Mediators of the relation between war experiences and suicidal ideation among former child soldiers in Northern Uganda: the WAYS study

BMC Psychiatry

Emilio Ovuga¹  Richard Meiser-Stedman²  Tlholego Molemane Lekhutlile³  Kennedy Amone-P’Olak³ 

[1] Department of Psychiatry and Mental Health, Gulu University, Gulu, Uganda;MRC Cognition and Brain Sciences Unit, Cambridge, UK;Department of Psychology, University of Botswana, Private Bag UB 00705, Gaborone, Botswana

关键词: Northern Uganda;    Former child soldiers;    Suicidal ideation;    War experiences;   

Others  :  1123321
DOI  :  10.1186/s12888-014-0271-2

 received in 2014-04-03, accepted in 2014-09-16,  发布年份 2014

【 摘 要 】

Background

Globally, suicide is a public health burden especially in the aftermath of war. Understanding the processes that define the path from previous war experiences (WE) to current suicidal ideation (SI) is crucial for defining opportunities for interventions. We assessed the extent to which different types of previous WE predict current SI and whether post-war hardships and depression mediate the relations between WE and SI among former child soldiers (FCS) in Northern Uganda.

Methods

We performed cross-sectional analyses with a sample of 539 FCS (61% male) participating in an on-going longitudinal study. The influence of various types of previous WE on current SI and mediation by post-war hardships and depression were assessed by regression analyses.

Results

The following types of war experiences: “witnessing violence”, “direct personal harm”, “deaths”, “Involvement in hostilities”, “sexual abuse” and “general war experiences” significantly predicted current SI in a univariable analyses whereas “direct personal harm”, “involvement in hostilities”, and “sexual abuse” independently predicted current SI in a multivariable analyses. General WE were linked to SI (β = 0.18 (95% CI 0.10 to 0.25)) through post-war hardships (accounting for 69% of the variance in their relationship) and through depression/anxiety (β = 0.17 (95% CI 0.12 to 0.22)) accounting for 65% of the variance in their relationship. The direct relationship between previous WE and current SI reduced but remained marginally significant (β = .08, CI: (.01, .17) for depression/anxiety but not for post-war hardships (β = .09, CI: (−.03, .20).

Conclusion

Types of WE should be examined when assessing risks for SI. Interventions to reduce SI should aim to alleviate post-war hardships and treat depression/anxiety.

【 授权许可】

   
2014 Amone-P'Olak et al.; licensee BioMed Central Ltd.

【 图 表 】

Figure 1.

Figure 2.

