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

Bridging technology and care: integrating web-based PROMs in mental health services for refugees: a study on clinician training and technology adoption

This study explores the integration of a web-based electronic database technology containing patient-reported outcome measures (PROMs) with electronic health records for refugees with PTSD, emphasizing the systematic inclusion of patient perspectives in clinical decision-making. Our research addresses the notable gap in literature regarding training clinicians for the competent integration of health information technology in healthcare. The training program developed aimed at equipping clinicians, particularly inexperienced with technology, to effectively utilize an electronic PROM system for collecting systematic patient information. Our study is set in the context of the Mental Health Services (MHS) in Denmark, focusing on a specialized clinic for treating trauma-affected refugees. The multidisciplinary team involved in this project reflects a wide range of healthcare professionals. The training program employed a variety of activities over nearly 2 years, adapting to feedback and aiming to engage clinicians in continuous improvement processes. Analyzing qualitative data with thematic analysis we interpreted that the training's extended focus on discussion of the implementation process, with limited hands-on experience, potentially reinforced clinicians' hesitations toward new technology, rather than reducing them. Clinicians prioritized immediate concerns over potential long-term benefits. Despite this, their approach reflects a strong commitment to patient welfare and careful evaluation of new practices. Notably, there were also positive engagements with the technology, highlighting its potential in patient care. This study concludes that the successful integration of technology in clinical settings hinges on its alignment with clinicians' workflows, respect for their professional judgment, and clear benefits to patient care.

A 'Cultural Models' Approach to Psychotherapy for Refugees and Asylum Seekers: A Case Study from the UK

Despite the existence of significant research on the mental health care challenges of migrants, particularly refugees and asylum seekers, less attention has been paid to treatment approaches. We used a case study from the UK to look at the topic from a cultural models approach (which comes from cognitive anthropology) to analyse migrants' experiences with mental health care. Twenty-five refugees and asylum seekers living in North East England and Northern Ireland were interviewed who had used at least six sessions of talking therapy during the last three years. Our results suggested that adopting a 'cultural models' approach, which offers a new conceptual and methodological framework of migrants' experiences and their underlying schemas and expectations, would significantly contribute to building therapeutic alliances and provide relevant and appropriate treatments for migrant clients, particularly for unrecognised pre- and post-migration traumatic experiences.

Sertraline versus venlafaxine combined with psychotherapy in trauma-affected refugees - a follow-up study on a pragmatic randomised trial

BACKGROUND

Research on long-term pharmacotherapy for trauma-affected refugees is scarce. The purpose of this follow-up study of a randomised trial was to investigate the effects of sertraline compared to venlafaxine in combination with psychotherapy, 6 and 18 months after end of trial.

METHOD

The primary outcome was PTSD symptoms, measured by the Harvard Trauma Questionnaire (HTQ). The secondary outcomes included: Hopkins Symptom Checklist-25 (HSCL-25), somatisation items of the Symptoms Checklist-90 (SCL), pain on a visual analogue scale, well-being on the WHO-5, Sheehan Disability Scale, Hamilton Depression and Anxiety scales and Global Assessment of Functioning. Moreover, the shorter version of the Recent Life Events (IRLE) was adopted to obtain information regarding the patients' treatment and life events between the follow-up periods.

RESULTS

Out of 195 patients eligible for intention-to-treat analyses during trial, 116 participated in the 6-month follow-up and 97 participated in the 18-month follow-up. The results of our intention-to-treat analyses revealed no significant long-term differences between the groups on the primary outcome assessing PTSD symptoms (HTQ). For the secondary outcomes significant differences were found at the 18-month follow-up in favour of venlafaxine assessing symptoms of anxiety, depression and somatisation (HSCL-25 and SCL), although only in intention-to-treat and not per-protocol analyses.

CONCLUSIONS

No conclusions could be drawn due to conflicting results between our intention-to-treat and per-protocol analyses.

The structure of ICD-11 post traumatic stress disorder in a clinical sample of refugees based on the International Trauma Interview

BACKGROUND

The ICD-11 proposes fundamental changes to the PTSD diagnostic criteria, prompting thorough validation. While this is ideally carried out based on diagnostic interviews, most-and in the case of transcultural psychiatry all-studies have relied on self-reported measures. In this study, we used the International Trauma Interview (ITI) to assess the factor structure of ICD-11 PTSD symptoms in a sample of trauma-affected refugees.

METHOD

The ITI was administered with a sample of refugees (n = 198), originating mainly from the Greater Middle East. The symptom ratings were subjected to a confirmatory factor analysis (CFA), comparing the ICD-11 concordant three-factor model with alternative two- and one-factor models.

RESULTS

The overall fit was adequate for both the two- and three-factor models, but favored the two-factor model. Results for both models indicated local misspecifications and that item 5, hypervigilance, displayed a suboptimal loading.

CONCLUSION

The results generally support the use of the ITI in a severely trauma-affected refugee population, albeit with particular attention needed in the administration of item 5. The superior fit of a two-factor model warrants further testing across populations.

The Danish Trauma Database for Refugees (DTD): A Multicenter Database Collaboration-Overcoming the Challenges and Enhancing Mental Health Treatment and Research for Refugees

Mental health of trauma-affected refugees is an understudied area, resulting in inadequate and poorer treatment outcomes. To address this, more high-quality treatment studies that include predictive analyses, long-term evaluations, cultural adaptations, and take account for comorbidities, are needed. Moreover, given the complex intertwining of refugees' health with post-migration stressors and other social factors, it is crucial to examine the social determinants of refugee mental health. The Danish Trauma Database for Refugees (DTD) is a multicenter research database uniting six national centers that provide outpatient treatment for trauma-affected refugees. Through the database, we collect clinical and sociodemographic data from approximately 1200 refugees annually and will merge the database with Danish population register data. The purpose of the DTD is two-fold; clinical and research. The DTD offers data-driven guidance for routine clinical treatment planning of the individual patient, as well as exceptional research opportunities for testing treatment interventions in clinical settings, with larger sample sizes, and more representative heterogeneity of the population. Complex analyses of risk and protective factors, barriers, access to treatment, and societal and transgenerational aspects of trauma are possible with the DTD. This conceptual paper introduces the DTD, the historical background, the development process and implementation strategy, and the associated challenges with developing and running a multicenter database. Most importantly, it highlights the clinical and research potential of the DTD for advancing the understanding and treatment of trauma-affected refugees.

