Lifetime events and posttraumatic stress disorder in 4 postconflict settings

Association Between Prolonged Grief and Attitudes Toward Reconciliation in Bereaved Survivors of the Khmer Rouge Regime in Cambodia

BACKGROUND

During the Khmer Rouge regime in Cambodia, about a quarter of the population died, resulting in many individuals losing close relatives. Still today, many individuals are suffering from the psychological consequences of these losses, which might also affect the process of reconciliation within the Cambodian society. The aim of this paper is therefore to investigate the association between symptoms of prolonged grief and attitudes toward reconciliation.

METHODS

A sample of 775 survivors of the Khmer Rouge regime who lost relatives during the conflict were interviewed about their losses and traumatic events, prolonged grief (PG; Complicated Grief Assessment Self-Report, CGA-SR), posttraumatic stress disorder (PTSD Checklist - Civilian Version) and attitudes toward reconciliation (Readiness to Reconcile Inventory, RRI).

RESULTS

A higher symptom severity of PG was significantly associated with readiness to reconcile even when controlling for other relevant variables (β = -0.22; p <.001). Persons who met caseness criteria for PG were significantly less ready to reconcile, t(773) = 5.47, p <.001, than persons who did not meet caseness for PG.

CONCLUSION

PG seems to be a relevant mental health correlate of attitudes toward reconciliation. The results of the current study underline the importance of also considering PG with regard to the reconciliation process in Cambodia and possibly also in other post-conflict regions.

Post-Migration Stressors and Their Association With Symptom Reduction and Non-Completion During Treatment for Traumatic Grief in Refugees

BACKGROUND

Resettled refugees exposed to trauma and loss are at risk to develop mental disorders such as posttraumatic stress disorder (PTSD) and persistent complex bereavement disorder (PCBD). Post-migration stressors have been linked to poor mental health and smaller treatment effects.

AIM

Our aim was to evaluate reductions in PTSD and PCBD symptoms and to explore the presence of post-migration stressors and their associations with symptom change and non-completion in a traumatic grief focused treatment in a cohort of refugees.

METHODS

Paired sample t-tests were used to test the significance of the symptom reductions in PTSD and PCBD symptoms during treatment. The presence of post-migration stressors was derived from a qualitative analysis of the patient files. Associations between post-migration stressors and symptom reductions as well as non-completion were calculated.

RESULTS

In this uncontrolled study, 81 files of consecutive patients were included. Significant reductions in both PCBD and PTSD symptomatology with medium effect sizes were found. Patients experienced a mean of three different post-migration stressors during the treatment. Undocumented asylum seekers were more likely to be non-completers. Ongoing conflict in the country of origin was associated with smaller PTSD symptom reductions and the total number of post-migration stressors was associated with smaller PCBD symptom reductions.

CONCLUSIONS

Treatment for resettled refugees for traumatic grief coincides with alleviations in both PCBD and PTSD symptomatology. Specific post-migration stressors were associated with reduced treatment effects and increased non-completion. This is a first step towards well-informed improvements of mental health interventions for resettled refugees.

Post-Traumatic Stress Disorder and Associated Factors Among Internally Displaced People in South Ethiopia: A Cross-Sectional Study

BACKGROUND

Displaced people experience different traumatic events. This can have serious and long-lasting consequences in terms of physical and mental health outcome. Post-traumatic stress disorder (PTSD) is the most frequent mental disorder following traumatic exposure. In 2018 Ethiopia saw the highest number of internal displacement, despite this, less attention has been given to mental health among internally displaced people in the country. This study aims to determine the estimated prevalence and associated factors of PTSD among internally displaced people in the Gede'o zone, south Ethiopia.

PARTICIPANTS AND METHODS

A community-based cross-sectional study was conducted between 1 and 30, May 2019 among 636 participants, who were selected using a simple random sampling technique. PTSD was measured by the Post-Traumatic Stress Disorder Checklist for DSM-5 (PCL-5). The association between outcome and independent variables was identified by bi-variable and multivariate logistic regression. Finally, variables with P-value less than 0.05 were considered statistically significant at 95% CI.

RESULTS

A total of 625 participants were interviewed with a response rate of 98.3%. The estimated prevalence of PTSD was 58.4% with 95% CI 55 to 61.9. In the multivariate logistic regression, being female (AOR=2.4, 95% CI 1.6 to 3.4), depression (AOR=2.6, 95% CI 1.2 to 3.9), displaced more than once (AOR=3.7, 95% CI 2.4 to 5.8), destruction of personal property (AOR=1.6, 95% CI 1.04 to 2.44), witness the murder of family (AOR=2, 95% CI 1.2, 3.9), and cumulative trauma (AOR=4, 95% CI 1.7 to 9.6) were significantly associated factors.

CONCLUSION

In the current study, the estimated prevalence of PTSD was high. Ministry of health should plan routine screening and management of PTSD, depression and linking with available mental health service is recommended.

A cross-country psychiatric screening of ICD-11 disorders specifically associated with stress in Kenya, Nigeria and Ghana

Background: The Global Forum for Health Research, with the support of the World Health Organization, highlighted the need to prioritize mental health research in Africa. The introduction of revised descriptions of Posttraumatic Stress Disorder (PTSD) and Adjustment Disorder, along with new diagnoses of Complex PTSD and Prolonged Grief Disorder, in the ICD-11 creates a need for additional national-level epidemiological studies on the prevalence of stress-related disorders. Methods: The prevalence rates of these four ICD-11 stress disorders were assessed in three African countries including Nigeria (N = 1006), Kenya (N = 1018), and Ghana (N = 500). Participants completed disorder-specific measures for each disorder. Findings: Across the entire sample, the current prevalence rate of probable Adjustment Disorder was 8.4% (95% C.I. = 7.4%, 9.6%), probable PTSD was 18.6% (95% C.I. = 17.2, 20.2%), probable Complex PTSD was 15.9% (95% C.I. = 14.5%, 17.4%) and probable Prolonged Grief Disorder was 3.7% (95% C.I. = 3.1%, 4.5%). Interpretation: The results are applicable primarily to well-educated urban and suburban adults in these African countries. Results indicated that Adjustment Disorder, PTSD, and CPTSD are highly prevalent in these three African countries. There is now a pressing need to develop culturally sensitive interventions to enable recovery from these conditions.

Cultural Scripts of Traumatic Stress: Outline, Illustrations, and Research Opportunities

As clinical-psychological scientists and practitioners increasingly work with diverse populations of traumatized people, it becomes increasingly important to attend to cultural models that influence the ways in which people understand and describe their responses to trauma. This paper focuses on potential uses of the concept of cultural script in this domain. Originally described by cognitive psychologists in the 1980s, scripts refer to specific behavioral and experiential sequences of elements such as thoughts, memories, attention patterns, bodily sensations, sleep abnormalities, emotions and affective expressions, motivation, coping attempts, and ritualized behaviors that are relevant to posttraumatic adjustment. We differentiate between experiences of traumatic stress that are scripted (e.g., cultural explanations are available) versus unscripted. Further characteristics such as script tracks, the effect of script interruptions, and contextual fit of scripts with other cultural models are also described. We consider examples of traumatic stress associated with war and organized, sexualized violence from "Western" and "non-Western" world regions. The concluding part of this review describes a number of possibilities for methodological approaches to assessment of cultural scripts. Capturing central elements of the script(s) of trauma would aid psychological researchers and clinicians in understanding the experiences of trauma in cultural context, which could ultimately lead to better clinical service opportunities worldwide.

Design and measurement in a study of war exposure, health, and aging: protocol for the Vietnam health and aging study

BACKGROUND

Survivors of war throughout the world experience illnesses and injuries that are crucial to understand, given the ongoing treatment and adaptation they demand. In developing countries like Vietnam, where population aging and chronic disease burdens are rapidly rising, aging populations have seen a disproportionate share of armed conflict and related casualties. This paper describes the Vietnam Health and Aging Study (VHAS), a unique resource for investigating mechanisms of association between diverse exposures to armed conflict during the Vietnam War and multiple dimensions of older adult health among survivors of that war.

