title: Culture in psychiatric epidemiology: using ethnography and multiple mediator models to assess the relationship of caste with depression and anxiety in Nepal.
abstract: BACKGROUND
  The causes of ethnic and caste-based disparities in mental health are poorly understood.
  
  
  OBJECTIVE
  The study aimed to identify mediators underlying caste-based disparities in mental health in Nepal.
  
  
  METHODS
  A mixed methods ethnographic and epidemiological study of 307 adults (Dalit/Nepali, n=75; high caste Brahman and Chhetri, n=232) was assessed with Nepali versions of Beck Depression (BDI) and Anxiety (BAI) Inventories.
  
  
  RESULTS
  One-third (33.7%) of participants were classified as depressed: Dalit/Nepali 50.0%, high caste 28.4%. One quarter (27.7%) of participants were classified as anxious: Dalit/Nepali 50.7%, high caste 20.3%. Ethnographic research identified four potential mediators: Stressful life events, owning few livestock, no household income, and lack of social support. The direct effect of caste was 1.08 (95% CI -1.10-3.27) on depression score and 4.76 (95% CI 2.33-7.19) on anxiety score. All four variables had significant indirect (mediation) effects on anxiety, and all but social support had significant indirect effects on depression.
  
  
  CONCLUSIONS
  Caste-based disparities in mental health in rural Nepal are statistically mediated by poverty, lack of social support, and stressful life events. Interventions should target these areas to alleviate the excess mental health burden born by Dalit/Nepali women and men.
authors.affiliation: Department of Anthropology, Emory University, Atlanta, GA 30322, USA. brandonkohrt@gmail.com
authors.forename: Brandon A
authors.initials: BA
authors.lastname: Kohrt
authors.forename: Rebecca A
authors.initials: RA
authors.lastname: Speckman
authors.forename: Richard D
authors.initials: RD
authors.lastname: Kunz
authors.forename: Jennifer L
authors.initials: JL
authors.lastname: Baldwin
authors.forename: Nawaraj
authors.initials: N
authors.lastname: Upadhaya
authors.forename: Nanda Raj
authors.initials: NR
authors.lastname: Acharya
authors.forename: Vidya Dev
authors.initials: VD
authors.lastname: Sharma
authors.forename: Mahendra K
authors.initials: MK
authors.lastname: Nepal
authors.forename: Carol M
authors.initials: CM
authors.lastname: Worthman
mesh_terms: D000328:Adult; D000367:Age Factors; D000822:Animal Husbandry; D000884:Anthropology, Cultural / Q000379:methods*; D001007:Anxiety / Q000453:epidemiology* / Q000523:psychology; D015986:Confounding Factors, Epidemiologic; D003430:Cross-Sectional Studies; D003863:Depression / Q000453:epidemiology* / Q000523:psychology; D005260:Female; D006801:Humans; D008016:Life Change Events; D008297:Male; D008393:Marriage; D008960:Models, Psychological; D009390:Nepal / Q000453:epidemiology; D010555:Personality Inventory; D011203:Poverty; D011581:Psychological Tests; D012307:Risk Factors; D012737:Sex Factors; D012923:Social Class; D012944:Social Support; D012959:Socioeconomic Factors; D013315:Stress, Psychological / Q000453:epidemiology / Q000523:psychology