overview of psychiatric scales used in nepal: their reliability, validity and cultural...

R E V I E W A R T I C L E

Overview of psychiatric scales used in Nepal: Their reliability,validity and cultural appropriatenessPatrick Chen1 MD, Soma Ganesan1,2 MD & Mario McKenna1 MS MHA

1 Department of Psychiatry, Clinical Practice Unit, Vancouver General Hospital, Vancouver, BC, Canada

2 Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada

KeywordsDSM-IV, Nepal, outcome measure, psychiatricassessment, review

CorrespondenceMario McKenna MS MHA, Vancouver General

Hospital, Willow Chest Centre 3rd Floor, Room

3132647, Willow Street, Vancouver, BC V5Z 3P1,

Canada.

Tel: +1 604 875 4111 ext. 62410

Fax: +1 604 875 4987

Email: [email protected]

Received 26 March 2012

Accepted 11 April 2012

DOI:10.1111/j.1758-5872.2012.00212.x

AbstractA review of the Western mental health scales that have been utilized inNepal was conducted. Academic search engines (PubMed, MEDLINE, Psy-chLIT, Social Sciences Citation Index, and Anthropology Plus) weresearched using relevant terms for the years 1990–2011. Search resultsindicated a limited number of mental health scales had been used and/ordeveloped in Nepal with mixed emphasis on reliability and validity, as wellas cultural considerations. These scales, methods and limitations are dis-cussed within the cultural and social background of Nepal.

Introduction

Nepal is a landlocked country measuring 885 km longby 193 km wide that is bordered by China and India.The capital city is Kathmandu and the national lan-guage is Nepali. The population in 2008 was approxi-mately 29 million including a significant population ofBhutanese (107,000) and Tibetan (20,100) refugees. Itis considered one of the poorest and most underdevel-oped countries in the world, with high rates of illiteracy(48%), unemployment (46%), and poverty (25%).

From 1996 to 2006, the country underwent 10years of violent civil conflict between Maoist rebelsand Nepali government forces. Issues such as genderinequality, caste/ethnic inequality, government cor-ruption, economic stagnation and violent governmentsuppression of dissidents have been cited as motivat-ing factors of the fighting (Tol et al., 2010). Civilianscaught in the fighting were subjected to human rightsviolations by both government and rebel forces,including torture, disappearance and execution (Singh

et al., 2005), while children endured specific traumas,including conscription as child soldiers, witnessing ofdeath and humiliation of adult figures, and indoctri-nation by Maoists (Singh, 2004; Singh et al., 2006;Pettigrew, 2007).

The already limited mental healthcare system ofNepal was further damaged by Maoist bombings ofhealth facilities and raids on pharmacies for medi-cal suppliers, and the imprisonment of healthcareworkers by the government for those who aided therebels. The result was a displacement of healthcareworkers from rural to urban areas (Tol et al., 2010).The civil war not only directly damaged mental healthinfrastructure, but also increased the psychologicaldistress of the population through death and displace-ment (Thapa and Hauff, 2005). By the time a peaceaccord was reached in 2006 there was an estimated15,000 killings, and there is an estimated 50,000 to70,000 people who remain internally displaced withinthe country (United States Central IntelligenceAgency The World Factbook, 2011).

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Offi cial journal of thePacifi c Rim College of Psychiatrists

Asia-Pacific Psychiatry ISSN 1758-5864

1Copyright © 2012 Blackwell Publishing Asia Pty Ltd

Current mental healthcare systemin Nepal

The Nepali National Mental Health Policy was draftedin 1996 with the goals of ensuring access to mentalhealth, training mental health workers, protecting therights of the mentally ill and increasing awarenessof mental health in the country. Today, the countrycontinues to struggle with manpower and funding.According to the 2006 WHO-AIMS Report on mentalhealth in Nepal, less than 1% of the health budget(0.17%) was devoted to mental health in 2006. Therewere 32 psychiatrists in the entire country, 68 psy-chiatric nurses, six psychologists, no occupationaltherapists and no social workers (Wold Health Orga-nization, 2006). There was one psychiatric hospitalwith the majority of psychiatric patients being seen ineither the 18 community outpatient centers or the 17community inpatient centers with only 20% of thesefacilities located in rural areas (Wold Health Organi-zation, 2006).

