Emotional and Behavioral Problems among Impoverished Kenyan Youth: Factor Structure and Sex-Differences.

Data on youth emotional and behavioral problems from societies in Sub-Saharan Africa are lacking. This may be due to the fact that few youth mental health assessments have been tested for construct validity of syndrome structure across multicultural societies that include developing countries, and almost none have been tested in Sub-Saharan Africa. The Youth Self-Report (YSR), for example, has shown great consistency of its syndrome structure across many cultures, yet data from only one developing country in Sub-Saharan Africa have been included. In this study, we test the factor structure of YSR syndromes among Kenyan youth ages 11-18 years from an informal settlement in Nairobi, Kenya and examine sex-differences in levels of emotional and behavioral problems. We find the eight syndrome structure of the YSR to fit these data well (Root Mean Square Error of Approximation=.049). While Kenyan girls have significantly higher internalizing (Anxious/Depressed, Withdrawn/Depressed, Somatic) problem scores than boys, these differences are of similar magnitude to published multicultural findings. The results support the generalizability of the YSR syndrome structure to Kenyan youth and are in line with multicultural findings supporting the YSR as an assessment of emotional and behavioral problems in diverse societies.

Validation of a modified version of the PRIME screen for psychosis-risk symptoms in a non-clinical Kenyan youth sample.

BACKGROUND: The PRIME screen is a self-administered questionnaire designed to quickly assess individuals at risk for developing a psychotic disorder. It is shorter in both length and administration time compared to the Structured Interview for Psychosis-Risk Syndromes (SIPS)-a standard instrument for psychosis prodromal risk assessment. Validation of the PRIME against the SIPS has not been reported in large non-clinical populations. METHODS: A culturally modified version of the PRIME screen (mPRIME) was administered to Kenyan youth between the ages of 14 and 29. 182 completed both the SIPS and mPRIME. Validation measures (sensitivity, specificity, positive predictive value, negative predictive value) were calculated and the study sample was then broken down into true positives, false positives, and false negatives for comparison on different quantitative measures. RESULTS: Using previously suggested thresholds for a positive screen, the mPRIME had a sensitivity of 40% and a specificity of 64.8% for our entire sample. Positive predictive value (PPV) and negative predictive value (NPV) were 12.3% and 89.7%, respectively. Breaking the sample down by questionnaire outcome showed that true-positive individuals scored higher on average rate and intensity of endorsement of mPRIME items compared to false-positive and false-negatives, while false-negatives on average registered disagreement on all mPRIME questionnaire items. CONCLUSIONS: The mPRIME does not appear to be an effective screener of at-risk individuals for psychosis in our non-clinical sample. Further validation efforts in other general populations are warranted.

Knowledge of psychiatric terms and concepts among Kenyan youth: analysis of focus group discussions.

Psychiatric disorders and symptoms are common worldwide. However, cultural differences in symptom manifestation and knowledge of psychiatric terms and concepts represent a challenge to accurate clinical assessment. Our previous youth surveys revealed higher rates of psychotic experiences in Kenya compared to several other countries, suggesting culture may influence psychosis risk assessment survey results. The goal of the present investigation is to evaluate understanding of general mental health related terms and concepts and specific items from the Structured Interview for Psychosis-Risk Symptoms (SIPS), a commonly used psychosis risk assessment instrument. Six focus groups were conducted in Nairobi, Kenya and surrounding areas with young adults from the community, university and secondary school students, and mental health professionals. Analysis of the information obtained from participants indicated that adolescents and young adults in Kenya were aware of mental illness in their communities, but had very limited knowledge of the meaning of specific psychiatric disorders and symptoms. Many believed that the cause of mental illness was spiritual in nature. These results suggest that in order to obtain accurate reported rates of psychiatric symptoms, assessment of Kenyan adolescents and young adults requires elaboration of assessment questions and use of simplified terms.

Major depressive disorder in a Kenyan youth sample: relationship with parenting behavior and parental psychiatric disorders.

