Lifetime events and posttraumatic stress disorder in 4 postconflict settings

The assessment of psychopathology among traumatized refugees: measurement invariance of the Harvard Trauma Questionnaire and the Hopkins Symptom Checklist-25 across five linguistic groups

Background: Questionnaires are widely used to assess the mental health status of refugees, whereas their construct validity largely remains unexplored. Objective: This study examined the construct validity of two widely-used instruments for the assessment of PTSD symptoms (Harvard Trauma Questionnaire [HTQ]; 16 items) and symptoms of anxiety and depression (Hopkins Symptom Check list-25 [HSCL-25]; 25 items) among Dutch and refugee patients with different linguistic backgrounds. Method: We applied exploratory factor analyses and measurement invariance analyses to test construct validity.Participants (n =1 256) were divided into five linguistic groups defined by language family, including four non-western linguistic groups (Indo-Iranian [n = 262], Niger-Congo [n = 134], Semitic [n = 288], and South Slavic languages [n = 199]) and one western linguistic group (Germanic languages; Dutch [n = 373]). Results: Exploratory factor analysis yielded a 3-factor structure of the HTQ and a 2-factor structure of the HSCL-25. Measurement invariance 20 analyses on the HTQ showed strong measurement invariance across the groups of refugee patients. However, Dutch patients reported milder symptom severity on most items of the HTQ. Measurement invariance analyses on the HSCL-25 (not conducted in Dutch patients) indicated partial strong measurement invariance across refugee patients. Conclusion: We conclude that mental health constructs measured by the HTQ and the HSCL25 25 are to a large extent interpreted in a similar way by refugee patients. This indicates that these instruments can be applied in non-western refugee patient populations, and that local idioms of distress and inherent response patterns may not play a major role when applying the HTQ and the HSCL-25 in these populations. Yet, whereas meaningful comparisons of observed PTSD and depression scores between groups of refugee patients with different non30 western linguistic background are feasible, comparisons between patients with a western and non-western linguistic background, as well as comparisons of anxiety scores, are likely to be biased. Future studies need to establish whether the commonly used cut-off scores of both questionnaires apply for refugee patients with non-western linguistic backgrounds.

Unbegleitete minderjährige Flüchtlinge

Zusammenfassung. Angesichts der aktuellen Flüchtlingsproblematik und der hohen Prävalenz psychischer Störungen bei Flüchtlingen stellt sich die Frage nach wirksamen Interventionen zur psychotherapeutischen Versorgung insbesondere minderjähriger Flüchtlinge. Das Review bietet einen Überblick über den aktuellen Forschungsstand zur Wirksamkeit verschiedener therapeutischer Interventionen bei unbegleiteten minderjährigen Flüchtlingen (UMF). Durch eine Recherche von acht Datenbanken wurden 12 Studien identifiziert, die mittels Prä- und Postmessungen psychologischer Outcomes in quantitativer Form über die Wirksamkeit psychotherapeutischer Interventionen bei UMF berichten. Mittels statistischer Informationen wurden außerdem Effektstärken berechnet. Zehn der zwölf Artikel berichteten signifikante Ergebnisse, wenngleich die Befundlage insgesamt dünn und die methodische Qualität oft mangelhaft ist. Replikationsstudien von hoher methodischer Qualität sowie die Erforschung weiterer Maßnahmen, beispielsweise multimodaler psychosozialer Unterstützungsprogramme und im schulischen Kontext, aber auch von potentiellen Moderatoren und Mediatoren, sind notwendig.

Executive Dysfunctions: The Role in Attention Deficit Hyperactivity and Post-traumatic Stress Neuropsychiatric Disorders

Executive functions (EFs) is an umbrella term for various cognitive processes controlled by a complex neural activity, which allow the production of different types of behaviors seeking to achieve specific objectives, one of them being inhibitory control. There is a wide consensus that clinical and behavioral alterations associated with EF, such as inhibitory control, are present in various neuropsychiatric disorders. This paper reviews the research literature on the relationship between executive dysfunction, frontal-subcortical neural circuit changes, and the psychopathological processes associated with attention deficit hyperactivity disorder (ADHD) and post-traumatic stress disorder (PTSD). A revision on the role of frontal-subcortical neural circuits and their presumable abnormal functioning and the high frequency of neuropsychiatric symptoms could explain the difficulties with putting effector mechanisms into action, giving individuals the necessary tools to act efficiently in their environment. Although, neuronal substrate data about ADHD and PTSD has been reported in the literature, it is isolated. Therefore, this review highlights the overlapping of neural substrates in the symptomatology of ADHD and PTSD disorders concerning EFs, especially in the inhibitory component. Thus, the changes related to impaired EF that accompany disorders like ADHD and PTSD could be explained by disturbances that have a direct or indirect impact on the functioning of these loops. Initially, the theoretical model of EF according to current neuropsychology will be presented, focusing on the inhibitory component. In a second stage, this component will be analyzed for each of the disorders of interest, considering the clinical aspects, the etiology and the neurobiological basis. Additionally, commonalities between the two neuropsychiatric conditions will be taken into consideration from the perspectives of cognitive and emotional inhibition. Finally, the implications and future prospects for research and interventions in the area will be outlined, with the intention of contributing scientific reference information that encompasses the knowledge and understanding of executive dysfunction and its relationship with these treated disorders.

Place and Posttraumatic Stress Disorder

Research on traumatic stress has focused largely on individual risk factors. A more thorough understanding of risk factors may require investigation of the contribution of neighborhood context, such as the associations between perceived neighbourhood disorder and social cohesion with reported trauma exposure (yes/no) and posttraumatic stress disorder (PTSD) diagnostic status (past-year PTSD, remitted). To examine these associations, we used a cross-sectional analysis of an epidemiological catchment area survey (N = 2,433). Visible cues, indicating a lack of order and social control in the community (neighbourhood disorder), were associated with increased trauma exposure (adjusted odds ratio [AOR] = 1.21, 95% confidence interval [CI] [1.12, 1.31]). For trauma-exposed individuals, neighbourhood disorder was associated with greater odds of lifetime PTSD (AOR = 1.38, 95% CI [1.10, 1.75]), and the willingness of residents who realize common values to intervene for the common good (social cohesion), was associated with lower likelihood of past-year PTSD (AOR = 0.64, 95% CI [0.42, 0.97]). For participants with a lifetime diagnosis of PTSD (including past-year), increased social cohesion was associated with higher odds of remission (AOR = 2.59, 95% CI [1.55, 4.30]). Environmental contexts play a role in the development and progression of PTSD. As such, traumatic stress outcomes may be better understood through a perspective that integrates individual and contextual risk factors.

Posttraumatic Stress Disorder Symptoms in Hispanic Immigrants After the September 11th Attacks: Severity and Relationship to Previous Traumatic Exposure

This study examined posttraumatic stress disorder (PTSD) symptom severity in Hispanic immigrants exposed to September 11th attacks through television, ascertained the relationship between previous traumatic exposure and September 11th–related symptoms, and investigated the effect of television exposure of the attacks on symptoms. A total of 110 Hispanic immigrant adults (22 males, 88 females) living more than 1,000 miles from the attacks completed measures of natural disaster exposure, war violence exposure, and September 11th–related PTSD symptoms. Of the sample, 14% self-reported September 11th–related PTSD symptoms consistent with a Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) diagnosis. Previous exposure to natural disasters and war violence was significantly related to September 11th–related PTSD symptomatology. Individuals with symptoms consistent with a DSM-IV PTSD diagnosis reported twice as much war violence exposure and one-and-a-half times as much natural disaster exposure as those not meeting criteria. Results are discussed regarding potential public health implications.