【 参考文献 】

• [1]Public Health Action for the Prevention of Suicide: A Framework. WHO Document Production Services, Geneva, Switzerland; 2012.
• [2]Schlebusch L: Suicidal Behaviour. In Crime, Violence and Injury in South Africa: 21st Century Solutions For Child Safety. Edited by Niekerk A, Suffla S, Seedat M. Psychological Society of South Africa, Houghton, Johannesburg; 2012:178-194.
• [3]Obida M, Govender I: Reasons for parasuicide among patients admitted to Tshilidzini Hospital, Limpopo Province: A qualitative study. S Afr J Psych 2013, 19(4):222-225.
• [4]Berttolote JM, Fleischmann A: A global perspective on the magnitude of suicide mortality. In Oxford Textbook of Suicidology and Suicide Prevention: A Global Perspective. Edited by Wasserman D, Wasserman C. Oxford University Press, Oxford; 2009:91-98.
• [5]Mars B, Burrows S, Hjelmeland H, Gunnell D: Suicidal behaviour across the African continent: a review of the literature. BMC Public Health 2014, 14:606. BioMed Central Full Text
• [6]Meehan SA, Peirson A, Fridjhon P: Suicide ideation in adolescents in South Africans: the role of gender and coping strategies. South African J Psychol 2007, 37(3):552-575.
• [7]Madu SN, Matla MP: The prevalence of suicidal behaviours among secondary school adolescents in the Limpopo Province, South Africa. South African J Psychol 2003, 33(2):125-132.
• [8]Roberts RE, Chen YR, Roberts CR: Ethno-cultural differences in prevalence of adolescent suicidal behaviours. Suicide Life Threat Behav 1997, 27:208-217.
• [9]Nye EC: Specific symptoms predict suicidal ideation in Vietnam combat veterans with chronic post- traumatic stress disorder. Mil Med 2007, 172:1144-1147.
• [10]Hawton K, Van Heeringen K: The International Handbook of Suicide and Attempted Suicide. In ᅟ. Edited by Kaplan HI, Sadock BJ. Chichester: Wiley; 1995.
• [11]Schlebusch L: Suicidal Behaviour in South Africa. University of KwaZulu-Natal Press, Pietermaritzburg; 2005.
• [12]Wasserman D: A Stress Vulnerability Model and the Development of the Suicidal Process. In Suicide: An Unnecessary Death (13–27). Edited by Wasserman D. Martin Dunitz, London; 2001.
• [13]Wasserman D, Wasserman C: Oxford Textbook of Suicidology and Suicide Prevention: A Global Perspective. Oxford University Press, Oxford; 2009.
• [14]Child Soldiers Global Report 2001. CSC, London; 2001.
• [15]Amone-P’Olak K: A study of the psychological state of former abducted children at Gulu World Vision Trauma Centre. Torture 2004, 14:24-4.
• [16]Amone-P’Olak K: Mental states of adolescents exposed to War in Uganda: finding appropriate methods of rehabilitation. Tortur 2006, 16(2):93-107.
• [17]Amone-P’Olak K: Torture against children in rebel captivity in Northern Uganda: physical and psychological effects and implications for clinical practice. Torture 2009, 19:102-117.
• [18]Kizza D, Hjelmeland H, Kinyanda E, Knizek BL: Alcohol and suicide in post-conflict Northern Uganda: a qualitative psychological autopsy study. Crisis 2012, 33(2):95-105.
• [19]Kinyanda E, Hjelmeland H, Musisi S: Negative life events associated with deliberate self-harm in an African population in Uganda. Crisis 2005, 26(1):4-11.
• [20]Kizza D, Knizek BL, Kinyanda E, Hjelmeland H: Men in despair: Aqualitative psychological autopsy study of suicide in Northern Uganda. Transcult Psychiatry 2012, 49(5):696-717.
• [21]Vinck P, Pham PN, Stover E, Weinstein HM: Exposure to war crimes and implications for peace building in northern Uganda. JAMA 2007, 298(5):543-554.
• [22]Murthy RS, Lakshminarayana R: Mental health consequences of war: a brief review of research findings. World Psychiatr 2006, 5(6):25-30.
• [23]Utas M, Jorgel M: The west side boys: military navigation in the Sierra Leone civil war. J Modern African Studies 2008, 46(3):487-511.
• [24]Maguen S, Metzler TJ, Bosch J, Marmar CR, Knight SJ, Neylan TC: Killing in combat may be independently associated with suicidal ideation. Depress Anxiety 2012, 29:918-923.
• [25]Mahon MJ, Tobin JP, Cusack DA, Kelleher C, Malone KM: Suicide among regular- duty military personnel: a retrospective case- control study of occupation- specific risk factors for work place suicide. Am J Psychiatr 2005, 16(9):1688-1696.
• [26]Schauer E, Elbert T: The Psychological Impact of Child Soldiering. In Trauma Rehabilitation After War and Conflict. 2010th edition. Edited by Martz E. ᅟ: Springer; 2010:360.
• [27]Beth V: Child Soldiers: Preventing, Demobilizing and Reintegrating. In Africa Region Working Paper Series. World Bank, Washington; 2001:1-29.
• [28]Somasundaram D: Child soldiers: understanding the context. Br Med J 2002, 324(7348):1268-1271.
• [29]Somasundaram D: Collective trauma: a Qualitative Psychosocial-Ecological Study. Int J Ment Heal Syst 2007, 1:5. doi:10.1186/1752-4458-1-5 BioMed Central Full Text
• [30]Dickson-Gomez J: The sound of barking dogs: violence and terror among Salvadoran families in the post- war. Med Anthropol Q 2001, 16(4):415-438.
• [31]Pietrzak RH, Goldstein MB, Malley JC, Rivers AJ, Johnson DC, Southwick SM: Risk and protective factors associated with suicidal ideation in veterans of Operations Enduring Freedom and Iraqi Freedom. J Affect Disord 2010, 123:102-107.
• [32]Hendin H, Haas AP: Suicide and guilt as manifestations of PTSD in Vietnam combat veterans. Am J Psychiatry 1991, 148:586-591.
