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Screening for the psychological consequences of a major disaster in a developing country

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Title:
Screening for the psychological consequences of a major disaster in a developing country
Series Title:
Quick response research report ;
Physical Description:
p. 561-567 : ; 28 cm.
Language:
English
Creator:
Lima, Bruno R
University of Colorado, Boulder -- Natural Hazards Research and Applications Information Center
Publisher:
Natural Hazards Research and Applications Center, University of Colorado
Place of Publication:
Boulder, Colo
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Subjects

Subjects / Keywords:
Disaster victims -- Psychological testing -- Colombia -- Armero   ( lcsh )
Volcanic eruptions -- Psychological aspects -- Colombia -- Armero   ( lcsh )
Disaster relief -- Psychological aspects   ( lcsh )
Genre:
government publication (state, provincial, terriorial, dependent)   ( marcgt )
bibliography   ( marcgt )
non-fiction   ( marcgt )

Notes

Bibliography:
Includes bibliographical references (p. 566-567).
Statement of Responsibility:
Bruno Lima, et al.
General Note:
Reprint. Originally published in: Acta psychiatrica scandinavica, v. 76, 1987, p. 561-567.

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Resource Identifier:
aleph - 001971514
oclc - 277052401
usfldc doi - F57-00003
usfldc handle - f57.3
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SFS0001084:00001


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Screening for the psychological consequences of a major disaster in a developing country
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1987.
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Natural Hazards Research and Applications Information Center CampusBox482UniversityofColorado Boulder, Colorado 80309-0482 SCREENINGFORTHEPSYCHOLOGICALCONSEQUENCESOFAMAJORDISASTERINADEVELOPINGCOUNTRYBrunoLimaetal1987QuickResponse Research Report#14This ublication is partofthe Natural Hazards &Applications Information Center's ongoing Quick Response Research Report Senes. http://\NWIN.colorado.edu/hazards InstituteofBehavioralScience#6 (303)492-6818

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Acta psychiatr.scand.1987:76:561-567Keywords: primary health care; mental heallh; disasters.Screening for the psychological consequencesofa major disaster in a developing country:Armero,Colombia... B.R.Lima',S.Pal',H.Santacruz2 ,J. Lozan02and J.Luna3 'DepartmentofPsychiatry, (Head: Paul McHugh), Johns Hopkins, University Baltimore, Maryland,U.S.A.'DepartmentofPsychiatry, UniversityofJaveriana, Bogota, Columbia and3HeaUhDepartment, StateofTolima,Columbia ABSfRACf Seven months following the volcaniceruptionthat destroyed the small town .ofArmero.200 victims were screened for emotional problems with theSelf-ReponingQuestionnaire. a simple and reliable instrument. Fifty-five percentofthe victims were found to be emotionally distressed. Variables associated with the presenceofemotional distress included living alone. having lost previous job, feeling not being helped,notknowing date for leaving temporary shelter, being dissatisfied with living arrangements, complainingofnon-specific ph)'sical symptoms or epigastric pain,andpresenting several physical problems.Thehigh prevalenceofemotional distresssupponsthe need to deliver mental care to diyster victimsindeveloping countries through the primary levelofcare.Ourfindings provide guidelines for earl)' detectionofindividuals at risk for developing emotional problems. March 24,1987,. acuplcdlor May1,1987Disasters are relatively common occurrences,buttheir impact on the psychiatric and psychosocial stateofvictimsisstill controversial. Some studies have suggested littleorno negative effects(1-4),while some others have suggested significant conse quences(5-15)which include long-term effectsonvictims(16)and effects specifictochildren(17,18).Thecontroversial findings may be due to the differ encesinassessing certain characteristicsofthe dis aster, such as the seriousnessandlevelofthe im pact, the speedofonset, the durationofthe disaster and the social preparednessofthe communitytohandle such a disaster(19),Also the variations in the research methods utilized by different research groups, such as sampling process, criteria for case identification and timingofthe study, may account for someofthe differences noted in outcomestudiesofdisaster mental health(20).36Indeveloping countries, disasters represent a significant public health problem. Excluding disas ters in the United States, in thiscenturythere were2,392disastersintheworld, but86.4%occurred in developing nations, producing a totalof42million deaths and1.4billion affected individuals. Seventy eight percentofall deaths occurred in developing countries, where97.5%ofall affected individuals are located. The observed ratio between affectedandkilled,ofonly2.9for the developed nations,istenfold greater for developing countries(21).Hence, not only are disasters disproportionately more frequent events in the Third World,butthey are also responsible for a much higher proportionofvictims who, having survivedtheimpact, need long-term managementoftheir biopsychosocial needs. Moreover, this situationislikelytoprove worse, as the fast riseinthe populationsofsome