METHODS

The VHAS utilizes a longitudinal design, the first wave of data collection conducted in 2018 among 2447 older adults. A second wave of follow-up data collection, scheduled to take place in 2021, will examine life course, social relational and health and mortality transitions. The VHAS was conducted in four northern Vietnamese districts purposively selected to represent a spectrum of war exposure as indicated by intensity of bombings. Additionally, VHAS uses random sampling within gender and military service subdomains to permit unique gender-specific analyses of military service, trauma exposure and health. The VHAS' face-to-face interviews include modules detailing war and military service experiences; warzone stressors; and multiple dimensions of health such as chronic disease, functional limitation, disability, health behaviors, cognition and psychological health. Biomarker data collected for the full VHAS sample includes anthropometric and functional tests such as grip strength and blood pressure, hair samples for cortisol assay, and capillary blood samples to assay C-reactive protein, cholesterol, HbA1c, and other markers of interest for cardiovascular and other disease risks and for testing the impact of early life stressors on later life health. Blood samples will also permit epigenetic analysis of biological aging.

DISCUSSION

Future VHAS investigations will examine dynamic linkages between war exposure, mortality and morbidity, while taking into account the selective nature of each of these processes. Longitudinal analyses will examine late-life health transitions and war-related resiliency.

Resilience and anxiety or depression among resettled Bhutanese adults in the United States

BACKGROUND

Resilience, or an individual's positive response in managing life's adversities, is of increasing interest in addressing the mental health disparities in refugees. Although the link between stressful life events and poor mental health is established, research on the role of resilience on the mental health of refugees is limited.

AIMS

This study assessed the association between resilience and anxiety or depression in resettled Bhutanese adults in Western Massachusetts.

METHODS

A cross-sectional survey was conducted among 225 Bhutanese (men: 113, women: 112) refugees aged 20-65 residing in Massachusetts. Resilience was measured with the 25-item Wagnild and Young's Resilience Scale including two constructs as follows: a 17-item 'personal competence' that measures self-reliance, independence, determination, resourcefulness, mastery and perseverance and an 8-item 'acceptance of self and life' that measures adaptability, flexibility and a balanced perspective of life. Higher total scores indicate greater resilience. The Hopkins Symptom Checklist-25 was used to measure anxiety (10-item) and depression (15-item) with a cutoff mean score of ⩾1.75 for moderate to severe symptoms. Associations of resilience with anxiety or depression scores were assessed using multiple-linear and logistic regression analyses.

RESULTS

The proportion of participants with above threshold anxiety and depression were 34.2% and 24%, respectively. Resilience was inversely associated with both anxiety (beta for 1 unit change in resilience scores: β = -0.026; p = .037) and depression (β = -0.036, p = .041). 'Personal competence' resilience was inversely associated with both anxiety (β = -0.041 p = .017) and depression (β = -0.058, p = .019), but 'acceptance of self and life' resilience was not. Participants with the highest tertile of resilience scores had a significantly decreased risk of anxiety (ORs (95% CI): 0.13 (0.04-0.40)) and depression (0.16 (0.04-0.60)).

CONCLUSION

Higher resilience was associated with reduced anxiety and depression among Bhutanese with personal competence resilience accounting for most of the effects. These findings suggest the potential targets for mental-health intervention to improve resilience in refugees.

Challenges in health-care service use among Burmese refugees: A grounded theory approach

The timely use of health-care services is essential to achieve the best health outcomes. We explore barriers to health-care access among refugees from Burma through interviews with key community informants who serve their community as interpreters, health-care professionals, paraprofessionals, and/or representatives. The interviews with a convenience sampling of 11 leaders from Burmese and Karen ethnic communities revealed three stages of health-care use (i.e., before, during, and after doctor's appointments), in which their community members encounter difficulties in accessing health-care services. Using grounded theory analysis approach, specific difficulties and cultural considerations for each stage were emerged. This study suggests that training programs for health-care providers on refugee populations' needs, cultural expectations, attitudes, and health behaviors may ease the process for refugees during each of these three stages. Interpreters as cultural brokers have an important role in facilitating cross-cultural communications not only before and during the appointment but also after doctor's visits, such as in the pharmacy and labs.

Symptoms of post-traumatic stress disorder and depression among Eritrean refugees in Ethiopia: identifying direct, meditating and moderating predictors from path analysis

OBJECTIVE

This study aimed at testing the significance of mediating and moderating roles of sense of coherence, adaptive coping styles and social support in the relationship between exposure to trauma and psychological symptoms in a refugee population in sub-Saharan Africa.

METHODS

A cross-sectional survey design was employed to collect data. The study was carried out in Mai Aini refugee camp in Ethiopia. A total of 562 adult Eritrean refugees aged 18-74 years were selected randomly to screen for depression and post-traumatic stress disorder (PTSD) symptoms and to examine associated factors. Data were collected using the premigration and postmigration living difficulties checklist, Center for Epidemiologic Studies Depression (CES-D) scale, Primary Care PTSD Screener, coping style scale, Sense of Coherence scale and Oslo Social Support scale. Path modelling was used to test the mediation and moderation effects of prespecified factors.

RESULTS

Premigration living difficulties were associated directly with symptoms of PTSD (β=0.09, p<0.05), and associated indirectly with PTSD symptoms in paths through duration of stay in the camp, sense of coherence, postmigration living difficulties, task-oriented coping style and depressive symptoms (β=0.26, p<0.01). Premigration and postmigration living difficulties were associated directly with depressive symptoms with standardised estimate of β=0.35(p<0.001) and β=0.23(p<0.05), respectively. Postmigration living difficulties were associated indirectly with PTSD through paths of sense of coherence, task-oriented coping style and depressive symptoms (β=0.13; p<0.01). Social support moderated the effect of postmigration living difficulties on depressive symptoms (p<0.05). Emotion-oriented coping style moderated the effect of premigration threat for abuse on PTSD (β=-0.18, p<0.001) and depressive (β=-0.12, p<0.01) symptoms, as well as moderating threat to life on PTSD symptoms (β=-0.13, p<0.001).

CONCLUSIONS

Sense of coherence and task-oriented coping style showed a partial mediating effect on the association between exposure to trauma and symptoms of PTSD. An emotion-oriented coping style and social support moderated the effect of premigration and postmigration living difficulties, respectively. Fostering social support, task-oriented and emotion-oriented coping styles may be beneficial for these refugees.

The prevalence of PTSD and major depression in the global population of adult war survivors: a meta-analytically informed estimate in absolute numbers

Background: Elevated prevalences of post-traumatic stress disorder (PTSD) and major depression (MD) have been reported in populations exposed to war. However, no global estimates of war survivors suffering from PTSD and/or MD in absolute numbers have been reported. Objective: We made the first attempt to estimate in absolute numbers how many adult war survivors globally may suffer PTSD and/or MD, which should inform local and global mental health programmes. Method: Drawing on the Uppsala Conflict Database, we reviewed all countries that suffered at least one war within their own territory between 1989 and 2015 (time span chosen on availability of geo-referenced data and population estimates). We then conducted a meta-analysis of current randomized epidemiological surveys on prevalence of PTSD and/or MD among war survivors. Finally, we extrapolated our results from the meta-analysis on the global population of adult war survivors by means of using general population data from the United Nations. Results: We estimate that about 1.45 billion individuals worldwide have experienced war between 1989 and 2015 and were still alive in 2015, including one billion adults. On the basis of our meta-analysis, we estimate that about 354 million adult war survivors suffer from PTSD and/or MD. Of these, about 117 million suffer from comorbid PTSD and MD. Conclusions: Based on the slim available evidence base, the global number of adult war survivors suffering PTSD and/or MD is vast. Most war survivors live in low-to-middle income countries with limited means to handle the enormous mental health burden. Since representative high quality data is lacking from most of these countries, our results contain a large margin of uncertainty and should be interpreted with caution.