Community mental health services are availablein only seven of 75 districts and these were largelycreated by non-governmental organizations workingin these districts (Wold Health Organization, 2006).There is currently no social insurance scheme toprovide medical coverage. Patients are required to payfor treatment and medications out of pocket. There isno mental health legislation to protect the rights ofpatients with a mental disorder. Epidemiological dataabout most mental disorders is limited to non-existent(Tol et al., 2010). Furthermore, there remains consid-erable stigma and ignorance surrounding mentalillness in Nepal adding to the distress and mistreat-ment of the mentally ill (Kohrt and Hruschka, 2010).The WHO-AIMS report suggests that the lack offunding and human resources in mental health willrequire training of all healthcare workers in mentalhealth issues and integration of mental healthcare intothe existing healthcare framework.

Methods

The following electronic databases were searched fordata on Western psychiatric scales used in Nepal:PubMed, MEDLINE, PsychLIT, Social Sciences Cita-tions Index, Anthropology Plus by online accessthrough the University of British Columbia Libraryusing the following terms: psychiatry, Nepal, mentalhealth, mental illness (including major Diagnostic andStatistical Manual of Mental Disorders (DSM) Axis Iand II categories), psychiatric scale, South East Asia.

The period of the search was 1990–2011. Two review-ers extracted study characteristics, quality, and theoutcomes of interest. The following paragraphs willpresent a general overview of the results of that searchincluding scales used, relevant studies, as well as adetailed explanation, including statistical data, pre-sented in Table 1.

Psychiatric scales used in Nepal

Kohrt et al. (2002, 2003) performed studies to validatethe Beck Depression Inventory (BDI) and the BeckAnxiety Inventory (BAI). In these two studies, theBeck inventories were translated into Nepali andadministered by an interviewer to subjects with for-mally diagnosed anxiety and/or depression as well ashealthy individuals in outpatient and inpatient set-tings. The researchers concluded that BDI and BAIwere reasonably sensitive and specific for detectinganxiety and depression with good internal reliability.However, some cultural considerations arose out oftheir studies. The researches noted that a few items onthe BAI and BDI tended to have poor inter-item cor-relation and decreased specificity in the Nepali popu-lations surveyed (e.g. BAI items: “feeling faint”, “faceflushed”, “sweating”, and “fear of losing control”; BDIitems: “being punished” and “decreased libido”.).

The researcher suggested that inadequate transla-tion or cultural factors may have played a role in thisdiscrepancy. In both cases, gastrointestinal complaintscould not help to distinguish between the ill and non-ill subjects. For example “indigestion” could not dis-tinguish non-anxious from anxious and “decreasedappetite” and “weight loss” could not distinguishdepressed from non-depressed. The researchers sug-gested that the high burden of illness such as gas-trointestinal parasites might interfere with thespecificity of gastrointestinal symptoms to predictdepression.

Eller and Mahat (2003) used the Perceived StressScale (PSS), Ways of Coping Questionnaire (WOC),Center for Epidemiological Study Depression Scale(CES-D) and Symptoms Checklist 90 Anxiety Subscale(SCL-90-R) for measuring the perceived distress,coping mechanisms and anxiety symptoms in Nepalifemale former commercial sex workers with HIV. Theresearchers translated the scales into Nepali and thenemployed a research assistant to administer the scales.

Tausig et al. (2003) created a novel instrumentbased on a modified version of the DSM III symptomchecklist. They translated the individual checklistitems into Nepali in the categories of somatization,

Psychiatric scales in Nepal P. Chen et al.

