A follow-up study of mental health and health-related quality of life in tortured refugees in multidisciplinary treatment

The Effect of Daily Meditative Practices Based on Mindfulness and Self-Compassion on Emotional Distress under Stressful Conditions: A Randomized Controlled Trial

Intervention programs based on self-compassion have demonstrated their efficacy both in reducing psychological distress and increasing well-being. The goal of this study was to test the efficacy of an online intervention to increase mindfulness and self-compassion levels in a non-clinical sample in a highly stressful context: the ten weeks of lockdown imposed in the early stages of the COVID-19 pandemic. The intervention sessions consisted of thirty-minute guided meditations followed by thirty minutes of inquiry. Sixty-one participants completed two thirds of the sessions or more, and 65 individuals participated in a waiting-list (WL) control group. Self-compassion, anxiety, depression and stress levels were assessed. The analysis of pre-post results suggests that the interventions increased self-compassion levels and decreased anxiety, depression and stress levels, whereas the WL group did not show any significant changes. The emotional changes in the intervention group were associated with the increase in self-compassion. However, at follow-up, the scores of emotional distress variables returned to the initial pre-intervention scores. These data can be interpreted in line with previous results that have shown the efficacy of self-compassion-based intervention programs. Given that this efficacy was not maintained at follow-up, data are discussed according to the pervasive role of a highly stressful context and-as described in other studies-the need for regular practice to maintain the benefits obtained.

Sleep impairments in refugees diagnosed with post-traumatic stress disorder: a polysomnographic and self-report study

Background: Post-traumatic stress disorder (PTSD) is the clinical manifestation of traumatic events and is associated with sleep disturbances. Sleep disturbances, if left untreated, may perpetuate or even worsen symptoms of PTSD. Previous studies of other PTSD populations show a higher incidence of sleep impairments and sleep disorders compared to healthy controls (HCs); however, this has never been investigated in trauma-affected refugees diagnosed with PTSD.Objectives: To examine subjective sleep quality, measure sleep architecture, and identify latent sleep disorders in refugees diagnosed with PTSD compared to HCs.Method: This comparative study included 20 trauma-affected refugees diagnosed with PTSD and 20 HC matched on age, sex, and body mass index. All participants completed self-report questionnaires assessing sleep quality, insomnia severity, and disturbing nocturnal behaviour, and all took part in a one-night polysomnography (PSG) assessment.Results: Patients reported significantly poorer subjective sleep quality, sleep latency, sleep duration, and sleep efficiency compared to HCs. Subjective reports on hours spent in bed were not significantly different between patients and HCs. Patients reported significantly higher nightmare frequency and severity compared to HCs. PSG measures showed that patients had significantly reduced sleep efficiency, more awakenings, and longer REM sleep latency, and spent more time awake, whereas there was no significant differences regarding total time in bed, total sleep time, or sleep latency. The prevalence of sleep disorders was equal between groups.Conclusions: The study identified significant impairments in several sleep domains, with a preponderance of disturbed regulation of sleep resulting in awakenings. These results indicate a need for more focus on hyperarousal and nightmares as key elements of disturbed sleep in PTSD. Furthermore, the study identified a discrepancy between subjective and objective measures concerning total sleep time, raising questions regarding the causes of 'sleep state misperception'.Trial registration: ClinicalTrials.gov identifier: NCT03535636..Trial registration: Sleep Impairments in Refugees Diagnosed with PTSD (PSG-PTSD). URL: https://clinicaltrials.gov/ct2/show/NCT03535636. ClinicalTrials.gov NCT03535636. Date of registration: 24/05/2018.

Does Time Heal Trauma? 18 Month Follow-Up Study of Syrian Refugees' Mental Health in Iraq's Kurdistan Region

The findings of longitudinal studies on traumatized refugees have shown that factors related to premigration, migration, and post-migration experiences determine changes in mental health over time. The primary aim of this follow-up study was to examine the potential change in the prevalence rates of probable PTSD and depression among Syrian refugees in Iraq. An unselected group of N = 92 Syrian adult refugees was recruited from Arbat camps in Sulaymaniyah Governorate in Iraq's Kurdistan Region, and then interviewed at two different time points between July 2017 and January 2019. Locally validated instruments were used to assess traumatic events and mental health symptoms. The primary results showed no significant change in the mean scores of PTSD and depression symptoms from the first measurement to the second measurement over the course of 18 months. On the individual level, no reliable change was found for either PTSD or depression symptoms in more than three-quarters of the participants (78.3% and 77.2%, respectively). New adversities and traumatic events that occurred over the 18 months between the interviews were a significant predictor of increasing trauma-related symptoms. After the flight from conflict settings, trauma-related disorders seem to be chronic for the majority of Syrian refugees. Further longitudinal studies are needed in order to identify specific risk factors that lead to maintaining or worsening mental health symptoms over time, and to explore effective therapeutic intervention methods for this traumatized population.

Prevalence and correlates of DSM-IV and DSM-5 Intermittent Explosive Disorder amongst Myanmar refugees living in Malaysia: a population-based study

AIMS

We investigate the prevalence and risk factor profiles of Intermittent Explosive Disorder (IED) and comparison between two diagnostic measures for IED in a large population-based study of three ethnic groups of refugees (Chin, Kachin and Rohingya) from Myanmar resettled in Malaysia.

METHODS

Trained field personnel interviewed in total 2058 refugees, applying a clustered, probabilistic, proportional-to-size sampling framework and using the DSM-IV and DSM-5 criteria to diagnose IED. We used descriptive and bivariate analyses to explore associations of IED (using DSM IV or DMS 5) with ethnic group membership, sociodemographic characteristics and exposure to premigration traumatic events (TEs) and postmigration living difficulties (PMLDs). We also examined associations of IED with other common mental disorders (CMDs) (depression, anxiety and posttraumatic stress disorder) and with domains of functional impairment. Finally, we compared whether IED measured using DSM IV or DSM 5 generated the same or different prevalence.

RESULTS

For the whole sample (n = 2058), the 12-month prevalence of DSM-IV IED was 5.9% (n = 122) and for DSM-5, 3.4% (n = 71). Across the three ethnic groups, 12-month DSM-5 IED prevalence was 2.1% (Chin), 2.9% (Rohingya) and 8.0% (Kachin), whereas DSM-IV defined IED prevalence was 3.2% (Chin), 7% (Rohingya) and 9.2% (Kachin). Being single, and exposure to greater premigration TEs and PMLDs were each associated with IED. Over 80% of persons with IED recorded one or more comorbid CMDs. Persons with IED also showed greater levels of functional impairment compared with those without IED.

CONCLUSIONS

The pooled IED prevalence was higher than global norms but there was substantial variation in prevalence across the three study groups.

The relationship between employment and health for people from refugee and asylum-seeking backgrounds: A systematic review of quantitative studies

Background

For the general population, the positive effects of paid employment on health and wellbeing are well established. However, less is known for people from refugee and asylum-seeking backgrounds. This review aims to systematically summarise the quantitative literature on the relationship between employment and health and wellbeing for refugees and asylum seekers.

Method

A search strategy was conducted in online databases, including MEDLINE, PsychINFO, EMCARE, SCOPUS, CINHAL, ProQuest and Web of Science. Articles were screened against inclusion and exclusion criteria. Studies published in English between 2000 to October 2021 were included if they used quantitative methods to consider the relationship between employment and health for refugees and asylum seekers in resettlement countries. Study quality was assessed using The Joanna Briggs Institute's Critical Appraisal Tools. Findings were synthesised using a narrative approach.

Results

Seventy-two papers were identified. The majority of papers (N = 58, 81%) examined the association between employment and mental health outcomes. Overall, while there were inconsistencies in the findings, employment had a positive effect on mental health particularly in reducing levels of psychological distress and depression. Though more limited in number, the papers examining physical health suggest that people who are employed tend to have better physical health than unemployed persons. There was some evidence to support the bi-directional relationship between employment and health. Poor mental and physical health negatively impacted the odds of employment and occupational status of refugees.