The impact of post-traumatic stress disorder on dental and gingival status of children during syrian crisis: A preliminary study

AIM

Most children in war zone countries often experience post-traumatic stress disorder (PTSD). This turns the war into a health issue of great importance. The aim was to evaluate dental and gingival status of children suffering from PTSD.

METHODS

A case control study, which included 60 children (30 diagnosed with PTSD and 30 healthy controls) between 9 and 14 years, was undertaken. Dental status was assessed using decayed, missing, and filled teeth (DMFT) for permanent and decayed, missing and filled teeth (dmft) for primary. Gingival status was examined using plaque (PI) and gingival (GI) indices. Child PTSD reaction index (CPTSD-RI) was used to evaluate the severity of PTSD.

RESULTS

There was no significant difference in DMFT and dmft indices between the PTSD children and the controls. However, PTSD children had more decay in permanent (DT) and primary teeth (dt), more primary missing teeth mt and less filled teeth in their permanent (FT) and primary (ft) dentition. Significant difference was found between PTSD children and controls regarding PI (P < 0.00001) and GI (P < 0.0001). CPTSD-RI was positively correlated with DMFT (P = 0.002), PI (P = 0.038), and GI (P = 0.007).

CONCLUSION

PTSD children had poor dental and gingival status than matched controls and they were affected by PTSD severity.

Prevalence of depression and posttraumatic stress disorder in adult civilian survivors of war who stay in war-afflicted regions. A systematic review and meta-analysis of epidemiological studies

BACKGROUND

Epidemiological surveys on depression and posttraumatic stress disorder (PTSD) among civilian war survivors in war-afflicted regions have produced heterogeneous prevalence estimates of these conditions.

METHODS

To determine the prevalence of both depression and PTSD in civilian war survivors in the area of conflict, we conducted a systematic search of Medline, PsycInfo, and Pilots databases. We included epidemiological studies that had used structured clinical interviews. We conducted random effects meta-analyses on prevalence proportions as well as univariate mixed model meta-regressions.

RESULTS

We included 33 studies that assessed prevalences of depression (k = 18) and/or PTSD (k = 30). Across all studies, pooled point prevalences of 0.27 and 0.26 were found for depression and PTSD, respectively. Ten percent of participants fulfilled criteria for both disorders. Surveys with a higher mean age of participants reported higher prevalence of depression. Furthermore, samples with higher rates of unemployment and higher percentages of women reported higher prevalence of PTSD, whereas samples with a higher number of participants living with a partner reported lower prevalence of PTSD.

LIMITATIONS

The findings are limited by poor psychometric reporting practices.

CONCLUSIONS

Our findings suggest that both depression and PTSD are highly prevalent in war survivors who stayed in the area of conflict. Yet, future research on this topic need to focus on psychometric properties of instruments used to assess psychopathology among war survivors. Notwithstanding this limitation, there is an urgent need for large-scale mental health programs that are appropriate for war-affected countries with limited resources and address depression as much as PTSD.

Human Rights as Political Determinants of Health: A Retrospective Study of North Korean Refugees

INTRODUCTION

The gravity, scale, and nature of human rights violations are severe in North Korea. Little is known about the mental health consequences of the lifelong exposures to these violations.

METHODS

In 2014-2015, a retrospective study was conducted among 383 North Korean refugees in South Korea using respondent-driven sampling to access this hidden population. This study collected information on the full range of political and economic rights violations and measured post-traumatic stress disorder, anxiety and depression symptoms, and social functioning by standard instruments. Multivariate regression analysis was performed with the adjustment of political, economic, and demographic variables in 2016-2017.

RESULTS

The results indicate elevated symptoms of anxiety (60.1%, 95% CI=54.3%, 65.7%), depression (56.3%, 95% CI=50.8%, 61.9%), and post-traumatic stress disorder (22.8%, 95% CI=18.6%, 27.4%), which are significantly associated with exposures to political rights violations (ten to 19 items versus non-exposure: anxiety AOR=16.78, p<0.001, depression AOR=12.52, p<0.001, post-traumatic stress disorder AOR=16.71, p<0.05), and economic rights violations (seven to 13 items versus non-exposure: anxiety AOR=5.68, p<0.001, depression AOR=4.23, p<0.01, post-traumatic stress disorder AOR=5.85, p<0.05). The mean score of social functioning was also lower in those who were exposed to political (adjusted difference= -13.29, p<0.001) and economic rights violations (adjusted difference= -11.20, p<0.001).

CONCLUSIONS

This study highlights mental health consequences of lifelong human rights violations in North Korea. Beyond the conventional approach, it suggests the need for a collaborative preventive response from global health and human rights activists to address human rights in regard to mental health determinants of the 20 million people in North Korea.

Coping with trauma and adversity among Palestinians in the Gaza Strip: A qualitative, culture-informed analysis

In this article, we propose that coping is not only an individual property but also a structural feature. Coping shapes what is referred to in social network theory as multiplex networks, which are based on relations with multiple functions, values and meanings. Focus groups with adult Palestinians were held and content analysed. Five main coping strategies were identified: (a) creating cultural and religious meaning; (b) individualism to collectivism; (c) normalization and habituation; (d) belonging, acceptance, expectation and readiness; and (e) social support. Participants also reported culture-specific expressions for indicating psychological distress. Implications for cultural informed clinical work are then discussed.

[Stress syndrome in patients receiving outpatient treatment at the General Hospital, in Bangui, in a context of armed conflict]

Introduction

dans les zones de conflit en Afrique les récentes études rapportent des fréquences élevées des états de stress posttraumatiques (ESPT) notamment en milieu communautaire. L'objectif général de cette étude est de contribuer à une meilleure prise en charge des patients confrontés à la violence subséquente au conflit sociopolitique en cours en République centrafricaine.

Méthodes

il s'agit d'une étude transversale portant sur les dossiers des patients reçus en consultation externe Trauma center de Médecins sans Frontières/France à Bangui.

Résultats

l'ESPT était présent chez 33.33 % (n = 35) alors que l'état de stress aigu était présent chez 17.14 % (n = 18) des patients. Les états de stress (ES) étaient associés au sexe féminin, au viol, à l'anxiété et à la dépression. Le viol multipliait par 8 le risque de survenue d'un ES. L'âge médian observé était de 30 ans (P25: 22 ans; P75: 40 ans). La majorité des patients présentait un trouble de l'humeur (63.81 %; n = 67). L'insomnie était présente chez 62.83 % (n = 66). L'anxiété (HADS) était présente chez 44.76 % des patients (n = 47). La dépression a été retrouvée chez 40.95 % (n = 43).

Conclusion

les résultats obtenus montrent à quel point, au-delà des membres de milices, la société est touchée par la violence du conflit que traverse le pays. Ces résultats pourraient nourrir la réflexion sur l'organisation des soins et la prise en charge de la population centrafricaine considérant l'impact à court, moyen et long terme des états de stress aigus en situation de conflit.

Well-being and pressures of daily life in two West Bank villages-Exploring context and history

Interest in the well-being of people exposed to long-term violence and conflict has tended to focus on measurable effects of acute traumatic events, while attention to the pressures of their daily living context is relatively new. Using qualitative and quantitative data from a 2005 survey of all female family caretakers in 2 neighbouring Israeli-occupied West Bank villages (n = 820), we explored the associations of demographic, health-related and contextual factors with reported pressures and WHO-5 well-being index scores. The final model explained 17.8% of the variance with negative associations between health-related factors ("back-aches," "stomach aches" "psychological illness in the family") and family-related factors ("male head of household aggressive", "male head of household physically violent") and the WHO-5 well-being index scores. We found positive associations between socio-economic factors ("standard of living"; "number of rooms") and village-related factors ("residency in village A/B") and the WHO-5 well-being index score. Exploring the daily living context of villages A and B illuminated how the impact of historical and political events differed, even in villages that are geographically close. The paper lends support to calls for including politics and history in research on well-being in contexts of long-term violence and conflict.

