 Okay good afternoon, thank you for all still being awake at this time of day after hearing so many people speak. Today I am presenting the results of the Kashmir Mental Health Survey that we conducted last year. This survey was conducted in collaboration with the Department of Psychology at the University of Kashmir and the Institute of Mental Health and Neurosciences in Srinagar. So from the map right there the state right at the top in purple is the state of Jammu and Kashmir. We conducted our survey on a portion of this state called the Kashmir Valley. The Kashmir Valley is made up of ten districts. It shares a border with Pakistan in its northeast. It has a total population of seven million people, 73% of which live in rural areas, 97% of Muslim religion and it has undergone sporadic political insecurity since the Division of India and Pakistan in 1947 by the British. The state of Jammu and Kashmir has faced ongoing conflict. So why did MSF conduct this survey? MSF conducted a smaller survey in 2005 in two districts of the Kashmir Valley and found a high prevalence of mental distress. Other empirical studies conducted in Kashmir have also found a high prevalence of mental distress. There was a need for updated baseline data across all ten districts of the Kashmir Valley in order to measure the mental health of the population. Where prior research on conflict affected populations has really focused on the effect of conflict related trauma on the mental health of a population. Current research now is looking at more a holistic view on the impact of living in an area affected by conflict. Also considering stresses of daily life and livelihood such as unemployment, underemployment, poverty and the breakdown of social cultural support systems which all have been shown to have negative impact on mental health. The objective of our survey was twofold. It was mixed methods research. We set out to estimate the prevalence of mental health related problems specific to depression, anxiety and post-traumatic stress symptoms in the Kashmir Valley and to determine accessibility to mental health services. The first part of this objective was done by a household survey and the second part was done through qualitative focus group discussions. Today I'm only presenting on the survey results. So our methodology we used a probability-based sample where we used population proportional to size to identify 40 clusters per district. Across the ten districts we covered 400 villages and 5,600 adults. We had 10 teams of 53 enumerators all with postgraduate qualifications in psychology, sociology and social work. They received two weeks of training. A pilot was conducted during October 2015 and the survey was conducted between October and December 2015. Our data was collected using an electronic questionnaire where two screening tools were embedded, the Hopkins symptoms checklist for depression and anxiety and the Harvard trauma questionnaire for post-traumatic stress disorder. We also collected data on demographics, functionality, substance use, problems of daily life, coping and traumatic experiences. Now just a note on the screening tools we conducted an earlier study in 2015 where these screening tools were culturally adapted and translated by an expert team of psychologists and psychiatrists in the Kashmir Valley. We conducted a validation study between February and April where the Hopkins symptoms checklist was validated for Kashmir. We developed a validated cut-off score for depression and anxiety. However, due to sample-sized restrictions we did not get a validated cut-off score for post-traumatic stress disorder. So we used the internationally recognised cut-off for our survey results. Our survey data was weighted and statistical analysis carried out. This is just a quick table from the validation to show the cut-off scores that we used. The international cut-off score for depression is 1.75. Our culturally validated cut-off score was 1.57, so quite a bit lower than the international. For anxiety, our cut-off score was the same as that recognised internationally at 1.75. And for post-traumatic stress, as I said, we used the international cut-off score. The results, we had a very high response rate, 97.7%. And after data cleaning, we had 5,428 interviews for analysis. 78% of our sample lived in rural areas, 67% were women. The mean age was 39 years. The age ranged from 18 to 120. I'll do a caveat here that in Kashmir, a lot of people don't know their exact age, so they estimate their age. Either that or Kashmir has some life-giving water that could be marketed. 68% were married, 35% reported having had no education, and 38% of men had some form of employment. For 81% of women, home duties was their main activity. Now, in the results I'm presenting next, these have been weighted for the overrepresentation of our sample, of females in our sample, and also for the complex sampling design. And what we found was that 45% of adults across the valley showed significant signs of mental distress. 