MIGRATION AND MENTAL HEALTH: A STUDY OF LOW-INCOME ETHIOPIAN WOMEN WORKING IN MIDDLE EASTERN COUNTRIES

BIRKE ANBESSE, CHARLOTTE HANLON, ATALAY ALEM, SAMUEL PACKER & ROB WHITLEY
ABSTRACT Background: Few studies have explored inuences on mental health of migrants moving between non-Western countries. Methods: Focus group discussions were used to explore the experiences of Ethiopian female domestic migrants to Middle Eastern countries, comparing those who developed severe mental illness with those remaining mentally well. Discussion: Prominent self-identied threats to mental health included exploitative treatment, enforced cultural isolation, undermining of cultural identity and disappointment in not achieving expectations. Participants countered these risks by afrming their cultural identity and establishing socio-cultural supports. Conclusions: Mental health of migrant domestic workers may be jeopardized by stressors, leading to experience of social defeat. Key words: Ethiopia, mental health, Middle East, migration, qualitative

INTRODUCTION
Some migrant groups appear relatively mentally healthier than native populations (Escobar et al., 2000), whereas, in other study settings, elevated levels of various mental disorders are found (Bhugra, 2000; Bhui et al., 2003; Fenta et al., 2004; Hutchinson & Haasen, 2004; McGrath et al., 2004; Selten et al., 2003; Zolkowska et al., 2001). A recent meta-analysis of the incidence of schizophrenia in migrants of various ethnicities provided strong evidence of increased rates in both rst- and second-generation migrants, particularly if they were migrating from a developing world country or from a predominantly black population (Cantor-Graae & Selten, 2005). In women from low-income countries migrating as domestic workers to the Middle East, psychiatric morbidity has been found to be two to ve times higher than that seen in the native population (el-Hilu et al., 1990; Zahid et al., 2004). Pre-migratory factors have been implicated due to the rapid onset of mental disorder after migrating (Zahid et al., 2003). However, post-migratory stressors were also evident, with three quarters having little or no contact with families back home, 22.8% worried due to maltreatment by their employing family and approximately 20% reporting sexual harassment (Zahid et al., 2002). Studies undertaken in the host country may be limited by the participants unwillingness to disclose adverse experiences due to an unequal power relationship and fear of reprisal. We are unaware of any studies that have examined the experiences of
International Journal of Social Psychiatry. Copyright 2009 SAGE Publications (Los Angeles, London, New Delhi and Singapore) www.sagepublications.com Vol 55(6): 557568 DOI: 10.1177/0020764008096704

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these domestic migrant workers once they have returned to their country of origin or that have been conducted by investigators of the same nationality as the migrants. Many Ethiopian women migrate to Middle Eastern countries to seek employment. It is extremely difcult to quantify the scale of this economic migration as many women migrate through trafckers or illegal agents, although the perception is that the numbers are ever-increasing (ILO, 2004; Kebede, 2002). By migrating illegally, the women circumvent access to labour safeguards and are vulnerable to debt bondage, forced labour and gross restrictions upon their freedom (Kebede, 2002). Concomitantly, within Ethiopia there has been a conspicuous rise in the number of women admitted for inpatient psychiatric care after developing severe mental disorder while employed in Middle Eastern countries as domestic workers (personal communication: Dr Atalay Alem, 2005). Aside from media and non-governmental organization (NGO) reports, this area has not been systematically researched in the Ethiopian setting. The reasons for this include lack of resources, both nancial and human, and decits in the necessary infrastructure to easily trace the women who migrate. Women from low-income countries who migrate for economic reasons constitute an understudied and extremely vulnerable population. In this context, a qualitative approach may be especially informative, allowing an exploration of the range of possible stressors associated with migrant work of this type. This can also lead to the development of hypotheses about potential risk factors for mental disorder. The aim of the study was to explore the experiences of two groups of Ethiopian women employed as domestic workers in Middle Eastern countries, those developing severe mental disorders and those remaining mentally well, in order to illuminate potential threats to mental health.

METHODS
Three focus group discussions (FGDs) were held with female Ethiopian migrants who had recently been employed as domestic workers in various Middle Eastern countries (Lebanon (n = 11), Saudi Arabia (n = 4), Abu Dhabi (n = 2) and Yemen (n = 2)), for periods ranging from a few days to several years (median 4.5 months, inter-quartile range 12.5 months). Two of these groups consisted of women who had returned to Ethiopia with a severe mental illness. The third group was composed of women who had returned in good mental health. This allowed us to make appropriate comparisons of experience. The research was carried out in Addis Ababa (Ethiopia) between January and July 2005.

