BackgroundEvidence is lacking on the mental health issues of internally displaced persons, particularly where displacement is prolonged. The COMRAID study was carried out in year 2011 as a comprehensive evaluation of Muslims in North-Western Sri Lanka who had been displaced since 1990 due to conflict, to investigate the prevalence and correlates of common mental disorders.MethodsA cross-sectional survey was carried out among a randomly selected sample of internally displaced people who had migrated within last 20 years or were born in displacement. The total sample consisted of 450 adults aged 18–65 years selected from 141 settlements. Common mental disorders (CMDs) and post-traumatic stress disorder (PTSD) prevalences were measured using the Patient Health Questionnaire and CIDI sub-scale respectively.ResultsThe prevalence of any CMD was 18.8%, and prevalence for subtypes was as follows: somatoform disorder 14.0%, anxiety disorder 1.3%, major depression 5.1%, other depressive syndromes 7.3%. PTSD prevalence was 2.4%. The following factors were significantly associated with CMDs: unemployment (odds ratio 2.8, 95% confidence interval 1.6–4.9), widowed or divorced status (4.9, 2.3–10.1) and food insecurity (1.7, 1.0–2.9).ConclusionsThis is the first study investigating the mental health impact of prolonged forced displacement in post-conflict Sri Lanka. Findings add new insight in to mental health issues faced by internally displaced persons in Sri Lanka and globally, highlighting the need to explore broader mental health issues of vulnerable populations affected by forced displacement.

BackgroundOne-in-ten Sri Lankans are employed abroad as International Labor Migrants (ILM), mainly as domestic maids or low-skilled laborers. Little is known about the impact their migration has on the health status of the children they ‘leave behind’. This national study explored associations between the health status of ‘left-behind’ children of ILM’s with those from comparative non-migrant families.MethodsA cross-sectional study design with multi-stage random sampling was used to survey a total of 820 children matched for both age and sex. Socio-demographic and health status data were derived using standardized pre-validated instruments. Univariate and multivariate analyses were used to estimate the differences in mental health outcomes between children of migrant vs. non-migrant families.ResultsTwo in every five left-behind children were shown to have mental disorders [95%CI: 37.4-49.2, p < 0.05], suggesting that socio-emotional maladjustment and behavioural problems may occur in absence of a parent in left-behind children. Male left-behind children were more vulnerable to psychopathology. In the adjusted analyses, significant associations between child psychopathological outcomes, child gender and parent’s mental health status were observed. Over a quarter (30%) of the left-behind children aged 6–59 months were ‘underweight or severely underweight’ compared to 17.7% of non-migrant children.ConclusionsFindings provide evidence on health consequences for children of migrant worker families in a country experiencing heavy out-migration of labour, where remittances from ILM’s remain as the single highest contributor to the economy. These findings may be relevant for other labour ‘sending countries’ in Asia relying on contractual labor migration for economic gain. Further studies are needed to assess longitudinal health impacts on the children left-behind.

Millions of people undergo displacement in the world. Internally displaced people (IDP) are especially vulnerable as they are not protected by special legislation in contrast to other migrants. Research conducted among IDPs must be correspondingly sensitive in dealing with ethical issues that may arise. Muslim IDPs in Puttalam district in the North-Western province of Sri Lanka were initially displaced from Northern Sri Lanka due to the conflict in 1991. In the backdrop of a study exploring the prevalence of common mental disorders among the IDPs, researchers encountered various ethical challenges. These included inter-related issues of autonomy, non-maleficence, beneficence, confidentiality and informed consent, and how these were tailored in a culture-specific way to a population that has increased vulnerability. This paper analyses how these ethical issues were perceived, detected and managed by the researchers, and the role of ethics review committees in mental health research concerning IDPs. The relevance of guidelines and methodologies in the context of an atypical study population and the benefit versus risk potential of research for IDPs are also discussed. The limitations that were encountered while dealing with ethical challenges during the study are discussed. The concept of post-research ethical conduct audit is suggested to be considered as a potential step to minimize the exploitation of vulnerable populations such as IDPs in mental health research.

