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Addressing mental health needs of 100,000 ethnic Nepali Bhutanese refugees relocated from Nepal is a new challenge for mental health clinicians in the receiving countries. A limitation of current services is the lack of knowledge about cultural understandings of mental health. Ethnopsychology is the study of emotions, suffering, the self, and social relationships from a cultural perspective. Nepali ethnopsychology can be used to develop and adapt mental health interventions for refugees. We discuss applying ethnopsychology to provide safe and effective mental healthcare for Bhutanese refugees, including cultural adaptation of cognitive behavior therapy, interpersonal therapy, and dialectical behavior therapy. Psychological interventions are proposed for the high rates of suicide among Bhutanese refugees. The contribution of ethnopsychology to applied anthropology and the growing field of neuroanthropology are discussed.

Context: Former child soldiers are considered in need of special mental health interventions. However, there is a lack of studies investigating the mental health of child soldiers compared with civilian children in armed conflicts. Objective: To compare the mental health status of former child soldiers with that of children who have never been conscripts of armed groups. Design, Setting, and Participants: Cross-sectional cohort study conducted in March and April 2007 in Nepal comparing the mental health of 141 former child soldiers and 141 never-conscripted children matched on age, sex, education, and ethnicity. Main Outcome Measures: Depression symptoms were assessed via the Depression Self Rating Scale, anxiety symptoms via the Screen for Child Anxiety Related Emotional Disorders, symptoms of posttraumatic stress disorder (PTSD) via the Child PTSD Symptom Scale, general psychological difficulties via the Strength and Difficulties Questionnaire, daily functioning via the Function Impairment tool, and exposure to traumatic events via the PTSD Traumatic Event Checklist of the Kiddie Schedule of Affective Disorders and Schizophrenia. Results: Participants were a mean of 15.75 years old at the time of this study, and former child soldiers ranged in age from 5 to 16 years at the time of conscription. All participants experienced at least 1 type of trauma. The numbers of former child soldiers meeting symptom cutoff scores were 75 (53.2%) for depression, 65 (46.1%) for anxiety, 78 (55.3%) for PTSD, 55 (39.0%) for psychological difficulties, and 88 (62.4%) for function impairment. After adjusting for traumatic exposures and other covariates, former soldier status was significantly associated with depression (odds ratio [OR], 2.41; 95% confidence interval [CI], 1.31-4.44) and PTSD among girls (OR, 6.80; 95% CI, 2.16-21.58), and PTSD among boys (OR, 3.81; 95% CI, 1.06-13.73) but was not associated with general psychological difficulties (OR, 2.08; 95% CI, 0.86-5.02), anxiety (OR, 1.63; 95% CI, 0.77-3.45), or function impairment (OR, 1.34; 95% CI, 0.84-2.14). Conclusion: In Nepal, former child soldiers display greater severity of mental health problems compared with children never conscripted by armed groups, and this difference remains for depression and PTSD (the latter especially among girls) even after controlling for trauma exposure. Armed groups throughout the world continue to exploit children to wage war.1 The dedicated efforts of humanitarian organizations,2 psychosocial workers,3 and former child soldiers4,5 have called international attention to this issue. However, in a recent report on the status of child soldiers, Betancourt et al6 revealed gaps in crucial areas of research to understand the impact of becoming a soldier on child mental health. First, child soldiers are considered in need of special psychosocial intervention. However, there is a lack of published research comparing the severity of mental health problems and functional status among child soldiers with children living through war who were not conscripted to armed groups6- 9; unpublished studies of nongovernmental organizations suggest there may not be a difference between these groups.6,10 Second, despite suggestions of increased psychological distress for girl soldiers,5,11- 13 prior to the conduct of this study no published epidemiological studies to our knowledge had explored sex differences in the psychological impact of soldiering. Third, child soldiers are assumed to have greater exposure to trauma than nonconscripted children.14 Yet, major studies of child soldiers have not shown an association between trauma and posttraumatic stress disorder (PTSD).15,16 Finally, Betancourt et al6 call for studies using validated and cross-culturally appropriate mental health measures, which have been lacking in this field. Researching these issues is crucial to designing the most effective mental health interventions for children in armed conflicts. In the current study, we worked toward addressing these gaps. Our first objective was to compare the mental health of former child soldiers who have returned home with that of children growing up in active conflict settings but who were not conscripted by armed groups in Nepal, using cross-culturally validated measures of psychosocial well-being. We sought to determine (1) if former child soldiers have more mental health problems than never-conscripted children; (2) if becoming a soldier has a greater impact on girls vs boys when compared with never-conscripted children; and (3) if differential exposure to trauma is associated with mental health differences between child soldiers and never-conscripted children. Our second objective was to describe predictors of mental health outcomes within child soldiers: whether trauma exposure, combat experience, military roles, and other soldier-related variables are associated with mental health outcomes and whether the associations between these factors and mental health outcomes were modified by voluntary vs involuntary recruitment, time since leaving military service, or maintained association with an armed group.