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   Table of Contents - Current issue
Coverpage
July-December 2021
Volume 19 | Issue 2
Page Nos. 145-270

Online since Thursday, September 9, 2021

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EDITORIAL  

Displaced, Dispossessed and Silenced: The Need for Suicide Prevention and Response for Conflict-affected Populations p. 145
Wendy Ager, Rabih El Chammay, Johanna Lechner, Peter Ventevogel, Lakshmi Vijayakumar
DOI:10.4103/intv.intv_24_21  
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COMMENTARY Top

Mental Health Interventions in Complex Political Contexts p. 149
Elena Cherepanov
DOI:10.4103/intv.intv_14_21  
Global mental health specialists provide mental health (MH) services worldwide in various settings with complex humanitarian needs. Tailoring MH interventions and psychosocial support to the context and culture is essential for ensuring safe and competent services. A complex political context (CPC) is characterised by complex political dynamics, social instability and political violence resulting in gross violation of human rights and massive trauma. Examples of such settings include dictatorships, military junta and other forms of government-sponsored, sectarian or ethnic violence towards marginalised groups who are targeted, oppressed and discriminated. In some countries, receiving MH services can expose beneficiaries and put them at risk. Scaling up MH support is needed when serving persons with special needs and those at particular risk for discrimination and victimisation. The coronavirus disease 2019 (COVID-19) pandemic has worsened the situation and been used by unscrupulous politicians to tighten governmental control, blame already marginalised groups and deny or further limit their access to resources and health care. These guidelines aim to equip MH workers with an understanding of the professional challenges and ethical dilemmas posed by CPCs. They offer recommendations for programming and delivering MH services in CPC. Providing MH interventions in a CPC calls for special professional expertise, extensive use of supervision and peer support, and personal competencies such as self-awareness and self-care.
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ARTICLE Top

Supporting and Sustaining Nonspecialists to Deliver Mental Health Interventions in Low- and Middle-Income Countries: An Umbrella Review p. 155
Mary Bunn, Nicole Gonzalez, Idan Falek, Stevan Weine, Mary Acri
DOI:10.4103/INTV.INTV_47_20  
This umbrella review used a systematic approach to examine the state of the evidence regarding the nonspecialist health worker (NSHW) workforce in mental health and psychosocial services in low- and middle-income countries (LMICs). Seventeen review articles were included in this analysis. Most reviews defined nonspecialists by their lack of formal mental health experience. Less than half of the reviews reported their qualifications and roles. Findings indicated that NSHWs were trained and supervised in a range of skills with variability in approaches, duration, format and topical focus. The evidence supporting NSHW-delivered interventions was mixed but mainly favourable, particularly for depression, anxiety and posttraumatic stress disorder; additionally, studies identified implementation challenges with the nonspecialist workforce. In conclusion, NSHWs are widely used in LMICs to address mental health needs and some indicators suggest the interventions they deliver are beneficial, yet little is known about their needs and requirements. Further work is needed to prioritise nonspecialists as a critical workforce in global mental health. This includes developing best practice models, new policies and investments and conducting further research.
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FIELD REPORT Top

Training Survivors of Gender-Based Violence in the Problem Management Plus Programme in Turkey p. 180
Sena Akbay-Safi, Areej Al Tabba, Laila Ragab Mahdy Mahmoud
DOI:10.4103/intv.intv_21_21  
Since the beginning of the Syrian conflict, the impact on the local population has rapidly increased, with severe consequent displacement to neighbouring countries (such as Turkey), material losses and psychological damage due to witnessing death, torture, physical and psychological abuse or surviving it, including high levels of gender-based violence. At the same time, available resources to aid impacted communities have not come close to matching need. To respond to this urgent need, the INSAN Psychosocial Support Centre in Istanbul, Turkey initiated the Safety Spark project as a capacity building project with 20 refugee gender-based violence survivors to be trained in Problem Management Plus. This is “a psychological intervention that aims to improve mental health, functioning and psychosocial wellbeing of adults” and thereafter to provide mental health and psychosocial support to other women survivors, thereby increasing the capacity of the community to heal itself. However, right after training, but 2 weeks before implementation sessions began, the onslaught of the coronavirus disease 2019 reached Turkey, making provision of traditional psychological support impossible. With the support of World Health Organization, an online training was added to the programme and survivors were taught to provide support remotely as well. The project is ongoing, and observed results appear to be promising. This field report provides an overview of the target population, procedures, settings and challenges faced during the training and implementation, solutions to overcome them and future recommendations.
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ARTICLES Top