BACKGROUND: Studies on mental health problems during childhood and youth development phases have reported that families of children diagnosed with a depressive disorder tend to be dysfunctional. These dysfunctions have been shown to be mediating factors for children to develop psychiatric disorders in the future. OBJECTIVE: This study was designed to investigate whether perceived parenting behavior and parental psychiatric disorders have any relationship with youth presenting with major depressive disorder. METHODOLOGY: The study sample had a total number of 250 purposely selected youth attending the Youth Clinic at Kenyatta National Hospital in Nairobi. RESULTS: This study found associations between major depressive disorders (MDD) in the youth and co-morbid psychiatric disorders among the youth: conduct disorder (OR = 2.93, 95% CI 1.04 to 8.26, p = 0.035), any anxiety disorder (OR = 2.41, 95% CI 1.20 to 4.87, p = 0.012), drug abuse (OR = 3.40, 95% CI 2.01 to 5.76, p < 0.001), alcohol use (OR = 3.29, 95% CI 1.94 to 5.57, p < 0.001), and suicidal behavior (OR = 5.27, 95% CI 2.39 to 11.66, p < 0.001). The results also indicate that a higher proportion of youth between 16 and 18 years had major depressive disorder than the youth below 16 years or above 18 years of age (OR = 2.66, 95% CI 1.40 to 5.05, p = 0.003). Multivariate analysis shows that both rejecting maternal behavior (AOR = 2.165, 95% CI 1.060 to 4.422, p = 0.003) and maternal MDD (AOR = 5.27, 95% CI 1.10 to 14.76, p < 0.001) are associated with MDD in youth. CONCLUSION: Negative maternal parenting behavior and maternal depressive disorder are associated with major depressive disorder in children.

Suicidal behaviour among youths associated with psychopathology in both parents and youths attending outpatient psychiatric clinic in Kenya.

BACKGROUND: Suicide is a major cause of death among youths particularly with psychiatric, alcohol abuse and substance abuse disorders. There are relatively few studies on the relationship between psychiatric and substance abuse disorders with suicidal behaviour from low-income countries. This study examines the relationship between suicidal behaviour and co-existing psychiatric or substance disorders among youths and depressive and alcohol use disorders in their parents. METHOD: The study sample had 678 respondents: 250 youths and 226 and 202 biological mothers and fathers, respectively. RESULTS: This study found a significant statistical association between depressive (p < 0.001), alcohol abuse (p <0.001) and substance abuse (p < 0.001) disorders and suicidal behaviour in youths. There was a significant relationship between maternal depressive disorder (p < 0.001) and perceived maternal rejecting parenting behaviour (p < 0.001) with suicidal behaviour in youths. There was a greater odds of a youth with two to three (odds ratio (OR) = 3.63; p = 0.009) and four or more (OR = 8.23; p < 0.001) co-existing psychiatric disorders to have suicidal behaviour than a youth with only one psychiatric disorder. The results also indicate that a higher proportion of youths between ages 16-18 years had suicidal behaviour than youths below 16 years or above 18 years of age (p = 0.004). CONCLUSION: These findings suggest that youths with psychiatric and substance abuse disorders have mothers living with a depressive disorder. Also, perceived maternal rejecting parenting behaviour contributes significantly to the development of suicidal behaviour later in adolescent years.

Classes of psychotic experiences in Kenyan children and adolescents.

Psychotic-like experiences (PLEs) have been observed worldwide in both adults and children outside the context of a clinical disorder. In the current study, we investigate the prevalence and patterns of PLEs among children and adolescents in Kenya. Among 1,971 students from primary and secondary schools around Nairobi (aged 8-19), 22.1 % reported a lifetime history of a psychotic experience, and 16.3 % reported this unrelated to sleep or drugs. Psychotic experiences were more common in males compared to females. LCA resulted in a three-class model comprised of a normative class (83.3 %), a predominately hallucinatory class (Type 1 psychosis: 9.6 %), and a pan-psychotic class (Type 2 psychosis: 7.2 %). These results indicate that PLEs are prevalent in children and adolescents, and the distributions of symptom clusters are similar to that found in adulthood. The relationship of specific PLEs to the future development of psychotic disorder, functional impairment or distress will require further study.

Prevalence and characteristics of psychotic-like experiences in Kenyan youth.

Current evidence suggests that there may be significant differences in psychotic symptom prevalence in Africa compared with other cultures. However, there have been few studies evaluating these symptoms in the continent. We conducted a cross-sectional survey of psychotic-like experiences (PLEs) in 2963 Kenyan students from seven tertiary academic institutions spread across Kenya, using a self-administered psychosis questionnaire evaluating psychotic experiences and demographic variables. Logistic regression was used to evaluate relationship between PLEs and demographic variables. Latent class analysis (LCA) was used to determine specific classes of psychotic experiences. Twenty-three percent of respondents reported having at least one PLE, and 19% reported this unrelated to drug use or sleep. Compared to students identifying as Protestant Christians, Catholics had a lower likelihood of having any PLE or visual hallucinations. Other demographic variables were not significantly associated with PLEs. LCA of PLEs resulted in a three-class model that comprised 1) a non-psychotic class (83.8%), 2) a predominantly hallucinatory class ("type I PLE"; 12.7%), and 3) a multiple symptom class ("type II PLE"; 3.5%). Both psychotic classes had a predominance of male students. Further studies are required to clarify functionality and clinical progression associated with observed patterns of psychosis, as well as the generalizability of our findings.