How Personality Affects Vulnerability among Israelis and Palestinians following the 2009 Gaza Conflict

Can the onset of PTSD symptoms and depression be predicted by personality factors and thought control strategies? A logical explanation for the different mental health outcomes of individuals exposed to trauma would seem to be personality factors and thought control strategies. Trauma exposure is necessary but not sufficient for the development of PTSD. To this end, we assess the role of personality traits and coping styles in PTSD vulnerability among Israeli and Palestinian students amid conflict. We also determine whether gender and exposure level to trauma impact the likelihood of the onset of PTSD symptoms. Five questionnaires assess previous trauma, PTSD symptoms, demographics, personality factors and thought control strategies, which are analyzed using path analysis. Findings show that the importance of personality factors and thought control strategies in predicting vulnerability increases in the face of political violence: the higher stress, the more important the roles of personality and thought control strategies. Thought control strategies associated with introverted and less emotionally stable personality-types correlate positively with higher levels of PTSD symptoms and depression, particularly among Palestinians. By extension, because mental health is key to reducing violence in the region, PTSD reduction in conflict zones warrants rethinking.

Psychotic-like experiences in a conflict-affected population: a cross-sectional study in South Sudan

PURPOSE

This study investigates the prevalence of psychotic-like experiences (PLEs) and examines exposure to potentially traumatic events and other relevant risk factors for PLEs in the general population of a conflict-affected, low-income country.

METHODS

We conducted a cross-sectional community based study of four Greater Bahr el Ghazal States, South Sudan (n = 1200). The Harvard Trauma Questionnaire was applied to investigate exposure to potentially traumatic events. The Mini-International Neuropsychiatric Interview was used to detect PLEs.

RESULTS

The estimated prevalence of lifetime PLEs was 23.3 % and the rate of PLEs which were evaluated as bizarre was 9.5 %. Exposure to higher number of potentially traumatic events, younger age, rural residency, being unemployed, not having a regular income and having traditional religion were significantly associated with having PLEs. PLEs were significantly associated with reporting of psychological distress when controlling for other covariates.

CONCLUSIONS

The finding of association between traumatic exposure and PLEs calls for greater attention to the diversity of negative mental health outcomes in conflict-affected populations.

Psychological distress and resources among siblings and parents exposed to traumatic events

We examined symmetries and asymmetries within family members' psychological distress and resources in general and when exposed to traumatic events in particular. PTSD and depressive symptoms indicated distress and resilient attitudes, and satisfaction with quality of life indicated resources. We also analysed potential complementary dynamics between family members and identified family types according to their distress and resources. Concerning trauma impact, we hypothesized that exposure to family military violence (FMV) and recent personal trauma (RPT) predict family members' psychological distress and resources differently, indicating asymmetry in family responses. The participants were 65 Palestinian families each consisting of a mother, a father and their 15-, 17and 19-year-old children. The within-family MANOVA results showed asymmetric in psychological distress and resources in sibling and spousal subsystems, for example older siblings reported a higher level of depressive symptoms than both parents, and mothers reported PTSD more often than fathers. The cluster analysis identified four family types, two with symmetric responses: In the “resilient families” all members showed low distress and high resources, and in the “ordeal families” all showed distress and low resources. In the asymmetric families either the children or the parents showed low distress and high resources, named the “children's strength families” and the “parental strength families”, respectively. Partial correlation analysis revealed complementary dynamics between children and their parents: If mothers reported high levels of psychological distress, the 15and 17-year-olds reported low or vice versa. Spousal complementary dynamics were found in psychosocial resources: If the mother showed highly resilient attitudes, the father showed low or vice versa. As hypothesized, exposure to traumatic events was differently associated with family members’ psychological distress and resources. Family military trauma (FMT) predicted depressive symptoms only among the youngest siblings, and recent personal trauma (RPT) was associated with dissatisfaction with quality of life only among the oldest sibling and fathers.

Positive and Negative Affect in Children Living in Refugee Camps

In the present study, we assessed the psychometric proprieties of the Positive and Negative Affect Scale–Child Version (PANAS-C) in a large sample of Palestinian children ( N = 1,376) of different age ranges living in refugee camps. In particular, we used standard confirmatory factor analysis to test competing factor structures for the PANAS-C, with a view to developing a stable version of the instrument, suitable for speedy administration in applied and research settings in the contexts of military violence. Four alternative models of the PANAS-C were evaluated: unidimensional; two-dimensional with independent PA and NA scales and covariance of item-level errors unallowed; two-dimensional with dependent PA and NA scales and covariance of item-level errors unallowed; and two-dimensional with dependent PA and NA scales and covariance of item-level errors. The results of the statistical analysis supported a 20-item measurement model comprising the PANAS-C20 Arabic version for children. The items in this best fitting model loaded on two different and negatively correlated factors. These findings encourage full adoption of the PANAS-C20 as a tool for assessing both PA and NA in Palestinian children living in contexts of warfare.

Reliability and validity of the Khmer version of the 10-item Connor-Davidson Resilience Scale (Kh-CD-RISC10) in Cambodian adolescents

BACKGROUND

Resilience has been characterized as a defensive factor against the refinement of mental health problems. This study adapted the Connor-Davidson Resilience Scale (Kh-CD-RISC10) for use in Khmer adolescents and subsequently investigates its psychometric properties.

METHODS

Using stratified random sampling, this cross-sectional study sampled Cambodian adolescents from high schools selected randomly within three provinces (Phnom Penh, Battambang and Mondulkiri)-location (rural, urban) combinations. Parallel analysis was used to identify the number of component(s), and the structure of the single factor was subsequently explored using principal axis factoring. A confirmatory factor analysis was then performed to establish the fit of the Kh-CD-RISC10 to another sample. To assess convergent validity, the factor scores of the Khmer version of Connor-Davidson Resilience Scale were categorized into three levels, and then the general negative affectivity (GNA) and physiological hyperarousal (PH) scales (derived from the DASS 21) were compared among the three resilience groups.

RESULTS

Of the 798 participants who responded (responded rate = 82.26 %), 440 (41.23 %) were female and the age ranged from 14 to 24 years old (mean = 17.36, SD = 1.325). The internal consistency of the Khmer 10-item CD-RISC was also shown to be high in Cambodian adolescents (Cronbach's alpha = 0. 82). Confirmatory factor analysis revealed the single factor model fit data adequately (χ(2) = 100.103, df = 35, p < 0.001, CFI = 0.9484, RMSEA = 0.0384). We found that there were significant differences in both General Negative affectivity and Physiological Hyperarousal among the three resilience groups (FGNA = 12. 84, df = 2, p < 0.001; FPH = 13. 01, df = 2, p < 0.001).

CONCLUSION

The results from the present study indicate that the Khmer version of CD-RISC shows good psychometric properties in Cambodian adolescents. Our result confirms that a single dimension underlay the 10 items on the CD-RISC scale of this population, and can be used to assess the resilience comparing to the level of PTSD symptoms in general Khmer adolescent.

