Context Prior qualitative work with internally displaced persons in war-affected northern Uganda showed significant mental health and psychosocial problems.Objective To assess effect of locally feasible interventions on depression, anxiety, and conduct problem symptoms among adolescent survivors of war and displacement in northern Uganda. Design, Setting, and ParticipantsA randomized controlled trial from May 2005 through December 2005 of 314 adolescents (aged 14-17 years) in 2 camps for internally displaced persons in northern Uganda. Interventions Locally developed screening tools assessed the effectiveness of interventions in reducing symptoms of depression and anxiety, ameliorating conduct problems, and improving function among those who met study criteria and were randomly allocated (105, psychotherapy-based intervention [group interpersonal psychotherapy]; 105, activity-based intervention [creative play]; 104, wait-control group [individuals wait listed to receive treatment at study end]). Intervention groups met weekly for 16 weeks. Participants and controls were reassessed at end of study.Main Outcome Measures Primary measure was a decrease in score (denoting improvement) on a depression symptom scale. Secondary measures were improvements in scores on anxiety, conduct problem symptoms, and function scales. Depression, anxiety, and conduct problems were assessed using the Acholi Psychosocial Assessment Instrument with a minimum score of 32 as the lower limit for clinically significant symptoms (maximum scale score, 105).Results Difference in change in adjusted mean score for depression symptoms between group interpersonal psychotherapy and control groups was 9.79 points (95% confidence interval [CI], 1.66-17.93). Girls receiving group interpersonal psychotherapy showed substantial and significant improvement in depression symptoms compared with controls (12.61 points; 95% CI, 2.09-23.14). Improvement among boys was not statistically significant (5.72 points; 95% CI, −1.86 to 13.30). Creative play showed no effect on depression severity (−2.51 points; 95% CI, −11.42 to 6.39). There were no statistically different improvements in anxiety in either intervention group. Neither intervention improved conduct problem or function scores.Conclusions Both interventions were locally feasible. Group interpersonal psychotherapy was effective for depression symptoms among adolescent girls affected by war and displacement. Other interventions should be investigated to assist adolescent boys in this population who have symptoms of depression.

Multiple studies have found that children from a variety of cultures who have been affected by war are at increased risk for a range of psychosocial problems. However, most studies are based on Western concepts and assume that these are locally applicable. Very few have investigated how psychosocial problems are perceived by the affected communities, families and the young people themselves. Understanding local perceptions is important to ensuring that local priorities are addressed, and addressed in ways that are likely to be acceptable and effective. In this study we used a previously developed rapid ethnographic assessment method to explore local perceptions of psychosocial problems among issues among children and adults from the Acholi ethnic group that have been displaced by the war in northern Uganda. We conducted 45 free list interviews (N= 30 10-17 year olds, N=15 adults) and 57 key informant interviews (N=32 10-17 year olds, N=25 adults) Our purpose was twofold: 1) To test whether this rapid ethnographic assessment approach previously used among adults would be suitable for use with children; and 2) To use this approach to understand the psychosocial problems affecting local children from their own viewpoint and that of their caretakers, in order to inform subsequent assessment and intervention efforts by organizations serving this population. The rapid assessment approach appears to have worked well for interviewing caretakers and children aged 10-17 years. Several locally defined syndromes were described: two tam/par/kumu (depression and dysthymia-like syndromes), ma lwor (an anxiety-like syndrome), and a category of conduct problems referred to as kwo maraco/gin lugero. The descriptions of these local syndromes are similar to Western mood, anxiety and conduct disorders, but contain some culturespecific elements.

This paper presents an approach for evaluating the reliability and validity of mental health measures in non-Western field settings. We describe this approach using the example of our development of the Acholi Psychosocial Assessment Instrument (APAI), which is designed to assess depression-like (two tam, par and kumu), anxiety-like (ma lwor) and conduct problems (kwo maraco) among war-affected adolescents in northern Uganda. To examine the criterion validity of this measure in the absence of a traditional gold standard, we derived local syndrome terms from qualitative data and used self reports of these syndromes by indigenous people as a reference point for determining caseness. Reliability was examined using standard test-retest and inter-rater methods. Each of the subscale scores for the depression-like syndromes exhibited strong internal reliability ranging from α =0.84 to 0.87. Internal reliability was good for anxiety (0.70), conduct problems (0.83), and the pro-social attitudes and behaviors (0.70) subscales. Combined inter-rater reliability and test-retest reliability were good for most subscales except for the conduct problem scale and prosocial scales. The pattern of significant mean differences in the corresponding APAI problem scale score between self-reported cases vs. noncases on local syndrome terms was confirmed in the data for all of the three depression-like syndromes, but not for the anxiety-like syndrome ma lwor or the conduct problem kwo maraco.

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