2 Copyright © 2012 Blackwell Publishing Asia Pty Ltd

Tab

le1.

Psy

chia

tric

scal

esus

edin

adul

tp

opul

atio

nsin

Nep

al

Pap

erSc

ale(

s)va

lidat

edSt

udy

met

hod

sSc

ale

valid

ityre

sults

Kohr

tet

al.,

2002

Bec

kD

epre

ssio

nIn

vent

ory

(BD

I)V

alid

atio

nst

udy

ofB

DIf

ord

iagn

osis

ofan

xiet

y.C

omp

ared

BD

Isco

res

toes

tab

lishe

d

dia

gnos

isof

gene

rala

nxie

tyd

isor

der

acco

rdin

gto

DSM

-IVcr

iteri

a.Em

plo

yed

four

pop

ulat

ions

:(1)

anou

tpat

ient

clin

ical

pop

ulat

ion

from

Trib

huva

nU

nive

rsity

Teac

hing

Hos

pita

lin

Mah

araj

gunj

(TU

TH)n

=47

;(2)

aco

mm

unity

sam

ple

with

psy

chia

tric

illne

ssfr

omth

ed

istr

ict

head

qua

rter

sin

Jum

lan

=31

6;(3

)aco

mm

unity

sam

ple

with

nop

sych

iatr

icill

ness

from

the

dis

tric

the

adq

uart

ers

inJu

mla

=93

;and

(4)a

com

mun

itysa

mp

lefr

omJu

mla

that

did

not

rece

ive

psy

chia

tric

dia

gnos

es.

Spec

ifici

tyof

0.86

and

sens

itivi

tyof

0.85

ofth

eB

DIw

as

obta

ined

whe

nco

mp

ared

agai

nst

DSM

-IVes

tab

lishe

d

dia

gnos

is.

Alp

hasc

ore

was

0.88

.Ind

ivid

ualf

acto

rco

rrel

atio

nsar

e

des

crib

edin

det

ail.

Kohr

tet

al.,

2003

Bec

kA

nxie

tyIn

vent

ory

(BA

I)V

alid

atio

nst

udy

ofB

AIf

ord

iagn

osis

ofan

xiet

y.C

omp

ared

BA

Isco

res

toes

tab

lishe

d

dia

gnos

isof

gene

rala

nxie

tyd

isor

der

acco

rdin

gto

DSM

-IVcr

iteri

a.Em

plo

yed

four

pop

ulat

ions

:(1)

anou

tpat

ient

clin

ical

pop

ulat

ion

from

Trib

huva

nU

nive

rsity

Teac

hing

Hos

pita

lin

Mah

araj

gunj

(TU

TH)n

=47

;(2)

aco

mm

unity

sam

ple

with

psy

chia

tric

illne

ssfr

omth

ed

istr

ict

head

qua

rter

sin

Jum

lan

=31

6;(3

)aco

mm

unity

sam

ple

with

nop

sych

iatr

icill

ness

from

the

dis

tric

the

adq

uart

ers

inJu

mla

=93

;and

(4)a

com

mun

itysa

mp

lefr

omJu

mla

that

did

not

rece

ive

psy

chia

tric

dia

gnos

es

Spec

ifici

tyof

0.89

and

sens

itivi

tyof

0.90

ofth

eB

AIw

as

obta

ined

whe

nco

mp

ared

agai

nst

DSM

-IVes

tab

lishe

d

dia

gnos

is.

Alp

hasc

ore

was

Rel

iab

ility

was

0.89

.