Effective Screening for Emotional Distress in Refugees: The Refugee Health Screener

Screening for emotional distress is important, but not widely available. This study assesses the utility of the Refugee Health Screener 15 (RHS-15) in a public health setting. Refugee Health Screener 15 and diagnostic proxy (DP) instruments assessing anxiety, depression, and posttraumatic stress disorder were administered to refugees from 3 countries at their public health examination. Properties of the RHS-15 and its components were evaluated utilizing appropriate methods. Scale Cronbach α was 0.95, and a factor analysis identified 1 factor accounting for 66% of scale variance. Refugee Health Screener 15 scores and cases discriminated between refugee groups similar to DPs. Refugee Health Screener 15 case sensitivity and specificity to DPs were acceptable (≥0.87/0.77). A shorter, 13-item component had acceptable metric properties. The RHS-15 appears to be a valid screener for emotional distress of refugees. The 13-item scale may be more efficient and as efficacious for case identification. The critical public health need and recommendations for implementation are discussed.

Exploring Psychological Distress in Burundi During and After the Armed Conflict

We assessed symptoms of psychological distress among a population-based sample of 9000-plus adults in Burundi during (1998) and after (2007) armed conflict. After exploratory and confirmatory factor analysis to an 8-item, self-report measure, we identified two domains of psychological distress "Depression/Anxiety" and "Functioning" with good fit to data. The questionnaire was invariant in males and females. Depression and Anxiety symptoms during conflict were more frequently reported than Functioning symptoms; all symptoms were more frequently reported by women. Psychological distress was found in 44 % of individuals during conflict and in 29 % 2 years after the conflict. Results call for further research in Burundi that can inform the development of mental health interventions.

PTSD and depression construct: prevalence and predictors of co-occurrence in a South Lebanese civilian sample

BACKGROUND

Armed conflict, occupation, and political and economic instability that are particularly experienced by the civilian Lebanese population of South Lebanon would almost inevitably affect these individuals psychologically. Therefore, identifying predictors of co-occurring mental disorders is paramount to sound assessment and intervention planning.

OBJECTIVE

This study aims to determine the prevalence and predictors of co-occurring posttraumatic stress disorder (PTSD) and major depressive disorder (MDD) in a post-war population from South Lebanon.

METHOD

A total of 991 citizens from 10 villages were interviewed using a cross-sectional design through random sampling. The prevalence of PTSD, MDD, or both was 23.4%. To identify predictors of PTSD and depression co-occurrence, multinomial logistic regression was used. Participants were divided into four groups (participants with no PTSD or depression, participants with PTSD only, participants with depression only, and participants with PTSD-depression comorbidity).

RESULTS

Among the significant predictors of PTSD-depression co-occurrence, female gender, health problems, social life events, and witnessed traumatic events were most consistently found. Additionally, employment and educational status, as well as social support, were found to significantly predict co-occurrence.

CONCLUSIONS

Results reveal the distinct risk and protective factors that characterize the PTSD-depression profile. These findings will hopefully assist in the development of interventions that are sensitive to individuals' psychosocial milieu.

Posttraumatic stress disorder among refugees: Measurement invariance of Harvard Trauma Questionnaire scores across global regions and response patterns

Despite the central role of posttraumatic stress disorder (PTSD) in international humanitarian aid work, there has been little examination of the measurement invariance of PTSD measures across culturally defined refugee subgroups. This leaves mental health workers in disaster settings with little to support inferences made using the results of standard clinical assessment tools, such as the severity of symptoms and prevalence rates. We examined measurement invariance in scores from the most widely used PTSD measure in refugee populations, the Harvard Trauma Questionnaire (HTQ; Mollica et al., 1992), in a multinational and multilingual sample of asylum seekers from 81 countries of origin in 11 global regions. Clustering HTQ responses to justify grouping regional groups by response patterns resulted in 3 groups for testing measurement invariance: West Africans, Himalayans, and all others. Comparing log-likelihood ratios showed that while configural invariance seemed to hold, metric and scalar invariance did not. These findings call into question the common practice of using standard cut-off scores on PTSD measures across culturally dissimilar refugee populations. In addition, high correlation between factors suggests that the construct validity of scores from North American and European measures of PTSD may not hold globally.

Estimating the Costs of Torture: Challenges and Opportunities

Due to its nature, extent and consequences, torture is considered a major public health problem and a serious violation of human rights. Our study aims to set the foundation for a theoretical framework of the costs related to torture. It examines existing challenges and proposes some solutions. Our proposed framework targets policy makers, human rights activists, professionals working in programmes, centres and rehabilitation projects, judges and lawyers, survivors of torture and their families and anyone involved in the prevention and fight against this practice and its consequences. We adopted a methodology previously used in studies investigating the challenges in measuring and valuing productivity costs in health disorders. We identify and discuss conceptual, methodological, political and ethical challenges that studies on the economic and social costs of torture pose and propose alternatives in terms of possible solutions to these challenges. The economic dimension of torture is rarely debated and integrated in research, policies and programmes. Several challenges such as epistemological, methodological, ethical or political ones have often been presented as obstacles to cost studies of torture and as an excuse for not investigating this dimension. In identifying, analysing and proposing solutions to these challenges, we intend to stimulate the integration of the economic dimension in research and prevention of torture strategies.

Internet-based interventions for posttraumatic stress: A meta-analysis of randomized controlled trials

Posttraumatic stress disorder (PTSD) is a prevalent and highly distressing affliction, but access to trauma-focused psychotherapy is limited. Internet-based interventions (IBIs) could improve the delivery of and access to specialized mental health care. Currently, no meta-analytical evidence is available on IBIs for PTSD. We conducted a meta-analysis of 20 randomized controlled studies, including 21 comparisons, in order to summarize the current state of efficacy for the treatment of PTSD and to identify moderator variables. Studies tested internet-based cognitive behavioral therapy (CBT) and expressive writing (EW) against active or passive comparison conditions, including subclinical and clinical samples. Results show that at post-assessment CBT-IBIs are significantly more efficacious than passive controls, resulting in medium to large effects on the PTSD sum and all sub-symptom scores (0.66<g<0.83), but both EW and CBT are not superior to active controls. EW differed from controls only at follow-up in reducing intrusions and hyperarousal, but based on merely two studies. Subgroup analyses reveal that for CBT none of the program components such as provision of therapeutic support, reminders, or number of sessions serves as a moderator. Overall, results for CBT-IBIs are promising, but the number of includable studies for subgroup analyses was low, limiting statistical power. Future research is necessary to systematically investigate the impact of treatment components and test against active controls with optimal power.

Child health in Syria: recognising the lasting effects of warfare on health

The war in Syria, now in its fourth year, is one of the bloodiest in recent times. The legacy of war includes damage to the health of children that can last for decades and affect future generations. In this article we discuss the effects of the war on Syria's children, highlighting the less documented longer-term effects. In addition to their present suffering, these children, and their own children, are likely to face further challenges as a result of the current conflict. This is essential to understand both for effective interventions and for ethical reasons.

Long-term mental health of war-refugees: a systematic literature review

BACKGROUND

There are several million war-refugees worldwide, majority of whom stay in the recipient countries for years. However, little is known about their long-term mental health. This review aimed to assess prevalence of mental disorders and to identify their correlates among long-settled war-refugees.

METHODS

We conducted a systematic review of studies that assessed current prevalence and/or factors associated with depression and anxiety disorders in adult war-refugees 5 years or longer after displacement. We searched Medline, Embase, CINAHL, PsycINFO, and PILOTS from their inception to October 2014, searched reference lists, and contacted experts. Because of a high heterogeneity between studies, overall estimates of mental disorders were not discussed. Instead, prevalence rates were reviewed narratively and possible sources of heterogeneity between studies were investigated both by subgroup analysis and narratively. A descriptive analysis examined pre-migration and post-migration factors associated with mental disorders in this population.