Headache comorbidity in refugees and migrants with post-traumatic stress disorder

BACKGROUND

Headache is often comorbid with post-traumatic stress disorder yet overlooked in health assessments of refugees.

OBJECTIVES

To describe prevalence of severe headache among refugees with post-traumatic stress disorder and compare severity of post-traumatic stress disorder symptoms and treatment outcomes among those with and without severe headache.

METHODS

This follow-up study used data from the Danish Database on Refugees with Trauma. Participants were recruited from 2009 to 2015 at a specialized psychiatric clinic. Prevalence of severe headache was computed by age, sex, and history of head injury or torture. Severe headache was defined as maximum headache scores on the Hopkins Symptom Checklist, Symptom Checklist-90 or the Visual Analogue Scale. Groups with and without severe headache were described according to validated questionnaires before and after 12-18 months of multidisciplinary treatment for post-traumatic stress disorder. Regression analyses were used to analyze associations between headache at start of treatment and symptom burden post-treatment, controlled for pre-treatment scores and possible confounders.

RESULTS

Among 403 female and 489 male participants, nearly all (97.5%) complained of headaches. Severe headache prevalence was 31.4% to 50.0% (depending on which questionnaire was used) and was significantly more common among females and those aged 30-49 years. There was no clear relationship between headache and head injury or torture. Participants with severe headache had heavier symptom burdens compared to those without severe headache. Post-treatment, headache prevalence by age and sex did not change significantly. Those without severe headache showed a tendency toward improvement in outcome measures; this was not seen among those with severe headache. Pre-treatment headache scores were correlated with all outcome measures. Regression analyses controlled for pre-treatment scores of the outcome variables showed associations between pre-treatment headache scores (Hopkins Symptom Checklist or Symptom Checklist-90) and post-treatment scores for intrusion, numbing, hyperarousal, anxiety, disability, and quality of life (all p < 0.02).

CONCLUSION

Headache is a prevalent comorbid condition among refugees with post-traumatic stress disorder. Measures of pre-treatment headache severity appear to predict post-traumatic stress disorder treatment outcomes. Severe headache adversely affects post-traumatic stress disorder prognosis. Assessment and treatment options should be studied further.

Convergence in a multi-method study between Rorschach and self-report data of traumatized refugees assessed before and after psychotherapy

Rorschach and self-report instruments represent methodologically different types of assessment, which together may yield incremental information about the test-taker. There is little evidence on whether and when results from these methods converge.

OBJECTIVE

To examine possible convergences between Rorschach trauma-related personality variables and self-reported variables.

METHOD

Before and after psychotherapy 22 traumatized adult refugee patients were assessed with the Rorschach Performance Assessment System (R-PAS), symptom checklists of posttraumatic stress, anxiety and depression, and a quality of life questionnaire. Correlational analyses between eight R-PAS variables and 10 self-reported variables were performed.

RESULTS

The findings showed inconsistent and nonsignificant correlations pretherapy. Posttherapy, however, all R-PAS variables except Complexity correlated positively with symptoms of mental disorder, and negatively with the quality of life variables, as predicted. The R-PAS variables Mutuality of Autonomy-Pathology, Poor Human Representation, Critical Content, and Form Quality-minus%, converged significantly with most of the self-reported variables, with medium to large correlations.

CONCLUSION

The finding of convergence only after psychotherapy, may tentatively suggest greater self-knowledge and internal consistency through the therapy experience, and increased trust and self-disclosure through the repeated meetings with the researchers. The findings represent a promising contribution to a cumulative validation process of convergence between Rorschach and self-report data.

The effectiveness of therapeutic interventions on psychological distress in refugee children: A systematic review

OBJECTIVE

To systematically review existing research exploring the effectiveness of psychological interventions in reducing symptoms of distress amongst refugee and asylum-seeker children.

METHOD

Six databases were searched to identify English studies presenting original empirical quantitative data (published before September 2022) testing the efficacy of psychological interventions for children from refugee and asylum-seeking backgrounds. Quality of studies were assessed through the Appraisal Tool for Cross-Sectional Studies as well as the Cochrane Risk of Bias Tool. Relevant data were extracted to facilitate a narrative synthesis.

RESULTS

Seventy-one eligible articles were identified (n > 10,000). A number of cognitive-behavioral, psychosocial, and trauma-focused interventions that catered specifically to children and their families were identified. A synthesis of these results suggest that interventions may assist in the reduction of various psychopathologies, although the effects were mixed across intervention types.

CONCLUSIONS

While the review yielded promising findings, most findings were derived from small pilot and empirical studies, leading to difficulties with drawing conclusions. There remains a need for studies using more rigorous research methodologies to expand and ratify this valuable knowledge base.

CLINICAL SIGNIFICANCE

 Forced displacement is at an all-time high. Many children are being forced to seek asylum and refuge, and they become vulnerable to the development of poor mental health, with limited understanding surrounding how to appropriately intervene. This review aims to equip clinicians with increased knowledge and confidence in working therapeutically alongside clients from refugee or asylum-seeking background, with the goal of fostering positive mental health and wellbeing.

Prevalence and prevention of suicidal ideation among asylum seekers in a high-risk urban post-displacement setting

AIMS

Among asylum seekers in a high-risk unstable post-displacement context, we aimed to investigate the prevalence of and risk for suicidal ideation (study 1), and then to test whether and how Mindfulness-Based Trauma Recovery for Refugees (MBTR-R) may prevent or treat suicidal ideation (study 2).

METHODS

Study 1 was conducted among a community sample of N = 355 (31.8% female) East African asylum seekers in a high-risk urban post-displacement setting in the Middle East (Israel). Study 2 was a secondary analysis of a randomised waitlist-control trial of MBTR-R among 158 asylum-seekers (46.2% female) from the same community and post-displacement setting.