Elle

ran

d

Mah

at,

2003

Perc

eive

dSt

ress

Scal

e(P

SS)

Scal

esad

min

iste

red

to98

Nep

alif

orm

erco

mm

erci

alse

xw

orke

rsw

ithH

IVre

ferr

edb

y

anN

GO

inN

epal

.Con

stru

ctva

lidity

for

the

PSS

was

calc

ulat

edth

roug

hco

rrel

atio

ns

agai

nst

the

two

sub

scal

esof

the

WO

C.C

onst

ruct

valid

ityfo

rth

eC

ES-D

was

calc

ulat

edus

ing

corr

elat

ions

bet

wee

ntw

osu

bsc

ales

ofth

eSF

-36

ina

sam

ple

of79

HIV

-pos

itive

wom

enin

the

USA

.Con

stru

ctva

lidity

for

the

SCL-

90-R

was

agai

n

calc

ulat

edth

roug

hco

rrel

atio

nsb

etw

een

sub

scal

esof

the

SF-3

6.

PSS

rece

ived

aco

effic

ient

alp

hare

liab

ility

of0.

72.

Way

sof

Cop

ing

Que

stio

nnai

re(W

OC

)

Cen

ter

for

Epid

emio

logi

ctu

die

s

Dep

ress

ion

Scal

e(C

ES-D

)

Sym

pto

ms

Che

cklis

t-90

Anx

iety

Sub

scal

e(S

CL-

90-R

)

Res

earc

hers

form

ulat

edtw

o-d

imen

sion

alsu

bsc

ales

of

the

WO

Cto

get

relia

bili

tyco

effic

ient

sof

0.78

and

0.69

.Con

stru

ctva

lidity

scor

esof

(R=

0.32

,P<

0.00

1;

and

r=

0.42

,P<

0.00

0).

The

CES

-Dre

ceiv

edC

ronb

ach’

sal

pha

scor

esof

0.83

.

Con

stru

ctva

lidity

scor

esw

ere

r=

0.42

and

r=

0.80

.

The

SCL-

90-R

rece

ived

anal

pha

relia

bili

tyco

effic

ient

of

0.88

.Con

stru

ctva

lidity

scor

esof

r=

0.65

and

r=

0.51

.

Taus

iget

al.,

2003

DSM

-IIIc

heck

list

Cen

ter

for

Epid

emio

logi

cSt

udie

s

Dep

ress

ion

Scal

e(C

ES-D

)

Ran

dom

sam

ple

of65

3p

eop

lein

Jirel

adm

inis

tere

dtr

ansl

ated

item

sfr

omth

eD

SM-II

I

sym

pto

mch

eckl

ist

inse

lect

edca

tego

ries

.CES

-Dw

asal

soad

min

iste

red

toes

tab

lish

conv

erge

ntva

lidity

inre

gard

sto

the

dep

ress

ion

por

tion

ofth

eD

SM-II

Iche

cklis

t.

Pre

vale

nce

rate

sof

men

tald

isor

der

sas

mea

sure

by

the

tran

slat

edch

eckl

ist

wer

e

com

par

edw

ithep

idem

iolo

gica

ldat

afr

omth

eU

SA.

Alp

hava

lues

for

the

DSM

-IIIc

heck

list

cate

gori

esw

ere:

•So

mat

izat

ion:

0.65

37

•A

nxie

ty:0

.980

3

•D

epre

ssio

n:0.

9248

•M

ania

:0.5

947

•Sc

hizo

phr

enia

:0.4

514

•A

ntis

ocia

lper

sona

lity

dis

ord

er:0

.615

4

The

zero

ord

erco

rrel

atio

nb

etw

een

the

DSM

-IIIc

heck

list

and

the

CES

-Dw

as0.

485.

Thap

aet

al.,

2003

Com

pos

iteIn

tern

atio

nal

Dia

gnos

ticIn

terv

iew

(CID

I)

Cro

ss-s

ectio

nals

urve

yof

418

tort

ured

and

392

non-

tort

ured

Bhu

tane

sere

fuge

es.T

he

CID

I,ve

rsio

n2.

1,an

dth

eW

HO

DA

Sw

ere

used

tom

easu

reIC

D-1

0p

sych

iatr

ic

dis

ord

ers

and

dis

abili

ty.

