, exposurebased treatments) have been shown to be efficacious in reducing both posttraumatic stress symptoms and depression, even when the latter is not specifically targeted in treatment and when the fear would be considered “legitimate”. 3 The misplaced treatment focus in the study by Bolton et al might well explain the partial treatment effects (eg, differential outcome by sex, no improvement in functioning) and the modest effect size obtained. An evidence-based approach and an adequate understanding of mechanisms of traumatic stress are important in choosing the right treatment for war survivors. 4 Interventions such as creative play might be culture-sensitive but are likely to be futile when not based on sound theory or evidence, as the study by Bolton et al demonstrates. A culturesensitive approach to treatment in third world countries makes sense only if it does not lose sight of the universals in human behavior. Fear in response to life-threatening events is a universal emotion and an important mediating factor in traumatic stress responses. 5 Whether these responses are labeled posttraumatic stress disorder, depression, or some other local syndrome does not alter this fact. Choice of treatment should be guided by mechanisms of traumatic stress, rather than by its phenomenological manifestations in a particular culture; a treatment is effective to the extent that its mechanisms of action match the causal processes underlying a health problem.