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562B.R.LIMAETAL.cities, the pressure on the land and the steadily de teriorating economic conditionsofdeveloping nations have forced the underprivileged population into more hazardous areas, thus rendering them more pronetobe disaster victims(22). In developing countries, the deliveryofmental health servicesisbest achieved through the appro priate utilizationofthe primary health care worker(23)who usuallyisa person \\ith limited education and training, selected by the local community,orwith the community's agreement, to perform basic health actions (24). Not only does the scarcityofmental health resources prevent that specialty care be delivered to the large number of patients who have emotional disorders (25), but itisactually felt that, by integrating the biological, psychological and social aspectsofthe patients' health problems, and by being able to utilize the available community resources more effectively. the primary care workerisinthe best postion to delivermore effective com prehensive helath care to larger numbersofpatients (26). Various studies have shown that the primary <:Bre worker can be trainedinthese specific mental health tasks (27).Inthe aftermathofa disaster,itisexpected that similar training results can be accom plished, but it has been difficult to establish theappropriate priority for mental health care delivery at the primary levelofcare. Given the competing general health delivery needs, the psychological consequencesofdisastersindeveloping countries have been the subjectof few studies, although preli minary observations (28) and empirical evidence(29,30)indicate that they may be significant and in needofgreater attention. Thereforeitneeds tobeestablished clearly that the frequency, severity and typesofmental health problems of victimsinthe community are significant, not onlyinthe immedi ate aftermathofthe tragedy, but alsointhe medi umand 10ng-tel'!'11 range. This initial report describes the mental health consequencesofa total disasterina developing country. It attempts to assess the prevalence rateofemotional disorders among victims locatedintentsandsheltersinthe disaster area.Italso attempts to identify specific personal or environmental factors associated with an increasedriskfor developing emotional disorders so that early identificationofvulnerable victims can be made for the implemen tationofeffective mental health interventions. Subsequent reports will address the frequencyofmen tal health problems seeninprimary care clinics in the disaster area, and the primary care worker's capabilitytocorrectly identify persons who present emotional difficulties. The ultimate goalofthe pro jectisto develop and evaluate a focussed training program in disaster mental health for the primary care worker. concentl"llting on the more frequent and more significant psychosocial problemsofvic tims. and increasing the efficiency and responsive nessofthe health care system to the varied health and mental health needsofdisaster victims.MethodsSeven months after a volcanic eruption which de stroyed the small town of Armero,inColombia (31), an assesssmentofthe emotional and psychia tric problemsofthe survivors was carried out to as certain the prevalenceofthese conditions and the relevant variables associated with their develop ment. Two hundred survivors over age18constituted the sample for the present study. drawn from two shelters and two camps of the disaster area.Thescreening was donebymental health professionals localtothe disaster and included two psychologists, a psychiatric nurse, and a psychiatric occupational ,therapist.The interviews were conducted ip the shelters and camps during a2 month period. Victims were approached by the interviewer and invited to participateinthe study. No subject refusedtobe in terviewed. Actually, they seemed to welcome the opportunity to go over the traumatic experience and to ventilate their feelings, often times extending the interview over the anticipated periodof30min utes. We were not able to collect data on a control group. The difficulties prescntincarryingouta dis aster studyina developing country are formidable, and focussing the health care workers' effortsincol lecting research data already distracts them from pressing service delivery issues. The populationinsurrounding communities, although not directly af fected by the volcanic eruption, had become so in volved with the disaster that they could notbeseenasa control group. To screen a community sample