A Preliminary Framework for Understanding Suicide Risk in LGBTQ Refugees and Asylum Seekers p. 187
Aaron Burgess, Miriam Potocky, Edward J Alessi
DOI:10.4103/INTV.INTV_5_21  
Lesbian, gay, bisexual, transgender and queer/questioning (LGBTQ) individuals continue to experience pervasive violence and victimisation, which has been associated with a host of negative mental health problems, including suicide. However, there is a gap in knowledge about LGBTQ refugees and asylum seekers, an especially vulnerable subgroup of both the LGBTQ and refugee/asylum seeker population. The aim of this study was therefore to develop a preliminary theoretical framework to identify factors that may contribute to suicide risk among LGBTQ refugees and asylum seekers, and those that may buffer this risk. We conducted a review of literature on the lived experiences of LGBTQ refugees and asylum seekers. We then used cumulative disadvantage and minority stress theories to conceptualise their risk for suicide and queer migration theory to highlight protective factors. Finally, this review provides practice implications for supporting the psychosocial and mental health needs of LGBTQ refugees and asylum seekers.
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Evaluation of Lebanon’s National Helpline for Emotional Support and Suicide Prevention: Reduction of Emotional Distress among Callers p. 197
Pia A Zeinoun, Farah E Yehia, Lila Z Khederlarian, Serene F Yordi, Mia M Atoui, Rabih El Chammay, Ziad H Nahas
DOI:10.4103/INTV.INTV_50_20  
Helplines provide time-limited help and orientation to callers who are suicidal or experiencing self-reported emotional distress, but there is no evidence regarding the efficacy of helplines in low-to-middle income countries like Lebanon. The Embrace Lifeline is Lebanon’s national and only helpline for emotional support and suicide prevention, operating since 2018. We accessed anonymous data of 4657 calls received between February 2018 and February 2020. We analysed caller characteristics and predictors of distress and evaluated the immediate outcome of calls by examining the difference in caller distress from beginning to end of call, using a repeated-measures design. The helpline received calls from a majority Lebanese sample that was diverse in terms of age, location, education, employment status and sexual orientation. We found a significant and large (d = 1.94 and 1.99, respectively) decrease in subjective levels of distress among those calling for emotional distress only, and those with additional suicide-related behaviour. The most distressed callers were likely to be female, in a relationship (as opposed to not), and experiencing at least one risk factor, and while everyone showed improved distressed, those with at least one risk factor showed the most decrease. The helpline is effectively reducing distress and suicidal ideation, across a wide sample of callers. Future studies need to investigate long-term sustenance and circumvent limitations related to data collection capture.
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The Process of Evolving a National Plan in Suicide Prevention in a Context of Political Violence p. 208
Samah Jabr, Maria Helbich
DOI:10.4103/INTV.INTV_55_20  
This article reports on suicide and suicidal behaviour in Palestine and sets this in the context of political violence related to the Israeli occupation. Accurate data about suicide and attempted suicide are limited and as such a range of studies including those concerned with the wider Middle East and North Africa region are used here to describe the context for suicide. The article indicates some of the individual and societal risk factors associated with suicide in Palestine and reflects on the role of Islam and religious leaders in tackling the stigma associated with suicide. It describes current mental health services for those who may attempt to take their own life and then outlines the steps that the Ministry of Health is taking to develop a national plan in suicide prevention.
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Waiting for Life to Begin, Wishing it Would End: Suicidal Ideation among Newly Arrived Refugees p. 215
Anna Leiler, Elisabet Wasteson, Ingrid Zakrisson, Anna Bjärtå
DOI:10.4103/INTV.INTV_48_20  
Research indicates that subgroups of refugees may be at increased risk for suicidal ideation, but further knowledge on this topic is needed. This study aimed to assess both prevalence and factors associated with suicidal ideation among newly arrived refugees in Sweden. Assessing suicidal ideation was part of a larger project, aiming to develop a model for assessment and treatment of mental health problems among refugees. The included data were based on a cross-sectional survey among 510 asylum seekers and refugees, all under the care of the Swedish Migration Agency. The project group visited 12 asylum accommodations and 9 other locations, asking potential participants to answer a survey with questions on mental health, suicidal ideation and quality of life. Data were analysed using logistic regression. Symptoms of depression, anxiety and posttraumatic stress disorder, low physical and psychological quality of life, and being of young age were all independently associated with suicidal ideation. This study points to the importance of identifying refugees with mental health problems and of providing them with adequate care. It also indicates the importance of assuring a decent quality of life at asylum accommodations, and it shows that the young may constitute an especially vulnerable group.
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FIELD REPORTS Top