RESULTS

Prevalence of suicidal ideation was elevated (31%). Post-migration living difficulties, as well as posttraumatic stress, depression, anxiety and their multi-morbidity were strongly associated with suicidal ideation severity. Likewise, depression and multi-morbidity prospectively predicted the onset of suicidal ideation. Relative to its incidence among waitlist-control (23.1%), MBTR-R prevented the onset of suicidal ideation at post-intervention assessment (15.6%) and 5-week follow-up (9.8%). Preventive effects of MBTR-R on suicidal ideation were mediated by reduced posttraumatic stress, depression, anxiety and their multi-morbidity. MBTR-R did not therapeutically reduce current suicidal ideation present at the beginning of the intervention.

CONCLUSIONS

Findings warn of a public health crisis of suicidality among forcibly displaced people in high-risk post-displacement settings. Although preliminary, novel randomised waitlist-control evidence for preventive effects of MBTR-R for suicidal ideation is promising. Together, findings indicate the need for scientific, applied and policy attention to mental health post-displacement in order to prevent suicide among forcibly displaced people.

The effect of an integrated care intervention of multidisciplinary mental health treatment and employment services for trauma-affected refugees: study protocol for a randomised controlled trial

Background

The complexity of past trauma and ongoing post-migration stressors challenges the existing mental health treatment for trauma-affected refugees. Therefore, interventions are needed to accommodate these complex challenges in mental health treatment. This study examines the effect of an add-on integrated care intervention compared to treatment as usual (TAU) for trauma-affected refugees in a randomised controlled trial (RCT).

Methods

The study is carried out at a Danish outpatient clinic and will include 197 treatment-seeking refugees with post-traumatic stress disorder (PTSD) who are unemployed and affiliated with municipal employment services. Mental health TAU comprises 10 sessions with a medical doctor (pharmacological treatment and psychoeducation) and 16–20 sessions with a psychologist (manual-based cognitive behavioural therapy) for a period of 8 to 12 months. The add-on intervention strengthens coordination between mental health treatment and employment interventions with three cross-sectoral collaborative meetings during the mental health treatment. The integrated care intervention draws attention to the bidirectional impact of mental health problems and post-migration stressors and focuses on cross-sectoral shared plans. The primary outcome is functioning, measured by WHODAS 2.0, the interviewer-administered 12-item version, with secondary outcomes measuring quality of life, mental health symptoms, and post-migration stressors.

Discussion

The RCT is novel in intervention design for trauma-affected refugees and will bring forward new perspectives and knowledge of integrated care interventions for trauma-affected refugees. The integrated care intervention is expected to reduce post-migration stressors that negatively affect the treatment of trauma-related mental health problems, thereby improving preconditions for enhanced treatment outcomes. The intervention builds on existing practices in the Danish healthcare and employment sectors, which ensures high scalability and sustainability for future practices.

Trial registration

ClinicalTrials.gov Identifier: NCT04244864, registered 28 January 2020. Protocol version: 17 September 2022, version 2.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06774-z.

White matter diffusivity and its correlations to state measures of psychopathology in male refugees with posttraumatic stress disorder

Post-traumatic stress disorder (PTSD) is a heterogenous condition and the underlying neurobiology is still poorly understood. In this study, we tested the hypothesis that PTSD is associated with microstructural changes in white matter (WM) fibre tracts that connect regions involved in emotional processing, memory, attention, and language. Furthermore, we examined how different response patterns to individualized trauma-provoking stimuli related to underlying WM microstructure. Sixty-nine trauma-affected male refugees with PTSD (N = 38) or without PTSD (N = 31) underwent clinical assessments and diffusion-weighted magnetic resonance imaging (DWI) of the whole brain at 3 Tesla. Diffusion tensor metrics were computed from DWI data and used to characterize regional white-matter microstructure. An automated tract segmentation method was used to extract diffusion tensor metrics from subject-based reconstructions of tract segments (ROI), including uncinate fasciculus (UF), cingulum bundle (CB), superior longitudinal fasciculus (SLF) in three subdivisions (SLF I - III), and fibre bundles connecting orbito-frontal cortex to striatum (OF-ST). Outside the scanner we obtained measures of immediate (state) arousal, avoidance and dissociation symptoms assessed in response to auditory exposure to a personal traumatic memory. Using mean FA of the middle part of each ROI, mixed ANOVA revealed a significant interaction between group, ROI and hemisphere. Post-hoc comparisons showed that, relative to refugees without PTSD, refugees with PTSD had lower FA in right CB, left SLF-I, bilateral OF-ST and bilateral SLF-II. Mean FA scaled negatively with avoidance in right CB while mean FA in bilateral UF scaled positively with individual scores reflecting dissociation symptoms. The results support a pathophysiological model of PTSD that implicates limbic structures, prefrontal cortex and striatum. The results also emphasize the need to consider PTSD's multifaceted manifestations when searching for functional-structural relationships.

Stress management versus cognitive restructuring in trauma-affected refugees - A follow-up study on a pragmatic randomised trial

BACKGROUND

There is a lack of research and consensus with respect to long-term effective treatments for trauma-affected refugees. The purpose of this follow-up study of a randomised clinical trial was to investigate the effectiveness of Stress Management (SM) versus Cognitive Restructuring (CR) in treating trauma-affected refugees, six and 18 months post-treatment, respectively.

METHODS

From a total of 126 refugees with PTSD, the intention-to-treat sample in the original trial, 74 patients were present at the six-month follow-up (SM; n = 37, CR; n = 37) and 34 patients at the 18-month follow-up (SM; n = 14, CR; n = 20). During the trial, the patients had been offered a total of 16 psychotherapy sessions and 10 sessions with a medical doctor.

RESULTS

Mixed regression analyses at six and 18-month follow-up showed a non-significant small reduction in PTSD symptoms at both follow-up points with no significant between-group differences between the two psychotherapeutic interventions. Statistically significant between-group treatment effects were, however, observed with the patients receiving SM having significantly reduced symptoms of somatisation measured by the Symptom Checklist (β = 0.40), depression (β = 0.29) and anxiety (β = 0.37) (measured by the Hamilton Depression and Anxiety ratings) at 18 months post-treatment compared to the CR group.