Inth

eW

HO

DA

S,d

isab

ility

mea

sure

men

tsof

diff

eren

t

dom

ains

ofd

isab

ility

had

anin

trac

lass

corr

elat

ion

coef

ficie

ntof

0.86

(CI0

.83–

0.87

).W

orld

Hea

lthO

rgan

izat

ion

Shor

t

Dis

abili

tyA

sses

smen

tSc

hed

ule

(WH

OD

AS)

Thap

aan

d

Hau

ff,

2005

Hop

kins

Sym

pto

mC

heck

list-

25(H

SCL-

25)

Post

-Tra

umat

icSt

ress

Dis

ord

erC

heck

list:

Civ

ilian

Ver

sion

(PC

L-C

)

Cro

ss-s

ectio

nals

urve

yof

290

inte

rnal

lyd

isp

lace

dp

erso

nsin

the

mid

stof

the

Nep

ali

civi

lwar

.Con

duc

ted

inKa

tman

du,

Bak

e,B

ard

iya,

Surk

het,

Dan

g,Ka

ilali

and

Ruk

um

dis

tric

ts.U

sed

HSC

L-25

toas

sess

for

anxi

ety

and

dep

ress

ion

sym

pto

ms

and

the

PC

L-C

toas

sess

for

PTS

Dsy

mp

tom

s.Se

nsiti

vity

and

spec

ifici

tyw

ere

esta

blis

hed

agai

nst

the

CID

Iad

min

iste

red

toa

rand

omsu

bsa

mp

le(n

=25

).

The

HSC

Lan

xiet

ysu

bsc

ale

rece

ived

aC

ronb

ach

scor

eof

0.89

.Sen

sitiv

ityan

dsp

ecifi

city

asw

ere

0.77

and

0.58

.

The

HSC

Ld

epre

ssio

nsu

bsc

ale

rece

ived

aC

ronb

ach

scor

eof

0.89

.Sen

sitiv

ityan

dsp

ecifi

city

wer

e0.

87an

d

0.60

,res

pec

tivel

y.

The

PC

L-C

rece

ived

aC

ronb

ach

scor

eof

0.90

.Sen

sitiv

ity

and

spec

ifici

tyw

as0.

80an

d0.

80,r

esp

ectiv

ely.

DSM

-III,

Dia

gnos

tican

dSt

atis

tical

Man

ualo

fMen

talD

isor

der

s,3rd

Editi

on;H

IV,h

uman

imm

unod

efic

ienc

yvi

rus;

ICD

-10,

Inte

rnat

iona

lSta

tistic

alC

lass

ifica

tion

ofD

isea

ses

and

Rel

ated

Hea

lthP

rob

lem

s,

10th

Rev

isio

n;N

GO

,non

-gov

ernm

enta

lorg

aniz

atio

n.

P. Chen et al. Psychiatric scales in Nepal


anxiety, depression, mania, schizophrenia and antiso-cial personality disorder and administered these ques-tions door-to-door to a random sample of 653 peoplein Jirel, Nepal (van Ommeren et al., 2000b). Interest-ingly, they did not include checklist items for post-traumatic stress disorder. They attempted to replicatethe decision tree that exists in the Composite Diagnos-tic International Diagnostic Interview (CIDI) by incor-porating “simple screening questions” into theirsurvey. For example, an interviewer was permitted toskip the anxiety checklist if a respondent answerednegatively to the question “have you ever beenanxious and worried about something in your life formore than six months during which time you feltbothered by these feelings of anxiety most of thetime?”