Despair and Suicide-Related Behaviours in Palorinya Refugee Settlement, Moyo, Uganda p. 224
Moses Mukasa Bwesige, Leslie Snider
DOI:10.4103/INTV.INTV_12_21  
This descriptive study illustrates the multitude of intertwining factors contributing to suicidal ideation and attempts, and deaths by suicide among South Sudanese refugees in Moyo/Obongi Palorinya settlements in northern Uganda. It was conducted from 2019 to 2020 due to escalating rates of suicide attempts and deaths by suicide noted in a rapid assessment by Lutheran World Federation mental health and psychosocial support (MHPSS) workers. This study aimed to better understand factors contributing to suicidal ideation and attempts among refugees, to tailor MHPSS interventions and prevent potential escalation of suicidality across the region, including nearby refugee hosting districts in Adjumani/Lamwo. Data collection techniques included key informant interviews, focus group discussions, case studies and review of the lead author’s therapy recovery notes. The findings highlighted the following factors contributing to escalating suicidality among the refugees: war stressors (experiencing and witnessing violent acts), daily stressors, social fragmentation, normalised violence, social isolation, lack of economic opportunities, loss of assets and loss of confidence and hope, among others. The assessment found that the spiking trend of increased suicidal behaviour is apparently unique to Moyo/Obongi, compared to neighbouring settlements, but emphasises the need for monitoring and preventive interventions in neighbouring districts. The psychosocial as well as economic impact of a reduction in funding for MHPSS programming is underlined, emphasising the need for long-term funding to consolidate programme effects and respond to realities on the ground. Community-based psychosocial support interventions provided by Lutheran World Federation are described that have subsequently helped to mitigate and respond to the escalating trend in suicidality and reflections given to strengthen the ongoing response with lessons learned for other contexts.
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Programming to Address Suicidal Behaviour among Unaccompanied Refugee Minors in a Camp Setting: A Field Report from Ethiopia p. 233
Medhanye Alem, Sandra Githaiga, Esayas Kiflom, Liyam Eloul
DOI:10.4103/INTV.INTV_52_20  
In response to a perceived increase in suicidal ideation and behaviour among minors and especially unaccompanied and separated children (UASC) in camps for Eritrean refugees in Ethiopia, we developed a multilayered response programme. This programme included public awareness and stigma-reduction campaigns, psychoeducation aimed at both UASC and their caregivers, capacity building for humanitarian and community partners, group and individual counselling for UASC and crisis response and postvention. We offer learnings from the development and implementation of this programme, highlighting the importance of working with relevant constructs such as grief, guilt, attachment and identity. It is our hope that our learnings will be informative and helpful to practitioners working with displaced UASC in other contexts. Recognising the heightened risk factors experienced by young people with trauma histories currently in camp settings, we recommend the coordinated development of a suicide prevention and response plan as a core component of any humanitarian response.
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Barriers, Attitudes, Confidence and Knowledge of Mental Health and Psychosocial Humanitarian Staff in Cox’s Bazar in Responding to Suicide Risk p. 242
Lauren Fischer, Ariel Zarate, Kamruzzaman Mozumder, Mohamed Elshazly, Simon Rosenbaum
DOI:10.4103/INTV.INTV_53_20  
Although suicide is a significant global health priority, it is underexamined in humanitarian crises. Over 850,000 Rohingya reside as refugees in Cox’s Bazar, Bangladesh; suicide risk may be high in this community by some indicators, but little is definitively known. Even less is known about humanitarian workers’ capacity to recognise and respond to suicide risk in affected communities. Participants were mental health and psychosocial support (30%), protection (31%), gender-based violence (17%) and others (22%) multisectoral humanitarian staff having weekly face-to-face contact with Rohingya refugees as part of their professional duties. We assessed barriers, attitudes, competence and knowledge regarding suicide-risk response. The survey was disseminated over 3 weeks in June 2020, engaging 181 respondents from multiple sectors of the coordinated response. Respondents who had prior training scored higher on the overall scale compared to those without (P ≤ 0.001), and there was a significant impact of prior training on attitudes (P = 0.005), confidence (P = 0.002) and knowledge (P ≤ 0.001). Humanitarian staff from multiple sectors reported low confidence or readiness to respond to suicide risk in the field. Training on suicide identification, intervention and response for such staff and related community gatekeepers is an urgent need in the Rohingya refugee response.
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An Initiative in Suicide Prevention: Best Practices, Challenges and Lessons Learnt from Nepal p. 249
Parbati Shrestha, Sita Maya Thing Lama, Rambabu Nepal
DOI:10.4103/INTV.INTV_11_21  
Suicide is a major problem at the current time in Nepal. Although suicide needs a multisectoral and comprehensive response, it is challenging to work in a community where mental health and psychosocial support are not available or are limited. These challenges are related to the lack of mental health services in the community, lack of awareness and help-seeking behaviours, and interpretation of suicide as a consequence of social problems. Drawing on the local experience of working in the community to the national level, we recommend some best practices on behalf of Transcultural Psychosocial Organization Nepal to overcome these challenges and to improve the outcomes in our mental health and psychosocial support response to the suicide prevention programme.
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International Organization for Migration Iraq Mental and Psychosocial Support Programme Suicide Prevention Activities p. 255
Hatem Alaa Marzouk
DOI:10.4103/INTV.INTV_6_21  
Many Iraqis have experienced a multitude of stressors over the past four decades due to war, sanctions and civil conflict. Being closely associated with social cohesion and community stabilisation, suicide prevention activities have been an increasingly important component of the International Organization of Migration (IOM)’s Mental Health and Psychosocial Support Programme. This report introduces the aims and activities implemented throughout different locations in Iraq by IOM. Statistics from 2015 to 2016 indicated that the rate of suicide per 100,000 persons in Iraq was between 0.97 and 1.54, with the majority of the cases being 29 years of age or younger. Following a brief situation analysis of socioeconomic, cultural and political aspects related to the phenomenon of suicide in Iraq, the subsequent report outlines the steps IOM Iraq has taken to support the government of Iraq in developing the National Suicide Prevention Strategy. It also details the efforts done towards building community awareness about suicide and building the capacity of community gatekeepers.
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PERSONAL REFLECTIONS Top