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ina geographically different area was simply not feasible. Data were collectedonthe victims' socio-demo graphic characteristics, their disaster experience, the emergency shelter environment and socialsupports available, and their reported physicalandemotional complaints.Anextensive screening questionnaire was prepared to include anumberofquestions covering the above areas.Italso included a modified versionofthe Self-Reporting Question naire(SRQ)which has been usedinseveral studies to identify individuals with emotional problems (32-34). Similar tootherscreening instruments for emotional problems, theSRQindicates that an in dividual who scores positivelyislikely tobea Mcase ", although the specific natureofthe disturb ance cannot be determined. Drawing fromourex perienceinutilizing theSRQina developing coun try (35), questions regarding epilepsy and alcohol abuse were added to the questions on neuroticandpsychotic symptoms, as they represent significant problems for primary mental health care. Victims were identifiedbytheSRQas suffering from emo tional distress if they had a positive scoreofeightormore on the 20-item neurotic subscale,ora scoreofoneormore on the 4-item psychotic subscale,ora scoreofone on either the question on epilepsyoralcoholism..Based on their scores on the SRQ, the total sampleof200 individuals was divided into two groups: those who scored positively as per the crite ria given above and those who scored negatively. The data regarding their socio-demographic char acteristics, their experienceofthe disaster, their emergency shelter environment andtheir reported physical and emotional problems were then com pared for those two groups to identify significant associations with the levelofemotional distress as measured bythe SRQ. Significanceofany such noted differences was testedbythe Xl test with Yates correction when appropriate.ResultsThefindingsofthe analysis are given in Tables 1 through 3. As can be seeninTable I, a little over halfofthe sample were males, with 70% being underage 45. Fifty seven percent were either legally married orhad a common-law marriage; onefifth36"DISASTER MENTAL HEALTH563 were single.Halfofthe sample had elementary education, butonethird were illiterate. All except two subjects either were employedorwere house wivesorstudents. All subjects wereofa mixed ra cial composition. The overall prevalenceofemotionalandpsychi atric problems was 56%. Asseen in Table 2, the most frequently reported symptoms in the neurotic subscale were feeling nervous, tenseorworried, be ing easily frightened and having headaches. How ever, the acknowledgementofthe presenceofanyofthe twenty symptoms in the neurotic subscaleoftheSRQwas significantly associated \\ith a positiveSRQscore.Thestrongest predictorsofSRQposi tivity were the symptomsoffeeling unable toplayauseful part in life, feeling tired all the time, and hav ing problemsinthinking clearly.Themost frequent psychotic symptoms were thoughts that someone was trying to harmhim/herin some wayorhearing voices without knowing where theycamefromorwhichotherpeople could not hear.Tahle I Demographic dimibulionofvictims(II-200)II "10SuMale 105 52 Female 95 48 A,Ilt 18-4414070 4322 65 +278 Mean 37.6:1:16.3 M'lrilolslOIUS Single .. 322Married 25 12Common-law90 45 Separated 15 8Widowed2714EducOliollNone61301 -5 109 54 6+30 ISOuupt2llo11 None2I Housewife65 32Unskilled worker58 29Skilled worker2211Olher 53 26

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564B.R.LIMA ET AL. 2Distribution of neurotic symptomsof the SRQ by results ofthe SRQSRQ Negltlve Posilive Total "/0"/0 Doyouof len have headaches? 1123169Isyour appetite poor?8S2476Doyou steep badly?1143070 Are you elSily frightened? 1173367Doyour hands shake?72IS8S Do you feel nervous. tense or worried? 1633763Isyour digestion poor?431981Doyou have trouble thinking clearly? 34991Do youfcll 6H2484Do you cry more than usual? 45 1883Do you liind it difficult10en-joy your daily activities?73II89Doyou find it difficult to make decisions?682476Isyour daily work suffering?631387 Are you unable to playa useful pariinlife?31100 Have you10Slintere51 in things?7017 83Do you feel thaI you are a won hie ..person? 441486 HI' the thought of ending your life been inyour mind?34IS8SDo you fceltired aUthe lime?42595Do you havc uncomforlable feonal"ariablos% % Age11I:44 49St45-643763 NS 6S+ 29 71Education None 38621-5 4S SS NS 6+5743 living Iione1783 <.02Duosrt'up"itncc Seen horrible things 45 S5 NS losingIn)' flmil)' member44 S6 NSUnlwlre of impendingdlnger42 S8 NS Notha'in!contingency plans4555NS Having been injured3763NSNot recovered from injuries2476NSN,ot been ofhelp to olhers 4654NS En";ronmcnral "ariablrslost prc"iousjob 75<.003Not being helped now 3367 <004Not knowing dale for leaving 3763<.02Dissatisfied wilh arrangements 4060<.01 RCfX'''td physical p'ob/cwu pain892<.006Non-specific sl'mrtnms 2872<.OS Number of physical complainlS None5S 45I4060 24060<.0231486Rtpo"tdtmo/ionalprobltnu Depression 3862<.02Psychosomatic prOblems100<.002. Interpersonal problems3070<.03