Multiple traumas, postelection violence, and posttraumatic stress among impoverished Kenyan youth.

Research on posttraumatic stress disorder (PTSD) among youth has focused on specific subgroups from developed countries. Most of the world's youth and war-like violence, however, is concentrated in developing countries, yet there is limited mental health data within affected countries. This study focused on a random community-based sample of 552 impoverished youth ages 6-18 within an informal settlement in Nairobi, Kenya, which experienced war-like violence for a month following the contested presidential election of 2007. Six months after the violence ended, 99 (18%) had PTSD according to the UCLA PTSD Reaction Index (Steinberg, Brymer, Decker, & Pynoos, 2004), and an additional 18 (3%) were found to have partial PTSD due to high overall scores. Kenyan psychologists conducted diagnostic interviews and found the positive predictive value of the assessment tool to be 72% in this sample; the confirmed prevalence was 12%. Similar to other studies worldwide, Criterion C (avoidance) was the limiting factor for diagnosing PTSD according to the DSM-IV-TR, and parent-child agreement was at best fair. The number of traumatic experiences was strongly associated with PTSD outcomes. Differences due to age or sex were not found. The findings indicate the need for universal mental health services for trauma-exposed youth and their families in the impoverished informal settlements of Nairobi, Kenya.

The Association between Alcohol Dependence and Depression before and after Treatment for Alcohol Dependence.

The presence of depression in alcohol-dependent persons is likely to influence treatment process and outcomes. Identification of depression is important though not every depressed alcohol-dependent person requires treatment with antidepressants. Understanding the association between depression and alcohol dependence is essential for proper management of alcohol dependence. Objectives. To determine the prevalence of depression among alcohol-dependent persons before and after alcohol detoxification and rehabilitation. Design. Clinical trial with pre-/postmeasurements. Method. The CIDI and WHO-ASSIST were administered to 188 alcohol-dependent persons at intake and after six months. A researcher-designed sociodemographic questionnaire was also administered at intake. Results. The prevalence of depression among alcohol-dependent persons is high (63.8%) with a significant association between depression and the mean AUDIT score. At posttest, depressed participants had a statistically significant craving for alcohol. Conclusion. Alcohol dependence is associated with major depression.

University medical education in Kenya: The challenges.

There are two medical schools training doctors in Kenya: the Moi University established in 1984 and the University of Nairobi established in 1967. The University of Nairobi has so far produced the majority of Kenyan doctors. Both are public universities with the Government being the main financier. The increased demand for university education and the inability to meet these demands has led to the introduction of a system of training self-sponsored medical students alongside Government-subsidised students. One other public university has started a medical school. The pressure to increase the number of schools and students in the absence of increased resources poses a particular challenge to the country.

Drug use in a rural secondary school in Kenya.

Alcohol abuse and alcohol-related use problems among adolescents are highly prevalent and are a major concern worldwide. This study estimated the prevalence of drug abuse, knowledge about drug abuse and its effect on psychosocial well-being and induced behavioral problems among students of a public rural secondary school that admitted both girls and boys which offered both boarding and day school facilities. The students filled out a self-reporting substance use tool which measures the prevalence, frequency, and general patterns of substance use. Alcohol, tobacco, khat (catha edulis) and bhang (cannabis) were the most commonly reported substance of use, with user prevalence rates of 5.2%, 3.8%, 3.2%, and 1.7%, respectively. Tobacco use was initiated at 10 years, while cannabis, hard drugs, khat, and alcohol were initiated at 11, 12, 13, and 15 years of age, respectively. Among the students 71% were aware that their schoolmates were on drugs and it was known by 49.8%, 41.7%, 37.6%, 44.3%, and 32.4% of these students that using alcohol, tobacco, khat, cannabis, and hard drugs, respectively was a behavioral problem in the school. Three quarters of the students were aware that use of drugs was harmful to their health, with majority (78.6%) indicating that drug users need help to stop the drug use behavior. However most (73.6%) of the students suggested drug users in school should be punished. The drug use behavioral problems included school dropout, poor scholastic attainment, drunken driving, delinquency, and adolescence pregnancy which threaten the stability of the education system, family as an institution (family difficulties) and society at large. Therefore, teachers have an added burden of playing an active role in guidance and counselling the survivors of drug abuse, a pandemic facing teaching institutions apart from instilling knowledge.