The researchers based construct validity on com-parisons of their prevalence data based on the DSM IIIchecklist survey with epidemiological data from theUSA. They quoted convergence validity based on com-parison of the DSM III depression checklist withresults obtained from administration of the CES-D.They also calculated alpha values for each of the cat-egories from the DSM III checklist. They concludedthat their prevalence data was similar to US epidemio-logical data. They found that internal validity wasexcellent for the categories of depression and anxiety,but was poor for the categories of somatization,mania, schizophrenia and antisocial personality disor-der. The researchers noted that their checklist admin-istered in Nepal could not distinguish mania fromschizophrenia but questioned whether this could bedone in any country. They also noted that their samplesize for confirmed antisocial personality disorder wastoo small to quote reliable data.

Thapa et al. translated components of the CIDIwith the aid of a “translation monitoring form” (vanOmmeren et al., 2000a) for the purpose of assessingpsychiatric disability in Bhutanese refugees. The CIDIwas considered a gold standard for diagnosis. Inter-viewers consisting of physicians and undergraduatestudents administered translated components of theCIDI as well as the World Health Organization ShortDisability Assessment Schedule (WHODAS). Femaleinterviewers were assigned to female subjects to com-pensate for anticipated reluctance to answer questionsabout sexual function.

Thapa and Hauff (2005) administered a survey toinvestigate traumatic experiences and psychologicaldistress in a cross-section of internally displaced localNepali. Interestingly the survey included local illnessesof dherai pir/chinta lageko (feeling very anxious andtense), dherai dukha lageko (feeling severe grief), and

dukha lagne ghatanako gahiro chap baseko (having deepand long-lasting impression of the terrifying event)which were correlated to positive screening throughthe HSCL-25 and PCl-C. The survey results were vali-dated the Hopkins Symptom Checklist 25 (HSCL-25)and the Post-Traumatic Stress Disorder Checklist Civil-ian Version (PCL-C). The HSCL-25 and PCL-C werealso validated against diagnoses obtained from CIDIderived diagnoses. Cultural taboo regarding discussingsexual symptoms caused the researchers to omit aquestion on the HSCL about sexual symptoms.

Discussion

The mental health system in Nepal continues to sufferfrom a lack of funding and human resources (WHO-AIMS) report. Culturally adapted and validated psy-chometric instruments will be essential to performingthe research and gathering the prevalence dataneeded to begin improving this situation (Kohrt et al.,2011). Furthermore the limited number of mentalhealth professionals in the country will likely requirethat such instruments be geared toward primary carephysicians and paramedical staff such as nurses (Kohrtet al., 2011). With this consideration in mind, broadlyapplicable psychometric scales would ideally be simpleand structured (Kohrt et al., 2011). It is apparent thatthere are a few possible approaches for introducing aculturally valid and comprehensive psychiatric instru-ment for Nepal.

One approach would be to adapt a comprehensivescale already validated in other countries for use inNepal. According to the Handbook of Psychiatric Mea-sures (2008) there are six published tools that aremeant to screen or diagnose a relatively comprehen-sive range of psychiatric illnesses. The Schedules forClinical Assessment in Neuropsychiatry (SCAN) is setof instruments developed by WHO that is meant tomeasure and diagnose psychiatric illness according tothe ICD-10. It takes two hours or more to administerand is meant to be administered by well-trained indi-viduals. Extensive study of the tool is required for anefficient SCAN interview. Interpretation of the tool isonerous without automated computer data entry. TheSCAN is, however, described as a toolbox withmodules that can be selected depending on the illnessof interest. It has been translated into 13 languages notincluding Nepali.

The Composite International Diagnostic Interviewand its predecessor the Diagnostic Interview Schedule(DIS) are highly structured interviews administered byexact reading of question sets that are meant to yield



diagnoses based on both the ICD-10 and DSM-IV. TheCIDI and the DIS require three and four days of train-ing, respectively and take an average of two hours toadminister. As discussed, Thapa et al. performed a vali-dation study of the CIDI in Nepal and Thapa and Hauff(2005) used this Nepali version of the CIDI in theirstudy as discussed previously.