LIMITATIONS

Limitations to the present study include the dropout rate at follow-up(s).

CONCLUSIONS

The findings suggest that the consolidation of coping strategies including relaxation, attention-diversion and behavioural activation in SM appears to be more beneficial than CR in reducing long-term somatisation, depression and anxiety symptoms for this population.

A Systematic Review of Autobiographical Memory and Mental Health Research on Refugees and Asylum Seekers

Research examining trauma, memory, and mental health among refugee and asylum-seeking people has increased in recent years. We systematically reviewed empirical work focusing on the link between autobiographical memory and mental health among these populations. The review protocol was registered with PROSPERO (CRD42018095888). Six major databases were searched in August-2020 with no time limit for publication. Following PRISMA Statement guidelines, 22 articles reporting ten quantitative, nine qualitative, and three mixed-method studies were selected from 254 articles identified in the initial search. A basic convergent and qualitative meta-integration technique was employed for data extraction. Four recurrent themes were extracted: (1) memory activation method, (2) memory features, (3) memory content, and (4) refugee mental health. Theme 1 illustrates that narrative interviews, important event recall, and cue word methods were used in most studies. Theme 2 highlights that memories of refugee people were often less specific, inconsistent, and negative-focused. Retrieval failure was also common among these people. Theme 3 reveals that refugee and asylum-seeking people frequently discussed their abandoned identities, lost resources, injustices, ongoing sufferings, and pointless futures. Finally, theme 4 identifies the prevalence of various mental health conditions like Post-traumatic Stress Disorder, depression, helplessness, and anger among these people. The results are discussed in the context of the current autobiographical memory and mental health theories, considering refugee-specific experiences in the asylum process and refugee status.

Investigating the link between subjective sleep quality, symptoms of PTSD and level of functioning in a sample of trauma-affected refugees

STUDY OBJECTIVES

To examine whether baseline sleep quality is associated with baseline symptoms of posttraumatic stress disorder (PTSD) and level of functioning, and whether baseline sleep quality and improvement of sleep quality are specific predictors of change in PTSD symptoms and level of functioning.

METHODS

Data were derived from a four-armed randomised controlled superiority trial (N=219 trauma-affected refugees). All four groups received treatment as usual consisting of a 10-12 months bio-psycho-social treatment program with an additional differential treatment component added to each arm. We performed bivariate correlation analyses, multiple linear regression analyses and mediation analyses to examine associations between baseline sleep quality, change in sleep quality and treatment response for PTSD symptoms and level of functioning.

RESULTS

Baseline sleep quality correlated with symptoms of PTSD (r = .33) and level of functioning (r=0.15). Baseline sleep quality, improvement of sleep quality and improvement of general well-being were predictors of treatment response for symptoms of PTSD and level of functioning when controlling for age, gender, and baseline symptoms of PTSD and depression.

CONCLUSIONS

We found that good sleep quality at baseline and improvement of sleep quality were predictors of PTSD treatment response. However, treatment response was more closely associated with improvement in general well-being. The results indicate that the effect of improved sleep quality was partly mediated by a more general mental state improvement. Further research is needed to differentiate if a selected subgroup of patients may profit from sleep enhancing treatment.

Predictors of treatment outcomes for trauma-affected refugees - results from two randomised trials

INTRODUCTION

Treatment effects in trials with trauma-affected refugees vary considerably between studies, but the variability in outcome between individual patients is often overlooked. Consequently, we know little about why some patients benefit more from treatment than others. The aim of the study was therefore to identify predictors of treatment outcome for refugees with Posttraumatic Stress Disorder (PTSD).

METHODS

Data was derived from two randomised trials including 321 refugees, who had all participated in a 6-7 months bio-psycho-social treatment programme. Outcome measures were the Harvard Trauma Questionnaire (PTSD, self-rating), Hopkins Symptom Checklist-25 (depression and anxiety, self-rating) and Hamilton Depression and Anxiety rating scales (observer-ratings). Using hierarchical regressions models, associations were analysed between pre- to post treatment score changes (dependent variable) and a range of variables including sociodemographics, pre-migration trauma, post-migratory stressors, baseline symptom scores and level of functioning.

RESULTS

A high baseline score (=more symptoms) and a high level of functioning were found to be associated with improvement on all ratings. Additionally, the following variables were associated with symptom improvement on at least one outcome measure: short time in host country, full time occupation, young age and status as family reunified (in contrast to refugee status). Being Muslim was inversely correlated with improvement.

LIMITATIONS

Translated self-ratings were used, which could impact reliability.

CONCLUSION

These results call for screening and early interventions for arriving refugees. For clinical populations, level of functioning should be included in assessments of refugees, to possibly begin stratifying samples to different interventions based on their likelihood of responding.

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.

Global Mental Health and Services for Migrants in Primary Care Settings in High-Income Countries: A Scoping Review

Migrants are at a higher risk for common mental health problems than the general population but are less likely to seek care. To improve access, the World Health Organization (WHO) recommends the integration of mental health services into primary care. This scoping review aims to provide an overview of the types and characteristics of mental health services provided to migrants in primary care following resettlement in high-income countries. We systematically searched MEDLINE, EMBASE, PsycInfo, Global Health, and other databases from 1 January 2000 to 15 April 2020. The inclusion criteria consisted of all studies published in English, reporting mental health services and practices for refugee, asylum seeker, or undocumented migrant populations, and were conducted in primary care following resettlement in high-income countries. The search identified 1627 citations and we included 19 studies. The majority of the included studies were conducted in North America. Two randomized controlled trials (RCTs) assessed technology-assisted mental health screening, and one assessed integrating intensive psychotherapy and case management in primary care. There was a paucity of studies considering gender, children, seniors, and in European settings. More equity-focused research is required to improve primary mental health care in the context of global mental health.

Processing of Positive Visual Stimuli Before and After Symptoms Provocation in Posttraumatic Stress Disorder - A Functional Magnetic Resonance Imaging Study of Trauma-Affected Male Refugees

Background

Symptoms of anhedonia are often central to posttraumatic stress disorder (PTSD), but it is unclear how anhedonia is affected by processes induced by reliving past traumatic memories.