• [33]Fontana A, Rosenheck R, Brett E: War zone traumas and posttraumatic stress disorder symptomatology. J Ner Men Dis 1992, 180:748-755.
• [34]Thoresen S, Mehlum L: Traumatic stress and suicidal ideation in Norwegian male peacekeepers. J Ner Men Dis 2008, 196:814-821.
• [35]Amone-P’Olak K, Jones BP, Abbott R, Meiser-Stedman R, Ovuga E, Croudace TJ: Cohort profile: mental health following extreme trauma in a northern Ugandan cohort of War-Affected Youth Study (The WAYS Study). Springer Plus 2013, 2(1):300. BioMed Central Full Text
• [36]Koopman R, Van Dyk G: Suicide prevention and management in the SA National Defence Force: A psychological discussion, Scientia Militaria. South Africa J Mil Studies 2012, 40:117-138. doi:10. 5787/40-1-987
• [37]Joshi PT, O’Donnell AO: Consequences of child exposure to war and terrorism. Clin Child Fam Psychol Rev 2003, 6:275-292.
• [38]Kaplan MS, Huguet N, McFarland BH, Newsom JT: Suicide among male veterans: a prospective population based study. J Epidemiol Community Health 2007, 61:619-624.
• [39]Smith P, Perri S, Yule W, Hacam B, Stuvland R: War exposure among children from Bosnia–Herzegovina: Psychological adjustment in a community sample. J Trauma Stress 2002, 15:147-156.
• [40]UNICEF B&H Post-war Screening Survey. UNICEF, New York, NY; 2010.
• [41]Betancourt TS, Bass J, Borisova I, Neugebauer R, Speelman L, Onyango G, Bolton P: Assessing local instrument validity and reliability: a field-based example from Northern Uganda. Soc Psychiatry Psychiatr Epidemiol 2009, 44:685-692.
• [42]Brodbeck J, Abbott RA, Goodyer IM, Croudace TJ: General and specific components of depression and anxiety in an adolescent population.BMC Psych 2011, 11(191):ᅟ.
• [43]Glantz SA, Slinker BK: Primer of Applied Regression and Analysis of Variance. McGraw- Hill, New York, NY; 1990.
• [44]Baron RM, Kenny DA: The moderator-mediator variable distinction in social psychological research: conceptual, strategic and statistical considerations. J Pers Soc Psychol 1986, 51:1173-1182.
• [45]Amone-P’Olak K: Psychological impact of war and sexual abuse among adolescent girls in Northern Uganda. Intervention 2005, 3:33-45.
• [46]Amone-P’Olak K: Coping with life in rebel captivity and the challenge of reintegrating formerly abducted boys in Northern Uganda. J Refugee Study 2007, 20(4):641-661. doi:10.1093/jrs/fem036
• [47]Lester D: The role of shame in suicide. Suicide Life Threat Behav 1997, 279(4):352-361.
• [48]Amone-P’Olak K, Garnefski N, Kraaij V: Adolescents caught between fires: cognitive emotion regulation in response to War experiences in Northern Uganda. J Adolesc 2007, 30:655-669.
• [49]Amone-P’Olak K, Stochl J, Ovuga E, Abbott R, Meiser-Stedman R, Croudace TJ, Jones PB: Postwar environment and long-term mental health problems in former child soldiers in Northern Uganda: the WAYS study.J Epidemiol Community Health ᅟ, ᅟ:ᅟ. Published Online First: [3 January 2014] doi:10.1136/jech-2013-203042.
• [50]Fernando G, Miller KE, Berger D: The impact of potentially traumatic and daily stressors on emotional and psychosocial functioning and development of children in Sri Lanka. Disasters and Their Impact on Child Development. Child Dev 2010, 81(Special issue):1192-1210.
• [51]Miller KE, Omidian P, Rasmussen A, Yaqubi A, Daudzai H: Daily stressors, war experiences, and mental health in Afghanistan. Transcult Psychiatry 2008, 45:611-639.
• [52]Amone-P’Olak K, Jones PB, Meiser-Stedman R, Abbott RA, Ayella-Ataro PS, Amone J, Ovuga E: War experiences, general functioning and barriers to care among former child soldiers in Northern Uganda: the WAYS study. J Public Health 2014, 0:1-9. doi:10.1093/pubmed/fdt126
• [53]Miller KE, Rasmussen A: War exposure, daily stressors, and mental health in conflict and post-conflict settings: Bridging the divide between trauma-focused and psychosocial frameworks. Soc Sci Med 2010, 70:7-11.
• [54]Al-Krenawi A, Lev-Wiesel R, Sehwail M: Psychological symptomatology among Palestinian children living with political violence. Child Adolesc Mental Health 2007, 12:27-31.
• [55]Betancourt TS, Brennan RT, Rubin-Smith J, Fitzmaurice GM, Gilman SE: Sierra Leone’s former child soldiers: a longitudinal study of risk, protective factors, and mental health. J Am Acad Child Adolesc Psychiatry 2010, 49:606-615.
• [56]Betancourt TS, Agnew-Blais J, Gilman SE, Williams DR, Ellis BH: Past horrors, present struggles: the role of stigma in the association between war experiences and psychosocial adjustment among former c hild soldiers in Sierra Leone. Soc Sci Med 2010, 70:17-26.
• [57]Oquendo M, Brent DA, Birmaher B, Greenhill L, Kolko D, Stanley B, Zelasny J, Burke AK, Firinciogullari S, Ellis SP, Mann JJ: Post-traumatic stress disorder co-morbid with major depression: Factors mediating the association with suicidal behavior. Am J Psychiatry 2005, 162:560-566.
• [58]Shanahan F: Cultural responses to the reintegration of formerly abducted girl soldiers in Northern-Uganda. Psychol Soc 2008, 1(1):14-28.
• [59]Bayer CP, Klasen F, Adam H: Association of trauma and PTSD symptoms with openness to reconciliation and feelings of revenge among former Ugandan and Congolese child soldiers. JAMA 2007, 298:555-559.
• [60]Grant KE, Compas BE, Thurm AE, McMahon SD, Gipson PY, Campbell AJ, Krochock K, Westerholm RI: Stressors and child and adolescent psychopathology: evidence of moderating and mediating effects. Clin Psychol Rev 2006, 26:257-283.