RESULTS

The review identified 29 studies on long-term mental health with a total of 16,010 war-affected refugees. There was significant between-study heterogeneity in prevalence rates of depression (range 2.3-80%), PTSD (4.4-86%), and unspecified anxiety disorder (20.3-88%), although prevalence estimates were typically in the range of 20% and above. Both clinical and methodological factors contributed substantially to the observed heterogeneity. Studies of higher methodological quality generally reported lower prevalence rates. Prevalence rates were also related to both which country the refugees came from and in which country they resettled. Refugees from former Yugoslavia and Cambodia tended to report the highest rates of mental disorders, as well as refugees residing in the USA. Descriptive synthesis suggested that greater exposure to pre-migration traumatic experiences and post-migration stress were the most consistent factors associated with all three disorders, whilst a poor post-migration socio-economic status was particularly associated with depression.

CONCLUSIONS

There is a need for more methodologically consistent and rigorous research on the mental health of long-settled war refugees. Existing evidence suggests that mental disorders tend to be highly prevalent in war refugees many years after resettlement. This increased risk may not only be a consequence of exposure to wartime trauma but may also be influenced by post-migration socio-economic factors.

Preventing gender-based violence engendered by conflict: The case of Côte d'Ivoire

Despite a growing awareness of the increased prevalence of intimate partner violence and sexual violence in conflict and post-conflict settings, much less is known about the dynamics, as well as the interventions that would be effective at individual, relational, and structural levels. In addition to the human capital lost by conflict violence, gender-based violence (GBV) poses a grave threat to the post-conflict rehabilitation process. With regard to violence that occurs during and post conflict, research must take into consideration the different types of violence that share similar causes as the larger conflict as well as become widespread as a result of the conflict and use existing frameworks to build future interventions. Researchers are trying to understand the interplay of personal, situational, and socio-cultural factors in conflict settings that combine to cause GBV and lead to guidelines for program planning to address the health and social needs of survivors as well as to prevent further GBV. These actions result from a growing recognition that violence represents a serious public health problem, is an important cause of many physical and psychological illnesses, and can cause social disruptions that impede reconstruction efforts for generations. This review studies the manifestations of GBV during and following the Ivoirian Civil War, juxtaposes them against narratives, as well as lists relevant interventions at the individual, relational, community, and institutional levels. Part of a growing literature that aims to better understand the nature of violence during and after conflict and to plan effective responses to it, this study hopes to suggest solutions for the situation of Côte d'Ivoire and elsewhere.

Post-traumatic stress disorder

Post-traumatic stress disorder (PTSD) occurs in 5-10% of the population and is twice as common in women as in men. Although trauma exposure is the precipitating event for PTSD to develop, biological and psychosocial risk factors are increasingly viewed as predictors of symptom onset, severity and chronicity. PTSD affects multiple biological systems, such as brain circuitry and neurochemistry, and cellular, immune, endocrine and metabolic function. Treatment approaches involve a combination of medications and psychotherapy, with psychotherapy overall showing greatest efficacy. Studies of PTSD pathophysiology initially focused on the psychophysiology and neurobiology of stress responses, and the acquisition and the extinction of fear memories. However, increasing emphasis is being placed on identifying factors that explain individual differences in responses to trauma and promotion of resilience, such as genetic and social factors, brain developmental processes, cumulative biological and psychological effects of early childhood and other stressful lifetime events. The field of PTSD is currently challenged by fluctuations in diagnostic criteria, which have implications for epidemiological, biological, genetic and treatment studies. However, the advent of new biological methodologies offers the possibility of large-scale approaches to heterogeneous and genetically complex brain disorders, and provides optimism that individualized approaches to diagnosis and treatment will be discovered.

Epigenetic Alterations Associated with War Trauma and Childhood Maltreatment

Survivors of war trauma or childhood maltreatment are at increased risk for trauma-spectrum disorders such as post-traumatic stress disorder (PTSD). In addition, traumatic stress has been associated with alterations in the neuroendocrine and the immune system, enhancing the risk for physical diseases. Traumatic experiences might even affect psychological as well as biological parameters in the next generation, i.e. traumatic stress might have transgenerational effects. This article outlines how epigenetic processes, which represent a pivotal biological mechanism for dynamic adaptation to environmental challenges, might contribute to the explanation of the long-lasting and transgenerational effects of trauma. In particular, epigenetic alterations in genes regulating the hypothalamus-pituitary-adrenal axis as well as the immune system have been observed in survivors of childhood and adult trauma. These changes could result in enduring alterations of the stress response as well as the physical health risk. Furthermore, the effects of parental trauma could be transmitted to the next generation by parental distress and the pre- and postnatal environment, as well as by epigenetic marks transmitted via the germline. While epigenetic research has a high potential of advancing our understanding of the consequences of trauma, the findings have to be interpreted with caution, as epigenetics only represent one piece of a complex puzzle of interacting biological and environmental factors. Copyright © 2015 John Wiley & Sons, Ltd.

Responding to the need for sleep among survivors of interpersonal violence: A randomized controlled trial of a cognitive-behavioral insomnia intervention followed by PTSD treatment

Sleep disturbance is a common feature of posttraumatic stress disorder (PTSD), but is not a focus of standard PTSD treatments. Psychological trauma exposure is associated with considerable physical and mental health morbidity, possibly due to the alterations in neuroendocrine function and inflammation observed in trauma exposed individuals. Although PTSD treatments are efficacious, they are associated with high drop-out rates in clinical trials and clinical practice. Finally, individuals with PTSD stemming from exposure to interpersonal violence represent an especially under-treated population with significant sleep disturbance. Community-based participatory research was utilized to design and prepare a clinical trial that randomizes recent survivors of interpersonal violence who have PTSD, depression, and insomnia to receive either: (1) Cognitive Behavioral Therapy for Insomnia (CBTi) followed by Cognitive Processing Therapy (CPT) for trauma, or (2) attention control followed by CPT. Outcome measures include subjective and objective measures of sleep, clinician-administered PTSD and depression scales, inflammatory cytokines, and salivary cortisol. Assessments are conducted at baseline, following the sleep or control intervention, and again following CPT. The design allows for: (1) the first test of a sleep intervention in this population; (2) the comparison of sequenced CBTi and CPT to attention control followed by CPT, and (3) assessing the roles of neuroendocrine function, inflammatory processes, and objective sleep markers in mediating treatment outcomes. The study's overarching hypothesis is that treating insomnia will produce reduction in insomnia, PTSD, and depression severity, allowing patients to more fully engage in, and derive optimal benefits from, cognitive processing therapy.

Facing Violence - A Global Challenge

Violence has been shown to be a global challenge resulting in long-lasting social, medical, and mental health sequelae. In this article, we focus on massive social violence, such as war and civil war. Social suffering and mental health problems related to violence as a global public health problem can be tackled only with a holistic approach that addresses the specific region, culture and group and the limited resources available in most countries. Research that can give a reliable assessment of complex long-term outcomes is still largely missing, and can be seen as a major and complex challenge for future study.