Methods

Sixty-nine male refugees (PTSD = 38) were interviewed and scanned with functional magnetic resonance imaging while viewing positive, neutral and Scrambled Pictures after being read personalized scripts evoking an emotionally neutral memory and a traumatic memory. We further measured postprovocation state symptoms, physiological measures and PTSD symptoms. We tested whether neural activity associated with positive picture viewing in participants with PTSD was differentially affected by symptom provocation compared to controls.

Results

For the pictures > scrambled contrast (Positive contrast), PTSD participants had significantly less activity than controls in fusiform gyrus, right inferior temporal gyrus and left middle occipital gyrus. The Positive contrast activity in fusiform gyrus scaled negatively with anhedonia symptoms in PTSD participants after controlling for total PTSD severity. Relative to the emotionally Neutral Script, the Trauma Script decreased positive picture viewing activity in posterior cingulate cortex, precuneus and left calcarine gyrus, but there was no difference between PTSD participants and controls.

Conclusions

We found reduced responsiveness of higher visual processing of emotionally positive pictures in PTSD. The significant correlation found between positive picture viewing activity and anhedonia suggests the reduced responsiveness to be due to the severity of anhedonia.

PTSD with secondary psychotic features among trauma-affected refugees: The role of torture and depression

This cross-sectional study examined the prevalence of PTSD with secondary psychotic symptoms (PTSD-SP), its comorbidities, and its association with torture and depression in treatment-seeking refugees. Data were pooled from the Danish Database on Refugees with Trauma (DART). The sample represents approximately 90% of trauma-affected refugee-patients (N = 627) attending a Danish psychiatric outpatient clinic from 2008 to 2013. PTSD, secondary psychotic symptoms, and comorbidities were assessed with structured and routine clinical interviews. The association of PTSD-SP with torture and depression was investigated using hierarchical logistic regression. The prevalence of PTSD-SP in treatment-seeking refugees with PTSD was 30%. Among these, 44% fulfilled the criteria for Enduring Personality Change After Catastrophic Experience (EPCACE). Psychotic symptoms comprised hallucinations and persecutory delusions, often reflecting trauma-related themes. Comorbidity with depression was high (79%). Neither torture, nor other war-trauma (ex-combatant, imprisonment, civilian war trauma) predicted PTSD-SP, but comorbid depression did. Depression only explained a small amount of the total PTSD-SP variance. Results indicate that PTSD-SP is common in treatment-seeking refugees. However, its etiology is poorly understood. This highlights the need for further research to improve diagnosis and treatment for this patient group.

Trauma-affected refugees treated with basic body awareness therapy or mixed physical activity as augmentation to treatment as usual-A pragmatic randomised controlled trial

BACKGROUND

The prevalence of post-traumatic stress disorder (PTSD) is estimated to be as high as 30% among refugees. The coexistence of prevalent chronic pain is believed to maintain symptoms of PTSD and add complexity to the condition. Despite this, little evidence exists on how to treat PTSD and comorbid conditions best in trauma-affected refugees.

AIM

The aim of the present study was to investigate if adding either BBAT or mixed physical activity to the treatment as usual (TAU) for trauma-affected refugees with PTSD would increase the treatment effect compared to TAU alone.

METHOD

Randomised controlled trial, 3-armed parallel group superiority study, conducted at Competence Centre for Transcultural Psychiatry, Denmark. Participants were adult trauma-affected refugees with PTSD. Allocation ratio was 1:1:1, stratified for PTSD severity and gender. An open-label design was applied due to the nature of the intervention. Participants were randomised to receive either individual basic body awareness therapy (group B) or individual mixed physical activity (group M) one hour/week for 20 weeks plus TAU, or TAU only (group C). The primary outcome was PTSD severity measured by Harvard Trauma Questionnaire (HTQ). Trial registration: ClinicalTrials.gov, NCT01955538.

RESULTS

Of the 338 patients included (C/B/M = 110/114/114), 318 patients were eligible for intention-to-treat analysis (C/B/M = 104/105/109). On the primary outcome, intention-to-treat as well as per-protocol analyses showed small but significant improvement on scores from pre- to post-treatment in all three groups but with no significant difference in improvement between groups.

CONCLUSIONS

The findings do not provide evidence that either BBAT or mixed physical activity as add-on treatment bring significantly larger improvement on symptoms of PTSD compared to TAU alone for adult, trauma-affected refugees. There is a need for studies on potential subpopulations of trauma-affected refugees who could benefit from physical activity as a part of their treatment.

Intensive psychotherapy and case management for Karen refugees with major depression in primary care: a pragmatic randomized control trial

BACKGROUND

Despite an unparalleled global refugee crisis, there are almost no studies in primary care addressing real-world conditions and longer courses of treatment that are typical when resettled refugees present to their physician with critical psychosocial needs and complex symptoms. We studied the effects of a year of psychotherapy and case management in a primary care setting on common symptoms and functioning for Karen refugees (a newly arrived population in St Paul, Minnesota) with depression.

METHODS

A pragmatic parallel-group randomized control trial was conducted at two primary care clinics with large resettled Karen refugee patient populations, with simple random allocation to 1 year of either: (1) intensive psychotherapy and case management (IPCM), or (2) care-as-usual (CAU). Eligibility criteria included Major Depression diagnosis determined by structured diagnostic clinical interview, Karen refugee, ages 18-65. IPCM (n = 112) received a year of psychotherapy and case management coordinated onsite between the case manager, psychotherapist, and primary care providers; CAU (n = 102) received care-as-usual from their primary care clinic, including behavioral health referrals and/or brief onsite interventions. Blinded assessors collected outcomes of mean changes in depression and anxiety symptoms (measured by Hopkins Symptom Checklist-25), PTSD symptoms (Posttraumatic Diagnostic Scale), pain (internally developed 5-item Pain Scale), and social functioning (internally developed 37-item instrument standardized on refugees) at baseline, 3, 6 and 12 months. After propensity score matching, data were analyzed with the intention-to-treat principle using repeated measures ANOVA with partial eta-squared estimates of effect size.