Suicide Prevention and Response Among Refugees: Personal Reflections on Self-Care for Frontline Mental Health and Psychosocial Support Workers p. 261
Gail Theisen-Womersley
DOI:10.4103/INTV.INTV_3_21  
No matter how experienced we are as professionals, we need to recognise the emotional and physical toll of the work we do as mental health and psychosocial support (MHPSS) frontline workers. The reflections in this article on the nature of trauma − and of shame − are offered to explore just why working with refugee populations may be such an intense experience for frontline MHPSS workers. Trauma is contagious. Shame and guilt are contagious. Feelings of despair, of anger, of guilt and of confusion are contagious. Suicidality among refugees may be considered a dialogue often including MHPSS frontline workers. When exposed to such despair, even our physical bodies may carry some of the pain and suffering. When faced with suicidality in our work, an extreme manifestation of this, we cannot help but be affected. We are human.
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Suicide in the Context of Adolescent Development: What Humanitarian Actors Can Do p. 266
Koen Sevenants
DOI:10.4103/INTV.INTV_8_21  
The author reflects from his own personal experience as a survivor, child psychologist and humanitarian on causes of suicidality among adolescents and prevention strategies. Suicide ideation or attempted suicide is a symptom of underlying issues that complicates developmental tasks. This personal reflection summarises the developmental tasks facing adolescents, carrying out a mental review and the search for self and separation from parents. The author describes major factors that complicate the completion of these developmental tasks in humanitarian contexts. He then discusses action for prevention on two levels: (1) Prevention through the creation of a social ecology that provides the basis for children’s healthy mental and psychosocial development and in which they have the highest chance of succeeding at resolving complicated development tasks. (2) Prevention of further harm when an adolescent has reached the level of ideation, has planned suicide or has already made a suicide attempt. For the first level, he uses Winnicott’s concept of “the holding environment” to guide various humanitarian aid sectors on suicide prevention. For the second level, he stresses the importance of overcoming a sense of isolation and the need for a long-term engagement in which verbal and nonverbal approaches are combined.
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