A scoping review of the associations between mental health and factors related to HIV acquisition and disease progression in conflict-affected populations

The association between poor mental health and factors related to HIV acquisition and disease progression (also referred to as HIV-related factors) may be stronger among conflict-affected populations given elevated rates of mental health disorders. We conducted a scoping review of the literature to identify evidence-based associations between mental health (depression, anxiety, and post-traumatic stress disorder [PTSD]) and factors related to HIV acquisition and progression in conflict-affected populations. Five electronic databases were searched on October 10, 2014 and updated on March 7, 2017 to identify peer-reviewed publications presenting primary data from January 1, 1994 to March 7, 2017. Articles were included if: 1) depression, anxiety, and/or PTSD was assessed using a validated scale, 2) HIV or HIV-related factors were a primary focus, 3) quantitative associations between depression/anxiety/PTSD and HIV or HIV-related factors were assessed, and 4) the study population was conflict-affected and from a conflict-affected setting. Of 714 citations identified, 33 articles covering 110,818 participants were included. Most were from sub-Saharan Africa (n = 25), five were from the USA, and one each was from the Middle East, Europe, and Latin America. There were 23 cross-sectional, 3 time-series, and 7 cohort studies. The search identified that mental health has been quantitatively associated with the following categories of HIV-related factors in conflict-affected populations: markers of HIV risk, HIV-related health status, sexual risk behaviors, and HIV risk exposures (i.e. sexual violence). Further, findings suggest that symptoms of poor mental health are associated with sexual risk behaviors and HIV markers, while HIV risk exposures and health status are associated with symptoms of poor mental health. Results suggest a role for greater integration and referrals across HIV and mental health programs for conflict-affected populations.

Four decades following the Khmer rouge: sociodemographic factors impacting depression, anxiety and PTSD in Cambodia

BACKGROUND

Reliable population-based epidemiological data of Cambodian mental health is lacking.

AIMS

This study identifies the prevalence of and factors associated with anxiety, depression and PTSD in Cambodian adults.

METHODS

A nationally representative sample of Cambodian adults (N = 2690) was interviewed utilizing the Harvard Trauma Questionnaire (assessment of PTSD symptoms) and the Hopkins Symptom Checklist-25 (assessment of symptoms of anxiety and depression).

RESULTS

Respondents expressed high rates of anxiety (27.4%), depression (16.7%) and PTSD (7.6%). Correlations between symptoms and sociodemographic markers varied in significance. Women had significantly higher rates of mental health symptoms than men. Women who were in debt, widowed or divorced and had low levels of education were the most likely to report symptoms.

CONCLUSIONS

These findings can inform Cambodian mental health policies and development strategies, especially targeting the most vulnerable groups.

Posttraumatic stress disorder (PTSD) and complex PTSD (CPTSD) as per ICD-11 proposals: A population study in Israel

BACKGROUND

The current study sought to advance the existing literature by providing the first assessment of the factorial and discriminant validity of the ICD-11 proposals for posttraumatic stress disorder (PTSD) and complex PTSD (CPTSD) in a nationwide level.

METHODS

A nationally representative sample from Israel (n = 1,003) using a disorder-specific measure (ITQ; International Trauma Questionnaire) in order to assess PTSD and CPTSD along with the Life Events Checklist and the World Health Organization Well-Being Index.

RESULTS

Estimated prevalence rates of PTSD and CPTSD were 9.0 and 2.6%, respectively. The structural analyses indicated that PTSD and disturbances in self-organization symptom clusters were multidimensional, but not necessarily hierarchical, in nature and there were distinct classes that were consistent with PTSD and CPTSD.

CONCLUSIONS

These results partially support the factorial validity and strongly support the discriminant validity of the ICD-11 proposals for PTSD and CPTSD in a nationally representative sample using a disorder-specific measure; findings also supported the international applicability of these diagnoses. Further research is required to determine the prevalence rates of PTSD and CPTSD in national representative samples across different countries and explore the predictive utility of different types of traumatic life events on PTSD and CPTSD.

Mental Health Effects of Stress over the Life Span of Refugees

Information about the relative impact of stressful events across the lifespan on the mental health of refugees is needed. Cross-sectional data from a community sample of 135 Kurdish and 117 Vietnamese refugees were fit to a path model about the effects of non-war stress, war-related stress, and post-migration stress on mental health. Kurdish and Vietnamese data were generally consistent with the model. However, war-related stress produced no direct but a large indirect effect through post-migration stress on mental health in Kurds. Vietnamese data indicated a modest direct war-related stress effect but no indirect influence through post-migration stress. Different types of stressful events lead to adverse mental health of displaced refugees in a somewhat group-dependent manner. Implications for prevention and treatment are discussed.

Civilians in World War II and DSM-IV mental disorders: results from the World Mental Health Survey Initiative

PURPOSE

Understanding the effects of war on mental disorders is important for developing effective post-conflict recovery policies and programs. The current study uses cross-sectional, retrospectively reported data collected as part of the World Mental Health (WMH) Survey Initiative to examine the associations of being a civilian in a war zone/region of terror in World War II with a range of DSM-IV mental disorders.

METHODS

Adults (n = 3370) who lived in countries directly involved in World War II in Europe and Japan were administered structured diagnostic interviews of lifetime DSM-IV mental disorders. The associations of war-related traumas with subsequent disorder onset-persistence were assessed with discrete-time survival analysis (lifetime prevalence) and conditional logistic regression (12-month prevalence).

RESULTS

Respondents who were civilians in a war zone/region of terror had higher lifetime risks than other respondents of major depressive disorder (MDD; OR 1.5, 95% CI 1.1, 1.9) and anxiety disorder (OR 1.5, 95% CI 1.1, 2.0). The association of war exposure with MDD was strongest in the early years after the war, whereas the association with anxiety disorders increased over time. Among lifetime cases, war exposure was associated with lower past year risk of anxiety disorders (OR 0.4, 95% CI 0.2, 0.7).

CONCLUSIONS

Exposure to war in World War II was associated with higher lifetime risk of some mental disorders. Whether comparable patterns will be found among civilians living through more recent wars remains to be seen, but should be recognized as a possibility by those projecting future needs for treatment of mental disorders.

Prevalence of Mental Distress Among Syrian Refugees With Residence Permission in Germany: A Registry-Based Study

Background: High rates of prevalence of mental distress among the Syrian refugee population have been repeatedly confirmed. However, little is known about the influence of length of stay, living conditions, and residence permission in the host country or about the duration of the escape journey and travel conditions on mental health in this refugee population. This study examines the mental health of Syrian refugees, taking into account the circumstances in their country of origin and host country, as well as their escape conditions. Methods: This investigation formed part of a registry-based study. A sample of 518 adult Syrian refugees in Erlangen, Germany, who have residence permission was identified. The response rate was 38.6%; a total of 200 Syrian refugees thus participated in the study. The respondents were investigated for post-traumatic stress disorder (ETI), depression (PHQ-9), generalized anxiety (GAD-7) and post-migration variables. Results: The prevalence of participants who had personally experienced and/or witnessed traumatic events was 75.3%. Symptoms of PTSD were found in 11.4% of the participants. Moderate to severe depression was confirmed in 14.5% and moderate to severe generalized anxiety in 13.5% of the sample. The criteria for at least one diagnosis were met by 30.5% of the participants. More severe PTSD symptoms were associated with older age, shorter validity of the residence permit, larger number of traumatic events (TEs) and higher generalized anxiety symptoms. Depression symptoms were associated with younger age, shorter duration of escape journey, larger number of TEs and higher generalized anxiety symptoms. Generalized anxiety symptoms correlated with female gender, PTSD, and depression symptoms. Conclusions: These findings suggest that Syrian refugees in Germany are a vulnerable population, especially if they have experienced and/or witnessed multiple traumatic events. However, post-migration conditions and positive future prospects in the host country can be protective factors for this population.