RESULTS

Of 214 participants, 193 completed a baseline and follow up assessment (90.2%). IPCM patients showed significant improvements in depression, PTSD, anxiety, and pain symptoms and in social functioning at all time points, with magnitude of improvement increasing over time. CAU patients did not show significant improvements. The largest mean differences observed between groups were in depression (difference, 5.5, 95% CI, 3.9 to 7.1, P < .001) and basic needs/safety (difference, 5.4, 95% CI, 3.8 to 7.0, P < .001).

CONCLUSIONS

Adult Karen refugees with depression benefited from intensive psychotherapy and case management coordinated and delivered under usual conditions in primary care. Intervention effects strengthened at each interval, suggesting robust recovery is possible.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT03788408. Registered 20 Dec 2018. Retrospectively registered.

Startle habituation, sensory, and sensorimotor gating in trauma-affected refugees with posttraumatic stress disorder

BACKGROUND

Impairments in mechanisms underlying early information processing have been reported in posttraumatic stress disorder (PTSD); however, findings in the existing literature are inconsistent. This current study capitalizes on technological advancements of research on electroencephalographic event-related potential and applies it to a novel PTSD population consisting of trauma-affected refugees.

METHODS

A total of 25 trauma-affected refugees with PTSD and 20 healthy refugee controls matched on age, gender, and country of origin completed the study. In two distinct auditory paradigms sensory gating, indexed as P50 suppression, and sensorimotor gating, indexed as prepulse inhibition (PPI), startle reactivity, and habituation of the eye-blink startle response were examined. Within the P50 paradigm, N100 and P200 amplitudes were also assessed. In addition, correlations between psychophysiological and clinical measures were investigated.

RESULTS

PTSD patients demonstrated significantly elevated stimuli responses across the two paradigms, reflected in both increased amplitude of the eye-blink startle response, and increased N100 and P200 amplitudes relative to healthy refugee controls. We found a trend toward reduced habituation in the patients, while the groups did not differ in PPI and P50 suppression. Among correlations, we found that eye-blink startle responses were associated with higher overall illness severity and lower levels of functioning.

CONCLUSIONS

Fundamental gating mechanisms appeared intact, while the pattern of deficits in trauma-affected refugees with PTSD point toward a different form of sensory overload, an overall neural hypersensitivity and disrupted the ability to down-regulate stimuli responses. This study represents an initial step toward elucidating sensory processing deficits in a PTSD subgroup.

Cross-Cultural Psychometric Properties of the Hamilton Depression Rating Scale

OBJECTIVE

The Hamilton Depression Rating Scale (HDRS) is considered the gold standard measure of depression. The factor structure of the HDRS is generally unstable, but 4 to 8 items appear to form a general depression factor. As transcultural studies of the HDRS have received little attention, and as most of the studies have taken a data-driven approach with a tendency to yield fragmented results, it is not clear if an HDRS general depression factor can also be found in non-Western populations. This is an important issue in deciding on the appropriateness of the scale as a gold standard in transcultural psychiatry.

METHOD

A systematic review was carried out to compare previously reported factor structures of the HDRS in non-Western cultures. Overlapping clusters across studies were identified and subsequently tested with confirmatory factor analysis (CFA) of responses from an independent sample.

RESULTS

Fourteen relevant studies were identified, 12 of which were obtained. A general depression factor was identified, consisting of the following symptoms: depressed mood, guilt, loss of interests, retardation, suicide, and psychological anxiety. The subsequent CFA analysis supported the fit of this model.

CONCLUSIONS

This study indicates that a general depression cluster is manifest in responses to the HDRS across cultures. While psychometric properties of the full-length HDRS are still debated, the general depression cluster appears pertinent to the assessment of depression across cultures. We recommend that cross-cultural clinicians and researchers focus on the use of unidimensional depression scales, which are in agreement with this cluster.

Interpreter-mediated psychotherapy with trauma-affected refugees - A retrospective cohort study

The aim of this retrospective cohort study was to examine if interpreter-mediated psychotherapy with trauma-affected refugees affects treatment outcome. The clinical sample consisted of 825 patients who, as part of treatment, were offered 16 sessions of cognitive behavioural therapy. The cohort was allocated to two subsamples based on whether interpreters were used in psychotherapy or not and the treatment outcome for the two subsamples was compared. The primary outcome measure was severity of PTSD-symptoms (Harvard Trauma Questionnaire (HTQ)) and secondary outcome measures were depression and anxiety symptoms (Hopkins Symptom Checklist-25 (HSCL-25), Hamilton Depression and Anxiety rating scales (HAM-D, HAM-A)), somatisation (somatisation items of SCL-90 (SI-SCL-90)), quality of life (WHO-5-Well-being Index (WHO-5)) and functioning (Sheehan Disability Scale (SDS), Global Assessment of Functioning (GAF-F, GAF-S)). Compared to no use of interpreter, the use of interpreter in psychotherapy was associated with less improvement during treatment on the primary outcome measure HTQ and the secondary outcome measures HSCL-25, SI-SCL-90, SDS, WHO-5, HAM-A, but not on GAF-S, GAF-F and HAM-D. Based on the primary outcome measure HTQ and the majority of the secondary ratings the subsample in interpreter-mediated psychotherapy had less improvement in their mental health status compared to the subsample without interpreter.

Stress management versus cognitive restructuring in trauma-affected refugees-A pragmatic randomised study

The aim of this randomised trial was to compare the effectiveness of stress management (SM) versus cognitive restructuring (CR) in trauma-affected refugees. The intention-to-treat sample comprised 126 refugees with PTSD (SM = 62, CR = 64). The treatment consisted of 16 sessions of psychotherapy with manualised SM or CR in addition to 10 sessions with a medical doctor (psychoeducation and pharmacological treatment). The primary outcome was PTSD symptom severity (Harvard Trauma Questionnaire). Secondary outcomes were symptoms of depression and anxiety (Hopkins Symptom Checklist-25, Hamilton Depression and Anxiety Ratings), quality of life (WHO-5), functioning (Global Assessment of Functioning, Sheehan Disability Scale), pain (Visual Analogue Scale) and somatisation (Symptom Checklist). There was no difference in the primary outcome between groups. A significant group difference was found on the Hamilton Anxiety Rating with the SM group improving more than the CR group (effect size 0.46) indicating that methods in SM could potentially be helpful in this population.

