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Loughnan SA, Boyle FM, Ellwood D, Crocker S, Lancaster A, Astell C, Dean J, Horey D, Callander E, Jackson C, Shand A, Flenady V. Living with Loss: study protocol for a randomized controlled trial evaluating an internet-based perinatal bereavement program for parents following stillbirth and neonatal death. Trials 2022; 23:464. [PMID: 35668502 PMCID: PMC9167910 DOI: 10.1186/s13063-022-06363-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 04/26/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Stillbirth and neonatal death are devastating pregnancy outcomes with long-lasting psychosocial consequences for parents and families, and wide-ranging economic impacts on health systems and society. It is essential that parents and families have access to appropriate support, yet services are often limited. Internet-based programs may provide another option of psychosocial support for parents following the death of a baby. We aim to evaluate the efficacy and acceptability of a self-guided internet-based perinatal bereavement support program "Living with Loss" (LWL) in reducing psychological distress and improving the wellbeing of parents following stillbirth or neonatal death. METHODS This trial is a two-arm parallel group randomized controlled trial comparing the intervention arm (LWL) with a care as usual control arm (CAU). We anticipate recruiting 150 women and men across Australia who have experienced a stillbirth or neonatal death in the past 2 years. Participants randomized to the LWL group will receive the six-module internet-based program over 8 weeks including automated email notifications and reminders. Baseline, post-intervention, and 3-month follow-up assessments will be conducted to assess primary and secondary outcomes for both arms. The primary outcome will be the change in Kessler Psychological Distress Scale (K10) scores from baseline to 3-month follow-up. Secondary outcomes include perinatal grief, anxiety, depression, quality of life, program satisfaction and acceptability, and cost-effectiveness. Analysis will use intention-to-treat linear mixed models to examine psychological distress symptom scores at 3-month follow-up. Subgroup analyses by severity of symptoms at baseline will be undertaken. DISCUSSION The LWL program aims to provide an evidence-based accessible and flexible support option for bereaved parents following stillbirth or neonatal death. This may be particularly useful for parents and healthcare professionals residing in rural regions where services and supports are limited. This RCT seeks to provide evidence of the efficacy, acceptability, and cost-effectiveness of the LWL program and contribute to our understanding of the role digital services may play in addressing the gap in the availability of specific bereavement support resources for parents following the death of a baby, particularly for men. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry, ACTRN12621000631808 . Registered prospectively on 27 May 2021.
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Affiliation(s)
- Siobhan A Loughnan
- NHMRC Centre of Research Excellence in Stillbirth, Mater Research Institute-University of Queensland, Raymond Terrace, Level 3 Aubigny Place, South Brisbane, QLD, Australia.
| | - Frances M Boyle
- NHMRC Centre of Research Excellence in Stillbirth, Mater Research Institute-University of Queensland, Raymond Terrace, Level 3 Aubigny Place, South Brisbane, QLD, Australia.,Institute for Social Science Research, The University of Queensland, 80 Meiers Rd, Indooroopilly, QLD, Australia
| | - David Ellwood
- NHMRC Centre of Research Excellence in Stillbirth, Mater Research Institute-University of Queensland, Raymond Terrace, Level 3 Aubigny Place, South Brisbane, QLD, Australia.,School of Medicine, Griffith University, Parklands Drive, Gold Coast, QLD, Australia.,Gold Coast University Hospital, 1 Hospital Drive, Southport, QLD, Australia
| | - Sara Crocker
- NHMRC Centre of Research Excellence in Stillbirth, Mater Research Institute-University of Queensland, Raymond Terrace, Level 3 Aubigny Place, South Brisbane, QLD, Australia
| | - Ann Lancaster
- NHMRC Centre of Research Excellence in Stillbirth, Mater Research Institute-University of Queensland, Raymond Terrace, Level 3 Aubigny Place, South Brisbane, QLD, Australia
| | - Chrissie Astell
- NHMRC Centre of Research Excellence in Stillbirth, Mater Research Institute-University of Queensland, Raymond Terrace, Level 3 Aubigny Place, South Brisbane, QLD, Australia
| | - Julie Dean