Conclusion

Good quality employment is an essential component of refugee resettlement and this review found that in general employment is also beneficial for refugee health, particularly aspects of mental health. More research regarding the effects of employment on physical health is required. The effects of refugee-specific factors such as gender roles, torture, and trauma on the relationship between employment and health also require further investigation.

Variations in prevalence and risk profiles for Common Mental Disorders amongst Rohingya, Chin and Kachin refugees from Myanmar

BACKGROUND

Large variations in prevalence rates of common mental disorder (CMD) amongst refugees and forcibly displaced populations have raised questions about the accuracy and value of epidemiological surveys in these cross-cultural settings. We examined the associations of sociodemographic indices, premigration traumatic events (TEs), postmigration living difficulties (PMLDs), and psychosocial disruptions based on the Adaptive Stress Index (ASI) in relation to CMD prevalence amongst the Rohingya, Chin and Kachin refugees originating from Myanmar and relocated to Malaysia.

METHODS

Parallel epidemiological studies were conducted in areas where the three groups were concentrated in and around Malaysia (response rates: 80-83%).

RESULTS

TE exposure, PMLDs and ASI were significantly associated with CMD prevalence in each group but the Rohingya recorded the highest exposure to all three of these former indices relative to Chin and Kachin (TE: mean = 11.1 v. 8.2 v. 11; PMLD: mean = 13.5 v. 7.4 v. 8.7; ASI: mean = 128.9 v. 32.1 v. 35.5). Multiple logistic regression analyses based on the pooled sample (n = 2058) controlling for gender and age, found that ethnic group membership, premigration TEs (16 or more TEs: OR, 2.00; 95% CI, 1.39-2.88; p < 0.001), PMLDs (10-15 PMLDs: OR, 4.19; 95% CI, 3.17-5.54; 16 or more PMLDs: OR, 7.23; 95% CI, 5.24-9.98; p < 0.001) and ASI score (ASI score 100 or greater: OR, 2.19; 95% CI, 1.46-3.30; p < 0.001) contributed to CMD.

CONCLUSIONS

Factors specific to each ethnic group and differences in the quantum of exposure to TEs, PMLDs and psychosocial disruptions appeared to account in large part for differences in prevalence rates of CMDs observed across these three groups.

Health-related quality of life of refugees: a systematic review of studies using the WHOQOL-Bref instrument in general and clinical refugee populations in the community setting

Purpose

To systematically review studies on HRQOL, measured by the WHOQOL-Bref instrument, of refugees in general and clinical populations who are settled in the community of the hosting country, and outline the differences in scores among the two population groups and across the four domains of WHOQOL-Bref (physical, psychological, social relationships and environment domain) as well as factors impacting those outcomes.

Methods

Several databases were systematically searched by using a broad search strategy. Additionally, a hand search for grey literature was performed. Studies had to comply with the following inclusion criteria: (a) population of refugees; (b) living in the community of the country of destination; (c) assessing HRQOL through the WHOQOL-Bref instrument.

Results

15 studies were identified and divided into two subgroups: (a) general population of refugees (b) clinical population of refugees, who were specifically selected for their mental status or because they had experienced relevant past traumas. Although we can outline common patterns among the two groups, in terms of domains scoring the highest and the lowest, heterogeneous values of HRQOL are observed across the studies included.

Conclusions

Individuals who were included in the clinical refugee group have a lower quality of life in respect to the general population of refugees. However, among the two groups different patterns can be outlined considering each domain of HRQOL: higher scores for the Physical and lower for the Environment domain when considering the general population of refugees and higher scores for the Environment and lower for the Psychological domain when referring to the clinical one. These lower scores are probably due to having a higher rate of mental distress and being more exposed to somatization, stigmatization and barriers to access the healthcare system of the hosting country.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13031-021-00378-1.

The 10-year course of mental health, quality of life, and exile life functioning in traumatized refugees from treatment start

Refugee patients with severe traumatic experiences may need mental health treatment, but treatment results vary, and there is scarcity of studies demonstrating refugees' long-term health and well-being after treatment. In a 10-year naturalistic and longitudinal study, 54 multi-origin traumatized adult refugee patients, with a background of war and persecution, and with a mean stay in Norway of 10.5 years, were recruited as they entered psychological treatment in mental health specialist services. The participants were interviewed face-to-face with multiple methods at admittance, and at varying points in time during and after psychotherapy. The aim was to study the participants' trajectories of symptoms of post-traumatic stress, anxiety and depression, four aspects of quality of life, and two aspects of exile life functioning. Linear mixed effects analyses included all symptoms and quality of life measures obtained at different times and intervals for the participants. Changes in exile life functioning was investigated by exact McNemar tests. Participants responded to the quantitative assessments up to eight times. Length of therapy varied, with a mean of 61.3 sessions (SD = 74.5). The participants improved significantly in symptoms, quality of life, and exile life functioning. Improvement in symptoms of posttraumatic stress, anxiety, and depression yielded small effect sizes (r = .05 to .13), while improvement in quality of psychological and physical health yielded medium effect sizes (r = .38 and .32). Thus, long-time improvement after psychological therapy in these severely traumatized and mostly chronified refugee patients, was more notable in quality of life and exile life functioning than in symptom reduction. The results imply that major symptom reduction may not be attainable, and may not be the most important indication of long-term improvement among refugees with long-standing trauma-related suffering. Other indications of beneficial effects should be applied as well.

A Rasch-based validity study of the Harvard Trauma Questionnaire

BACKGROUND

The Harvard Trauma Questionnaire (HTQ) is the predominant questionnaire for assessing PTSD in trauma-affected refugees. Although the scale is increasingly used for measuring treatment outcomes, it has never been specifically validated for such use. The current study does so by testing the HTQ with the Rasch model.

METHODS

The analysis is based on 641 Arabic and Persian speaking refugees, diagnosed with PTSD and undergoing psychiatric treatment in Denmark. The responses were tested against the assumptions of the Rasch model, including unidimensionality, local independence and the absence of differential item function across subgroups.

RESULTS

Results reveal two subscales that, when accounting for local dependence and differential item functioning, meet criteria for the Rasch model in the included samples: An arousal/intrusion subscale and an avoidance/numbing subscale.

LIMITATIONS

The included sample was highly chronic and suffered from major depressive disorder. Results may not be fully representative of less chronic populations, e.g. recently arrived refugees.

CONCLUSIONS

We recommend the use of the arousal/intrusion subscale and the avoidance/numbing subscale as an optimized way of summarizing responses to the HTQ, which remains simple to administer while effectively summarizing all the information available in the scores.

Systematic review of factors associated with quality of life of asylum seekers and refugees in high-income countries

The stressful experiences that many asylum seekers and refugees (AS&R) are exposed to during forced migration, and during resettlement in host countries, can have a profound impact on their mental health. Comparatively less research attention has been allocated to exploring other indices of quality of life (QoL) in AS&R populations. This review aimed to (i) synthesize the predictors and correlates of QoL of AS&R populations in high-income countries, and (ii) to identify the methodological strengths and weaknesses of this body of research. Fourteen databases were systematically searched (Medline, PsychINFO, CINAHL, Cochrane Library, Health Technology Assessment, National Health Service Economic Evaluation, Educational Resource Index and Abstracts, BiblioMap, Scopus, Social Sciences Citation Index, Evidence Aid, DARE, Web of Science and PubMed). Eligibility criteria included: adults seeking asylum or refuge in a high-income country, primary quantitative data, the use of a measure based on the WHO's definition of QoL, published in a peer-reviewed journal. A narrative synthesis approach was used, and the quality was assessed using the AXIS tool for cross-sectional studies and the CASP tool for longitudinal studies. Of the 13.656 papers identified, 23 met the eligibility criteria. A wide range of factors were found to have significant associations with QoL. Both positive and negative correlates of QoL were largely dominated by social (e.g. social networks) and mental health factors (e.g. depression). Although all of the cross-sectional studies met over half of the quality criteria, only 12 met 75% or more of these criteria. For the longitudinal studies, for all but one study lacked statistical precision and the results cannot be applied to the local population. Key findings across the various forms of QoL (overall, physical, psychological, social and environmental) were that having established social networks and social integration were associated with higher QoL, whereas having mental disorders (i.e. PTSD or depression) was strongly associated with reduced QoL. More research is needed into physical and environmental predictors and correlates of QoL. The findings of the review can be used to inform policies and interventions aimed at supporting AS&R and promoting the integration and wellbeing of these populations.