Mental Health of Refugees and Asylum Seekers: Assessment and Intervention

With unprecedented numbers of displaced persons worldwide, mental health clinicians in high-income countries will increasingly encounter refugee and asylum-seeking patients, many of whom have experienced significant adversity before and after their migration. This paper presents a summary of the recent evidence on the assessment and treatment of refugees across the lifespan to inform clinicians' approaches to care of refugee patients in mental health care settings. Assessment and interventions for refugees are grounded in an ecosystemic approach which considers not only pre-migratory trauma, but social, familial, and cultural determinants of mental health in the host country. Evidence for psychotherapy and pharmacological treatments are reviewed, highlighting promising interventions while acknowledging that further research is needed. Ultimately, serving refugees necessitates a biopsychosocial approach that engages clinicians as medical experts, therapists, and advocates.

Replicability and Generalizability of Posttraumatic Stress Disorder (PTSD) Networks: A Cross-Cultural Multisite Study of PTSD Symptoms in Four Trauma Patient Samples

The growing literature conceptualizing mental disorders like posttraumatic stress disorder (PTSD) as networks of interacting symptoms faces three key challenges. Prior studies predominantly used (a) small samples with low power for precise estimation, (b) nonclinical samples, and (c) single samples. This renders network structures in clinical data, and the extent to which networks replicate across data sets, unknown. To overcome these limitations, the present cross-cultural multisite study estimated regularized partial correlation networks of 16 PTSD symptoms across four data sets of traumatized patients receiving treatment for PTSD (total N = 2,782). Despite differences in culture, trauma type, and severity of the samples, considerable similarities emerged, with moderate to high correlations between symptom profiles (0.43-0.82), network structures (0.62-0.74), and centrality estimates (0.63-0.75). We discuss the importance of future replicability efforts to improve clinical psychological science and provide code, model output, and correlation matrices to make the results of this article fully reproducible.

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

BACKGROUND

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

AIMS

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

Pharmacological treatment of refugees with trauma-related disorders: What do we know today?

There is a dearth of evidence on the effectiveness of pharmacological treatment for refugees with trauma-related disorders. The present paper provides an overview of available literature on the subject and discusses the transferability of results from studies on other groups of patients with post traumatic stress disorder (PTSD). We conducted a systematic review of published treatment outcome studies on PTSD and depression among refugees. Fifteen studies were identified and reviewed. Most studies focused on the use of antidepressants. Included studies differed widely in method and quality. The majority were observational studies and case studies. Small sample sizes limited the statistical power. Few studies reported effect sizes, confidence intervals, and statistical significance of findings. No specific pharmacological treatment for PTSD among refugees can be recommended on the basis of the available literature. There is a need for well-designed clinical trials, especially with newer antidepressants and antipsychotics. Until such studies are available, clinical practice and design of trials can be guided by results from studies of other groups of PTSD patients, although differences in pharmacogenetics, compliance, and trauma reactions may affect the direct transferability of results from studies on nonrefugee populations.

Secondary psychotic features in refugees diagnosed with post-traumatic stress disorder: a retrospective cohort study

BACKGROUND

A substantial amount of refugees (10-30%) suffer from Post-Traumatic Stress Disorder (PTSD). In Denmark there are different facilities specialised in psychiatric treatment of trauma-affected refugees. A previously published case report from such a facility in Denmark shows that some patients suffer from secondary psychotic symptoms alongside their PTSD. The aim of this study was to illustrate the characteristics and estimate the prevalence of psychotic features in a clinical population of trauma-affected refugees with PTSD.

METHODS

Psychiatric records from 220 consecutive patients at Competence Centre for Transcultural Psychiatry (CTP) were examined, and all the PTSD patients were divided into two groups; one group with secondary psychotic features (PTSD-SP group) and one without (PTSD group). A categorisation and description of the secondary psychotic features was undertaken.

RESULTS

One hundred eighty-one patients were diagnosed with PTSD among which psychotic symptoms were identified in 74 (40.9, 95% CI 33.7-48.1%). The majority of symptoms identified were auditory hallucinations (66.2%) and persecutory delusions (50.0%). There were significantly more patients diagnosed with enduring personality change after catastrophic experience in the PTSD-SP group than in the PTSD group (P = 0.009). Furthermore the PTSD-SP group included significantly more patients exposed to torture (P = 0.001) and imprisonment (P = 0.005).

CONCLUSION

This study provides an estimation of PTSD-SP prevalence in a clinical refugee population with PTSD. The study points to the difficulties distinguishing psychotic features from flashbacks and the authors call for attention to psychotic features in PTSD patients in order to improve documentation and understanding of the disorder.

Learning to Work with Trauma Survivors: Lessons from Tbilisi, Georgia

Survivors of armed conflict may experience traumatic stress, psychological symptoms, distress, or other behavioral health issues related to the disaster of war. This article outlines the historical background of the Russian-Georgian war, details the implementation of social work in the developing country of Georgia, and describes the training and application of social work knowledge and values using macro and micro examples of interventions that provide Masters of social work students and social workers with tools to address the needs of refugees affected by disaster. Following the macro- and microexamples, pedagogy and implications for social workers and social work students working with victims of trauma with few available resources are discussed.

Treatment of trauma-affected refugees with venlafaxine versus sertraline combined with psychotherapy - a randomised study

BACKGROUND

The prevalence of trauma-related psychiatric disorders is high among refugees. Despite this, little is known about the effect of pharmacological treatment for this patient group. The objective of the present study was therefore to examine differences in the effects of venlafaxine and sertraline on Post-Traumatic Stress Disorder (PTSD), depression and functional impairment in trauma-affected refugees.