The Effects of Traumatic and Multiple Loss on Psychopathology, Disability, and Quality of Life in Iraqi Asylum Seekers in the Netherlands

Emerging evidence suggests that the loss of loved ones under traumatic circumstances is highly prevalent among refugees and asylum seekers. We evaluated the effects of traumatic and multiple losses of family members and friends on psychopathology, disability, and quality of life in Iraqi asylum seekers in the Netherlands, and investigated mediation of these effects through psychopathology. Respondents (N = 294) completed structured Arabic interviews. Data were analyzed using structural equation modeling. The loss of a loved one was reported by 87.6% of the sample. Traumatic and multiple losses of family members independently predicted psychopathology, taking the effects of other traumatic events, postmigration stressors, and sociodemographic characteristics into account. Effects of traumatic and multiple losses on quality of life and disability were either partially or fully mediated by psychopathology. These findings highlight the need to evaluate and treat the effects of the loss of loved ones when working with asylum seekers and refugees as well as to incorporate grief-related psychopathology in diagnostic classifications.

Psychological Predictors of Sexual Intimate Partner Violence against Black and Hispanic Women

Background: Although various types of intimate partner violence (IPV) tend to co-occur, risk factors of each type of IPV may differ. At the same time, most of the existing literature on risk factors of IPV among minorities has used a cross-sectional design and has focused on physical rather than sexual IPV. We conducted the current study to compare Black and Hispanic women for psychological predators of change in sexual IPV over time. Methods: Using data from the Fragile Families and Child Wellbeing Study (FFCWS), this study followed 561 Black and 475 Hispanic women with their male partners for four years. Independent variables included male partners' depression, anxiety, problem alcohol use, and male-to-female physical and psychological IPV perpetration. The dependent variable was sexual IPV reported by female partners, measured at baseline, two years, and four years later. Covariates included age, income, marital status and educational level. We used a multi-group latent growth curve model (LGCM) to explain intercept, linear, and quadratic slopes, which represent the baseline, and linear and curvilinear trajectories of male-to-female sexual IPV, where groups were defined based on ethnicity. Results: Psychological IPV was associated with sexual IPV at baseline among both ethnic groups. The male partner's depression was a risk factor for an increase in sexual IPV over time among Black but not Hispanic women. Anxiety, problem alcohol use and physical IPV did not have an effect on the baseline or change in sexual IPV over time. Psychological IPV was not associated with an increase in sexual IPV over time in either ethnic groups. Conclusions: There is a need for screening of sexual IPV in the presence of psychological IPV among minority women. There is also a need for screening and treatment of male partners' depression as a strategy to reduce sexual IPV among Black women.

Trauma-Informed HIV Prevention and Treatment

The high prevalence of trauma and its negative impact on health and health-promoting behaviors underscore the need for multi-level interventions to address trauma and its associated sequelae to improve physical and mental well-being in both HIV-infected and HIV-uninfected populations. Growing global awareness of the intersection of trauma and HIV has resulted in development and testing of interventions to address trauma in the context of HIV treatment and HIV prevention in the USA and globally. Despite increasing recognition of the widespread nature of trauma and the importance of trauma to HIV transmission around the globe, several gaps remain. Through a survey of the literature, we identified eight studies (published in the past 5 years) describing interventions to address the effects of trauma on HIV-related outcomes. In particular, this study focused on the levels of intervention, populations the interventions were designed to benefit, and types of trauma addressed in the interventions in the context of both HIV prevention and treatment. Remarkably absent from the HIV prevention, interventions reviewed were interventions designed to address violence experienced by men or transgender individuals, in the USA or globally. Given the pervasive nature of trauma experienced generally, but especially among individuals at heightened risk for HIV, future HIV prevention interventions universally should consider becoming trauma-informed. Widespread acknowledgement of the pervasive impact of gender-based violence on HIV outcomes among women has led to multiple calls for trauma-informed care (TIC) approaches to improve the effectiveness of HIV services for HIV-infected women. TIC approaches may be relevant for and should also be tested among men and all groups with high co-occurring epidemics of HIV and trauma (e.g., men who have sex with men (MSM), transgendered populations, injection drug users, sex workers), regardless of type of trauma experience.

Differences in posttraumatic stress characteristics by duration of exposure to trauma

Ongoing exposure of civilian populations to war and terror is associated with adverse responses beyond those specified in DSM-5 for PTSD. Current PTSD assessment practices are not fully sensitive to the complex symptomatic picture observed among individuals exposed to ongoing stress and are therefore limited for use in these situations. The current survey aimed to portray the posttraumatic characteristics most salient to ongoing exposure to political conflict. A questionnaire enquiring about various aspects of the posttraumatic consequences of ongoing exposure to political conflict as compared with those associated with a single exposure to trauma was disseminated to therapists throughout the country. Participants were asked to rank 75 posttraumatic characteristics for their relevance to each trauma type (about the symptom frequency and severity) and item mean scores were compared. The sample consisted of 66 responses valid for analysis. Our findings pinpoint some of the posttraumatic characteristics most salient to ongoing exposure to political conflict and highlight the complexity of the posttraumatic picture observed in these situations. Incorporating these in post trauma assessment tools will allow for the development of standardized, reliable definitions, which in turn will allow for more accurate diagnosis and more effective treatment protocols.

Prevalence and determinants of common mental illness among adult residents of Harari Regional State, Eastern Ethiopia

INTRODUCTION

Common mental disorders include depression, anxiety and somatoform disorders are a public health problem in developed as well as developing countries. It represents a psychiatric morbidity with significant prevalence, affecting all stages of life and cause suffering to the individuals, their family and communities. Despite this fact, little information about the prevalence of common mental illness is available from low and middle-income countries including Ethiopia. The aim of this study was to determine the magnitude of common mental disorders and its associated factors among adult residents of Harari Region.

METHODS

Comparative cross-sectional, quantitative community-based survey was conducted From February 1, 2016 to March 30, 2016 in Harari Regional State using multi-stage sampling technique. A total of 968 residents was selected using two stage sampling technique. Of this 901 were participated in the study. Validated and Pretested Self reported questionnaire (SQR_20) was used to determine the maginitude of common mental disorders. Data was entered and analyzed using Epi-info version 3.5.1 and SPSS-17 for windows statistical packages. Univirate, Bi-variate and multivariate logistic regression analysis with 95% CI was employed in order to infer associations.

RESULTS

The prevalence of common mental illnesses among adults in our study area was 14.9%. The most common neurotic symptoms in this study were often head ache (23.2%), sleep badly (16%) and poor appetite (13.8%). Substance use like Khat chewing (48.2%), tobacco use (38.2%) and alcohol use (10.5%) was highly prevalent health problem among study participant. In multivariate logistic regression analysis, respondents age between 25-34 years, 35-44 years, 45-54 years and above 55years were 6.4 times (AOR 6.377; 95% CI: 2.280-17.835), 5.9 times (AOR 5.900; 95% CI: 2.243-14.859), 5.6 times (AOR 5.648; 95% CI: 2.200-14.50) and 4.1 times (AOR 4.110; 95% CI: 1.363-12.393) more likely having common mental illnesses than those age between 15-24 years, respectively. The occurrence of common mental illness was twice (AOR: 2.162; 95% CI 1.254-3.728) higher among respondents earn less than the average monthly income than those earn more than average monthly income. The odds of developing common mental illnesses were 6.6 times (AOR 6.653; 95% CI: 1.640-6.992) higher among adults with medically confirmed physical disability than those without physical disability. Similarly, adults who chewed Khat were 2.3 times (AOR 2.305; 95% CI: 1.484-3.579) more likely having common mental illnesses than those who did not chew Khat. Adults with emotional stress were twice (AOR 2.063; 95% CI: 1.176-3.619) higher chance to have common mental illnesses than adults without emotional stress.