Psychometric Properties of the Subjective Wellbeing Assessment Scale—French Version (SWBAS-18F): A Study With Young Refugees and Internally Displaced People in Nigerien Refugee Camps

The aim of our research was to identify an easy-to-administer instrument for evaluating wellbeing in an at-risk population of young internal displaced people and young refugees in sub-Saharan Africa ( N = 462). To this end, we adapted the French-language 17-item version of the Subjective Wellbeing Assessment Scale (SWBAS—French version) and evaluated its factor structure, using a combination of exploratory factor analysis and confirmatory factor analysis. We observed five underlying factors (positive functioning, negative functioning, human insecurity, school domain, and social domain) and 17 items. Participants’ scores on the positive functioning, negative functioning, and social domain subscales were associated with their levels of psychological distress, and the statistical outcomes provided support for practical adoption of the instrument. The SWBAS-17F may, therefore, represent user-friendly instruments that practitioners might use alongside adaptations of more traditional diagnostic tools to obtain a complete and holistic assessment of refugees, asylum seekers, and internally displaced people.

Predictors of asylum seekers' mental health course in the early stages of resettlement: Results of a longitudinal study

OBJECTIVE

Asylum seekers who have experienced persecution, war and torture show high prevalence rates of stress-related mental disorders. After arrival in the host country, the early stages of resettlement seem to be a particularly vulnerable phase characterized by social instability. This longitudinal study aimed to explore predictors of the asylum seekers' course of mental health during the transition phase from a state registration and reception center to municipal shelters.

METHODS

We used hierarchical regression analysis to assess the symptom course of posttraumatic stress disorder (PTSD), depression, anxiety and panic disorders as well as well-being in n = 84 asylum seekers. The follow-up assessment took place three to five months after baseline assessment. The following blocks of possible predictors were included in the statistical models: (1) sociodemographic variables, (2) cultural background related variables, (3) psychometric measures of emotion regulation and sense of coherence and (4) time range to follow-up.

RESULTS

Language proficiency, origin, religion and gender were stronger predictors of the asylum seekers' mental health course in the early stages of resettlement than emotion regulation and sense of coherence.

CONCLUSIONS

Sociodemographic and cultural background related variables, like language proficiency have a high psychosocial relevance for asylum seekers in the early phase of the asylum process. Therefore, language courses should be implemented progressively. Psychotherapy for asylum seekers should always be performed with awareness for cultural specific perspectives and acculturative adjustment processes.

Measuring subjective well-being in an understudied population of young Western-African IDPs and refugees

Purpose

The purpose of this paper is to report a real-life empirical case and discuss some caveats emerged in measuring subjective well-being (SWB) in an understudied population of adolescents refugees from West Africa.

Design/methodology/approach

During the process of translation and cultural adaptation of the subjective well-being assessment scale in the target population, the model of measurement presented some weakness with regard to content validity criteria.

Findings

This leads to a partial revision of the model and the development of new locally-based domains of SWB.

Originality/value

Context-specific factors’ robustness showed the dynamic and culture-informed nature of the SWB construct. Practical and theoretical implications of using quantitative questionnaires in non-western contexts characterized by high grades of insecurity and instability will be discussed.

Asylum seekers' mental health and treatment utilization in a three months follow-up study after transfer from a state registration-and reception-center in Germany

Even though asylum seekers show a high prevalence of trauma-related disorders and comorbid psychological stress symptoms, little is known about how their mental health develops during the asylum process and what options of care are provided. We aimed to investigate the mental health and treatment utilization of asylum seekers after they were transferred from a state registration- and reception-center to municipal shelters in Germany. N = 228 asylum seekers with on-going asylum procedure were recruited in the psychosocial walk-in clinic located in a state registration- and reception-center. We firstly captured symptoms of posttraumatic stress, depression, anxiety disorders, quality of life, as well as alcohol or drug abuse. Subsequently we performed a follow-up after three months to evaluate a potential shift in symptoms and determining rates of access to treatment. In the pre-post psychometric assessment, there were statistically significant changes in depression (PHQ-2), panic (PHQ-PD) and psychosocial well-being scores (WHO-5). However, all these scores still remained within a clinical relevant range, respectively. Traumatic stress (PC-PTSD-5) and general anxiety scores (GAD-2) did not change significantly. Although N = 44 (66%) of the interviewed patients had been referred to psychotherapy initially, none (0%) of them had received outpatient psychotherapeutic treatment after three months. Our results emphasize a strong need for low-threshold, cultural adapted psychotherapeutic treatment for asylum seekers.

Defining a combined constellation of complicated bereavement and PTSD and the psychosocial correlates associated with the pattern amongst refugees from West Papua

BACKGROUND

Refugees are at risk of experiencing a combined constellation of complicated bereavement and posttraumatic stress disorder (PTSD) symptoms following exposure to complex traumas associated with personal threat and loss. Features of identity confusion are central to both complicated bereavement and PTSD and these characteristics may be particularly prominent amongst refugees from traditional cultures displaced from their homelands, families, and kinship groups. We investigate whether a combined pattern of complicated bereavement and PTSD can be identified amongst West Papuan refugees participating in an epidemiological survey (n = 486, response rate: 85.8%) in a remote town in Papua New Guinea.

METHODS

Latent class analysis was applied to derive subpopulations of refugees based on symptoms of complicated bereavement and PTSD. Associations were examined between classes and traumatic loss events, post-migration living difficulties (PMLDs), and psychosocial support systems.

RESULTS

The four classes identified comprised a complicated bereavement class (11%), a combined posttraumatic bereavement class (10%), a PTSD class (11%), and a low symptom class (67%). Symptoms of identity confusion were prominent in the posttraumatic bereavement class. Compared with the low symptom class, the combined posttraumatic bereavement class reported greater exposure to traumatic loss events (OR 2.43, 95% CI 1.11-5.34), PMLDs (OR 2.24, 95% CI 1.01-4.6), disruptions to interpersonal bonds and networks (OR 3.3, 95% CI 1.47-7.38), and erosion of roles and identities (OR 2.18, 95% CI 1.11-4.27).

CONCLUSIONS

Refugees appear to manifest a combined pattern of complicated bereavement and PTSD symptoms in which identity confusion is a prominent feature. This response appears to reflect the combined impact of high levels of exposure to traumatic losses, PMLDs, and disruption of relevant psychosocial systems.

Access to primary health care for asylum seekers and refugees: a qualitative study of service user experiences in the UK

Background

Asylum seekers and refugees (ASR) face difficulty accessing health care in host countries. In 2017, NHS charges for overseas visitors were extended to include some community care for refused asylum seekers. There is growing concern that this will increase access difficulties, but no recent research has documented the lived experiences of ASR accessing UK primary health care.

Aim

To examine ASR experiences accessing primary health care in the UK in 2018.

Design and setting

This was a qualitative community-based study. ASR were recruited by criterion-based sampling through voluntary community organisations.

Method

A total of 18 ASR completed face-to-face semi-structured recorded interviews discussing primary care access. Transcripts underwent thematic analysis by three researchers using Penchansky and Thomas’s modified theory of access.

Results

The qualitative data show that participants found primary care services difficult to navigate and negotiate. Dominant themes included language barriers and inadequate interpretation services; lack of awareness of the structure and function of the NHS; difficulty meeting the costs of dental care, prescription fees, and transport to appointments; and the perception of discrimination relating to race, religion, and immigration status.

Conclusion

By centralising the voices of ASR and illustrating the negative consequences of poor healthcare access, this article urges consideration of how access to primary care in the UK can be enhanced for often marginalised individuals with complex needs.