Participant recruitment
Mentally Ill Group 1 (n = 6) was recruited from a psychiatric outpatient clinic in Addis Ababa. Mentally Ill Group 2 (n = 5) was recruited from Amanuel Mental Referral Hospital, the only psychiatric hospital in Ethiopia. All participants in this group had been admitted to the inpatient ward but were outpatients at the time of the FGD. Psychiatrists working in both the in- and outpatient settings notied the rst author (BA) of all women returning from Middle Eastern countries who made contact with psychiatric services over the study period. These women were approached and all agreed to participate. They were assessed as being in full remission and having the capacity to consent to participation.

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Participants were recruited for Mentally Healthy Group 3 (n = 8) through the Gebenaye NGO, which offers skills training and support to women after they have returned to Ethiopia from Middle Eastern countries. All participating women had been screened by BA (a consultant psychiatrist) as being free of mental illness at time of the FGD and none had experienced severe mental illness requiring intervention of mental health services during their time working overseas.

Sample characteristics
The age range of women in the three groups was 2030 years. The majority were Orthodox Christians (75%) and all except one were single at the time of migration. The majority of the women had completed high-school education but only three had paid employment prior to migration, and all considered their families to be of relatively low socioeconomic status. In the women who had been mentally unwell, the diagnoses received from treating psychiatrists included major depressive disorder, brief psychotic disorder and bipolar I disorder (American Psychiatric Association, 1994). All the women who developed severe mental illness in the new country had to return to Ethiopia as a consequence.

Qualitative methods
The initial topic guide for the FGDs was structured around eliciting womens experiences before, during and after migration. Questions also allowed for the exploration of known risk factors for mental illness associated with migration. Women were asked about how it was they decided to migrate, how they funded their travel and their experiences upon arrival, including their working conditions. They were also asked about any emotional difculties they faced. The guide was not rigid and afforded the facilitator freedom to respond to the priorities of the participants. All FGDs were facilitated by BA and conducted in the national language of Ethiopia (Amharic). The three FGDs were tape-recorded and contemporaneous notes taken. Tapes were immediately transcribed in Amharic and translated into English by BA. The topic guide was revised after each focus group to ensure relevance and comprehensibility. FGD 1 was held at St Pauls hospital (a general hospital with outpatient psychiatric facilities); FGD 2 was held in the teaching room at Amanuel Hospital; and FGD 3 was held on the premises of the Gebenaye NGO. The duration of the FGDs ranged from one hour 45 minutes to two hours and refreshments were provided.

Data analysis
Data analysis proceeded alongside data collection to allow for iterative development of the FGD topic guide. Our analytic approach followed content analysis, whereby texts are analysed in relation to a specied conceptual model (Silverman, 2006). However, we endeavoured to allow these concepts to emerge a posteriori from the data to best reect the experience, language and categories most important to study participants. Initial open-coding was carried out independently by BA and CH using qualitative computer software to assist with data management (OpenCode, 2001). Coding schemes were compared and differences discussed. Descriptive codes were subsequently grouped into higher order conceptual themes, which were then applied to the data. Quotes from participants were fully anonymized and care was taken to ensure contextual validity. Ethical approval was granted by the Faculty of Medicine, Addis Ababa University. Participants were fully informed as to the purpose of the study and consented verbally.

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RESULTS
Recurring descriptions of inhumane treatment, enforced cultural isolation, undermining of cultural identity and disappointed expectations dominated the discussions of these domestic worker migrants to Middle Eastern countries. The most salient hardships related to the reportedly exploitative dayto-day living and working conditions, perceived as a threat to their physical and mental integrity. The women who remained mentally well were more likely to talk about strategies they used to counter these threats to their well-being.