Compared to the CIDI/DIS, the Mini InternationalNeuropsychiatric Interview (MINI) is a much shorterstructured diagnostic interview taking approximately15 minutes to administer. It is meant to yield diag-noses according to the DSM-IV and ICD-10 criteriaand to be a tool for tracking outcomes in clinical prac-tice. There also exists a child version of the instru-ment: the MINI Kid. The MINI contains 19 sectionsmeant to evaluate the 17 most common Axis I disor-ders with the MINI Plus covering an additional eightdisorders. The modules consist of closed-ended,yes/no questions. The MINI is intended for “profes-sional interviewers”, including non-physicians. Train-ing requires two hours for psychiatrists andpsychologists and three hours for general practitionerswith laypersons requiring more training time. TheMINI has been translated into 40 languages and hasbeen used in a research study in Nepal (Bales et al.,2009).

The Psychiatric Diagnostic Screening Question-naire (PDSQ) and Patient Health Questionnaire (PHQ)represent short self-administered questionnaires to befilled out by patients prior to clinic visits to screen forcommon psychiatric illnesses. The PDSQ covers mostof the common Axis I disorders whereas the PHQ isuseful mainly for anxiety, depression and somatic typedisorders. Neither tools are meant to be diagnostic andrequire physician follow-up to confirm diagnoses(Rush et al., 2008).

Another approach to formulating a comprehen-sive psychiatric instrument specific for Nepal would beto combine illness-specific tools that have been vali-dated in Nepal. Toward that end, a limited number ofpsychiatric instruments have been validated so far.Many of the studies validating these tools have beendiscussed in this paper. Mostly, these studies havefocused on tools that measure and screen for anxi-ety, depression and post-traumatic stress disordersymptoms.

The most time and resource consuming approachto developing a comprehensive psychiatric instrumentfor Nepal would be to develop a novel instrument.One study did not go quite this far but instead used theDSM-III checklist of symptoms directly as a screeningtool as described above (Tausig et al., 2003). This studydid not employ an expert panel to confirm the validity

of their translation. Internal validity of this version ofthe checklist questions was poor for the categories ofmania, schizophrenia, somatization disorder and anti-social personality disorder and good only for the cat-egories of anxiety and depression. The researchers didnot screen for post-traumatic stress in their study.Other than this study, there do not appear to havebeen any attempts to create a novel psychiatric screen-ing tool specifically for Nepal.

Conclusion

Whatever the approach to be applied, there are spe-cific cultural considerations that will likely need to bekept in mind when producing a psychiatric instrumentthat is valid, reliable and applicable for the Nepalipopulation as identified in some of the studies dis-cussed in this paper. For example, Kohrt et al. (2003)suggested that the high burden of gastrointestinaldisease (such as parasites) in Nepal reduced the speci-ficity of some gastrointestinal symptom-based screen-ing questions in the BAI. Cultural illnesses need to beweighed against ICD-10 and DSM-IV diagnoses asKohrt et al. (2002, 2003) found while attempting tovalidate the BDI and BAI for Nepal. Sexual taboos inNepal may require care when eliciting sexual symp-toms. For this consideration, Thapa et al. (2003) speci-fied female interviewers for female patients and maleinterviewers for male patients and Thapa and Hauff(2005) removed some sexually oriented questionsfrom their Nepali version of the HSCL. Increasedsomatization in the Nepali population has beendescribed and may affect the typical presentation ofpsychiatric symptoms (Kohrt and Hruschka, 2010).The low rates of literacy in Nepal (United StatesCentral Intelligence Agency The World Factbook,2011) may also limit the utility of self-administeredtools such as the PDSQ and the PHQ. There alsoappears to be pervasive and extensive stigma aroundmental illness in Nepal (Kohrt and Harper, 2008;Kohrt and Hruschka, 2010), which must be consid-ered in all aspects of developing a psychiatric tool fromtranslation/development of questions to actual admin-istration of the tool. Other cultural issues that mayneed to be considered include issues of caste inequal-ity, gender inequality and translation issues.

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