Arab Adolescents: Health, Gender, and Social Context

This article reviews the evidence about adolescent health in the Arab world, against the background of social, economic, and political change in the region, and with a particular focus on gender. For the literature review, searches were conducted for relevant articles, and data were drawn from national population- and school-based surveys and from the Global Burden of Disease project. In some parts of the Arab world, adolescents experience a greater burden of ill health due to overweight/obesity, transport injuries, cardiovascular and metabolic conditions, and mental health disorders than those in other regions of the world. Poor diets, insufficient physical activity, tobacco use, road traffic injuries, and exposure to violence are major risk factors. Young men have higher risks of unsafe driving and tobacco use and young women have greater ill-health due to depression. Several features of the social context that affect adolescent health are discussed, including changing life trajectories and gender roles, the mismatch between education and job opportunities, and armed conflict and interpersonal violence. Policy makers need to address risk factors behind noncommunicable disease among adolescents in the Arab region, including tobacco use, unhealthy diets, sedentary lifestyles, unsafe driving, and exposure to violence. More broadly, adolescents need economic opportunity, safe communities, and a chance to have a voice in their future.

The legacy of gender-based violence and HIV/AIDS in the postgenocide era: Stories from women in Rwanda

Drawing on qualitative interviews with 22 Rwandan women, we describe the lived experiences of women survivors of gender-based violence (GBV) more than a decade and a half after the 1994 Genocide. We argue that the intersection between GBV and human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS) has long-term implications: the majority of women interviewed continue to endure trauma, stigma, social isolation, and economic hardship in the postgenocide era and are in need of expanded economic and mental health support. Our findings have implications for the importance of providing integrated psychosocial support to survivors of GBV postconflict contexts.

Perceived current needs, psychological distress and functional impairment in a war-affected setting: a cross-sectional study in South Sudan

OBJECTIVES

To examine the current perceived needs of the general population in a war-affected setting, and to study the influence of perceived needs on the participants' mental health status and functional impairment across genders.

METHODS

A cross-sectional community survey (n=464) was conducted in war-affected South Sudan. Three regression models were analysed. Perceived needs were assessed with the Humanitarian Emergency Settings Perceived Needs Scale. Psychological distress was measured with the General Health Questionnaire and level of functioning by the Short Form Health Survey (SF-12).

RESULTS

The most frequently expressed needs were related to drinking water, alcohol and drug use in the community and access to sanitation facilities. No gender differences were found regarding the level of perceived needs or the number of traumatic events. Higher level of perceived needs significantly predicted psychological distress and lower level of functioning even when numbers of experienced trauma events were taken into account.

CONCLUSIONS

The associations of higher level of needs and trauma experiences, on the one hand, and negative health outcomes on the other, necessitate a greater integration of interventions directed towards the population's perceived needs and mental health, particularly for those who have been exposed to trauma.

Calming the mind: Healing after mass atrocity in Cambodia

After catastrophic events in which people's survival has been threatened, as happened during the Khmer Rouge regime in Cambodia 1975-1979, some continue to suffer from painful mental symptoms. Surveys carried out in Cambodia based on Western diagnostic categories have found a high prevalence of posttraumatic stress disorder (PTSD), depression, and anxiety symptoms in the population. This study explored Cambodian approaches to healing trauma, examining the ways in which Cambodians appeal to elements of Buddhism in their efforts to calm their minds, situating this mode of coping in the context of broader Khmer Buddhist practice and understandings. Western psychology may have much to learn from local, contextualised methods of dealing with the aftermath of trauma, including Khmer understandings of distress and approaches to relief. Methods of assessment and treatment of distress cannot be transposed wholesale from one cultural setting to another but require considerable cultural adaptation. This kind of cultural interchange may give rise to innovative, hybrid discourses and methods that may have much to offer in the support of victims of organised violence.

Prevalence and factors associated with Posttraumatic Stress Disorder seven years after the conflict in three districts in northern Uganda (The Wayo-Nero Study)

BACKGROUND

Research on the prevalence of Posttraumatic Stress Disorder (PTSD) is still limited in low income countries yet PTSD can be a public health problem in post conflict areas. In order to respond to the burden of PSTD in northern Uganda, an area that experienced civil strife for over two decades, we need accurate data on its (PTSD) prevalence and the associated risk factors to facilitate public mental health planning.

METHODS

This study employed a cross-sectional study design and data collection was undertaken in three districts in northern Uganda: Gulu, Amuru and Nwoya. Respondents were aged 18 years and above and were randomly selected at community level. A total of 2400 respondents were interviewed using a structured questionnaire in the three study districts. In this study, multivariate logistic regression was employed to analyze the associations of socio-demographic factors, trauma related variables and the outcome of PTSD.

RESULTS

The prevalence of Posttraumatic Stress Disorder (PTSD) in the study population was 11.8 % (95 % CI: 10.5 %, 13.1 %) with a prevalence of 10.9 % (95 % CI: 9.3 %, 12.5 %) among female respondents and 13.4 % (95 % CI: 11.2 %, 15.7 %) among male respondents. Quite a number of factors were strongly associated with PTSD. Overall, a respondent had experienced 9 negative life events. In a multivariate logistic regression, the factors that were strongly associated with PTSD were: exposure to war trauma events, childhood trauma, negative life events, negative copying style and food insecurity. The findings also indicate no association between sex, age and PTSD.

CONCLUSION

The prevalence rate of PTSD in the study communities is unacceptably high. Quite a number of factors were associated with PTSD. Effective public mental health services are needed that combine treatment (medical) psychological and social welfare programs especially at community level to address the high burden of PTSD. Longitudinal studies are also recommended to continuously assess the trends in PTSD in the study communities and remedial action taken.

Dissemination of psychotherapy for trauma spectrum disorders in postconflict settings: a randomized controlled trial in Rwanda

BACKGROUND

Dissemination of psychotherapeutic modules to local counselors seems a key requirement for coping with mental health disasters in conflict regions. We tested a train-the-trainer (TTT) dissemination model for the treatment of posttraumatic stress disorder (PTSD).

METHODS

We randomly assigned widowed or orphaned survivors of the 1994 Rwandan genocide with a PTSD diagnosis to narrative exposure therapy (NET) treatment (NET-1, n = 38) or to a 6-month waiting list (WL) condition to be followed by treatment (WL/NET-2, n = 38). Expert therapists trained a first dissemination generation of local Rwandan psychologists in NET complemented by 2 sessions of interpersonal psychotherapy modules. Under the supervision of the experts, these Rwandan psychologists (a) provided NET to the NET-1 participants and (b) subsequently trained and supervised a second generation of local psychologists. This second dissemination generation provided treatment to the WL/NET-2 group. The primary outcome measure was the Clinician-Administered PTSD Scale total score before therapy and at 3- and 12-month follow-ups.

RESULTS

At the 3-month follow-up, the NET-1 participants suffered significantly and substantially less from PTSD symptoms than the participants in the WL group. The treatment gains of NET-1 were maintained and increased at follow-up, with a within-group effect size of Cohen's d = 1.47 at the 12-month follow-up. After treatment by the second dissemination generation of therapists, the WL/NET-2 participants improved to an extent similar to that of the NET-1 group at follow-ups, with an effect size of Cohen's d = 1.37 at the 12-month follow-up.

CONCLUSIONS

A TTT model of PTSD treatment dissemination can be effective in resource-poor postconflict societies.

Long-term mental health outcome in post-conflict settings: Similarities and differences between Kosovo and Rwanda

BACKGROUND

Few studies investigated the long-term mental health outcome in culturally different post-conflict settings. This study considers two surveys conducted in Kosovo 8 years after the Balkans war and in Rwanda 14 years after the genocide.