Exploitation
Almost all of the women described inhumane working conditions, physical and sexual maltreatment, and denial of basic freedoms. Upon reaching their new place of employment, the women spoke of having to cope with impossibly high workloads, long hours and inadequate rest. Often the women reported being the only worker looking after an extended family, expected to be at their beck and call both day and night. Once employed in a home, the women could expect to be shared by other families so that their responsibilities would multiply. The women spoke of being exhausted and overwhelmed by what was required of them, and linked this to the development of mental ill-health. Difculties in the womens day-to-day existence extended to having their access to food restricted and their eating utensils segregated. You are overloaded with work. They dont see you as a human being. When you eat food they act as if you eat a lot. They dont think you are becoming too tired and they dont think you need rest and they dont think that you will be thirsty and you should drink. They dont mind about you. (FGD 1. Page 2, paragraph 113. Saudi Arabia. ID05) The thing that was making me worry was having no rest because of the overload of work. Even when I had time to have a two-hour sleep I was not able to sleep. So I started having no sleep, even though I tried to rest, since I was working beyond my capacity. (FGD 1. Page 2, paragraph 323. Lebanon. ID01) There were times when I would take food from the wastebasket and eat. It was too difcult She gave me a very small amount of food. Usually I worked very hard so you should eat well. Otherwise how you do you work? When she did this, there was a lot of food; it was even in excess. She took it and threw it away, so then I would see whether she saw me or not and then I would take from that and eat that. (FGD 2. Page 3, paragraph 457459. Lebanon. ID08) All of the women reported being aware of others who had suffered physical maltreatment, sometimes leading to injury, permanent disability or even death. Reports from their experiences included being kicked or beaten by employers and living in fear that more serious harm could come to them if they were not obedient. The women were reluctant to openly discuss sexual assault in the focus groups, instead making oblique references and speaking about what they had heard of others experiences. From the discussions, however, it was evident that sexual harassment was a common and distressing experience.

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There is problem regarding the men. You will be very tired and you will be disturbed by matters that you dont understand. You plan sometimes to open the window and to throw yourself from that. (FGD 1. Page 2, paragraph 113. Saudi Arabia. ID05) Among the women who remained mentally well, there was more discussion about how they had succeeded in resisting employers demands or coping with abusive situations: they were planning for me to work in another house, in addition to the work that I was doing in their house. Because of that, I started to challenge them, saying: I am not employed to work in the other house and I cant work in another house. I am employed to work in your house. So nally, due to this I didnt work as they had planned. (FGD 3. Page 4, Paragraph 161. Lebanon. ID19) At this moment I was weeping. There was an Ethiopian lady there. I told her about these problems. She advised me. She told me that it is their behaviour so I shouldnt worry. She was also advising me how I could keep myself away from these sorts of problems. So, when I discussed my problems with Ethiopian people my worry was relieved. (FGD 3. Page 4, paragraph 364364. Lebanon. ID13)

Enforced cultural isolation

Perhaps surprisingly, most of the women spoke of adapting to alien cultural practices with minimal difculty. Some related minor misunderstandings due to language but accepted these as a predictable and manageable component of migration. What was much more problematic for the women was being apart from their families and dislocated from ties with Ethiopia. This situation was exacerbated by the restrictions placed by employers on their freedom to move around, meet with other Ethiopians or attend religious worship. Many of the women were locked inside the house by their employers. Such restrictions were sometimes justied to them as providing necessary protection. However, other women commented on their employers unwillingness to allow them contact with other Ethiopians, believing that they would share information and be likely to leave if they had the opportunity. They want you to be under their control. They didnt want us to have rest. They didnt allow us to have contact with our friends that had come from Ethiopia. In addition to these things, they didnt allow us to go to church. In general they didnt allow us to come out of the house. Even when they went out, they would only go after locking us up we were not even allowed to come out of the house. (FGD 3. Page 1, paragraph 19. Lebanon. ID13) The other thing was that they hid my letters; those that were sent from my family and the letters that I wrote to my family There were times when I found letters that were sent from my family but hidden by them. I tried to read them but I left them as I was afraid because they were unopened. (FGD 2. Page 3, paragraph 532. Lebanon. ID11)

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But my problem was homesickness. I missed people very much. Seeing Ethiopians who were living there was very precious for me. Inside the house there was a window where I had access to speak with them I think my problem was homesickness. I was missing my family very much. I was eager to meet these people. (FGD 2. Page 3, paragraph 185187. Lebanon. ID09)