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the temporary housingandbeing dissastisfied with living arrangements. Certain reported physical pro blems weresignificantly relatedtoa positiveSRQscore, particularly complaintsofepigastric pain, non-specific symptomsandincreasing numberofphysical complaints. Patients who complainedofemotional distress, such as depression, psychoso matic problemsorinterpersonal difficulties, were also significantly more likely to score positively on theSRQ.DiscussionTheinterpretationofthese findingsislimited by the characteristicsofthe sampleandthe instrument used.Thesample screenedisnot representativeofall the survivors, as the research subjects are drawn from the lower socio-economic stratum. Havingnoother resources for alternative housing, they were forced to remain in the sheltersofthe disaster area. However, this populationisthe main target for the deliveryofprimary mental health careinroutine clinical settings in developingcountries. A positiveSRQscore indicates a probable "psy chiatric the validating case-identification resting on a psychiatric interview. However, theSRQhas been used as a screening instrument for emotional problems in various clinical settings andcommunity-based studies with adequate sensitivity and specificity (34).ThevalidityoftheSRQfor this populationisfurther supported by the fact that victims who complainedofhaving emotional, psy chosomaticorinterpersonal problems were signifi cantly more likely to have a positive score.Itshould also be noted thatwedo not have a control population to see whether the56%preval ence rate for emotional problemsnoted.inoursample differs from the levelsofemotional distressofthe general non-affected population. However, theSRQwas usedintheWHOCollaborative Study on "Strategies for Extending Mental Helath indeveloping countries which was carried out in seven centers, including Colombia (36). This study produced prevalence ratesofemotional problems in primary health care clinics rather than in commu nities, butitseems reasonable to assume that emo tional disorderswillbe at least the same, and prob ably higher, in health facilities when compared to a community sample.Thetotal pre .... alence rate forDISASTER MENTAL HEALTH565emotional problems among the primary care clinic attendersinfour developing countries wasof13.9%.Inthe Colombian center, the observed rate wasof10.8%.Ourfindings reveal a community based prevalence ratewhichisfour times theonefound in primary health care clinics. These obser vations lend support to the assumption that this high prevalenceofpsychiatric disordersislikely to have been precipitated by the disaster either directlyorby the difficult socio-economic situation vic tims had to face in the post-impact period.Thefactors identified as being associatedwiththe developmentofmental health problems have important consequences for the early identificationofindividuals at risk for emotional disorders.Theprimary care worker could easily learn to identify an individual at higher risk by screening such fac tors.Theprimary care worker can also be trained through a brief and objective course to implement simple mental health interventions for these indi viduals. These findings further indicate that certain envi ronmental aspects need to be considered while pro viding emergency shelter to disaster victims. For ex ample, identifying a specific date for moving from the temporary shelters into permanent housing seems to be an important protective factor. Addi tionally, the disaster-relief agencies could make spe cial efforts to inform the victims of the various ac tionsbeing taken to help them.Itisofinterest to note that events that one may intuitively and naturally expect to be associated with emotional distress, suchasdeathofa family member, failed to be significantly associated with a positiveSRQscore.Onemay conjecture at this point that in a disasterofsucha magnitude the total loss experienced by manyofthe survivors blurs the capacity to discriminate emotionally among indi vidual losses, the response being to the total loss, irrespectiveofits individuals components.Itshould also be noted that these data were col lected 7 months after the tragedy. Hence, transient emotional reactions seen in the aftermathofthe ca tastrophe were not identified, and we were probably dealing with more severe delayedorchronic fromsofpsychopathology.Itisalso possible that someofthe emotional problems seen may have been pro ducednotby the disaster itself, but by the continu ing difficult living situation, with poor housing, un-