41% with probable depression, 26%, probable anxiety, and 19% probable post-traumatic stress disorder. The reason we classify these as probable is that we did use screening tools based on a cut-off score, so they are not diagnostic. What they do is they pick up people with signs and symptoms of these disorders, and all three of these disorders have a large range of symptoms, from subsyndromal illness, minor presentations from transient symptoms to severe symptoms, and the screening tools would pick up everybody across that spectrum. Both of our screening tools also had diagnostic algorithms developed by the Harvard Trauma Group based on the actual symptoms and item responses. When we ran these diagnostic algorithms on our data, we found that 10% were classified with severe depression, meeting all the DSM-4 criteria for diagnosis of major depression, and 6% met all the diagnostic criteria for post-traumatic stress disorder. This is a distribution across the districts of the valley. You can see that Baramulla and Bud Gum had the highest prevalence rates, and the lowest were found in the mid and western districts. You can see a common pattern across all three disorders, and this is largely due to the co-morbidity. A lot of people that scored high on PTSD also scored high on depression, so there's a lot of crossover of morbidity of these three. We look at trauma on average in adult living in the Kashmir Valley as witnessed or experienced 7.7 traumatic events during their lifetime. 73% of men and 52% of women had experienced or witnessed greater than six traumatic events during their lifetime. As consistent with the literature, we found a dose response relationship with the number of traumatic events experienced or witnessed, and the prevalence of mental distress. Here we have in the bars the proportion of people in each of the districts that have experienced or witnessed greater than six traumatic events. The little shapes represent the prevalence rates in those districts for depression, anxiety, and PTSD, and the linear line shows that there is a steady increase with the increase of number of traumatic events, so the prevalence rates also increase. The main problems of daily life were financial, poor health of self, and unemployment, and the main coping mechanisms include prayer, talking to a friend or family member, and trying to keep busy. Now, we recognise that substance use is a very difficult thing to measure in a cross-sectional survey, but an effort was made to assess substance use in the valley with the reporting by practitioners that it is increasing across the valley. However, due to the cultural stigma associated with these substances, we do feel our data is underreported. However, we did find that 11.5% of Kashmiri adults are taking benzodiazepines. 45% of which have been taking them for more than one year, and this was distributed across all age groups. We also found a very high prevalence of tobacco use. Tobacco use was also reported as one of the main coping mechanisms by one in five men. When we look at their predictive factors, we find that being female aged over the age of 55, having poor education outcomes and a greater exposure to trauma was a predictive factor for symptoms of depression. For anxiety, it was a similar picture with being female, poor education outcomes, having a higher exposure to trauma and living in a rural area, being predictive for symptoms of anxiety. We also found that education was also a protective factor. Those reporting secondary or tertiary education actually had a less likelihood of developing symptoms. Post-traumatic stress disorder was a slightly different picture. Females, those aged over 55, those widowed, divorced or separated, living in a rural area and having increased exposure to trauma had a higher likelihood of showing symptoms of post-traumatic stress disorder. Now, the limitations of our survey is that it was restricted to only three mental health disorders. The survey only collected data on adults, adolescents and children were not included. Data on ethnicity was not included, and due to the length of the survey questionnaire, a screening tool for general health was not included. As mentioned, the Harvard trauma questionnaire, although it had been culturally adapted and translated, was not validated for the Kashmiri population. The public health action that has come from this with the evident high prevalence of mental distress in the population, particularly in rural areas, the stakeholders working in mental health across the valley met for a roundtable conference on the 11th of May, at which time recommendations for public health action were formulated. There is a long list of recommendations, the basis of which is around the decentralization of mental health services and capacity building at village level for early detection, intervention and referral. A working group has been established with the stakeholders to follow up these recommendations. I would like to acknowledge the team from MSF, from the University of Kashmir Institute of Mental Health and Neurosciences and a colleague from the Australian National University, but most of all, I would like to acknowledge the people of Kashmir who gave their time, their personal information and shared with the team fantastic hospitality throughout the survey process. Thank you.