METHODS

All participants (n = 864 in Kosovo; n = 962 in Rwanda) were interviewed using the posttraumatic stress disorder (PTSD) and major depressive episode (MDE) sections of the Mini International Neuropsychiatric Interview (MINI) and the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36).

RESULTS

Proportions of participants who met diagnostic criteria for either PTSD or MDE were 33.0% in Kosovo and 31.0% in Rwanda, with co-occurrence of both disorders in 17.8% of the Rwandan sample and 9.5% of the Kosovan sample. Among patients with PTSD, patterns of symptoms significantly differed in the two settings, with avoidance and inability to recall less frequent and sense of a foreshortened future and increased startle response more common in Rwanda. Significant differences were also observed in patients with MDE, with loss of energy and difficulties concentrating less frequent and suicidal ideation more common in Rwanda. Comorbid PTSD and MDE were associated with decreased SF-36 subjective mental and physical health scores in both settings, but significantly larger effects in Kosovo than in Rwanda.

CONCLUSION

Culturally different civilian populations exposed to mass trauma may differ with respect to their long-term mental health outcome, including comorbidity, symptom profile and health perception.

The factor structure of posttraumatic stress disorder symptoms among Rwandans exposed to the 1994 genocide: A confirmatory factor analytic study using the PCL-C

The factor structure of posttraumatic stress disorder (PTSD) symptoms in Euro-American populations has been extensively studied, but confirmatory factor analytic studies from non-Western societies are lacking. Alternative models of DSM-IV symptoms were tested among Rwandan adults (N=465) who experienced trauma during the 1994 genocide. A cluster random survey was conducted with interviews held in Rwandan households. PTSD was assessed with the Posttraumatic Stress Disorder Checklist-Civilian version. Competing models were the DSM-IV, emotional numbing, dysphoria, aroused intrusion, and dysphoric arousal models. Results showed that the emotional numbing, dysphoria, and dysphoric arousal models had almost identical, good fit indices and fit the data significantly better than the other models. The emotional numbing and dysphoric arousal models also exhibited good construct validity. Results suggest that the latent structure of PTSD symptoms in Rwanda are comparable to that found in Euro-American samples, thereby lending further support to the cross-cultural validity of the construct.

Loss of social resources predicts incident posttraumatic stress disorder during ongoing political violence within the Palestinian Authority

BACKGROUND

Exposure to ongoing political violence and stressful conditions increases the risk of posttraumatic stress disorder (PTSD) in low-resource contexts. However, much of our understanding of the determinants of PTSD in these contexts comes from cross-sectional data. Longitudinal studies that examine factors associated with incident PTSD may be useful to the development of effective prevention interventions and the identification of those who may be most at-risk for the disorder.

METHODS

A 3-stage cluster random stratified sampling methodology was used to obtain a representative sample of 1,196 Palestinian adults living in Gaza, the West Bank and East Jerusalem. Face-to-face interviews were conducted at two time points 6-months apart. Logistic regression analyses were conducted on a restricted sample of 643 people who did not have PTSD at baseline and who completed both interviews.

RESULTS

The incidence of PTSD was 15.0 % over a 6-month period. Results of adjusted logistic regression models demonstrated that talking to friends and family about political circumstances (aOR = 0.78, p = 0.01) was protective, and female sex (aOR = 1.76, p = 0.025), threat perception of future violence (aOR = 1.50, p = 0.002), poor general health (aOR = 1.39, p = 0.005), exposure to media (aOR = 1.37, p = 0.002), and loss of social resources (aOR = 1.71, p = 0.006) were predictive of incident cases of PTSD.

CONCLUSIONS

A high incidence of PTSD was documented during a 6-month follow-up period among Palestinian residents of Gaza, the West Bank, and East Jerusalem. Interventions that promote health and increase and forestall loss to social resources could potentially reduce the onset of PTSD in communities affected by violence.

Factors predicting risk for PTSD among highly exposed civilians: two longitudinal studies

The impact of exposure to constant, prolonged, life threatening, war-related stress is understudied. Previous studies did not examine stressors with an objective history of exposure to a traumatic event such as armed conflict. A set of predictors were assessed in two longitudinal studies. The studies included a civilian population (Study 1, N = 194; Study 2, N = 26) that was exposed to war-related stress. Both groups had a documented objective history of the stressor. A set of logistic regression models in Study 1 and an hierarchical multiple regression in Study 2 were conducted in order to assess the relationship between various predictors from the aforementioned domains and PTSD symptoms. In Study 1, having an elevated risk for clinical level of ASD led to a higher probability of elevated risk for clinical level of PTSD (odds ratio = 7.772, 95% CI 1.225-49.300; p < .01). Similar results were found in Study 2, where ASD symptoms were the best predictor of PTSD symptoms (standardized β = .644; t = 3.183; p < .01). Whereas ASD was a moderate predictor of PTSD in studies which focused mainly on the impact of a single traumatic event, ASD was a major and potent predictor of PTSD in the current studies which focused on prolonged traumatic exposure to war-related stress.

Previous violent events and mental health outcomes in Guatemala

OBJECTIVES

We analyzed a probability sample of Guatemalans to determine if a relationship exists between previous violent events and development of mental health outcomes in various sociodemographic groups, as well as during and after the Guatemalan Civil War.

METHODS

We used regression modeling, an interaction test, and complex survey design adjustments to estimate prevalences and test potential relationships between previous violent events and mental health.

RESULTS

Many (20.6%) participants experienced at least 1 previous serious violent event. Witnessing someone severely injured or killed was the most common event. Depression was experienced by 4.2% of participants, with 6.5% experiencing anxiety, 6.4% an alcohol-related disorder, and 1.9% posttraumatic stress disorder (PTSD). Persons who experienced violence during the war had 4.3 times the adjusted odds of alcohol-related disorders (P < .05) and 4.0 times the adjusted odds of PTSD (P < .05) compared with the postwar period. Women, indigenous Maya, and urban dwellers had greater odds of experiencing postviolence mental health outcomes.

CONCLUSIONS

Violence that began during the civil war and continues today has had a significant effect on the mental health of Guatemalans. However, mental health outcomes resulting from violent events decreased in the postwar period, suggesting a nation in recovery.

Mental health services in Cambodia, challenges and opportunities in a post-conflict setting

Cambodia had suffered enormously due to war and internecine conflict during the latter half of the twentieth century, more so during the Vietnam War. Total collapse of education and health systems during the Pol Pot era continues to be a challenge for developing the necessary infrastructure and human resources to provide basic minimum mental health care which is compounded by the prevailing cultural belief and stigma over mental, neurological and substance abuse disorders (MNSDs). The mental health research and services in Cambodia had been predominantly 'trauma focused', a legacy of war, and there is a need to move toward epidemiologically sound public health oriented mental health policy and service development. Integrating mental health program with primary health care services with specifically stated minimum package of activities at primary level and complementary package of activities at secondary level is an opportunity to meet the needs and rights of persons with mental, neurological and substance abuse disorders (PWMNSDs) in Cambodia, provided there is mental health leadership, government commitment and political will.