METHODS

The study was a randomised pragmatic trial comparing venlafaxine and sertraline in combination with psychotherapy and social counselling. PTSD symptoms were measured on the Harvard Trauma Questionnaire - part IV, which was the primary outcome measure. Other outcome measures included: Hopkins Symptom Check List-25 (depression and anxiety), Social Adjustment Scale - short version (social functioning), WHO-5 Well-being Index (quality of life), Crisis Support Scale (support from social network), Sheehan Disability Scale (disability in three areas of functioning), Hamilton Depression and Anxiety scale, the somatisation items of the Symptoms Checklist-90, Global Assessment of Functioning scales and the summarised score of pain in four body areas rated on visual analogue scales.

RESULTS

Two hundred seven adult refugee patients were included in the trial (98 in the venlafaxine and 109 in the sertraline group). Of these, 195 patients were eligible for intention-to-treat analyses. Small but significant pre-treatment to post-treatment differences were found on the Harvard Trauma Questionnaire and a number of other ratings in both groups. On the primary outcome measure, no difference was found in treatment effect between the sertraline and venlafaxine group. A significant group difference was found in favour of sertraline on the Sheehan Disability Scale.

CONCLUSION

Sertraline had a slightly better outcome than venlafaxine on some of the secondary outcome measures, but not on the primary outcome measure. Furthermore, a higher percentage of dropouts was found in the venlafaxine group compared to the sertraline group. Although this could indicate that sertraline was better tolerated, which is supported by other studies, a final conclusion on tolerability cannot be drawn from the current study due to lack of systematic reporting of side effects.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01569685 . Registration date: 28/2/12.

The latent structure of post-traumatic stress disorder among Arabic-speaking refugees receiving psychiatric treatment in Denmark

BACKGROUND

Refugees are known to have high rates of post-traumatic stress disorder (PTSD). Although recent years have seen an increase in the number of refugees from Arabic speaking countries in the Middle East, no study so far has validated the construct of PTSD in an Arabic speaking sample of refugees.

METHODS

Responses to the Harvard Trauma Questionnaire (HTQ) were obtained from 409 Arabic-speaking refugees diagnosed with PTSD and undergoing treatment in Denmark. Confirmatory factor analysis was used to test and compare five alternative models.

RESULTS

All four- and five-factor models provided sufficient fit indices. However, a combination of excessively small clusters, and a case of mistranslation in the official Arabic translation of the HTQ, rendered results two of the models inadmissible. A post hoc analysis revealed that a simpler factor structure is supported, once local dependence is addressed.

CONCLUSIONS

Overall, the construct of PTSD is supported in this sample of Arabic-speaking refugees. Apart from pursuing maximum fit, future studies may wish to test simpler, potentially more stable models, which allow a more informative analysis of individual items.

Mental health screening in immigration detention: A fresh look at Australian government data

OBJECTIVES

The poor mental health of asylum seekers and refugees in immigration detention has consistently been reported in peer-reviewed literature internationally; however, data on the mental health of asylum seekers and refugees detained in Australian immigration has been very limited.

METHODS

We re-analysed mental health screening data obtained by the Human Rights Commission.

RESULTS

Longer time in detention was associated with higher self-reported depression scores, with female individuals being more vulnerable to time in detention than those of male gender. Approximately one-half of the refugee group who agreed to complete the Harvard Trauma Questionnaire had post-traumatic stress disorder symptoms. On clinician-rated measures, one-third of the children, adolescents and adults suffered with clinical symptoms requiring tertiary outpatient assessment.

CONCLUSIONS

This paper consolidates the findings of the 2014 Australian Human Rights Commission report and it provides an argument for public reporting of refugee data.

Psychosocial predictors of treatment outcome for trauma-affected refugees

BACKGROUND

The effects of treatment in trials with trauma-affected refugees vary considerably not only between studies but also between patients within a single study. However, we know little about why some patients benefit more from treatment, as few studies have analysed predictors of treatment outcome.

OBJECTIVE

The objective of the study was to examine possible psychosocial predictors of treatment outcome for trauma-affected refugees.

METHOD

The participants were 195 adult refugees with posttraumatic stress disorder (PTSD) who were enrolled in a 6- to 7-month treatment programme at the Competence Centre for Transcultural Psychiatry (CTP), Denmark. The CTP Predictor Index used in the study included 15 different possible outcome predictors concerning the patients' past, chronicity of mental health problems, pain, treatment motivation, prerequisites for engaging in psychotherapy, and social situation. The primary outcome measure was PTSD symptoms measured on the Harvard Trauma Questionnaire (HTQ). Other outcome measures included the Hopkins Symptom Check List-25, the WHO-5 Well-being Index, Sheehan Disability Scale, Hamilton Depression and Anxiety Scales, the somatisation scale of the Symptoms Checklist-90, Global Assessment of Functioning scales, and pain rated on visual analogue scales. The relations between treatment outcomes and the total score as well as subscores of the CTP Predictor Index were analysed.

RESULTS

Overall, the total score of the CTP Predictor Index was significantly correlated to pre- to post treatment score changes on the majority of the ratings mentioned above. While employment status was the only single item significantly correlated to HTQ-score changes, a number of single items from the CTP Predictor Index correlated significantly with changes in depression and anxiety symptoms, but the size of the correlation coefficients were modest.

CONCLUSIONS

The total score of the CTP Predictor Index correlated significantly with outcomes on most of the rating scales, but correlations were modest in size, possibly due to the number of different factors influencing treatment outcome.

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.

Relationships of Childhood Adverse Experiences With Mental Health and Quality of Life at Treatment Start for Adult Refugees Traumatized by Pre-Flight Experiences of War and Human Rights Violations

Adverse and potentially traumatic experiences (PTEs) in childhood were examined among 54 adult refugee patients with pre-flight PTEs of war and human rights violations (HRVs) and related to mental health and quality of life at treatment start. Extent of childhood PTEs was more strongly related to mental health and quality of life than the extent of war and HRV experiences. Childhood PTEs were significantly related to arousal and avoidance symptoms of posttraumatic stress disorder (PTSD) and to quality of life, whereas pre-flight war and HRV experiences were significantly related to reexperiencing symptoms of PTSD only. Within childhood adversities, experiences of family violence and external violence, but not of loss and illness, were significantly related to increased mental health symptoms and reduced quality of life. These results point to the importance of taking childhood adverse experiences into account in research and treatment planning for adult refugees with war and HRVs trauma.