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566B.R.LIMAETAL.employment and disrupted family and social sup port systems. Nonetheless, particularlyindevelop ing countries, this situationismore often the rule, rather than an exception, in the medium and long term managementofdisaster victims, anditcan be seen as an integral componentofthe disaster, 'ex tending its impact over time. Conclusio'"ns Ourfindings indicate that a disasterofsuch a mag nitude in a developing countryislikely to produce very high levelsofemotional distress, essentially af fectingevery other. adult victim. These problems moreover are present as late as half a year after the impact, andourclinical observations lendnosup port to the expectation that this situation may im prove. Therefore, it can be stated with certainty that, for the underprivileged population in develop ing countries which becomes victimsofa major dis aster, a very high levelofmental morbidity can be expected whichwillrequire adequate management.Indeveloping countries, specialized mental health 'resources are already inadequate for the managementofemotional problemsinroutine clinical set tings, andina disaster situation, when the mental morbidity may increase manyfold, they will be come totally insufficient. Hence, the mental health actions of the primary care workerindeveloping countries need to be further exploredasan ade quate alternative for meeting these important needs. TheSRQseems to be a simple instrument that can be used for the detectionofprobable casesofemotional disorders among disaster victims.Theidentification of certain characteristicsofvictims that are significantly related to their being emotion ally distressed can provide an invaluable guideline to increase the primary care workers' capability for detecting emotional problemsinthe communityoramong clinic all enders. Additional studies are ne cessary to further validate the instrumentinassess ing disaster victims, to identify the specific emo tional disorders seen among disaster victims, to de velop educational strategies for training the primary care worker to carry out well-defined mental health tasks, and to evaluate the effectivenessofthese in terventions.Acknowledgements WeIrc indebledto Aguirre. SariAliciaArias deRodrigues, Luz Mireyl SinlamarilIndGloriaAmparo Montenegro."'hose huminqUllil;es. unrclenlin, clinical work wilh Ihe viclims.Ind unselfish enlhusiasm in Ihe dallcolleclionpermilledIhllthis projectbecome arelmy.Suppor1ed by Ihe John.Hopkins Univcnily Schoolof Medicine; Ihe UniversilYJaverianlSchoolof Medicine. BO&OII. Co lombil;Ihe Dhisions of Menlll HelllhofIheTolimlHealthDeplr1menlInd Ihe ColombianMinislryofHeallh; Ihe PanAmericanHeallhOrglnizalion;Ind Ihe Nalural Research andApplicalionsInformalionCenler.UniversityofColorado.ReferencesI.BromclC. Schulltc:r1 HC.DunnL.Reaclionsof psychialric 10 IhcThreeMile Island nuclcaraccidenl. Arch Gen Psychialry1982:39:725-730.2.DohrenwendBp.DohrewendB S.Wlrheil G, Blr1lell G S.GoldsleenRL. K.Marlin J L. Slress in Ihe com munily: A repor110 Ihe Commissionon Ihe accidenl IIThree Mile Island.AnnNY ACid Sci 1981 :365: 159174. 3. Mellick M E.Life chlnge Indillness: Illnessbeha\iorof in Ihe recoveryperiod ofanalural di.a... r.HcalthSocB.hlv1978:19:335.4.OU .. lnlelliE L, RR.Response10social crisisand disaSlCr. Ann Rev Sociol1977:3:23.5.DunllC.Gaviril M. Flaher1yJ,BinS.Perceived disruption Ind psycholo8icil di ... Imongncodviclim . OperllPsy . chialry1985:16:9-16.6. Glass A J. Psychologicalaspecisofdisaslcr. 1959: 1 71:222-225.7.HoibergA. McCaughey BG.The traumaticIher-effeCls ofcolli,ion al sea.AmJ Psychiatry1984:/4/:70-73.8. Kin510n W,Ro .. erR. Di""sler: Effects ofmenialand physi cal slale. J Psychosom Res 1974:18:437-456.9.ParkerG. Psychological di51urbance in Darwin evacuee. fol lo ....ing cyclone Tracy. Med JAusl1975:1:650-652.10.Palrick V, PalrickWK. Cyclone '78in SriLankaIhemen'lal hcallh trail. BrJ 1981: 1.18:210-216.II.Perry R, Lindell M K.The con,equences ofnaluraldisasters: A review ofresearchonAmericancommunilies. MassEmergencies 1978:3:105-115,12. Popovic M, Pelrovic D.Aher Ihe ear1hquake. Lancel 1964:ii:1169J. 13.ShoreJH.TltumE L.VollmerW M. Psychillricreaclions 10 disasler:The MI. SI.Helen's Experience. AmJPSYChiatry 1986: 14.TitchenerJ L.Kapp FT.FamilyIndchlracler change alBuffaloCreek.AmJPsychillry1976:13J:29S-299.15. Wilkinson C B.Ahermalhofa dislSter:The ofIheHyal\ Regency HOlel skywalks. AmJPsychillry1983:/40:1134-1139.16.GieserGC, Green B L. WingelC.Prolonged psychosocial effeclS of diusler. NewYork: AcademicPress, 1981.