Acute and chronic plasma metabolomic and liver transcriptomic stress effects in a mouse model with features of post-traumatic stress disorder

Acute responses to intense stressors can give rise to post-traumatic stress disorder (PTSD). PTSD diagnostic criteria include trauma exposure history and self-reported symptoms. Individuals who meet PTSD diagnostic criteria often meet criteria for additional psychiatric diagnoses. Biomarkers promise to contribute to reliable phenotypes of PTSD and comorbidities by linking biological system alterations to behavioral symptoms. Here we have analyzed unbiased plasma metabolomics and other stress effects in a mouse model with behavioral features of PTSD. In this model, C57BL/6 mice are repeatedly exposed to a trained aggressor mouse (albino SJL) using a modified, resident-intruder, social defeat paradigm. Our recent studies using this model found that aggressor-exposed mice exhibited acute stress effects including changed behaviors, body weight gain, increased body temperature, as well as inflammatory and fibrotic histopathologies and transcriptomic changes of heart tissue. Some of these acute stress effects persisted, reminiscent of PTSD. Here we report elevated proteins in plasma that function in inflammation and responses to oxidative stress and damaged tissue at 24 hrs post-stressor. Additionally at this acute time point, transcriptomic analysis indicated liver inflammation. The unbiased metabolomics analysis showed altered metabolites in plasma at 24 hrs that only partially normalized toward control levels after stress-withdrawal for 1.5 or 4 wks. In particular, gut-derived metabolites were altered at 24 hrs post-stressor and remained altered up to 4 wks after stress-withdrawal. Also at the 4 wk time point, hyperlipidemia and suppressed metabolites of amino acids and carbohydrates in plasma coincided with transcriptomic indicators of altered liver metabolism (activated xenobiotic and lipid metabolism). Collectively, these system-wide sequelae to repeated intense stress suggest that the simultaneous perturbed functioning of multiple organ systems (e.g., brain, heart, intestine and liver) can interact to produce injuries that lead to chronic metabolic changes and disorders that have been associated with PTSD.

Global mental health and trauma exposure: the current evidence for the relationship between traumatic experiences and spirit possession

BACKGROUND

We present a literature review on trauma exposure and spirit possession in low- and middle-income countries (LMICs). Despite the World Health Organization's objective of culturally appropriate mental health care in the Mental Health Action Plan 2013-2020, and the recommendations of the Inter-Agency Standing Committee to consider local idioms of distress and to collaborate with local resources, this topic still receives very little attention. Pathological spirit possession is commonly defined as involuntary, uncontrollable, and occurring outside of ritual settings. It is often associated with stigmatization, suffering, and dysfunctional behavior. While spirit possession has been discussed as an idiom of distress in anthropological literature, recent quantitative studies have presented support for a strong relationship between traumatic experiences and pathological possession states.

OBJECTIVE

The aim of this review was to investigate this relationship systematically in LMICs, in view of the debate on how to address the mental health gap in LMICs.

METHODS

Twenty-one articles, published in peer-reviewed English-language journals between 1994 and 2013, were identified and analyzed with regard to prevalence of possessive trance disorders, patients' sociodemographic characteristics, and its relation to traumatic experiences.

RESULTS

The review and analysis of 917 patients with symptoms of possessive trance disorders from 14 LMICs indicated that it is a phenomenon occurring worldwide and with global relevance. This literature review suggests a strong relationship between trauma exposure and spirit possession with high prevalence rates found especially in postwar areas in African countries.

CONCLUSIONS

More attention for possessive trance disorders in mental health and psychosocial intervention programs in humanitarian emergency settings as well as in societies in transition in LMICs is needed and justified by the results of this systematic literature review.

Posttraumatic stress symptoms and structure among orphan and vulnerable children and adolescents in Zambia

BACKGROUND

Scant information exists on posttraumatic stress disorder (PTSD) symptoms and structure in youth from developing countries.

METHODS

We describe the symptom profile and exposure to trauma experiences among 343 orphan and vulnerable children and adolescents from Zambia. We distinguished profiles of posttraumatic stress symptoms using latent class analysis.

RESULTS

Average number of trauma-related symptoms (21.6; range 0-38) was similar across sex and age. Latent class model suggested three classes varying by level of severity: low (31% of the sample), medium (45% of the sample), and high (24% of the sample) symptomatology.

CONCLUSIONS

Results suggest that PTSD is a continuously distributed latent trait.

Traumatic event exposure and depression severity over time: results from a prospective cohort study in an urban area

PURPOSE

A substantial proportion of adults experience traumatic events each year, yet little is known about the effects of different types of traumatic events on depression severity over time. We prospectively assessed the effects of traumatic event exposure during a 1-year period on changes in depression severity during that period among a representative sample of adults living in Detroit, Michigan in the United States.

METHODS

We used data from 1,054 participants in the first two waves of the Detroit Neighborhood Health Study (2008-2010). Depression severity was measured with the Patient Health Questionnaire-9 (PHQ-9). Negative binomial regression was used to estimate the effect of traumatic event exposure on depression severity at Wave 2, adjusting for Wave 1 PHQ-9 score and potential confounders.

RESULTS

The mean depression severity score at Wave 2 among those exposed to at least one traumatic event during follow-up was 1.71 times higher than among those with no traumatic event exposure [95 % confidence interval (CI) 1.27-2.29]. Also positively associated with depression severity at Wave 2 (vs. no traumatic events) were assaultive violence (mean ratio 2.49, 95 % CI 1.41-4.38), injuries and other directly experienced shocking events (mean ratio 2.59, 95 % CI 1.62-3.82), and three or more traumatic events (mean ratio 2.58, 95 % CI 1.62-4.09).

CONCLUSIONS

Violence, injuries, and other directly experienced traumatic events increase depression severity and may be useful targets for interventions to alleviate the burden of depression in urban areas.

Pharmacological interventions for preventing post-traumatic stress disorder (PTSD)

BACKGROUND

Post-traumatic stress disorder (PTSD) is a debilitating disorder which, after a sufficient delay, may be diagnosed amongst individuals who respond with intense fear, helplessness or horror to traumatic events. There is some evidence that the use of pharmacological interventions immediately after exposure to trauma may reduce the risk of developing of PTSD.

OBJECTIVES

To assess the effects of pharmacological interventions for the prevention of PTSD in adults following exposure to a traumatic event.

SEARCH METHODS

We searched the Cochrane Depression, Anxiety and Neurosis Controlled Trials Register (CCDANCTR-Studies and CCDANCTR-References) (to 14 February 2014). This register contains relevant reports of randomised controlled trials from the following bibliographic databases: CENTRAL (all years); EMBASE (1974 to date); MEDLINE (1950 to date) and PsycINFO (1967 to date). We identified unpublished trials by searching the National Institute of Health (NIH) Reporter, the metaRegister of Controlled Trials database (mRCT) and the WHO International Clinical Trials Registry Platform (to December 2013). We scanned the reference lists of articles for additional studies. We placed no constraints on language and setting.

SELECTION CRITERIA

We restricted studies to randomised controlled trials (RCTs) of pharmacological interventions compared with placebo for the prevention of PTSD in adults.

DATA COLLECTION AND ANALYSIS

Two authors (TA and JI) independently assessed trials for eligibility and inclusion based on the review selection criteria. We independently extracted sample, methodological, outcome and 'Risk of bias' data, as well as the number of side effects, from each trial and entered these into a customised data extraction form. We contacted investigators for missing information. We calculated summary statistics for continuous and dichotomous variables (if provided). We did not undertake subgroup analyses due to the small number of included studies.