Sri Lanka is a major labour sending country in Asia, with a high proportion of female labour migrants employed as domestic housemaids in the Middle East with increasing remittances. Despite such financial gains for families and national economy, health and social effects on the left-behind families have had limited exploration. This qualitative study was carried out across five districts with high labour migration rates in Sri Lanka. Twenty in-depth interviews were conducted with participants recruited through purposive sampling. Data was analysed using content and thematic analysis and emerging themes were mapped. Pre-migration socio-economic situation, economic difficulties and higher earning possibilities abroad were considered to be the major push and pull factors for labour migration. Post-migration periods were shown to be of mixed benefit to left-behind families and children suffer the negative effects of parental absence. The absence of support mechanisms for dealing with adverse events such as serious injury, death, abuse or imprisonment were cited as major concerns. Post-migration periods affect the health, well-being and family structures of left-behind families. Promoting economic prosperity while ensuring health and social protection is a formidable policy challenge for 'labour sending' countries such as Sri Lanka.

BackgroundInadequacy in mental health care in low and middle income countries has been an important contributor to the rising global burden of disease. The treatment gap is salient in resource-poor settings, especially when providing care for conflict-affected forced migrant populations. Primary care is often the only available service option for the majority of forced migrants, and integration of mental health into primary care is a difficult task. The proposed pilot study aims to explore the feasibility of integrating mental health care into primary care by providing training to primary care practitioners serving displaced populations, in order to improve identification, treatment, and referral of patients with common mental disorders via the World Health Organization Mental Health Gap Action Programme (mhGAP).Methods/DesignThis pilot randomized controlled trial will recruit 86 primary care practitioners (PCP) serving in the Puttalam and Mannar districts of Sri Lanka (with displaced and returning conflict-affected populations). The intervention arm will receive a structured training program based on the mhGAP intervention guide. Primary outcomes will be rates of correct identification, adequate management based on set criteria, and correct referrals of common mental disorders. A qualitative study exploring the attitudes, views, and perspectives of PCP on integrating mental health and primary care will be nested within the pilot study. An economic evaluation will be carried out by gathering service utilization information.DiscussionIn post-conflict Sri Lanka, an important need exists to provide adequate mental health care to conflict-affected internally displaced persons who are returning to their areas of origin after prolonged displacement. The proposed study will act as a local demonstration project, exploring the feasibility of formulating a larger-scale intervention study in the future, and is envisaged to provide information on engaging PCP, and data on training and evaluation including economic costs, patient recruitment, and acceptance and follow-up rates. The study should provide important information on the WHO mhGAP intervention guide to add to the growing evidence base of its implementation.Trial registrationSLCTR/2013/025.

BackgroundNearly one-in-ten Sri Lankans are employed abroad as International migrant workers (IMW). Very little is known about the mental health of adult members in families left-behind. This study aimed to explore the impact of economic migration on mental health (common mental disorders) of left-behind families in Sri Lanka.MethodsA cross-sectional survey using multistage sampling was conducted in six districts (representing 62% of outbound IMW population) of Sri Lanka. Spouses and non-spouse caregivers (those providing substantial care for children) from families of economic migrants were recruited. Adult mental health was measured using the Patient Health Questionnaire. Demographic, socio-economic, migration-specific and health utilization information were gathered.ResultsA total of 410 IMW families were recruited (response rate: 95.1%). Both spouse and a non-spouse caregiver were recruited for 55 families with a total of 277 spouses and 188 caregivers included. Poor general health, current diagnosed illness and healthcare visit frequency was higher in the non-spouse caregiver group. Overall prevalence of common mental disorder (CMD; Depression, somatoform disorder, anxiety) was 20.7% (95%CI 16.9-24.3) with 14.4% (95%CI 10.3-18.6) among spouses and 29.8% (95%CI 23.2-36.4) among non-spouse caregivers. Prevalence of depression (25.5%; 95%CI 19.2-31.8) and somatoform disorder 11.7% (95%CI 7.0-16.3) was higher in non-spouse caregiver group. When adjusted for age and gender, non-returning IMW in family, primary education and low in-bound remittance frequency was associated with CMD for spouses while no education, poor general health and increased healthcare visits was significantly associated in the non-spouse caregiver group.ConclusionsTo our knowledge, this is one of the first studies to explore specific mental health outcomes among adult left-behind family members of IMW through standardized diagnostic instruments in Sri Lanka and in South Asian region. Negative impact of economic migration is highlighted by the considerably high prevalence of CMD among adults in left-behind families. A policy framework that enables health protection whilst promoting migration for development remains a key challenge for labour-sending nations.