CONCLUSION

This study had reveals that common mental disorders are major public health problems. Advancing age, low average family monthly income, Khat chewing and emotional stress were independent predictors of common mental illnesses. Whereas sex, place of residence, educational status, marital status, occupation, family size, financial stress, taking alcohol, tobacco use and family history of mental illnesses were not statistically associated with common mental illnesses.

Avoidance in posttraumatic stress among refugee survivors of violent conflict and atrocities: Testing trans-cultural risk processes and candidate intervention targets

BACKGROUND

A fast-growing population of refugees and survivors of violent conflict and atrocities are at risk for trauma-related mental health problems. Experimental clinical research key to the development of interventions tailored to this population is limited.

AIMS

In an experimental psychopathology laboratory paradigm, we tested the expression and function of avoidance in posttraumatic stress (PTS) among a highly traumatized community sample of forcibly displaced refugees seeking asylum.

METHOD

We measured behavioral avoidance and emotional reactivity to repeated exposure to threatening stimuli (trauma-, war-, and geographically-relevant natural threat) in 110 Sudanese male asylum seekers (M(SD)_age = 32.7(6.5)) recruited from the community in Israel.

RESULTS

First, we found evidence of sensitization - traumatized refugees expressed increasing levels of behavioral avoidance and emotional reactivity in response to repeated exposure to threatening stimuli. Second, as predicted, refugees suffering from more severe PTS were more likely to exhibit greater behavioral avoidance and emotional reactivity reflexively or immediately upon exposure to threat stimuli. Finally, as predicted, behavioral avoidance mediated the effect of PTS severity on emotional reactivity to threat exposure.

CONCLUSIONS

Findings are consistent with theorizing that avoidance may function as a trans-cultural malleable risk process sub-serving PTS and thereby a promising intervention target among highly traumatized refugees from E. Africa.

Enduring impact of conflict on mental health and gender-based violence perpetration in Bougainville, Papua New Guinea: A cross-sectional study

BACKGROUND

Violence against women is often exacerbated by war, but most civilian research has investigated short term impact. We describe the conflict experiences of men and women from the general population of Bougainville Papua New Guinea, perceptions of the enduring impact of conflict, and the associations between these and the major health and development problems on the islands: mental ill-health and violence against women.

METHODS

Fourteen years after the end of the decade long civil war, we conducted a household survey with a random sample of adult (n = 864) men and (n = 879) women living in Bougainville. The interviews were mostly conducted face-to-face, with very sensitive questions self-completed.

RESULTS

Mental ill-health was highly prevalent, 37.8% of women and 32% of men had high levels of depressive symptomatology, 34.4% of men abused alcohol and 15.1% of women and 24.6% of men had high levels of PTSD symptoms. Among women, 23.3% had been raped in the year prior to the interview and 33.3% had experience physical or sexual partner violence. The prevalence of exposure to trauma during the civil war was very high and many of the men and women experienced lingering impact of conflict. Multiple logistic regression models showed that war trauma was associated with PTSD symptoms in women and PTSD symptoms, alcohol abuse and depressive symptoms in men. The perceived enduring impact of conflict was associated with depressive symptoms in men and women, problem drinking and suicidal thoughts in women and drug use in men. The perceived enduring conflict impact was associated with perpetration of past year rape and physical and/or sexual partner violence.

DISCUSSION

The Bougainville civil war had a devastating impact on the population's lives. Reversing this legacy is essential but requires addressing what is perceived as the enduring social, economic and psychological impact of the conflict and a major focus on prevention of violence against women.

Physical and Mental Health Consequences of War-related Stressors Among Older Adults: An Analysis of Posttraumatic Stress Disorder and Arthritis in Northern Vietnamese War Survivors

Objectives

We examine the impacts of trauma exposures and family stressors associated with the Vietnam War on musculoskeletal health and posttraumatic stress disorder (PTSD) outcomes in elderly Vietnamese who were widely impacted by the war as young adults. Noting that wars' impacts extend beyond male veterans in most survivor populations, we give attention to male and female war survivors placed in a variety of roles vis-a-vis the war.

Method

Utilizing data from the 2010 Vietnam Health and Aging Pilot Study (N = 405), we use logistic and Poisson regression models to estimate the effect of wartime trauma exposures and family stressors on disabling arthritis and PTSD symptoms in male and female northern Vietnamese adults aged 55 and older.

Results

The odds of experiencing recent PTSD symptoms are greater in respondents who report involvement in killing/causing severe injury and who observed war atrocities. In women, PTSD is positively correlated with war era child death and spousal separation. Arthritis also exhibits a significant, positive association with killing/causing severe injury.

Discussion

Our study provides insights into the burden of conflict upon health among populations of the global south that survived war and are now entering older adulthood. The pattern of results, indicating greatest suffering among those who inflicted or failed to prevent bodily harm or loss of life, is consistent with the concept of moral injury.

Cultural translation of refugee trauma: Cultural idioms of distress among Somali refugees in displacement

Westernized approaches to mental health care often place limited emphasis on refugees' own experiences and cultural explanations of symptoms and distress. In order to effectively assess community mental health needs and develop interventions grounded in local needs, mental health programs need to be informed by an understanding of cultural features of mental health, including cultural idioms of distress (CIDs). The current study aims to explore CIDs among Somali refugees displaced in Kenya to understand mental health needs in cultural context and serve the community in a culturally responsive and sensitive manner. This research was conducted as a two-phase qualitative study. First, key informant interviews with Somali mental health stakeholders generated a list of 7 common Somali CIDs: buufis, buqsanaan, welwel, murug, qaracan, jinn, and waali. Typologies of each CID were further explored through four focus group interviews with Somali community members. The findings from a template analysis revealed Somali lay beliefs on how trauma and daily stressors are experienced and discussed in the form of CIDs and how each term is utilized and understood in attributing symptoms to associated causes. This study highlights the need to incorporate colloquial terms in mental health assessment and to adopt a culturally relevant framework to encourage wider utilization of services and religious/spiritual support systems.

Posttraumatic stress disorder in the World Mental Health Surveys

BACKGROUND

Traumatic events are common globally; however, comprehensive population-based cross-national data on the epidemiology of posttraumatic stress disorder (PTSD), the paradigmatic trauma-related mental disorder, are lacking.

METHODS

Data were analyzed from 26 population surveys in the World Health Organization World Mental Health Surveys. A total of 71 083 respondents ages 18+ participated. The Composite International Diagnostic Interview assessed exposure to traumatic events as well as 30-day, 12-month, and lifetime PTSD. Respondents were also assessed for treatment in the 12 months preceding the survey. Age of onset distributions were examined by country income level. Associations of PTSD were examined with country income, world region, and respondent demographics.

RESULTS

The cross-national lifetime prevalence of PTSD was 3.9% in the total sample and 5.6% among the trauma exposed. Half of respondents with PTSD reported persistent symptoms. Treatment seeking in high-income countries (53.5%) was roughly double that in low-lower middle income (22.8%) and upper-middle income (28.7%) countries. Social disadvantage, including younger age, female sex, being unmarried, being less educated, having lower household income, and being unemployed, was associated with increased risk of lifetime PTSD among the trauma exposed.

CONCLUSIONS

PTSD is prevalent cross-nationally, with half of all global cases being persistent. Only half of those with severe PTSD report receiving any treatment and only a minority receive specialty mental health care. Striking disparities in PTSD treatment exist by country income level. Increasing access to effective treatment, especially in low- and middle-income countries, remains critical for reducing the population burden of PTSD.

Utilization of traditional, complementary and alternative medicine and mental health among patients with chronic diseases in primary health care settings in Cambodia

Background

Coping with chronic illnesses often involves major lifestyle changes that may lead to poor mental health. Furthermore, in order to treat the chronic conditions, many sufferers in Asia turn to traditional, complementary and alternative medicines (TCAM). This study explores prevalence of TCAM use and factors associated with anxiety and depressive symptoms among patients with chronic diseases in Cambodia.