Does multidisciplinary rehabilitation of tortured refugees represent 'value-for-money'? A follow-up of a Danish case-study

BACKGROUND

The recent surge of asylum seekers in the European Union (EU) is raising questions about the EU's ability to integrate newcomers into the economy and into society; particularly those who need specialized services for the treatment of severe trauma. This study investigated whether rehabilitating traumatised refugees represents 'value-for-money' (VfM) in terms of intervention cost per health gain and in a long-term and societal perspective.

METHODS

The economic evaluation comprised a cost-utility analysis (CUA) and a partial cost-benefit analysis (CBA). The CUA incorporated data on Quality Adjusted Life Years (QALY) for 45 patients who were treated at the Rehabilitation and Research Centre for Torture Victims, Copenhagen, Denmark, in 2001-2004 and followed for up to 2 years, to determine the incremental cost effectiveness ratio (ICER). For the CBA, data was collected for 44 patients who completed treatment between 2001 and 2004 and 44 matched controls on the waiting list, for the patients' primary health care utilisation, and personal and family labour income from 2001 to 2014. This was analysed to evaluate the Net Social Benefit (NSB) of the programme.

RESULTS

The average cost of treatment was found to be about 32,000 USD per patient (2016 prices) with an average gain in QALY of 0.82. The treatment was cost effective according to the ICER threshold suggested by the National Institute of Health and Care Excellence (UK). At the individual level, the NSB remained negative throughout the study period. However, at the family income level the intervention proved to have been beneficial after 3 years.

CONCLUSION

The implication of the study is, that providing rehabilitation to severely traumatised refugee families can be an economically viable strategy, considering the economic effects observed at the family level.

The Range and Impact of Postmigration Stressors During Treatment of Trauma-Affected Refugees

Trauma-affected refugees commonly experience postmigration stressors, which can compound conflict-related emotional distress. Our study aimed to assess clinician-rated frequency and types of postmigration stressors deemed to be interfering with the treatment of refugees attending a service for trauma-related mental distress. A total of 116 patients completed 6 months of multidisciplinary treatment. Clinician-rated postmigration stressors were registered at each session. Outcome measures were Harvard Trauma Questionnaire and Global Assessment of Functioning, function (GAF-F) and symptom. Postmigration stressors were deemed to impact on 39.1% of treatment sessions with medical personnel. Issues related to work, finances, and family were the most frequently identified stressors. Postmigration stressors interfering with treatment were more common among male refugees, those living alone, those from Middle Eastern origin, and persons with low baseline GAF-F. Explicitly identifying and, where possible, dealing with postmigration stressors may assist in averting their interference with the treatment of distress in refugees.

Changes in Post-migration Living Difficulties Predict Treatment Outcome in Traumatized Refugees

Background: Refugee mental health is affected by traumatic stressors as well as post-migration living difficulties (PMLD). However, their interaction and causal pathways are unclear, and so far, no distinct treatment recommendations regarding exile-related stressors exist. Methods: In a 3-year follow-up study, PMLD and symptoms of post-traumatic stress (PTS), depression and anxiety were examined in a clinical sample of severely traumatized refugees and asylum seekers (N = 71). Results: In regression analysis, reduction in PMLD predicted changes over time in depression/anxiety, but not in PTS. The opposite models with PMLD changes as outcome variable proved not significant for PTS, and significant, though less predictive, for depression/anxiety. Conclusions: In addition to well-established trauma-focused interventions for the treatment of PTS, psychosocial interventions focusing on PMLD might contribute to a favorable treatment response in traumatized refugees, particularly with regard to depression and anxiety.

Recommendations for Canadian Mental Health Practitioners Working With War-Exposed Immigrants and Refugees

With the inception of the mental health strategy for Canada, Changing Directions, Changing Lives, the ever increasing ethnic diversity in this country demands re-examination of our approaches to mental wellbeing and illness in the immigrant and refugee population arriving from war-torn countries. Contemporary clinical practice among mental health practitioners is not reflective of the emerging literature in this field, which points towards meaningful and culturally competent care. This article seeks to bridge the gap between existing knowledge and current practice, and provides recommendations for mental health practitioners who work with this population.

Comorbidity of Posttraumatic Stress Disorder and Depression in Tortured, Treatment-Seeking Refugees

Comorbid posttraumatic stress disorder (PTSD) and depression is common in refugee groups; however, little is known about the predictors and correlates of comorbidity in treatment-seeking refugees. Participants in this study were 134 refugees resettled in Switzerland. Most participants were from Turkey, Iran, and Sri Lanka, and 92.7% had been exposed to torture. Self-report measures were implemented to assess PTSD, depression, mental and physical health-related quality of life (QoL), as well as pre- and postmigration experiences. Findings indicated that approximately half the sample met criteria for PTSD and depression, 33.6% met criteria for depression only, and only 2.2% met criteria for PTSD only. Several variables emerged as predictors of comorbidity in contrast to no diagnosis: female gender, odds ratio (OR) = 0.17; age, OR = 0.93; time in Switzerland, OR = 1.16; and trauma exposure, OR = 1.19. Postmigration stress was also associated with greater likelihood of comorbidity compared with no diagnosis, OR = 1.32, and a single diagnosis, OR = 1.14. Further, dual diagnosis was associated with significantly poorer mental health-related and physical health-related QoL (mental health-related QoL: dual diagnosis vs. single diagnosis, d = -0.52 and dual diagnosis vs. no diagnosis, d = -1.30; physical health-related QoL: dual diagnosis vs. single diagnosis, d = -0.73 and dual diagnosis vs. no diagnosis: d = -1.04). Findings indicated that comorbidity was highly prevalent in this sample of treatment-seeking refugees and was associated with a substantial impairment burden. Psychological interventions for refugees should consider the dual impact of PTSD and depression symptoms to optimally decrease distress and improve QoL in this vulnerable group.

A systematic review of psychosocial interventions for adult refugees and asylum seekers

Background: Europe is in the midst of the largest refugee migration since the Second World War; there is an urgent need to provide an updated systematic review of the current best evidence for managing mental distress in refugee populations.Aims: The aim of this review is to provide an exhaustive summary of the current literature on psychosocial interventions, both trauma- and non-trauma-focused, for refugee populations experiencing post-traumatic stress disorder (PTSD), depressive or anxiety symptoms. To produce recommendations for future research and current clinical practice.Method: Searches were conducted in PubMed, PsychINFO (Hosted by Ovid), PILOTS and Social Services Abstracts; 5305 articles were screened and 40 were included.Results: This review found medium to high quality evidence supporting the use of narrative exposure therapy (NET). A lack of culturally adapted treatments was apparent and there was less evidence to support standard cognitive behavioural therapy (CBT), Eye Movement Desensitisation and Reprocessing (EMDR) and multidisciplinary treatments.Conclusion: NET produced positive outcomes in refugees from a diverse range of backgrounds and trauma types. There is a general dearth of research in all intervention types: further research should include more "real-world" multidisciplinary interventions that better model clinical practice. Recommendations for evaluating local need, and creating a culturally sensitive workforce are discussed.

A novel bio-psycho-social approach for rehabilitation of traumatized victims of torture and war in the post-conflict context: a pilot randomized controlled trial in Kosovo

Background

Some evidence showed that multidisciplinary rehabilitation in Western countries is effective for treating war-related trauma, but it remains unclear whether this approach is applicable to civilians living in resource-poor countries affected by war. In 2012–14, Danish Institute against Torture (DIGNITY) conducted a randomized controlled trial (RCT), in partnership with Kosova Rehabilitation Centre for Torture Victims (KRCT), to examine the effects of multidisciplinary intervention among victims of torture and war in Kosovo.

Methods

A single-center, randomized, parallel-arm, single-masked, waiting-list controlled trial was implemented in northern Kosovo. Thirty-four participants meeting the recruiting criteria were randomized to either intervention group, which received integrated treatments plus a once-daily multivitamin, or the waiting list group, which received multivitamin alone. The integrated treatments consisted of 10 weekly individual 60-min sessions of cognitive behavioral therapy (CBT), based on an adapted prolonged exposure therapy manual, an individual 20-min breathing exercise with an emWave biofeedback device, and 90-min group physiotherapy. The waiting list group also received the same treatment after the intervention group had completed their sessions. Outcome assessments were conducted at 3, 6 and 9 months after baseline assessment. Outcomes measures consisted of 4 subtypes: mental, emotional, physical health, functioning and social outcomes, i.e. PTSD, depression, anxiety, chronic pain, anger and hatred expression, body mass index, handgrip strength, standing balance, income, employment rate and disability score.

