The Major Disorders of the Brain in Nepal
Not only are headache disorders very common in Nepal, but also, they are highly burdensome both at the individual and at the population levels. The prevalence of migraine in Nepal was found to be unusually high. The strong association with altitude of dwelling may largely explain this observation. Headache on =15 days/month and probable medication overuse headache (pMOH) are also very common in comparison with the world averages. Together, these disorders, migraine, tension-type hadache (TTH), headache on =15 days/month including pMOH, cause considerable disability and reduce the functional capacity, with a substantial penalty in suffering and lost production for the individual, their families and the Nepalese society. The project is also the first nationwide study on major psychiatric disorders in SEAR. It brought forward important public health findings with implications for future health policies in Nepal, and perhaps also for other SEAR countries. The study developed a culturally-validated instrument for the detection of anxiety and depression – symptom severity and caseness (HADS) which has now been made available also for others to use freely in clinical and research settings, and thus it adds to the available research tools of the country. Anxiety and depression were highly prevalent and between them, extensive comorbidity was found. The same was also true for the headache and the psychiatric disorders. Moreover, all studied conditions had negative impact on the quality of life (QoL), and thus, they contributed essentially to the burden of individuals, their immediate families and society.
One of the purposes of this study was to inform the public-health policy agents about these headache disorders. These headache disorders are treatable. A structured headache-care service has the potential to provide adequate remedies and also, to be cost-saving in Nepal, a low-income country within South-East Asia Region (SEAR). The study demonstrates the need to co-ordinate the activities of neurologists, psychiatrists and general practitioners in the country to lessen the burden, disability and thereby contribute via means related to health against productivity loss. The study underscores that by using simple and low cost means, all health practitioners in the country should develop higher reciprocal awareness about these disabling, common and highly comorbid conditions.
Hjernens sykdommer i Nepal
Vi har i 2015 analysert og delvis publisert forekomsten av de viktigste hjernesykdommer i Nepal og deres sammenheng med faktorer slik som høyde over havet
Hodepine var svært vanlig i Nepal med en 1-års prevalens på 85%. , Prevalensen av migrene var 34%, av spenningshodepine (TTH) 42%, hodepine =15 dager / mnd 7% og sannsynlig legemiddeloverforbrukhodepine 2%. Det var en sterk sammenheng mellom migrene og å bo bo på høyde >1,000 m og en mindre sterk sammenheng mellom spenningshodepine og urban bolig. Forekomsten av ren angst, ren depresjon, og kombinert angst og depresjon (CAD) var 16%, 4% og 6%. Ren angst var assosiert med urban bolig og nevrotisisme, og negativt assosiert med alkoholforbruk, og livskvalitet. Ren depresjon var positivt assosiert med marihuana bruk, og negativt assosiert med livskvalitet. CAD var positivt assosiert med å være enke, urban bolig, høyde =2000m, nevrotisisme, og negativt med alkoholbruk og livskvalitet (AOR = 0,79; p <0,001). Angst og depresjon er viktige mentale sykdommer i Nepal. De har betydelig innvirkning på folkehelsen og krever primærhelsetjenestens fokus. Hodepinelidelser er svært vanlig i Nepal. Bare utbredelsen av TTH er i tråd med det globale gjennomsnittet. Forekomsten av hodepine på =15 dager / mnd var dobbel, mens utbredelsen av pMOH var mot den øvre enden av intervallet for de fleste land studert. Forekomsten av migrene var unikt høy, og det tror vi, forklares av noen spesifikke egenskaper til landet. Den ene er en kombinasjon av fjell og kupert terreng. En annen er den demografiske karakteren av befolkningen. De nye data fra denne studien vil kunne brukes til å informere nasjonale helsepolitiker, og gi grunnlag for helsevesenets behovsvurdering. Samtidig trenges forskning av en annen type for å finne forklaringer på sammenhengen mellom migrene og høyde, da disse kan være relevante for intervensjoner. Kontinuerlig lang eksponering for stor høyde gir manglende oksygenopptak og hemodynamiske endringer, med forhøyede hemoglobinverdier, økt blod viskositet og redusert oksygentilførsel til hjernen vev. Migrene har vært knyttet til konsekvenser av slike endringer, men deres relevans ved lavere høyder, mellom 500 og 2000 m, må undersøkes nærmere.