- NHMRC Centre of Research Excellence in Stillbirth, Mater Research Institute-University of Queensland, Raymond Terrace, Level 3 Aubigny Place, South Brisbane, QLD, Australia.,Institute for Social Science Research, The University of Queensland, 80 Meiers Rd, Indooroopilly, QLD, Australia
| | - Dell Horey
- NHMRC Centre of Research Excellence in Stillbirth, Mater Research Institute-University of Queensland, Raymond Terrace, Level 3 Aubigny Place, South Brisbane, QLD, Australia.,La Trobe University, Plenty Rd &, Kingsbury Dr, Bundoora, VIC, Australia
| | - Emily Callander
- Monash University, 553 St Kilda Road, Melbourne, VIC, Australia
| | | | - Antonia Shand
- Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW, Australia
| | - Vicki Flenady
- NHMRC Centre of Research Excellence in Stillbirth, Mater Research Institute-University of Queensland, Raymond Terrace, Level 3 Aubigny Place, South Brisbane, QLD, Australia
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Wilks CR, Khalifian CE, Glynn SM, Morland LA. The association between anger experiences and expression and veteran suicidal thoughts in intimate couple relationships. J Clin Psychol 2020; 76:1869-1881. [DOI: 10.1002/jclp.22960] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Chelsey R. Wilks
- Department of Psychology Harvard University Cambridge Massachusetts
- Semel Institute of Neuroscience and Human Behavior University of California, Los Angeles Los Angeles CA
| | - Chandra E. Khalifian
- Regional TeleMental Health Program Veterans Affairs Healthcare System San Diego California
- Department of Psychiatry University of California La Jolla California
| | - Shirley M. Glynn
- Research Service Veterans Affairs Greater Los Angeles Healthcare System Los Angeles California
| | - Leslie A. Morland
- Regional TeleMental Health Program Veterans Affairs Healthcare System San Diego California
- Department of Psychiatry University of California La Jolla California
- Pacific Islands Division National Center for PTSD Honolulu Hawaii
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Silove D, Mohsin M, Klein L, Tam NDJ, Dadds M, Eapen V, Tol WA, da Costa Z, Savio E, Soares R, Steel Z, Rees SJ. Longitudinal path analysis of depressive symptoms and functioning among women of child-rearing age in postconflict Timor-Leste. BMJ Glob Health 2020; 5:e002039. [PMID: 32337078 PMCID: PMC7170425 DOI: 10.1136/bmjgh-2019-002039] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 02/11/2020] [Accepted: 03/07/2020] [Indexed: 11/11/2022] Open
Abstract
This longitudinal study indicates that exposure to the traumas of mass conflict and subsequent depressive symptoms play an important role in pathways leading to functional impairment in the postconflict period among women of child-rearing age. Our study, conducted in Timor-Leste, involved an analytic sample of 1292 women recruited at antenatal clinics in the capital and its surrounding districts. Women were re-interviewed at home 2 years later (77.3% retention). We applied the Edinburgh Postnatal Depression Scale, the Harvard Trauma Questionnaire for conflict-related traumatic events, the WHO Violence Against Women Instrument covering the past year for intimate partner violence and the WHO Disability Assessment Schedule (WHODAS V.2.0) to assess functional impairment. A longitudinal path analysis tested direct and indirect relationships involving past conflict-related trauma exposure, depressive symptoms measured over the two time points and functional impairment at follow-up. The prevalence of predefined clinically significant depressive symptoms diminished from 19.3% to 12.8%. Nevertheless, there was a tendency for depressive symptoms to persist over time (β=0.20; p<0.001). Follow-up depressive symptoms were associated with functional impairment (β=0.35; p<0.001). Reported conflict-related trauma occurring a minimum of 6 years earlier (β=0.23; p<0.001) and past-year physical intimate partner violence (β=0.26; p<0.001) were each associated with depressive symptoms at baseline and at follow-up. A measure of poverty specific to the context and reported health problems in the mother and infant also contributed to depressive symptoms. The findings highlight the association between ongoing trauma-related depressive symptoms and the capacity of women in the childbearing age to function in multiple areas of their lives in a postconflict country. Recognition of these relationships is important in the formulation and implementation of contemporary international recovery and development policies applied to postconflict countries.