Results

Over 1/3 of PTSD cases were successfully treated. Inconsistent patterns with mental health and chronic pain outcomes were observed while there was a definite impact of intervention on functioning and social outcomes, i.e. the employment rate, which increased nearly 15 %, and the monthly wage, which rose 45–137 %. There was also a noticeable improvement in handgrip strength and disability score; the feelings of anger and hatred diminished. However, most of these changes did not reach statistical significance.

Conclusions

The impact of bio-psycho-social intervention is likely sensitive to the context of post-war economy in Kosovo and the treatment goals. The potential for improving the emotional well-being and employment outcome in victims was demonstrated. A larger scale RCT in a similar setting is needed, with close monitoring of treatment integrity and data reliability.

Trial registration

Clinicaltrials.gov (NCT01696578).

The Relationship of Complex Post-traumatic Stress Disorder and Post-traumatic Stress Disorder in a Culturally Distinct, Conflict-Affected Population: A Study among West Papuan Refugees Displaced to Papua New Guinea

BACKGROUND

Controversy continues about the validity of the construct of complex post-traumatic stress disorder (C-PTSD). In particular, questions remain whether C-PTSD can be differentiated from post-traumatic stress disorder (PTSD) and, secondarily, other common mental disorders. The examination of these issues needs to be expanded to populations of diverse cultural backgrounds exposed to prolonged persecution. We undertake such an inquiry among a community sample of West Papuan refugees exposed to extensive persecution and trauma.

METHODS

We interviewed over 300 West Papuan refugees using the Refugee-Mental Health Assessment Package to record symptoms of PTSD, C-PTSD, major depressive disorder (MDD), and complex grief (CG). We used first- and second-order confirmatory factor analysis (CFA) to test aspects of the convergent and discriminant validity of C-PTSD.

RESULTS

The CFA analysis supported both a one-factor and two-factor model of PTSD and C-PTSD. Nested model comparison tests provide support for the parsimonious one-factor model solution. A second-order CFA model of PTSD and C-PTSD produced a poor fit. The modified three-factor multi-disorder solution combining a traumatic stress (TS) factor (amalgamating PTSD and C-PTSD), MDD, and CG yielded a good fit only after removing three CG domains (estrangement, yearning, and behavioral change), a model that produced large standardized residuals (>0.20).

CONCLUSION

The most parsimonious model yielded a single TS factor combining symptom domains of C-PTSD and PTSD in this culturally distinct community exposed to extensive persecution and conflict-related trauma. There may be grounds for expanding the scope of psychological treatments for refugees to encompass this wider TS response. Our findings are consistent with theoretical frameworks focusing on the wider TS reaction of refugees exposed to human rights-related traumas of mass conflict, persecution, and displacement.

Multidisciplinary treatment for traumatized refugees in a naturalistic setting: symptom courses and predictors

Background: Multidisciplinary treatment approaches are commonly used in specialized psychosocial centres for the treatment of traumatized refugees, but empirical evidence for their efficacy is inconsistent. Objective: In order to obtain more evidence on the development of mental health and well-being of traumatized refugees who receive multidisciplinary treatment, symptom courses of posttraumatic stress disorder (PTSD), anxiety, depression and somatoform symptoms as well as in the subjective quality of life were investigated in the course of a multidisciplinary treatment. In addition, it was analysed if sociodemographic variables were predictors for possible changes in symptomatology and quality of life. Method: N = 76 patients of the outpatient clinic of a psychosocial centre for traumatized refugees receiving regular multidisciplinary treatment were surveyed using standardized questionnaires at three measurement points (at the beginning of treatment, and after an average of 7 and 14 months of treatment) in a single-group design. Results: Multilevel analysis showed significant improvements of symptoms of PTSD (p < .001), depression (p < .001), anxiety (p < .001), and somatoform symptoms (p = .002) as well as of the subjective quality of life (p < .001) over time. Among the tested predictors (gender, age, country of origin), age was a significant predictor for the course of somatoform symptoms (p < .05). Younger patients showed greater improvements in symptomatology over time than older ones. Conclusions: The results suggest that the received multidisciplinary treatment had a positive effect on trauma-related symptoms as well as on quality of life of traumatized refugees. There was no indication that sociodemographic characteristics predicted the symptom courses of the patients, except for somatoform symptoms. Younger patients benefitted more from multidisciplinary treatment than older ones.

The effect of flexible cognitive-behavioural therapy and medical treatment, including antidepressants on post-traumatic stress disorder and depression in traumatised refugees: pragmatic randomised controlled clinical trial

BACKGROUND

Little evidence exists on the treatment of traumatised refugees.

AIMS

To estimate treatment effects of flexible cognitive-behavioural therapy (CBT) and antidepressants (sertraline and mianserin) in traumatised refugees.

METHOD

Randomised controlled clinical trial with 2 × 2 factorial design (registered with Clinicaltrials.gov, NCT00917397, EUDRACT no. 2008-006714-15). Participants were refugees with war-related traumatic experiences, post-traumatic stress disorder (PTSD) and without psychotic disorder. Treatment was weekly sessions with a physician and/or psychologist over 6 months.

RESULTS

A total of 217 of 280 patients completed treatment (78%). There was no effect on PTSD symptoms, no effect of psychotherapy and no interaction between psychotherapy and medicine. A small but significant effect of treatment with antidepressants was found on depression.

CONCLUSIONS

In a pragmatic clinical setting, there was no effect of flexible CBT and antidepressants on PTSD, and there was a small-to-moderate effect of antidepressants and psychoeducation on depression in traumatised refugees.

Challenging future, challenging past: the relationship of social integration and psychological impairment in traumatized refugees

BACKGROUND

Refugees have been shown to present high prevalence rates of trauma-related mental disorders. Despite their psychological impairment, they are expected to meet high functional requirements in terms of social integration into, and financial independence from, the host society.

METHODS

This cross-sectional study examined the relationship of mental health problems, post-migration living difficulties (PMLD), and social integration in a sample of 104 refugees seeking treatment for severe posttraumatic stress and comorbid symptoms in two outpatient clinics in Switzerland.

RESULTS

Despite an average time of residence in Switzerland of over 10 years, participants showed poor integration and a high number of PMLD. Integration difficulties were closely associated with psychological symptoms, but not with socio-demographic parameters such as education or visa status.

CONCLUSIONS

Psychological impairment in treatment-seeking traumatized refugees is associated with poor integration. To foster social integration, it is crucial to better understand and address the specific needs of this highly vulnerable population.

The factor structure of complex posttraumatic stress disorder in traumatized refugees

BACKGROUND

The construct of complex posttraumatic stress disorder (CPTSD) has attracted much research attention in previous years, however it has not been systematically evaluated in individuals exposed to persecution and displacement. Given that CPTSD has been proposed as a diagnostic category in the ICD-11, it is important that it be examined in refugee groups.

OBJECTIVE

In the current study, we proposed to test, for the first time, the factor structure of CPTSD proposed for the ICD-11 in a sample of resettled treatment-seeking refugees.

METHOD

The study sample consisted of 134 traumatized refugees from a variety of countries of origin, with approximately 93% of the sample having been exposed to torture. We used confirmatory factor analysis to examine the factor structure of CPTSD in this sample and examined the sensitivity, specificity, positive predictive power and negative predictive power of individual items in relation to the CPTSD diagnosis.

RESULTS

Findings revealed that a two-factor higher-order model of CPTSD comprising PTSD and Difficulties in Self-Organization (χ² (47)=57.322, p=0.144, RMSEA=0.041, CFI=0.981, TLI=0.974) evidenced superior fit compared to a one-factor higher-order model of CPTSD (χ² (48)=65.745, p=0.045, RMSEA=0.053, CFI=0.968, TLI=0.956). Overall, items evidenced strong sensitivity and negative predictive power, moderate positive predictive power, and poor specificity.