Suicidality and depression among adult patients admitted in general medical facilities in Kenya.

AIM: To document Beck Depression Inventory (BDI) II suicidal symptoms among patients admitted to Kenyan non-psychiatric general medical facilities METHODS: All consenting adults admitted within a period of 4 weeks at 10 general medical facilities in Kenya were interviewed for suicidal symptoms and depression using the BDI-II. RESULTS: In all, 2,780 patients responded to item 9 (suicidal symptoms of the BDI-II). The prevalence of all BDI-II suicidal symptoms combined was 10.5%. Thoughts of 'killing oneself but have not carried them out' accounted for 9% of the suicidal symptoms. The younger age group had the highest prevalence of suicidal symptoms and the oldest age group had the least prevalence of suicidal symptoms. The more depressed the patients were on the overall BDI-II score, the higher the prevalence of suicidal symptoms. CONCLUSION: On average 1 out of 10 of the patients had suicidal symptoms, more so in younger than the older people and in the more depressed. These symptoms had not been clinically recognised and therefore not managed. This calls for clinical practice that routinely enquires for suicidal symptoms in general medical wards.

Recognition of depression in children in general hospital-based paediatric units in Kenya: practice and policy implications.

BACKGROUND: Physical disorders are commonly comorbid with depression in children attending general medical facilities. However, the depression component is rarely recognised. METHODS: A questionnaire on sociodemographics and history of presenting medical conditions was administered together with the Children's Depression Inventory (CDI) to all 11-year-old to 17-year-old children attending at nine medical facilities. RESULTS: In all, 408 children were recruited from 9 health facilities. Whereas the clinicians diagnosed a mental disorder in only 2.5% of the sample studied, 41.3% had CDI scores that suggested mild to moderate depression. The highest proportion of children with depressive symptomatology was found at the Kenyatta National and Teaching Referral Hospital. CONCLUSION: Although prevalence rate for depression among children is high, detection rates remain low. This finding has clinical practice and policy implications within and outside Kenya.

A cross-sectional study of co-occurring suicidal and psychotic symptoms in inpatients at mathari psychiatric hospital, nairobi, kenya.

UNLABELLED: To investigate the prevalence of suicidal symptoms and their co-occurrence with psychotic symptoms in patients at Mathari Hospital. METHOD: A descriptive cross-sectional study was conducted in June 2004 on inpatients at Mathari Hospital, the national psychiatric teaching and referral hospital. Data on sociodemographic characteristics and clinical diagnoses of inpatients were extracted from their clinical notes. The Structured Clinical Interview for DSM-IV (SCID) Screening Module was used to elicit information on psychotic and suicidal symptoms. RESULTS: A total of 691 patients were interviewed, of whom 308 (44.6%) had suicidal symptoms. There were significant positive correlations (p < .05) between psychotic and suicidal symptoms diagnosed according to the criteria of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) suggesting co-existence of these 2 sets of disorders. CONCLUSIONS: There is a high prevalence of suicidal symptoms in the patients admitted at Mathari Hospital with predominantly psychotic disorders. Although these prevalence rates are much lower than those reported elsewhere, especially for schizophrenia, they are still a cause for concern given that these suicidal symptoms were not being managed.

Prevalence of substance abuse among patients in general medical facilities in Kenya.

Alcoholism and other substance abuse continue to be a problem among younger and older populations. The prevalence of substance abuse has only been studied among outpatients and in limited samples of inpatients in Kenya. This study therefore aimed to establish patterns of substance abuse in patients admitted in general medical facilities in Kenya. The Alcohol Use Disorders Identification Test (AUDIT) and the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) were used to measure the prevalence of substance abuse among patients in 10 medical facilities in Kenya. Data were collected over a 4-week period in November 2005. The overall alcohol user rate using the two instruments was 25.1% and 25.5%, respectively. All the patients who used alcohol exhibited pathological use, which bordered from harmful use to dependence. Apart from alcohol, other abused substances included tobacco, cannabis, cocaine, amphetamines/khat, and sedatives. The clinicians' pick rate for substance use in general hospitals was negligible. These findings suggest the need for specific enquiry for substance abuse in patients in general medical facilities.

Patterns of drug abuse in public secondary schools in Kenya.