BackgroundMental health care in post-conflict settings is often not prioritized, despite its important public health role. There is a salient gap in integrating mental health into primary care, especially in post-conflict settings. In the post-conflict Northern province of Sri Lanka, a pilot study was conducted to explore the feasibility of integrating mental health into primary care through a mhGAP-based training intervention.MethodsUsing the mhGAP training intervention modules, a 24 h training programme was held over 3 days for primary care practitioners serving post-conflict populations (including internally displaced people and returnees). mhGAP intervention guide and video material was used in the training. Pre/post knowledge increase was measured. A qualitative study was also nested within the training programme to explore views, attitudes and perceptions of primary care practitioners on integrating mental health into primary care in the region. In-depth interviews were conducted.ResultsTwelve primary care practitioners participated. The average service duration of the group was 7.6 years. The mean pre- and post-test scores of the PCP group were 72.8 and 77.2 % respectively. All 12 took part in the qualitative component. Participants highlighted their experiences of conflict and displacement, discussed the health profiles/needs of post-conflict populations in the region and provided insight into mental health care and training needs at primary care level. Participants also provided feedback on the mhGAP-based training; the cultural and contextual relevance of training material and content.ConclusionThis study was planned as a local demonstrative project to explore the feasibility of training primary care practitioners to promote the integration of mental health into primary care for post-conflict populations. To our knowledge, this is the first such attempt in Sri Lanka. Findings highlight the practical, operational and attitudinal barriers to integrate mental health into primary care, especially in resource-poor, post-conflict settings. Important feedback on mhGAP intervention guide, its implementation and training material was gained.

BackgroundThe disease burden related to mental disorders and metabolic syndrome is growing in low-and middle-income countries (LMIC). The Colombo Twin and Singleton Study (COTASS) is a population-based sample of twins and singletons in Colombo, Sri Lanka. Here we present prevalence estimates for metabolic syndrome (metS) and mental disorders from a follow-up (COTASS-2) of the original study (COTASS-1), which was a mental health survey.MethodsIn COTASS-2, participants completed structured interviews, anthropometric measures and provided fasting blood and urine samples. Depressive disorder, depressive symptoms, anxiety symptoms, post-traumatic stress disorder (PTSD) and hazardous alcohol use were ascertained with structured psychiatric screens (Composite International Diagnostic Interview (CIDI), Beck Depression Inventory (BDI-II), Generalised Anxiety Disorder Questionnaire (GAD-7), PTSD Checklist – Civilian Version (PCL-C), and Alcohol Use Disorders Identification Test (AUDIT)). We defined metS according to the International Diabetes Federation (IDF) criteria and the revised National Cholesterol Education Programme Adult Treatment Panel (NCEP ATP III) criteria. We estimated the prevalence of psychiatric disorders and metS and metS components, and associations with gender, education and age.ResultsTwo thousand nine hundred thirty-four twins and 1035 singletons were followed up from COTASS-1 (83.4 and 61.8% participation rate, respectively). Prevalence estimates for depressive disorder (CIDI), depressive symptoms (BDI ≥ 16), anxiety symptoms (GAD-7 ≥ 10) and PTSD (PCL-C DSM criteria) were 3.8, 5.9, 3.6, and 4.5% respectively for twins and 3.9, 9.8, 5.1 and 5.4% for singletons. 28.1 and 30.9% of male twins and singletons respectively reported hazardous alcohol use. Approximately one third met the metS criteria (IDF: 27.4% twins, 44.6% singletons; NCEP ATP III: 30.6% twins, 48.6% singletons). The most prevalent components were central obesity (59.2% twins, 71.2% singletons) and raised fasting blood glucose or diabetes (38.2% twins, 56.7% singletons).ConclusionMetS was highly prevalent in twins, and especially high in singletons, whereas the prevalence of mental disorders was low, but consistent with local estimates. The high levels of raised fasting plasma glucose and central obesity were particularly concerning, and warrant national diabetes prevention programmes.Electronic supplementary materialThe online version of this article (doi:10.1186/s12889-017-4992-2) contains supplementary material, which is available to authorized users.