Undermining of cultural identity

Related to the importance of ties to home was the womens powerfully described reactions to any undermining of Ethiopia and its culture. The women were very emotional as they spoke, talking across one another and becoming angry. They described how their employers held stereotypical views of Ethiopia as a poverty-stricken country where hunger was widespread. Some of the women reported being unable to control their feelings but would be sure to take themselves away from the family before crying, rather than show them weakness. Ah I felt very much. I asked them: Did we come since we didnt have things to eat? Since we didnt have food to eat? We have things to eat. We only came here to improve our lives Otherwise, ours is not the type of country to be described as poor. I tried to tell them. But there were even times that I was not able to speak. That was due to the anger I felt. I was not even able to nish what I had started to say. At that time tears came out from my eyes. (FGD 3. Page 4, paragraph 490. Lebanon. ID13) At the beginning when I arrived, he brought me a potato and asked some questions. He asked me: Do you know this? Is it available in your country? How do you prepare it? Is there any food at all to eat in your country? These people ask you such types of questions. They see us like as if we are slaves. They dont think we have homes to live in and food to eat. That affects you very much. They upgrade themselves. (FGD 3. Page 4, paragraph 487489. Lebanon. ID13) Among the mentally well women were stories of how they were able to challenge the negative views of their country: I told my friend who was living in Ethiopia to send me a videocassette of her wedding ceremony. I did that as I was angry about the way they were acting towards us. I planned to show them I said to them: See it. That is the country called Ethiopia. On that video there were lot of very nice places with also a variety of foods. After seeing it they started to ask whether there were things like this. (FGD 3. Page 4, paragraph 518. Lebanon. ID13)

Disappointed expectations
The women left Ethiopia with high expectations. Most had been motivated by seeing women in Ethiopia for whom the opportunity to work in a Middle Eastern country had brought about noticeable improvements in their lives. Although the participants did not speak directly of family demands, they indicated that they felt a strong pressure not to fail and an obligation to help improve their familys circumstances.

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It was for the sake of my family. But it was also since I saw some of the ladies who went to different Arab countries and improved their life and that of their families. (FGD 2. Page 2, paragraph 300. Lebanon. ID09) The majority of the women had low socioeconomic status prior to migration, with most unemployed and nancially dependent on their family. They reported not even having enough money to pay for their transportation. In order to migrate, they either had to borrow money or enter into agreements with their employers to pay back all expenses later. Some women reported being unable to pay back the borrowed money as they had returned early due to their mental illness and not been able to complete their contracted time. Being indebted placed pressure on the women before and during their migration, as well as after they had returned to Ethiopia. However, returning home having failed to better their circumstances was often a more important concern. I would have rested if I had paid the money that I borrowed. But returning back without any improvement would create a bad feeling in my mind. There might even be a change in your behaviour. You may be easily angered. Although being at peace before, now you will disagree with your sisters and brothers. There may even be disagreement with your family. You may respond to simple matters that might not even concern you. So, all of these conditions are due to the loss of the things that you were expecting to get. (FGD 3. Page 4, paragraph 302. Lebanon. ID17)

Pre-migratory factors
All the women claimed to have been in good health prior to migrating, although one had a personal history of mental disorder in remission. Factors potentially predisposing to mental disorder were present in a minority, with three women reporting a family history of serious mental disorder including probable psychosis and suicide (one who did not become mentally unwell and two who did) and others having experienced parental loss (n = 2; FGD 1 and 2) and/or divorce (n = 1; FGD 1) during early childhood. However, the women did not choose to emphasize any inherent individual vulnerability to mental disorder in discussing the impact of their migration experiences, seeming rather to conceptualize threats to their mental well-being as coming from the extraordinary external circumstances they found themselves in after migration.

DISCUSSION
This exploration of the experiences of returned Ethiopian women who had migrated as domestic workers to Middle Eastern countries reveals a disturbing picture of severe hardships endured in the new country. The women identied these as threatening their physical and mental health. Enforced cultural isolation and cultural discrimination were perceived as particularly potent stressors.

Limitations
This study has a number of limitations. The number of women available to participate in the FGDs was small, especially those with severe mental illness. We could not be condent that we had reached theoretical saturation, although the identied themes dominated the discussions and

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appeared to have a strong emotional valence. The ndings are best considered as a preliminary insight into the experiences of this neglected group of migrant workers, as yet insufcient to support the generation of theory. A further potential shortcoming of this study is the reliance on domestic workers who had returned to Ethiopia without hearing the reported experiences of those who remained working in Middle Eastern countries. This could have biased our sample towards those with more adverse experiences. Although most women who develop severe mental illness appear to be deported (Zahid et al., 2004), given the low mental healthcare coverage in Ethiopia, not all these women would have come to the attention of psychiatric services. However, previous studies of domestic worker migrants have been conducted by host country researchers prior to deportation, which may have affected the willingness of women to speak openly of their experiences. Reliance on participants retrospective accounts of past mental illness could have led to underreporting of pre-migration vulnerabilities (Zahid et al., 2003). Likewise, there could have been recall bias in the accounts of women who had recovered from mental disorder, either because of ongoing dysphoria leading to negative recall bias or the process of effort after meaning (Bartlett, 1932). However, the nding of little difference in the reporting of adverse experiences between study and comparison groups argues against this as an important source of bias in our study.