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Affiliation(s)
- Derrick Silove
- Psychiatry, University of New South Wales, Sydney, New South Wales, Australia
| | - Mohammed Mohsin
- Psychiatry, University of New South Wales, Sydney, New South Wales, Australia.,Mental Health Academic Unit, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Louis Klein
- Psychiatry, University of New South Wales, Sydney, New South Wales, Australia.,Mental Health Academic Unit, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Natalino De Jesus Tam
- Psychiatry, University of New South Wales, Sydney, New South Wales, Australia.,Child and Maternal Health, Alola Foundation, Dili, Timor-Leste
| | - Mark Dadds
- Psychology, The University of Sydney, Sydney, New South Wales, Australia
| | - Valsamma Eapen
- Psychiatry, University of New South Wales, Sydney, New South Wales, Australia.,Mental Health Academic Unit, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Wietse A Tol
- Department of Mental Health, Johns Hopkins Sch Publ Hlth, Baltimore, Maryland, USA
| | - Zelia da Costa
- Psychiatry, University of New South Wales, Sydney, New South Wales, Australia.,Child and Maternal Health, Alola Foundation, Dili, Timor-Leste
| | - Elisa Savio
- Psychiatry, University of New South Wales, Sydney, New South Wales, Australia.,Child and Maternal Health, Alola Foundation, Dili, Timor-Leste
| | - Rina Soares
- Psychiatry, University of New South Wales, Sydney, New South Wales, Australia.,Child and Maternal Health, Alola Foundation, Dili, Timor-Leste
| | - Zachary Steel
- Psychiatry, University of New South Wales, Sydney, New South Wales, Australia.,Richmond Hospital, St John of God Health Care, North Richmond, New South Wales, Australia
| | - Susan J Rees
- Psychiatry, University of New South Wales, Sydney, New South Wales, Australia.,Mental Health Academic Unit, Liverpool Hospital, Sydney, New South Wales, Australia
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Theoretical background, first stage development and adaptation of a novel Integrative Adapt Therapy (IAT) for refugees. Epidemiol Psychiatr Sci 2019; 29:e47. [PMID: 31441397 PMCID: PMC8061213 DOI: 10.1017/s2045796019000416] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
AIMS Refugees are confronted with the task of adapting to the long-term erosion of psychosocial systems and institutions that in stable societies support psychological well-being and mental health. We provide an overview of the theoretical principles and practical steps taken to develop a novel psychotherapeutic approach, Integrative Adapt Therapy (IAT), which aims to assist refugees to adapt to these changes. This paper offers the background informing ongoing trials of IAT amongst refugees from Myanmar. METHODS A systematic process was followed in formulating the therapy and devising a treatment manual consistent with the principles of the Adaptation and Development After Persecution and Trauma (ADAPT) model. The process of development and refinement was based on qualitative research amongst 70 refugees (ten from West Papua and 60 Rohingya from Myanmar). The therapeutic process was then piloted by trained interventionists amongst a purposively selected sample of 20 Rohingya refugees in Malaysia. RESULTS The final formulation of IAT represented an integration of the principles of the ADAPT model and evidence-based techniques of modern therapies in the field, including a transdiagnostic approach and the selective use of cognitive behavioural treatment elements such as problem-solving and emotional regulation techniques. The steps outlined in refining the manual are outlined in relation to work amongst West Papuan refugees, and the process of cultural and contextual modifications described during early piloting with Rohingya refugees in Malaysia. CONCLUSIONS IAT integrates universal principles of the ADAPT model with the particularities of the culture, history of conflict and living context of each refugee community; this synthesis of knowledge forms the basis for participants gaining insights into their personal patterns of psychosocial adaptation to the refugee experience. Participants then apply evidence-based techniques to improve their capacity to adapt to the serial psychosocial changes they have encountered in their lives as refugees. The overarching goal of IAT is to provide refugees with a coherent framework that assists in making sense of their experiences and their emotional and interpersonal reactions to the challenges they confront within the family and community context. As such, the principles of a general model (ADAPT) are used as a springboard for making concrete, manageable and meaningful life changes at the individual level, a potentially novel approach for psychosocial interventions in the field.