The objective of this study was to establish the association between substance abuse and the sociodemographic characteristics of secondary school students. All the students of 17 randomly stratified public secondary schools in Nairobi were required to complete self-administered sociodemographic and the School Toolkit questionnaires in a cross-sectional descriptive survey. Nearly all (96.6%; 1252/1296) the students, comprising more males (62.5%) than females, completed all the items on the questionnaires. Their mean age was 17 years. Alcohol and cigarette use were common and began as early as before age 11. No significant correlation was found between fathers' education and substance abuse. Mothers' education had a significant but negative correlation. There were increased rates of substance abuse compared to past surveys. Campaigns against drug use should include those aged 11 years and should focus on education on the dangers of alcohol and tobacco use, as these are gateways to use of other drugs.

Psychosocial and health aspects of drug use by students in public secondary schools in Nairobi, Kenya.

The objective of this study was to evaluate the influence of family, psychosocial, health, demographic, and behavioral characteristics on regular drug use. All the students of 17 randomly stratified public secondary schools in Nairobi were required to complete self-administered sociodemographic and the Drug Use Screening Inventory-Revised (DUSI-R) questionnaires in a cross-sectional descriptive study. All the 1328 students, of whom 58.9% were male, responded to all the questions, giving a response rate of 100%. The mean age of the respondents was 16 years and 78.1% were in boarding school. One third (33.9%) scored positively for substance abuse. Significant correlations were found between several domains of substance abuse and school, class, mode of school attendance, age, and gender. Students abusing drugs have multiple comorbidity of medical, psychological, and social pathologies. There are evidence-based intervention entry points for drug abuse that go beyond mere impartation on knowledge about the harmful effects of drugs.

The prevalence of mental disorders in adults in different level general medical facilities in Kenya: a cross-sectional study.

BACKGROUND: The possibility that a significant proportion of the patients attending a general health facility may have a mental disorder means that psychiatric conditions must be recognised and managed appropriately. This study sought to determine the prevalence of common psychiatric disorders in adult (aged 18 years and over) inpatients and outpatients seen in public, private and faith-based general hospitals, health centres and specialised clinics and units of general hospitals. METHODS: This was a descriptive cross-sectional study conducted in 10 health facilities. All the patients in psychiatric wards and clinics were excluded. Stratified and systematic sampling methods were used. Informed consent was obtained from all study participants. Data were collected over a 4-week period in November 2005 using various psychiatric instruments for adults. Descriptive statistics were generated using SPSS V. 11.5. RESULTS: A total of 2,770 male and female inpatients and outpatients participated in the study. In all, 42% of the subjects had symptoms of mild and severe depression. Only 114 (4.1%) subjects had a file or working diagnosis of a psychiatric condition, which included bipolar mood disorder, schizophrenia, psychosis and depression. CONCLUSION: The 4.1% clinician detection rate for mental disorders means that most psychiatric disorders in general medical facilities remain undiagnosed and thus, unmanaged. This calls for improved diagnostic practices in general medical facilities in Kenya and in other similar countries.

Outcome of a working diagnosis of "psychosis" in relation to DSM-IV diagnostic criteria in a Kenyan in-patient cohort at Mathari hospital, Nairobi.

BACKGROUND: When a patient presents with mental illness and displays psychotic symptoms which are not clearly delineated, a clinical diagnosis of psychosis is usually entertained. AIM: To determine the underlying Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition (DSM-IV) disorders in clinical entities admitted with a working diagnosis of "psychosis" at Mathari Psychiatric Hospital, Nairobi, Kenya. STUDY DESIGN: Descriptive cross-sectional quantitative study METHOD: A total of 138 patients with a working diagnosis of "psychosis" on admission at Mathari Hospital during the period of this study were recruited over a one-month period. Their DSM-IV diagnoses were made using the Structured Clinical Interview for DSM-IV (SCID). Analysis of the results was done using SPSS version 11.5. RESULTS: Nearly three quarters (72.5%) of the patients were male, 68.5% were aged between 20 and 34 years and 63.7% reported that they were single. Nearly half (49.2%) had attained up to 12 years of formal education and 90% were dependants of a member of the family. The most common DSM-IV diagnoses were schizophrenia, bipolar disorder, substance abuse, depression and anxiety disorders. Co-morbidity was recorded with an average of three DSM-IV disorders. CONCLUSION: "Psychosis" as a working diagnosis was reported in relatively young adults. The patients whose working clinical diagnosis was "psychosis" met the criteria for an average of three DSM-IV diagnoses. There is need for a proactive policy in clinical practice so that definitive diagnoses rather than just "psychosis" are made and appropriate management initiated as early as possible.