Models of migration and mental illness

Models seeking to explain the relationship between migration and schizophrenia, and other mental disorders, have increasingly moved away from assuming an existing predisposition to mental disorder (Odegaard, 1932) or that the process of migration per se is pathological and have instead looked towards an interplay of psychosocial stressors and buffers (Bhugra, 2000; Boydell et al., 2001; Sharpley et al., 2001). For example, the migration contingencies model (Beiser, 1999; Fenta et al., 2004) balances risk, in terms of pre- and post-migration stressors, against resilience in understanding the development of mental disorder in migrants. The applicability of this model to the experiences described by the women in this study will now be considered.

Exploitation and disappointed expectations

In considering the risks side of the equation, the post-migration experiences of these Ethiopian migrant domestic workers seemed overwhelming. Almost all the returnee migrants in our study reported extreme hardships, which were likely to have threatened their physical and mental integrity, regardless of any existing predisposition and, conceivably, in spite of the presence of resilience factors. Severe life events and chronic difculties, particularly those characterized by humiliation, entrapment and defeat, have a well-established role in bringing about episodes of mental disorder (Brown & Harris, 1989; Brown et al., 1995). Numerous potentially humiliating experiences following migration are described by the women in our study: the degradation associated with inhumane treatment, overwork, having insufcient food, being prey to physical and sexual assault, and having ones ethnic identity denigrated. Themes of entrapment and defeat also leap out from the womens discussions, for example, entrapment in terms of physical connement: being locked up, without passport or money, fearful of escape and the consequences it might bring with it. But the women were also trapped due to the lack of control over their situation, being at the whim of the employers with regard to whether they could eat or not, who they could contact or meet up with, and whether they would be paid. Entrapment and defeat are also pertinent to the experience

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of disappointed expectations: the women were trapped by their aspirations and the thought of failure, keeping them working whatever the conditions. The reporting of severe exploitation accords with the International Labour Organization (ILO) ndings from their own series of FGDs and case studies of returned migrant workers (ILO, 2004; Kebede, 2002) but differs from the Kuwaiti study investigating frequency of exposure to postmigration stressors in hospitalized migrant domestic workers (Zahid et al., 2002). In the latter, only a minority of women reported problems of overwork, non-payment of wages, physical or verbal abuse or harassment, although they may have felt inhibited in disclosing such experiences while still in-country. A further limitation of the Kuwaiti study was that potential stressors were identied from case notes of previous mentally ill domestic workers. Such an approach may have overlooked stressors as perceived by the women themselves, for example those involving cultural discrimination and disappointed expectations.

Cultural isolation
The important role of social networks and contact with other Ethiopians came out strongly in the discussions. Being able to share information and advice, engage in religious worship together and even just see their fellow country-women from afar gave them comfort. Correspondingly, when such contacts were prohibited by their employers, women spoke of the distress they experienced. Contact with other people from ones own country has been shown to be important as an escapehatch allowing emotional release and maintaining mental health, at least in the early stages of migration (Koryani, 1981). Other studies showing lower rates of psychosis in areas where immigrants make up a greater proportion of the population also support the protective role of likeethnic contacts (Boydell et al., 2001). This is in keeping with an important role of resilience as predicted by the migration contingencies model.

Undermining of cultural identity

In the FGDs, no topic generated more heated debate than denigration of Ethiopia by employers, what we have termed undermining of cultural identity. Such discriminatory experiences have been shown to be associated with subsequent onset of psychosis (Janssen et al., 2003), including in migrant populations (Noh et al., 1999). The ability of the women to resist such attacks may have been an important factor in remaining mentally well. Resilience may be directly associated with mental health or may act indirectly as a buffer to preserve mental health in the presence of a stressor. A strong sense of ethnic pride was found to be an important predictor of mental health in Ethiopian migrants to Toronto (Fenta et al., 2004). In this study, the FGD of women who remained mentally well was striking because of the impassioned argument that arose around the issue of attacks on cultural identity. These women described strategies to ght back against the discriminatory assumptions of their employers and this may have helped them to preserve their mental well-being.