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17. Burke J D. Borus J F, Bums B J. Millstein, K H. Beasley. M C. Changesinchildren's behavior Irter Inllurll disasler. Am J Psychillry 1982:139:1010-1014. 18. Newmln. C J. Childrenor disasler: Clinical observalions inBuffllo Creek. Am J Psychillry 1976: 133:306. 19.BanonAL.Communilies in dislster: A socioloSicl1 Inalysisor collective Slress silualion. New York: Doubledly. Archor Books, 1970. 20. Green B.Assessing levels orpsychological impairment fol lowing disasler: ConsideralionorletuIIand methodological dimensions. J Nerv Menl"Ois 1982: 170:544. 21. Uniled Stiles Agency ror Inlemational Development. Office or U.S. foreign Disasler Assislance. Disaster history. Signifi canl Dala on Major Disaslers Worldwide. 1900 Presenl. Washinglon, D.C.: 1986. 22.SeamlnJ. cd. Epidemiolog)" or nalural disaslers. Basel, Swil' z.erllnd:Karger, 1984. 23. World Health Organizalion. Menlll health care in developing countries: A crilical Ippraisal or research findings. ReponorIWHOSlud)' Group. WHO Tech Rep Ser 1984:698. 24. World Health Orglnization. The primlry health worker. GenevI: World Health Organizalion, 1980. Harding T W. Psychillryinrural agrarian lOCielies. Psychillr Ann 1976:8:302. 26. LinT. MenIal health In Ihe Third World. J Nerv Menl Dis 1983: 171:71 78. 27. Srinh'asa Munhy R. WigN N. The WHO collaborative study onslra,legies ror exlending menIal health care. IV: A IrainingIpprolchto enhancing the Ivailabilit)'or mental healthman'powerina developing country. Am J Psychialry 1983: 140: 1486-1490. 28. Lima BR.Primary mental health care ror disaster viclims in developins counlries. Disasters 1986: 10:203. 29. Ahearn F. Insresas en servidos de psiquialria ,despues de un desame nalural. BolorSanit Pan am 1984: 97:325.DISASTER MENTAL HEALTH56730. Cohen R E. Reacdones individulles anle desaslres nalurales.BolOf Sanil Panam1985:98:171-180. 31. Sigurdsson H, CareyS.Volcanic disaslers in Lalin America and the 131h November 1985 eruplionof Nevado del Ruiz VolcanoinColombia. Disaslers 1986:10:205. 32. Hardins T W. deArango M V, Baltazar J. C1imenl CE.1brl''him HH A. Labridolsnacio L.Srinivasa Munhy R, WiS NN. Menial disorders inprimary health care: A sludyoftheir frequency infour developing countries. Psychol Med 1980: 10:231. 33. Mari J J. Wiliams P. A comparisonof the validityof two psy chialric screening queslionnaires (GHO-12 and SRQ)in Brazil. using relalive operating charaeteriSli .. (ROC) analy' sis. Psychol Med 1985:15:651. 34. Mari J J, WilliamsP.Misclassification by psychialric screen ing queSlionnaires. J Chronic Dis 1986:39:377-378. 35.Bu5ftelloE. LimaB,Benolote J. PsychiatricIndPsychosocial IssuesinVila Sao Jose do Murialdo Selling in Brazil. In:JI' blensky A.ed.Intemalional perspectives on Ihcir diagnosisInd classification. Inlernalional Congress. Series 66&.Amslerdam: Excerpla Medica. 1983:383-390. 36.HlrdinlTW,CllmenlC'E.Diop M 0,Giel R, fblahim HHA, Srinivasa Munhy R, Suleiman M A.WilNN. The WHO collaborative Sludy on Slrllegies for extending menIal health care.11: The developmenlor ne""research methods.AmJ Psychialry 1983: 140: 1474. Address Bruno R.Limit, M.D. 180 Meyer Johns Hopkins Hospital Baltimore Maryland 21205 U.S.A.