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Miah MA, Mahmuda M, Elshazly M, Khan S, Tay A, Ventevogel P. Contextual adaptation and piloting of Group Integrative Adapt Therapy (IAT-G) amongst Rohingya refugees living in Bangladesh. INTERVENTION-INTERNATIONAL JOURNAL OF MENTAL HEALTH PSYCHOSOCIAL WORK AND COUNSELLING IN AREAS OF ARMED CONFLICT 2019. [DOI: 10.4103/intv.intv_48_19] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Killikelly C, Bauer S, Maercker A. The Assessment of Grief in Refugees and Post-conflict Survivors: A Narrative Review of Etic and Emic Research. Front Psychol 2018; 9:1957. [PMID: 30405474 PMCID: PMC6204364 DOI: 10.3389/fpsyg.2018.01957] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Accepted: 09/21/2018] [Indexed: 12/29/2022] Open
Abstract
Background: Prolonged grief disorder (PGD) is a new mental health disorder that will be recognized by the World Health Organization’s disorder classification, the ICD-11, in 2018. Current assessment measures of PGD are largely based on North American and European conceptualizations of grief (etic i.e., from the perspective of the observer). However, research is emerging from communities outside of the Global North, in particular, conflict-exposed communities, exploring local models (emic i.e., from within the cultural group), assessment measures and symptoms of grief. Several reviews have found that refugees have higher rates of mental illness, defined by etic standards as depression, post-traumatic stress disorder (PTSD), anxiety disorders and psychotic symptoms. Yet, presently there are no reviews documenting the assessment of PGD in refugees and post conflict survivors. Method: This narrative review will provide an overview of studies that assess grief in refugees to (1) identify current assessment measures of grief in refugees (i.e., type and frequency of questionnaires used, whether Global North-based, etic, or locally developed, emic, and the level of cultural adaptation) and (2) to document the variety and rate of grief symptoms identified with Global North standard measures and/or local measures (i.e., the endorsement of standard symptom items and the identification of culturally specific symptoms of grief). Results: This review revealed 24 studies that assessed disordered grief in refugee or post conflict samples. Studies were heterogeneous in their assessment methods; the majority (n = 17) used an etic approach, four used a combined etic/emic approach, and three used a predominantly emic approach. The rate of disordered grief was high depending on cultural adaptation approach (31–76%) and when standard etic measures were used the disordered grief rate was 32%. Conclusion: These findings will help to guide future studies to provide accurate assessment of grief in refugee and post conflict populations and has implications for improving cultural knowledge in clinical practice.
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Affiliation(s)
- Clare Killikelly
- Division Psychopathology and Clinical Intervention, Department of Psychology, University of Zürich, Zürich, Switzerland
| | - Susanna Bauer
- Division Psychopathology and Clinical Intervention, Department of Psychology, University of Zürich, Zürich, Switzerland
| | - Andreas Maercker
- Division Psychopathology and Clinical Intervention, Department of Psychology, University of Zürich, Zürich, Switzerland
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Wang SH, Phillips P, Dong ZC, Zhang YD. Intelligent facial emotion recognition based on stationary wavelet entropy and Jaya algorithm. Neurocomputing 2018. [DOI: 10.1016/j.neucom.2017.08.015] [Citation(s) in RCA: 109] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Risk of perpetrating intimate partner violence amongst men exposed to torture in conflict-affected Timor-Leste. Glob Ment Health (Camb) 2018; 5:e23. [PMID: 29997895 PMCID: PMC6036651 DOI: 10.1017/gmh.2018.16] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Revised: 03/29/2018] [Accepted: 04/05/2018] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND A key issue in need of empirical exploration in the post-conflict and refugee mental health field is whether exposure to torture plays a role in generating risk of intimate partner violence (IPV), and whether this pathway is mediated by the mental health effects of torture-related trauma. In examining this question, it is important to assess the impact of socio-economic hardship which may be greater amongst survivors of torture in low-income countries. METHODS The study data were obtained from a cohort of 870 women (recruited from antenatal clinics) and their male partners in Dili district, Timor-Leste. We conducted bivariate and path analysis to test for associations of men's age, socioeconomic status, torture exposure, and mental disturbance, with IPV (the latter reported by women). RESULTS The path analysis indicated positive paths from a younger age, torture exposure, and lower socio-economic status amongst men leading to mental disturbance. Mental disturbance, in turn, led to IPV. In addition, younger age, lower socio-economic status, torture exposure, and mental disturbance were directly associated with IPV. CONCLUSIONS Our data provide the first systematic evidence of an association between torture and IPV in a low-income, post-conflict country, confirming that low socio-economic status, partly related to being a torture survivor, adds to the risk. The high prevalence of IPV in this context suggests that other structural factors, such as persisting patriarchal attitudes, contribute to the risk of IPV. Early detection and prevention programs may assist in reducing the risk of IPV in families in which men have experienced torture.