Methods

In 2015, this cross-sectional study was conducted with outpatients receiving treatment and care for chronic diseases in two urban and two rural primary health centers. Every eligible patient was randomly selected at the health centers using a systematic sampling procedure. Symptoms of anxiety and depression were assessed by using the Hospital Anxiety and Depression Scale (HADS). Multivariate logistic regression models were constructed to explore factors associated with anxiety and depressive symptoms.

Results

The study participants included 1528 patients, of whom 77.2% were female, with a mean age of 46.5 years (SD = 15.3). After adjustment, patients with depressive symptoms remained significantly more likely to be in the age groups between 41 and 60 years old and to be married, separated/divorced or widowed compared to those without depressive symptoms. Regarding the use of TCAM, patients with depressive symptoms remained significantly more likely to report using an herbalist, practicing visualization and praying for own health, but less likely to report using vitamins or supplements in the past 12 months. For quality of life, patients with depressive symptoms remained significantly less likely to agree that they had enough energy for their everyday life and had enough money to meet their daily needs. Similar risk factors were also found to be significantly associated with anxiety symptoms.

Conclusions

Cambodian patients with chronic diseases who experienced symptoms of anxiety or depression were more likely to report reduced quality of life, greater chronic disease-related stigma and more TCAM use. Given the potential interaction of TCAM, mental health and other chronic conditions, a history of TCAM use and mental health should be elicited in clinical practices in primary health care settings, particularly in developing countries.

Post-traumatic stress disorder in adult victims of cluster munitions in Lebanon: a 10-year longitudinal study

OBJECTIVE

This study aims to explore the short-term and long-term prevalence and effects of post-traumatic stress disorder (PTSD) among victims of cluster munitions.

DESIGN AND SETTING

A prospective 10-year longitudinal study that took place in Lebanon.

PARTICIPANTS

Two-hundred-and-forty-four Lebanese civilian victims of submunition blasts, who were injured in 2006 and were over 18 years old, were interviewed. Included were participants who had been diagnosed with PTSD according to the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) and the PTSD Checklist - Civilian Version in 2006. Interviewees were present for the 10-year follow-up.

MAIN OUTCOME MEASURES

PTSD prevalence rates of participants in 2006 and 2016 were compared. Analysis of the demographical data pertaining to the association of long-term PTSD with other variables was performed. p Values <0.05 were considered statistically significant for all analyses (95% CI).

RESULTS

All the 244 civilians injured by cluster munitions in 2006 responded, and were present for long-term follow-up in 2016. The prevalence of PTSD decreased significantly from 98% to 43% after 10 years (p<0.001). A lower long-term prevalence was significantly associated with male sex (p<0.001), family support (p<0.001) and religion (p<0.001). Hospitalisation (p=0.005) and severe functional impairment (p<0.001) post-trauma were significantly associated with increased prevalence of long-term PTSD. Symptoms of negative cognition and mood were more common in the long run. In addition, job instability was the most frequent socioeconomic repercussion among the participants (88%).

CONCLUSIONS

Psychological symptoms, especially PTSD, remain high in war-affected populations many years after the war; this is particularly evident for Lebanese civilians who were victimised by cluster munitions. Screening programmes and psychological interventions need to be implemented in vulnerable populations exposed to war traumas. Officials and public health advocates should consider the socioeconomic implications, and help raise awareness against the harm induced by cluster munitions and similar weaponry.

Meta-analysis of interventions for posttraumatic stress disorder and depression in adult survivors of mass violence in low- and middle-income countries

BACKGROUND

Most survivors of mass violence live in low- and middle-income countries (LMICs). We conducted a meta-analysis of randomized controlled psychotherapy trials for adult posttraumatic stress disorder (PTSD) and/or depression in LMICs.

METHODS

We included 18 clinical trials (3,058 participants), in which 25 and 18 treatment arms measured symptoms of PTSD and depression, respectively.

RESULTS

Active treatments for PTSD yielded a large aggregated pre-post effect size (g = 1.29; 95% CI = [0.99; 1.59]) and a small to medium effect size at posttreatment when compared to control conditions (g = 0.39; 95% CI = [0.24; 0.55]). Effect sizes were similar for pretreatment versus follow-up (g = 1.75; 95% CI = [1.17; 2.32]) and in comparison to waitlist at follow-up (g = 0.93; 95% CI = [0.56; 1.31]). Active treatments for depression produced large pre-post (g = 1.28; 95% CI = [0.96; 1.61]) and controlled effect sizes (posttreatment, comparison to control conditions, g = 0.86; 95% CI = [0.54; 1.18]).

CONCLUSIONS

Our findings suggest that psychological interventions can effectively reduce symptoms of PTSD and depression in LMICs. Future research needs to focus on cost-effective interventions that are likely to be disseminated to the large numbers of war survivors in LMICs.

High Manifestations of Mental Distress in Arabic Asylum Seekers Accommodated in Collective Centers for Refugees in Germany

The number of asylum seekers in Germany has significantly increased in the last two years. Coming from regions of political conflict and war, the refugees have often experienced traumatic events which designate them as a high risk group for mental disorders. In a sample of Arabic speaking asylum seekers in collective accommodation centers in Erlangen, Germany, we estimated the extent of posttraumatic stress, depression, and anxiety. A further objective of the study was to test the comprehensibility and cultural appropriateness of the Arabic translations of the questionnaires in this sample. Between August and September 2016, 56 Arabic speaking asylum seekers placed among three collective accommodation centers in Erlangen completed self-report questionnaires assessing posttraumatic stress disorder (Essen Trauma-Inventory, ETI), and symptoms of depression (Patient Health Questionnaire—depression module, PHQ-9) and anxiety (Generalized Anxiety Disorder, GAD-7). The prevalence of participants with personally and/or witnessed traumatic events was 80.4% (n = 45). About one-third of the examinees (35.7%, n = 20) endorsed symptoms of PTSD (posttraumatic stress disorder). The total score for depression in this sample was M = 11.9 (SD = 7.9, range: 0–27). Moderate to severe depression (PHQ-9 score ≥ 15) was found in 35.7% (n = 20) of our sample and severe depression (PHQ-9 score ≥ 20) was found in 23.2% (n = 13). The total score for anxiety was M = 8.8 (SD = 6.9, range: 0–21), with 26.8% (n = 15) of the sample showing symptoms of severe anxiety (GAD-7 score ≥ 15). No significant difference between women and men with respect to frequency and symptom scores of PTSD, depression, and anxiety was found. Amongst asylum seekers of the presented sample, the rates of traumatic events as well as the prevalence of possible PTSD, depression, and anxiety were significantly higher than in the German population. This indicates that the refugee population is in need of culturally sensitive psychological interventions. However, more studies are required to improve the understanding of mental health among this particularly vulnerable population.

A community-based qualitative study of intergenerational resilience with Palestinian refugee families facing structural violence and historical trauma

The purpose of this study was to explore resilience processes in Palestinian refugee families living under Israeli occupation for multiple generations. Qualitative methods, critical postcolonial theories, and community-based research approaches were used to examine intergenerational protective practices and to contribute to reconceptualizations of resilience from indigenous perspectives. First, the researcher developed a collaborative partnership with a nongovernmental organization (NGO) in a UN refugee camp in the occupied West Bank. Then, with the support of this NGO, semistructured group and individual interviews were completed with a total of 30 participants ( N = 30) ranging in age from 18 to 90 years old coming from 5 distinct extended family networks. Using grounded theory situational analysis, the findings were organized in a representation entitled Palestinian Refugee Family Trees of Resilience (PRFTR). These findings explain resilience in terms of three interrelated themes: (a) Muqawama/resistance to military siege and occupation; (b) Awda/return to cultural roots despite historical and ongoing settler colonialism; and (c) Sumoud/perseverance through daily adversities and accumulation of trauma. The study findings shed light on how Palestinian families cultivate positive adaptation across generations and highlight how incorporating community-based perspectives on the historical trauma and violent social conditions of everyday life under occupation may be critical for promoting resilience. Results may be relevant to understanding the transgenerational transmission of trauma and resilience within other displaced communities internationally.