CONCLUSIONS

Findings provide preliminary evidence for the validity of the CPTSD construct with highly traumatized treatment-seeking refugees.

Treatment of traumatised refugees with basic body awareness therapy versus mixed physical activity as add-on treatment: Study protocol of a randomised controlled trial

Background

Treatment of traumatised refugees is one of the fields within psychiatry, which has received little scientific attention. Evidence based treatment and knowledge on the efficiency of the treatment for this complex patient group is therefore scarce. This leads to uncertainty as to which treatment should be offered and potentially lowers the quality of life for the patients.

Chronic pain is very common among traumatised refugees and it is believed to maintain the mental symptoms of trauma. Hence, treating chronic pain is believed to be of high clinical value for this patient group.

In clinical studies, physical activity has shown a positive effect on psychiatric illnesses such as depression and anxiety and for patients with chronic pain. However, scientific knowledge about physical activity as part of the treatment for traumatised refugees is very limited and no guidelines exist on this topic.

Methods/design

This study will include approximately 310 patients, randomised into three groups. All three groups receive psychiatric treatment as usual for the duration of 6–7 months, consisting of consultations with a medical doctor including pharmacological treatment and manual-based Cognitive Behavioural Therapy. The first group only receives treatment as usual while the second and the third groups receive either Basic-Body Awareness Therapy or mixed physical activity as add-on treatments. Each physical activity is provided for an individual 1-hour consultation per week, for the duration of 20 weeks. The study is being conducted at the Competence Centre for Transcultural Psychiatry, Mental Health Centre Ballerup in the Capital Region of Denmark.

The primary endpoint of the study is symptoms of Post Traumatic Stress Disorder; the secondary endpoints are depression and anxiety as well as quality of life, functional capacity, coping with pain, body awareness and physical fitness.

Discussion

This study will examine the effect of physical activity for traumatised refugees. This has not yet been done in a randomised controlled setting on such a large scale before. Hereby the study will contribute to important knowledge that is expected to be used in future clinical guidelines and reference programs.

Trial registration

ClinicalTrials.gov NCT01955538. Date of registration: 18 September 2013.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-015-0974-9) contains supplementary material, which is available to authorized users.

A systematic review of naturalistic interventions in refugee populations

Naturalistic interventions with refugee populations examine outcomes following mental health interventions in existing refugee service organisations. The current review aimed to examine outcomes of naturalistic interventions and quality of the naturalistic intervention literature in refugee populations with the view to highlight the strengths and limitations of naturalistic intervention studies. Database search was conducted using the search terms 'refugee', 'asylum seeker', 'treatment', 'therapy' and 'intervention. No date limitations were applied, but searches were limited to articles written in English. Seven studies were identified that assessed the outcome of naturalistic interventions on adult refugees or asylum seekers in a country of resettlement using quantitative outcome measures. Results showed significant variation in the outcomes of naturalistic intervention studies, with a trend towards showing decreased symptomatology at post-intervention. However, conclusions are limited by methodological problems of the studies reviewed, particularly poor documentation of intervention methods and lack of control in the design of naturalistic intervention studies. Further examination of outcomes following naturalistic interventions is needed with studies which focus on increasing the rigour of the outcome assessment process.

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.

Difficult to treat? A comparison of the effectiveness of treatment as usual in refugees and non-refugees

Aims and method To examine treatment response in traumatised refugees, we compared routine outcome monitoring data (Harvard Trauma Questionnaire) of two refugee populations with those of individuals experiencing profession-related trauma who were treated at a specialised psychotrauma institute. Results Asylum seekers/temporary refugees (n = 21) and resettled refugees (n = 169) showed significantly lower post-traumatic stress disorder (PTSD) symptom reduction between intake and 1 year after intake than did a comparison group of non-refugees (n = 37), but the interaction effect was clinically small (partial η(2) = 0.03). Refugees who had more severe symptoms at intake showed significantly greater symptom reduction after 1 year. Clinical implications Therapists and refugee patients should have realistic expectations about response to treatment as usual. Additional treatment focusing on improving quality of life may be needed for refugees whose PTSD symptom severity remains high. At the same time, novel approaches may be developed to boost treatment response in refugee patients with low responsiveness.

Chronic pain in multi-traumatized outpatients with a refugee background resettled in Norway: a cross-sectional study

Background

Traumatized refugees often report significant levels of chronic pain in addition to posttraumatic stress disorder symptoms, and more information is needed to understand pain in refugees exposed to traumatic events. This study aimed to assess the frequency of chronic pain among refugee psychiatric outpatients, and to compare outpatients with and without chronic pain on trauma exposure, psychiatric morbidity, and psychiatric symptom severity.

Methods

We conducted a cross-sectional study of sixty-one psychiatric outpatients with a refugee background using structured clinical diagnostic interviews to assess for traumatic events [Life Events Checklist (LEC)], PTSD (Posttraumatic Stress Disorder) and complex PTSD [Structured Clinical Interview for DSM-IV PTSD Module (SCID-PTSD) and Structured Interview for Disorders of Extreme Stress (SIDES)], chronic pain (SIDES Scale VI) and psychiatric symptoms [M.I.N.I. International Neuropsychiatric Interview (M.I.N.I.)]. Self-report measures were used to assess symptoms of posttraumatic stress [Impact of Event Scale-revised (IES-R)], depression and anxiety [Hopkins Symptom Checklist (HSCL-25)] and several markers of acculturation in Norway.

Results

Of the 61 outpatients included, all but one reported at least one chronic pain location, with a mean of 4.6 locations per patient. Chronic pain at clinical levels was present in 66% of the whole sample of outpatients, and in 88% of the outpatients with current PTSD diagnosis. The most prevalent chronic pain locations were head (80%), chest (74%), arms/legs (66%) and back (62%). Women had significantly more chronic pain locations than men. Comorbid PTSD and chronic pain were found in 57% of the outpatients. Significant differences were found between outpatients with and without chronic pain on posttraumatic stress, psychological distress, and DESNOS severity.

Conclusions

Chronic pains are common in multi-traumatized refugees in outpatient clinics in Norway, and are positively related to symptomatology and severity of psychiatric morbidity. The presence of chronic pain, as well as comorbid chronic pain and PTSD, in psychiatric outpatients with a refugee background call for an integrated assessment and treatment for both conditions.

Emotion dysregulation mediates the relationship between trauma exposure, post-migration living difficulties and psychological outcomes in traumatized refugees

BACKGROUND

While emotion dysregulation represents an important mechanism underpinning psychological responses to trauma, little research has investigated this in refugees. In the current study, we examined the mediating role of emotion dysregulation in the relationship between refugee experiences (trauma and living difficulties) and psychological outcomes.

METHODS

Participants were 134 traumatized treatment-seeking refugees who completed measures indexing trauma exposure, post-migration living difficulties, difficulties in emotion regulation, posttraumatic stress disorder, depression, and explosive anger.

RESULTS

Findings revealed distinctive patterns of emotion dysregulation associated with each of these psychological disorders. Results also indicated that emotion regulation difficulties mediated the association between both trauma and psychological symptoms, and living difficulties and psychological symptoms.

LIMITATIONS

Limitations include a cross-sectional design and the use of measures that had not been validated across all cultural groups in this study.

CONCLUSIONS

These findings underscore the key role of emotion dysregulation in psychological responses of refugees, and highlight potential directions for treatment interventions for traumatized refugees.

Mental health interventions for traumatized asylum seekers and refugees: What do we know about their efficacy?

BACKGROUND

The prevalence of trauma-related problems among refugees and asylum seekers is extremely high due to adverse experiences associated with forced migration. Although the literature presents a considerable number of guidelines and theoretical frameworks for working with traumatized refugees and asylum seekers, the efficacy, feasibility and applicability of these interventions have little empirical evidence.

AIMS

The purpose of this article is to critically review the literature to provide a rationale for developing culturally sensitive, evidence-based interventions for refugees and asylum seekers.