Models for threats to mental health: social defeat

The post-migration stressors component of the migration contingencies model came out as most pertinent to the development of mental ill-health as perceived and reported by the women in our study. There was also suggestive evidence for the counterbalancing role of factors promoting resilience such as access to other Ethiopians and an ability to ght back against undermining of cultural identity. In the comparison group of women who remained mentally well, these latter

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factors were more prominent. Pre-migration vulnerabilities, such as low educational level, being single and having a history of mental or physical illness, have been used to explain the early onset of mental disorder after migration of domestic workers to Kuwait (Zahid et al., 2003). In this study we do not have reliable information about pre-existing vulnerabilities in those who became mentally unwell but can say that such factors were not emphasized by the women. We would contend that the extreme nature of the adverse stressors reported by the majority of women would constitute severe threats to mental health in all but the most robust. The emerging concept of social defeat has been advanced as a pertinent factor in the development of psychosis in migrants (Selten & Cantor-Graae, 2005) and provides a parsimonious explanation for risk of mental disorder in this study. Social defeat captures the idea of being subordinated or forced into outsider status. In animal studies, experience of social defeat is associated with sensitization of the mesolimbic dopamine system (and/or increased baseline activity of this system), which in turn is thought to predispose to psychosis (Tidey & Miczek, 1996; Isovich et al., 2001). In the context of this study, the concept of social defeat unies the main themes that emerged from the discussions: stressors characterized by humiliation; entrapment and thwarted expectations; enforced cultural isolation; and the denigration of the womens sense of cultural identity.

CONCLUSIONS
This study supports mounting concerns about the experiences of Ethiopian migrant domestic workers in Middle Eastern countries and suggests mechanisms by which these may lead to serious mental illness. A recent hypothesis about the possible aetiological contribution of social defeat to psychosis seems particularly apposite. Role frustrations and undermining of cultural identity were prominent migration experiences associated with emotional disturbance in the women participating in this study. Further exploration of the action of social defeat is indicated, as well as investigation into the potentially protective strategies utilized by domestic workers to withstand or overcome social defeat while living and working in extremely adverse settings. Our interest in conducting this study stemmed from observations of an increasing number of returnee migrants with severe mental disorder requiring treatment in formal psychiatric institutions in Ethiopia. This should be recognized as the tip of the iceberg of mental disorder in this group. As discussed, severe life events and chronic difculties have also been associated with anxiety, depression and post-traumatic stress disorder. An important next step would be to systematically assess the mental health of mentally well returnees where we might expect to nd undetected but important levels of mental morbidity.

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Zahid, M.A., Fido, A.A., Alowaish, R., Mohsen, M.A. & Razik, M.A. (2002) Psychiatric morbidity among housemaids in Kuwait: The precipitating factors. Annals of Saudi Medicine, 22, 384387. Zahid, M.A., Fido, A.A., Razik, M.A., Mohsen, M.A.M. & El-Sayed, A.A. (2004) Psychiatric morbidity among housemaids in Kuwait. a. Prevalence of psychiatric disorders in the hospitalized group of housemaids. Medical Principles & Practice, 13(5), 249254. Zolkowska, K., Cantor-Grae, E. & McNeil, T. (2001) Increased rates of psychosis among immigrants to Sweden: Is migration a risk factor? Psychological Medicine, 31(4), 669678. Birke Anbesse, MD, St Pauls General Specialized Hospital, PO Box 31657, Addis Ababa, Ethiopia. Charlotte Hanlon, MRCPsych, MSc, Kings College London, Institute of Psychiatry, London, UK. Atalay Alem, MD, PhD, Department of Psychiatry, Addis Ababa University, Addis Ababa, Ethiopia. Samuel Packer, MD, FRCPC, University of Toronto, Centre for Addiction and Mental Health, Toronto, Canada. Rob Whitley, PhD, Department of Psychiatry, Dartmouth Medical School, New Hampshire-Dartmouth Psychiatric Research Centre, Lebanon, USA. Correspondence to: charlotte.hanlon@iop.kcl.ac.uk