MAIN RESULTS

We included nine short-term RCTs (duration 12 weeks or less) in the analysis (345 participants; age range 18 to 76 years). Participants were exposed to a variety of traumas, ranging from assault, traffic accidents and work accidents to cardiac surgery and septic shock. Seven studies were conducted at single centres. The seven RCTs included four hydrocortisone studies, three propranolol studies (of which one study had a third arm investigating gabapentin), and single trials of escitalopram and temazepam. Outcome assessment measures included the Clinician-Administered PTSD Scale (CAPS), the 36-Item Short-Form Health Survey (SF-36) and the Center for Epidemiological Studies - Depression Scale (CES-D).In four trials with 165 participants there was moderate quality evidence for the efficacy of hydrocortisone in preventing the onset of PTSD (risk ratio (RR) 0.17; 95% confidence interval (CI) 0.05 to 0.56; P value = 0.004), indicating that between seven and 13 patients would need to be treated with this agent in order to prevent the onset of PTSD in one patient. There was low quality evidence for preventing the onset of PTSD in three trials with 118 participants treated with propranolol (RR 0.62; 95% CI 0.24 to 1.59; P value = 0.32). Drop-outs due to treatment-emergent side effects, where reported, were low for all of the agents tested. Three of the four RCTs of hydrocortisone reported that medication was more effective than placebo in reducing PTSD symptoms after a median of 4.5 months after the event. None of the single trials of escitalopram, temazepam and gabapentin demonstrated evidence that medication was superior to placebo in preventing the onset of PTSD.Seven of the included RCTs were at a high risk of bias. Differential drop-outs between groups undermined the results of three studies, while one study failed to describe how the allocation of medication was concealed. Other forms of bias that might have influenced study results included possible confounding through group differences in concurrent medication and termination of the study based on treatment response.

AUTHORS' CONCLUSIONS

There is moderate quality evidence for the efficacy of hydrocortisone for the prevention of PTSD development in adults. We found no evidence to support the efficacy of propranolol, escitalopram, temazepam and gabapentin in preventing PTSD onset. The findings, however, are based on a few small studies with multiple limitations. Further research is necessary in order to determine the efficacy of pharmacotherapy in preventing PTSD and to identify potential moderators of treatment effect.

Military service, exposure to trauma, and health in older adulthood: an analysis of northern Vietnamese survivors of the Vietnam War

OBJECTIVES

We sought to better understand the association between early life exposure to war and trauma and older adult health status in a developing setting.

METHODS

We analyzed data of 405 Vietnamese men and women in 1 northern Vietnam commune who entered early adulthood during the Vietnam War and who are now entering late adulthood (i.e., ages 55 years and older in 2010).

RESULTS

The toll of war's trauma in the aging northern Vietnamese population was perceptible in the association between exposure to war trauma and various measures of physical health, including negative self-reported health and somatic symptoms. Killing another person and being exposed to toxic substances in warfare was especially detrimental to health in older adulthood. War traumas were likely implicated more strongly as determinants of late adulthood health in men than in women. The weak association between trauma exposure and reported depressive symptoms raised questions about measuring mental health.

CONCLUSIONS

Military service and war trauma were important determinants of older adult health beyond the US context, given the widespread waging of war and concentration of recent armed conflicts within developing societies.

Family violence exposure and associated risk factors for child PTSD in a Mexican sample

This study was undertaken in an effort to help illuminate the deleterious effects of traumatic stress on children and families in Mexico. Rates of exposure to traumatic events, family and community violence, and posttraumatic stress disorder (PTSD) were investigated in 87 school-age children and their mothers. Binary logistic regression analysis was performed to examine potential family and ecological risk factors for the presence of child PTSD. A total of 51 children (58.6%) reported an event that met the DSM-IV A criteria, and 36 children (41.4%; 20 boys and 16 girls) met criteria for full PTSD. Traumatic exposure in this sample was considerable, particularly intense, and chronic as a result of interpersonal violence in the home and community. Results support the need for preventive systemic interventions targeting the individual level, parent-child dyadic level, and the larger cultural and community context.

Effects of post-migration factors on PTSD outcomes among immigrant survivors of political violence

This study examined the predictors of posttraumatic stress disorder (PTSD) in a clinical sample of 875 immigrant survivors of political violence resettled in the United States, with a specific aim of comparing the relative predictive power of pre-migration and post-migration experiences. Results from a hierarchical OLS regression indicated that pre-migration experiences such as rape/sexual assault were significantly associated with worse PTSD outcomes, as were post-migration factors such as measures of financial and legal insecurity. Post-migration variables, which included immigration status in the US, explained significantly more variance in PTSD outcomes than premigration variables alone. Discussion focused on the importance of looking at postmigration living conditions when treating trauma in this population.

Associations between exposure to intimate partner violence, armed conflict, and probable PTSD among women in rural Côte d'Ivoire

BACKGROUND

Objectives were to assess associations between intimate partner violence (IPV), violence during armed conflict (i.e. crisis violence), and probable post-traumatic stress disorder (PTSD).

METHODS

Using a sample of 950 women in rural Côte d'Ivoire, logistic generalized estimating equations assessed associations between IPV and crisis violence exposures with past-week probable PTSD.

RESULTS

Over one in 5 (23.4%) women reported past-year IPV, and over one in 4 women (26.5%) reported experiencing IPV prior to the past year (i.e. remote IPV). Crisis violence was experienced by 72.6% of women. In adjusted models including demographics, crisis violence (overall and specific forms), and IPV (remote and past-year), women who reported past-year IPV had 3.1 times the odds of reporting probable past-week PTSD (95%CI: 1.8-5.3) and those who reported remote IPV had 1.6 times the odds (95%CI: 0.9-2.7). Violent exposures during the crisis were not significantly associated with probable PTSD (any crisis violence: aOR: 1.04 (0.7-1.5); displacement: aOR: 0.9 (95%CI: 0.5-1.7); family victimization during crisis: aOR: 1.1 (95%CI: 0.8-1.7); personal victimization during crisis: aOR: 1.7 (95%CI: 0.7-3.7)).

CONCLUSION

Past-year IPV was more strongly associated with past-week probable PTSD than remote IPV and violence directly related to the crisis. IPV must be considered within humanitarian mental health and psychosocial programming.

Posttraumatic stress in emergency settings outside North America and Europe: a review of the emic literature

Mental health professionals from North America and Europe have become common participants in postconflict and disaster relief efforts outside of North America and Europe. Consistent with their training, these practitioners focus primarily on posttraumatic stress disorder (PTSD) as their primary diagnostic concern. Most research that has accompanied humanitarian aid efforts has likewise originated in North America and Europe, has focused on PTSD, and in turn has reinforced practitioners' assumptions about the universality of the diagnosis. In contrast, studies that have attempted to identify how local populations conceptualize posttrauma reactions portray a wide range of psychological states. We review this emic literature in order to examine differences and commonalities across local posttraumatic cultural concepts of distress (CCDs). We focus on symptoms to describe these constructs - i.e., using the dominant neo-Kraepelinian approach used in North American and European psychiatry - as opposed to focusing on explanatory models in order to examine whether positive comparisons of PTSD to CCDs meet criteria for face validity. Hierarchical clustering (Ward's method) of symptoms within CCDs provides a portrait of the emic literature characterized by traumatic multifinality with several common themes. Global variety within the literature suggests that few disaster-affected populations have mental health nosologies that include PTSD-like syndromes. One reason for this seems to be the almost complete absence of avoidance as pathology. Many nosologies contain depression-like disorders. Relief efforts would benefit from mental health practitioners getting specific training in culture-bound posttrauma constructs when entering settings beyond the boundaries of the culture of their training and practice.