METHODS

A literature review integrating research findings on interventions designed especially for traumatized asylum seekers and refugees was conducted. Retained studies had to use some quantitative measurements of post-traumatic stress and to have pre- and post-measurements to evaluate the efficacy of the intervention. Studies included in this review cover a wide variety of interventions, including trauma-focused interventions, group therapy, multidisciplinary interventions and pharmacological treatments.

RESULTS

The majority of studies with traumatized refugees and asylum seekers reported positive outcomes of the intervention in reducing trauma-related symptoms. There is evidence to support the suitability of cognitive-behavioral therapy (CBT) and narrative exposure therapy (NET) in certain populations of refugees. Other intervention studies are limited by methodological considerations, such as lack of randomization, absence of control group and small samples.

CONCLUSIONS

This review has again highlighted the shortage of guiding frameworks available to investigators and clinicians who are interested in tailoring interventions to work with refugees and asylum seekers. Theoretical, ethical and methodological considerations for future research are discussed.

From pioneers to scientists: challenges in establishing evidence-gathering models in torture and trauma mental health services for refugees

Outcome studies on treatment of trauma-affected refugees have been published but are limited in design and quality. In this article, we discuss possible impediments to pursuing research aimed at gathering evidence to support the efficacy of treatments in the field and the challenges in carrying out such inquiries. We then present a working model that demonstrates the feasibility of integrating outcome research into clinical settings. The aim of this model is to involve all personnel in generating research of high quality with minimal additional costs and time commitment. We conclude that although challenges remain in carrying out treatment outcome studies, they can be overcome by careful consultation and negotiation in a setting with an established ethos of commitment to the scientific endeavor. Ultimately, identifying the most effective interventions will provide better treatment and quality of life for the large number of traumatized refugees seeking assistance for mental health problems.

Reducing refugee mental health disparities: a community-based intervention to address postmigration stressors with African adults

Refugees resettled in the United States have disproportionately high rates of psychological distress. Research has demonstrated the roles of postmigration stressors, including lack of meaningful social roles, poverty, unemployment, lack of environmental mastery, discrimination, limited English proficiency, and social isolation. We report a multimethod, within-group longitudinal pilot study involving the adaptation for African refugees of a community-based advocacy and learning intervention to address postmigration stressors. We found the intervention to be feasible, acceptable, and appropriate for African refugees. Growth trajectory analysis revealed significant decreases in participants' psychological distress and increases in quality of life, and also provided preliminary evidence of intervention mechanisms of change through the detection of mediating relationships whereby increased quality of life was mediated by increases in enculturation, English proficiency, and social support. Qualitative data helped to support and explain the quantitative data. Results demonstrate the importance of addressing the sociopolitical context of resettlement to promote the mental health of refugees and suggest a culturally appropriate, and replicable model for doing so.

Course of post-traumatic stress disorder and health care utilisation among resettled refugees in the Netherlands

BACKGROUND

Post-traumatic stress disorder (PTSD) is a major health problem among refugees worldwide. After resettlement, the prevalence of PTSD remains high despite the fact that various PTSD treatments are known to be effective.

METHODS

We examined the course of PTSD and the role of mental health care utilisation at a 7-year interval (2003-2010) among a cohort of refugees from Iran, Afghanistan, and Somalia after resettlement in the Netherlands.

RESULTS

The unchanged high prevalence of PTSD (16.3% in 2003 and 15.2% in 2010) was attributable in part to late onset of PTSD symptoms (half of the respondents with PTSD at T2 were new cases for whom PTSD developed after 2003). The second reason concerned the low use of mental health care services at T1. Whereas the multivariate analyses showed the effectiveness of mental health care, only 21% of respondents with PTSD at T1 had had contact with a mental health care provider at that time. Use of mental health care during the first wave increased the odds of improvement in PTSD symptoms between both measurements (OR 7.58, 95% CI 1.01; 56.85).

CONCLUSIONS

The findings of this study suggest there are two possible explanations for the persistently high prevalence of PTSD among refugees. One is the late onset of PTSD and the other is the low utilisation of mental health care. Health care professionals should be aware of these issues, especially given the effectiveness of mental health care for this condition.

Gender and offender status predicting treatment success in refugees and asylum seekers with PTSD

BACKGROUND

Current knowledge is limited regarding patient characteristics related to treatment outcome of posttraumatic stress disorders (PTSD) in refugees and asylum seekers.

OBJECTIVE

Gender, torture status, offender status, level of anger, and level of depression were investigated for possible effects on the treatment outcome.

METHOD

Patient characteristics were explored in 54 refugees and asylum seekers who had completed a treatment program for PTSD. Non-responders (10), those who had the same or higher levels of symptom severity after treatment, were compared with responders, those who had lower symptom severity after treatment (44). Symptom severity was measured by Clinician-Administered PTSD Scale. The non-responders and responders constituted the dichotomous, dependent variable. The independent variables were gender, torture status, offender status, level of anger, and level of depression. T-tests and Exact Unconditional Homogeneity/Independence Tests for 2×2 Tables were used to study the relationship to treatment outcome.

RESULTS

Being male and reporting to have been a violent offender were significantly more frequent characteristics among the non-responders compared to the responders. The levels of pretreatment anger, depression and torture status did not affect the treatment outcome.

CONCLUSIONS

The study adds support to findings that females benefit more from treatment of PTSD than males and that violent offenders are difficult to treat within the standard treatment programs.

EMDR With Traumatized Refugees: From Experience-Based to Evidence-Based Practice

Many refugees resettled in Western countries suffer from an accumulation of traumatic and current stressors that contribute to mental health problems and may complicate trauma-focused treatment. Consequently, the acceptability, safety, and efficacy of trauma-focused treatment with refugees have been a matter of clinical and scientific interest. In recent years, the evidence has accumulated for narrative exposure therapy and culturally adapted cognitive behavioral therapy. Although eye movement desensitization and reprocessing (EMDR) is practiced with resettled refugees, only five small studies of limited quality have been conducted on EMDR with this population. In the absence of strong evidence, therapists practising EMDR with refugees may be aided by transcultural psychiatric principles, especially matching of explanatory models. In addition, high-quality research is needed to reliably determine acceptability, safety, and efficacy of EMDR with traumatized refugees.

Treating PTSD in refugees and asylum seekers within the general health care system. A randomized controlled multicenter study

OBJECTIVE

There has been uncertainty about whether refugees and asylum seekers with PTSD can be treated effectively in standard psychiatric settings in industrialized countries. In this study, Narrative Exposure Therapy (NET) was compared to Treatment As Usual (TAU) in 11 general psychiatric health care units in Norway. The focus was on changes in symptom severity and in the diagnostic status for PTSD and depression.

METHOD

Refugees and asylum seekers fulfilling the DSM-IV criteria for PTSD (N = 81) were randomized with an a-priori probability of 2:1 to either NET (N = 51) or TAU (N = 30). The patients were assessed with Clinician Administered PTSD Scale, Hamilton rating scale for depression and the MINI Neuropsychiatric Interview before treatment, and again at one and six months after the completion.

RESULTS

Both NET and TAU gave clinically relevant symptom reduction both in PTSD and in depression. NET gave significantly more symptom reduction compared to TAU as well as significantly more reduction in participants with PTSD diagnoses. No difference in treatment efficacy was found between refugees and asylum seekers.

CONCLUSIONS

The study indicated that refugees and asylum seekers can be treated successfully for PTSD and depression in the general psychiatric health care system; NET appeared to be a promising treatment for both groups.

Rorschach assessment of traumatized refugees: an exploratory factor analysis

Fifty-one multitraumatized mental health patients with refugee backgrounds completed the Rorschach (Meyer & Viglione, 2008), Harvard Trauma Questionnaire, and Hopkins Symptom Checklist-25 (Mollica, McDonald, Massagli, & Silove, 2004), and the World Health Organization Quality of Life-BREF questionnaire (WHOQOL Group, 1998) before the start of treatment. The purpose was to gain more in-depth knowledge of an understudied patient group and to provide a prospective basis for later analyses of treatment outcome. Factor analysis of trauma-related Rorschach variables gave 2 components explaining 60% of the variance; the first was interpreted as trauma-related flooding versus constriction and the second as adequate versus impaired reality testing. Component 1 correlated positively with self-reported reexperiencing symptoms of posttraumatic stress (r = .32, p < .05). Component 2 correlated positively with self-reported quality of life in the physical, psychological, and social relationships domains (r = .34, .32, and .35, p < .05), and negatively with anxiety (r = -.33, p < .05). Each component also correlated significantly with resources like work experience, education, and language skills.