Annual report (year 2014) of the project ”The Major Disorders of the Brain in Nepal”
The philosophical background and straightforward methodology applied during the survey were published as two articles in a highly ranked journal. The two Nepali PhD-students have presented these results at an international, scientific congress and completed the planned first half of educational courses in Norway.
We have presented the methodology of the study in two articles, published in one of the top-ranked headache journals. In the first paper, the anticipated methodological problems were sorted into different themes: study design; climate; geography, access and transport; sociocultural issues; safety of interviewers. Each of these was dealt with separately, and their inter-relationships explored, in finding solutions that were sometimes pragmatic. A cross-sectional questionnaire-based study, with teams of interviewers visiting households across the three physiographic divisions (with extremes in altitude) in each of the five development regions of the country, would enable national sampling with sociocultural representativeness. However, the study instruments and interviews would be in Nepali only. Transport and access challenges were considerable, and their solutions combined travel by air, bus, river and foot, with allowances for rain-damaged roads, collapsed bridges and cancelled scheduled flights. The monsoon would render many routes impassable, and therefore set an absolute time limitation. Engaging participants willingly in the enquiry would be the key to success, and several tactics would be employed to enhance the success of this, most importantly enlisting the support of local community volunteers in each study site. The second paper is a straightforward description of what was then done during the first year. We ran pre-pilot and pilot studies before embarking on the main study. The study design was cross-sectional. The population of interest were adults aged 18– 65 years who were Nepali speaking and living in Nepal. We selected, employed and trained groups of interviewers to visit randomly selected households by cold-calling. Households were selected from 15 representative districts out of 75 in the country through multistage cluster sampling. One participant was selected randomly from each household. We used structured questionnaires (the HARDSHIP questionnaire, Hospital Anxiety and Depression Scale, and Eysenck Personality Questionnaire -Neuroticism), culturally adapted and translated into Nepali. We recorded blood pressure, weight, height and waist circumference, and altitude of each household. We implemented various quality-assurances measures. We completed the survey in one month, prior to onset of the monsoon. Among 2,210 selected households, all were contacted, 2,109 were eligible for the study and, from these, 2,100 adults participated. The participation rate was 99.6%. The two Nepali PhD-students presented posters at an international, scientific congress (The European Headache and Migraine Trust International Congress, EHMTIC 2014) in Copenhagen. They have also stayed for half a year in Trondheim while successfully participating in the first half of the planned educational courses at NTNU. In November, the project was also the topic of a lecture in a series of global health seminars at NTNU.
Anxiety and depression in Nepal: prevalence, comorbidity and associations.
BMC Psychiatry 2016 Apr 14;16():102. Epub 2016 apr 14
Comorbidities of psychiatric and headache disorders in Nepal: implications from a nationwide population-based study.
J Headache Pain 2016;17():45. Epub 2016 apr 22
Reliability and Validity of a Nepali-language Version of the Hospital Anxiety and Depression Scale (HADS).
Kathmandu Univ Med J (KUMJ) 2015 Apr-Jun;13(50):115-24.
Measuring Neuroticism in Nepali: Reliability and Validity of the Neuroticism Subscale of the Eysenck Personality Questionnaire.
Kathmandu Univ Med J (KUMJ) 2015 Apr-Jun;13(50):156-61.
Undertreated Hypertension and its Implications for Public Health in Nepal: Nationwide Population-Based Survey.
Kathmandu Univ Med J (KUMJ) 2015 Jan-Mar;13(49):3-7.
The prevalence of primary headache disorders in Nepal: a nationwide population-based study.
J Headache Pain 2015;16():95. Epub 2015 nov 10
Estimating prevalence and burden of major disorders of the brain in Nepal: cultural, geographic, logistic and philosophical issues of methodology.
J Headache Pain 2014;15():51. Epub 2014 aug 15
Estimating the prevalence and burden of major disorders of the brain in Nepal: methodology of a nationwide population-based study.
J Headache Pain 2014;15():52. Epub 2014 aug 21