The contemporary refugee crisis: an overview of mental health challenges

There has been an unprecedented upsurge in the number of refugees worldwide, the majority being located in low-income countries with limited resources in mental health care. This paper considers contemporary issues in the refugee mental health field, including developments in research, conceptual models, social and psychological interventions, and policy. Prevalence data yielded by cross-sectional epidemiological studies do not allow a clear distinction to be made between situational forms of distress and frank mental disorder, a shortcoming that may be addressed by longitudinal studies. An evolving ecological model of research focuses on the dynamic inter-relationship of past traumatic experiences, ongoing daily stressors and the background disruptions of core psychosocial systems, the scope extending beyond the individual to the conjugal couple and the family. Although brief, structured psychotherapies administered by lay counsellors have been shown to be effective in the short term for a range of traumatic stress responses, questions remain whether these interventions can be sustained in low-resource settings and whether they meet the needs of complex cases. In the ideal circumstance, a comprehensive array of programs should be provided, including social and psychotherapeutic interventions, generic mental health services, rehabilitation, and special programs for vulnerable groups. Sustainability of services, ensuring best practice, evidence-based approaches, and promoting equity of access must remain the goals of future developments, a daunting challenge given that most refugees reside in settings where skills and resources in mental health care are in shortest supply.

Posttraumatic symptom profiles among adult survivors of childhood sexual abuse: A longitudinal study

In the present study, our aim was to examine longitudinal posttraumatic stress symptom (PTSS) trajectories in a Norwegian sample of adults who had experienced sexual abuse during childhood, and to identify predictors of PTSS-trajectory belongingness. The sample consisted of 138 adult survivors of childhood sexual abuse (96.4% women, mean age=42.9years, mean age at the first abuse=5.9 years), recruited from support centers for sexual abuse survivors. The majority (78.3%) reported penetrative abuse, and a large proportion of the sample reported that the perpetrator was a biological parent (38.4%) or someone they trusted (76.1%), reflecting a high severity level of the abusive experiences. Latent Profile Analyses revealed the best overall fit for a two PTSS-trajectories model; one trajectory characterized by sub-clinical and decreasing level of PTSS (54.9%), and the other by high and slightly decreasing level of PTSS (45.1%). Increased odds for belonging to the trajectory with clinical level symptoms was found among those who reported higher levels of exposure to other types of childhood maltreatment (OR=3.69, p=0.002), sexual abuse enforced by physical violence (OR=3.04, p=0.003) or threats (OR=2.56, p=0.014), very painful sexual abuse (OR=2.73, p=0.007), or who had experienced intense anxiety, helplessness or fear during the abuse (OR=2.97, p=0.044). Those in the trajectory with clinical level PTSS reported lower levels of perceived social support and more relational difficulties compared to those in the sub-clinical PTSS trajectory. In conclusion, different longitudinal PTSS trajectories can be found among adult survivors of childhood sexual abuse. Significant predictors of PTSS-trajectory belongingness are discussed alongside their potential implications for preventive efforts and clinical interventions.

Psychological interventions for post-traumatic stress disorder and depression in young survivors of mass violence in low- and middle-income countries: meta-analysis

BackgroundThe majority of survivors of mass violence live in low- and middle-income countries (LMICs).AimsTo synthesise empirical findings for psychological interventions for children and adolescents with post-traumatic stress disorder (PTSD) and/or depression in LMICs affected by mass violence.MethodRandomised controlled trials with children and adolescents with symptoms of PTSD and/or depression in LMICs were identified. Overall, 21 812 records were found through July 2016 in the Medline, PsycINFO and PILOTS databases; 21 met the inclusion criteria and were reviewed according to recommended guidelines.ResultsTwenty-one studies were included. Active treatments for PTSD yielded large pre-treatment to post-treatment changes (g = 1.15) and a medium controlled effect size (g = 0.57). Effect sizes were similar at follow-up. Active treatments for depression produced small to medium effect sizes. Finally, after adjustment for publication bias, the imputed uncontrolled and controlled effect sizes for PTSD were medium and small respectively.ConclusionsPsychological interventions may be effective in treating paediatric PTSD in LMICs. It appears that more targeted approaches are needed for depressive responses.

Special competencies for psychological assessment of torture survivors

In spite of the absolute prohibition against torture in international law, this grave human rights abuse is still practiced systematically and with impunity in the majority of countries around the world. Mental health professionals can play a positive role in the fight against torture and impunity, by developing competencies to assess the psychological sequelae of torture. High-quality psychological evidence can help to substantiate allegations of torture, thereby increasing the likelihood of success in civil, administrative, and criminal proceedings. This article will orient mental health professionals to issues specific to forensic assessment of torture survivors. It provides a brief introduction to the sociopolitical context of torture, reviews literature on the psychological sequelae of torture, introduces the reader to key competencies, offers information on strategies for producing documentary evidence and expert opinion, highlights ethical considerations, and suggests areas for development in the field.

Focus Groups Investigating Mental Health Attitudes and Beliefs of Parents and Teachers in South Lebanon: Are They Culturally Determined?

Introduction: The wars that Lebanon had endured led to a devastating number of deaths, injuries, and displacements. Such tragedies have detrimentally affected its civilians psychologically. Purpose: To identify knowledge, attitudes, and practices of teachers and parents concerning child/adolescent mental health. Method: Using purposeful sampling, five focus groups were conducted with teachers and parents of students from elementary, middle, and secondary levels in two private hub schools in South Lebanon. Results: A total of 27 teachers and 18 parents participated separately in focus groups. Three themes emerged: (a) Mental health care is a priority for overall health, (b) Mental illness is a cultural taboo, and (c) There is a need for better education and cultural understanding about mental health. Discussion: This is the first study in Lebanon directly targeted at parents’ and teachers’ mental health concerns. Such findings will add to transcultural nursing knowledge about the importance of mental health care.

Socio-demographic patterns of posttraumatic stress disorder in Medellin, Colombia and the context of lifetime trauma exposure

Colombia, South America is currently transitioning to post-conflict status following 6 decades of armed conflict. The population has experienced extensive exposures to potentially traumatic events throughout the lifespan. Sources of trauma exposure include the prolonged armed insurgency, narco-trafficking violence, urban gang violence, violent actions of criminal bands, intra-familial violence, gender-based violence, and sex trafficking. Exposure to potentially traumatic events is related to a variety of psychiatric outcomes, in particular, posttraumatic stress disorder. Given this context of lifetime trauma exposure, socio-demographic patterns of posttraumatic stress disorder were explored in a sample of residents of Medellin, Colombia, the nation's second largest city and a nexus for multiple types of trauma exposure.

Longitudinal Study of Posttraumatic Stress Disorder in the Community: Risk and Recovery Factors

Posttraumatic stress disorder (PTSD) is a multicausal phenomenon and a final end point of the combination of a number of potential causes. Our study aimed to examine potential risk and recovery factors of PTSD in general adult population at 1-year follow-up period. The sample consisted of 640 subjects in the initial phase, chosen by random walk technique in five regions of the country, and 100 in the follow-up. The assessment has been carried out by the following instruments: Mini-International Neuropsychiatric Interview, Life Stressor Checklist-Revised, Brief Symptom Inventory, and Manchester Short Assessment of Quality of Life Scale. Older age, low education, and lower monthly income are potential risk factors for current PTSD, as well as decreased quality of life, psychiatric comorbidity, and higher personal distress. Urban population, higher quality of life, smaller number of stressors, and lower personal distress contributed to recovery of PTSD. It is essential to know the risk and resilience factors that contribute to the development and recovery of PTSD, which is important for prevention and treatment of this disorder.