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Silove D, Mohsin M, Tay AK, Steel Z, Tam N, Savio E, Da Costa ZM, Rees S. Six-year longitudinal study of pathways leading to explosive anger involving the traumas of recurrent conflict and the cumulative sense of injustice in Timor-Leste. Soc Psychiatry Psychiatr Epidemiol 2017; 52:1281-1294. [PMID: 28825139 DOI: 10.1007/s00127-017-1428-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Accepted: 08/06/2017] [Indexed: 11/30/2022]
Abstract
PURPOSE Cumulative evidence suggests that explosive anger may be a common reaction among survivors of mass conflict. However, little is known about the course of explosive anger in the years following mass conflict, or the psychosocial factors that influence the trajectory of that reaction pattern. We examined these issues in a 6-year longitudinal study (2004-2010) conducted among adult residents of a rural and an urban village in Timor-Leste (n = 1022). METHODS We derived a brief, context-specific index of explosive anger using qualitative methods. Widely used measures of post-traumatic stress disorder (PTSD) and severe psychological distress were calibrated to the Timor context. We developed an index of the cumulative sense of injustice related to consecutive historical periods associated with conflict in Timor-Leste. We applied partial structural equation modeling (SEM) to examine pathways from baseline explosive anger, socio-demographic factors, recurrent trauma, mental health indices (PTSD, severe psychological distress) and the sense of injustice, to explosive anger. RESULTS Half of the sample with explosive anger at baseline continued to report that reaction pattern after 6 years; and a third of those who did not report explosive anger at baseline developed the response by follow-up. A symmetrical pattern of younger age, female gender and the trauma count for the preceding historical period predicted explosive anger at each assessment point. The sense of injustice was related to explosive anger at follow-up. Explosive anger was associated with impairment in functioning and conflict with the intimate partner and wider family. CONCLUSIONS Sampling constraints caution against generalizing our findings to other populations. Nevertheless, our data suggest that explosive anger may persist for a prolonged period of time following mass conflict and that the response pattern is initiated and maintained by recurrent trauma exposure associated with a sense of injustice. Averting recurrence of mass violence and addressing persisting feelings of injustice may assist in reducing anger in conflict-affected societies. Whether explosive anger at the individual level increases risk of collective violence under conditions of social and political instability requires further inquiry.
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Affiliation(s)
- Derrick Silove
- Psychiatry Research and Teaching Unit, University of New South Wales, Sydney, Australia. .,Academic Mental Health Unit, Level 2 Mental Health Centre, The Liverpool Hospital, Sydney, Australia.
| | - Mohammed Mohsin
- Psychiatry Research and Teaching Unit, University of New South Wales, Sydney, Australia.,Academic Mental Health Unit, Level 2 Mental Health Centre, The Liverpool Hospital, Sydney, Australia
| | - Alvin Kuowei Tay
- Psychiatry Research and Teaching Unit, University of New South Wales, Sydney, Australia.,Academic Mental Health Unit, Level 2 Mental Health Centre, The Liverpool Hospital, Sydney, Australia
| | - Zachary Steel
- School of Psychiatry, St Johns of God, Richmond Hospital, The Black Dog Institute, University of New South Wales, St. John of God, Australia
| | | | | | | | - Susan Rees
- Psychiatry Research and Teaching Unit, University of New South Wales, Sydney, Australia.,Academic Mental Health Unit, Level 2 Mental Health Centre, The Liverpool Hospital, Sydney, Australia
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Silove D, Ventevogel P, Rees S. The contemporary refugee crisis: an overview of mental health challenges. World Psychiatry 2017; 16:130-139. [PMID: 28498581 PMCID: PMC5428192 DOI: 10.1002/wps.20438] [Citation(s) in RCA: 263] [Impact Index Per Article: 37.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
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.
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Affiliation(s)
- Derrick Silove
- School of Psychiatry, University of New South Wales, and Psychiatry Research and Teaching Unit, Academic Mental Health Centre, Southwestern Sydney Local Health District, Sydney, Australia
| | - Peter Ventevogel
- Public Health Section, United Nations High Commissioner for Refugees, Geneva, Switzerland
| | - Susan Rees
- School of Psychiatry, University of New South Wales, and Psychiatry Research and Teaching Unit, Academic Mental Health Centre, Southwestern Sydney Local Health District, Sydney, Australia
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