Treatment of a multitraumatized tortured refugee needing an interpreter with exposure therapy

This paper described the application and feasibility of exposure therapy treatment (ET) for posttraumatic stress disorder (PTSD) in a multitraumatized tortured refugee with chronic PTSD and depression, in need of an interpreter. The patient received 26 one-hour sessions of ET involving exposure to his trauma-related memories. Symptoms of PTSD, depression, and anxiety were assessed at pre- and posttreatment and 3-, 6-, and 12-month followup with the Harvard Trauma Questionnaire (HTQ-R), PTSD Symptom Scale-Self Report (PSS-SR), Major depression inventory (MDI), and Beck Anxiety Inventory (BAI). Treatment led to a significant improvement across all measures of posttraumatic stress disorder, anxiety, and depression, and the improvement was maintained at the 12-month follow-up. The results from this case study provide further preliminary evidence that ET may be effective in treating multi-traumatized torture survivors who are refugees and in need of an interpreter, despite the additional stressors and symptoms complexity experienced by tortured refugees.

Sensory functions in the foot soles in victims of generalized torture, in victims also beaten under the feet (falanga) and in healthy controls - A blinded study using quantitative sensory testing

Background

Falanga torture (beatings on the foot soles) produces local chronic pain and severe walking difficulties. We have previously reported signs of neuropathic pain in the feet of falanga victims. The objective here was to clarify underlying pain mechanisms by quantifying sensory impairments in the feet of torture victims who had experienced both generalized torture and those who had been exposed to falanga in addition. An ethnically matched control group was available.

Methods

We employed quantitative sensory testing (QST) by investigators blinded to whether the patients, 32 male torture victims from the Middle East, had (n=15), or had not (n=17) been exposed to falanga. Pain intensity, area and stimulus dependence were used to characterize the pain as were interview data on sensory symptoms. QST included thresholds for touch, cold, warmth, cold-pain, heat-pain, deep pressure pain and wind-up to cutaneous noxious stimuli in the foot soles. Clinical data on anxiety and depression were retrieved.

Results

Almost all falanga victims had moderate or strong pain in their feet and in twice as large an area of their foot soles as other torture victims. One-third of the latter had no pain in their feet and many reported slight pain; in spite of this, there were no differences in foot sole QST data between the tortured groups. A comparison with normal data indicated that both tortured groups had hypoesthesia for all cutaneous sensory fibre groups except those transmitting cold and heat pain, in addition to deep mechano-nociceptive hyperalgesia.

Conclusion

A comparison of the QST data between victims having been exposed to generalized torture and victims who in addition had been exposed to falanga, showed no differences on the group level. The sensory disturbances in relation to our control group are compatible with central sensitization and de-sensitization, pointing to a core role of central mechanisms. A further analysis to create individual sensory profiles from our measurements is in progress.

A longitudinal study of mental health in refugees from Burma: The impact of therapeutic interventions

OBJECTIVE

The present study seeks to examine the impact of therapeutic interventions for people from refugee backgrounds within a naturalistic setting.

METHODS

Sixty-two refugees from Burma were assessed soon after arriving in Australia. All participants received standard interventions provided by a resettlement organisation which included therapeutic interventions, assessment, social assistance, and referrals where appropriate. At the completion of service provision a follow-up assessment was conducted.

RESULTS

Over the course of the intervention, participants experienced a significant decrease in symptoms of post-traumatic stress disorder, anxiety, depression and somatisation. Pre-intervention symptoms predicted symptoms post-intervention for post-traumatic stress, anxiety and somatisation. Post-migration living difficulties, the number of traumas experienced, and the number of contacts with the service agency were unrelated to all mental health outcomes.

CONCLUSIONS

In the first Australian study of its kind, reductions in mental health symptoms post-intervention were significantly linked to pre-intervention symptomatology and the number of therapy sessions predicted post-intervention symptoms of post-traumatic stress. Future studies need to include larger samples and control groups to verify findings.

Posttraumatic growth, depressive symptoms, posttraumatic stress symptoms, post-migration stressors and quality of life in multi-traumatized psychiatric outpatients with a refugee background in Norway

Background

Psychiatric outpatients with a refugee background have often been exposed to a variety of potentially traumatizing events, with numerous negative consequences for their mental health and quality of life. However, some patients also report positive personal changes, posttraumatic growth, related to these potentially traumatic events. This study describes posttraumatic growth, posttraumatic stress symptoms, depressive symptoms, post-migration stressors, and their association with quality of life in an outpatient psychiatric population with a refugee background in Norway.

Methods

Fifty five psychiatric outpatients with a refugee background participated in a cross-sectional study using clinical interviews to measure psychopathology (SCID-PTSD, MINI), and four self-report instruments measuring posttraumatic growth, posttraumatic stress symptoms, depressive symptoms, and quality of life (PTGI-SF, IES-R, HSCL-25-depression scale, and WHOQOL-Bref) as well as measures of social integration, social network and employment status.

Results

All patients reported some degree of posttraumatic growth, while only 31% reported greater amounts of growth. Eighty percent of the patients had posttraumatic stress symptoms above the cut-off point, and 93% reported clinical levels of depressive symptoms. Quality of life in the four domains of the WHOQOL-Bref levels were low, well below the threshold for the’life satisfaction’ standard proposed by Cummins.

A hierarchic regression model including depressive symptoms, posttraumatic stress symptoms, posttraumatic growth, and unemployment explained 56% of the total variance found in the psychological health domain of the WHOQOL-Bref scale. Posttraumatic growth made the strongest contribution to the model, greater than posttraumatic stress symptoms or depressive symptoms. Post-migration stressors like unemployment, weak social network and poor social integration were moderately negatively correlated with posttraumatic growth and quality of life, and positively correlated with psychopathological symptoms. Sixty percent of the outpatients were unemployed.

Conclusions

Multi-traumatized refugees in outpatient clinics reported both symptoms of psychopathology and posttraumatic growth after exposure to multiple traumatic events. Symptoms of psychopathology were negatively related to the quality of life, and positively related to post-migration stressors such as unemployment, weak social network and poor social integration. Posttraumatic growth was positively associated with quality of life, and negatively associated with post-migration stressors. Hierarchical regression modeling showed that posttraumatic growth explained more of the variance in quality of life than did posttraumatic stress symptoms, depressive symptoms or unemployment. It may therefore be necessary to address both positive changes and psychopathological symptoms when assessing and treating multi-traumatized outpatients with a refugee background.

Evidence-based psychological interventions for adult survivors of torture and trauma: a 30-year review

In this paper we review research evidence on psychosocial interventions for adult survivors of torture and trauma. We identified 40 studies from 1980 to 2010 that investigated interventions for adult survivors of torture and trauma. Population subtypes include resettled refugees, asylum seekers, displaced persons, and persons resident in their country of origin. Settings include specialized services for torture and trauma, specialized tertiary referral clinics, community settings, university settings, as well as psychiatric and multidisciplinary mental health services. Interventions were delivered as individual or group treatments and lasted from a single session to 19 years duration. The studies employed randomized controlled trials, nonrandomized comparison studies and single cohort follow-up studies. In all, 36 of the 40 studies (90%) demonstrated significant improvements on at least one outcome indicator after an intervention. Most studies (60%) included participants who had high levels of posttraumatic stress symptomatology. Improvements in symptoms of posttraumatic stress, depression, anxiety, and somatic symptoms were found following a range of interventions. Little evidence was available with regard to the effect on treatment outcomes of the amount, type, or length of treatment, the influence of patient characteristics, maintenance of treatment effects, and treatment outcomes other than psychiatric symptomatology. The review highlights the need for more carefully designed research that addresses the shortcomings of current studies and that integrates the experience of expert practitioners.