Trauma and posttraumatic stress disorder in South Africa: analysis from the South African Stress and Health Study

Post-traumatic stress disorder and associated factors among inpatients at Eastern Command Referral Hospital in Dire Dawa, Eastern Ethiopia

Background

Post-traumatic stress disorder (PTSD) is characterized by heightened stress and anxiety after experiencing a traumatic event. While numerous studies have been conducted to investigate the magnitude and factors associated with PTSD, there is limited evidence available on specific study populations of military personnel.

Objective

The study aimed to determine the magnitude of post-traumatic stress disorder and associated factors among military personnel admitted to the Eastern Command Referral Hospital in Eastern Ethiopia from May 1 to 30, 2023.

Methods and materials

A cross-sectional study was carried out at an institution. Face-to-face interviews were conducted to collect data using the post-traumatic stress disorder military version checklist for the Diagnostic and Statistical Manual, Fifth Edition. Data were entered and analyzed using EpiData version 3.1 and STATA version 14. Descriptive statistics were employed to summarize the information. To investigate factors linked with outcome variables, bivariate and multivariate logistic regression analyses were conducted. The results were presented using odds ratios with 95% confidence intervals, with statistical significance given at a p-value of 0.05.

Results

This study found that approximately 23.6% (95% CI = 19.9-27.8) of admitted military members fulfilled the diagnostic criteria for PTSD. Participants' history of mental illness [adjusted odds ratio (AOR) = 5.73, 95% CI = 2.66-12.31], family history of mental illness (AOR = 10.38, 95% CI = 5.36-20.10), current chewing of khat (AOR = 2.21, 95% CI = 1.13-4.32), physical trauma (AOR = 2.03, 95% CI = 1.00-4.13), moderate social support (AOR = 0.27, 95% CI = 0.1-4.53), strong social support (AOR = 0.09, 95% CI = 0.02-0.35), and severe depression (AOR = 2.06, 95% CI = 1.74-5.71) were factors significantly associated with post-traumatic stress disorder.

Conclusions

The magnitude of post-traumatic stress disorder is high among military personnel. Factors such as participants' history of mental illness, family history of mental illness, depression, lack of social support, current use of khat, and physical trauma are significantly associated with PTSD. It is crucial to identify and intervene early in individuals with these risk factors to address PTSD effectively.

Influence of childhood trauma and traumatic stress on a woman's risk of having a child with a fetal alcohol spectrum disorder

BACKGROUND

Maternal risk factors for having a child diagnosed on the fetal alcohol spectrum disorders (FASD) continuum are complex and include not only the quantity, frequency, and timing of alcohol use but also a woman's physical stature, socio-economic status, and pregnancy-related factors. Exposure to trauma may predispose women to a range of physiological and mental disorders. A woman's mental and physical health may in turn influence her probability of having a child with FASD. This study investigated the role of maternal childhood trauma and lifetime traumatic stress on prenatal alcohol consumption and on the risk of having a child with FASD.

METHODS

A nested, case-control study was conducted for maternal risk assessment. Study participants were mothers of first-grade learners from five rural communities in the Western Cape Province of South Africa who were assessed for FASD. Face-to-face surveys were conducted, which included mental health and trauma assessment questionnaires.

RESULTS

In logistic regression analyses, higher maternal childhood trauma scores were associated with an increased likelihood of having a child diagnosed with FASD, although the increase in risk was modest (OR = 1.014, p = 0.015). In addition, structural equation modeling investigated relationships between maternal drinking, childhood trauma, traumatic stress, and a child's FASD diagnosis. Traumatic stress and drinking during pregnancy, but not lifetime alcohol use, were associated with maternal childhood trauma. Lifetime alcohol use influenced drinking during pregnancy, which in turn was significantly associated with having a child diagnosed on the continuum of FASD.

CONCLUSION

No direct influence of maternal childhood trauma on FASD diagnosis could be demonstrated. However, maternal trauma may indirectly contribute to the risk of having a child diagnosed with FASD.

Experiences of trauma and psychometric properties of the Life Events Checklist among adults in Uganda

Exposure to potentially traumatic events (PTE) is common and increases an individual's risk of developing post-traumatic stress disorder (PTSD) and other psychiatric disorders. PTEs can be screened with the Life Events Checklist for DSM 5 (LEC-5). However, the psychometric properties of the LEC-5 have never been assessed in Uganda. We aimed to estimate the prevalence of PTEs and evaluate the factor structure of the LEC-5 in a sample of N = 4,479 Ugandan adults between February 2018 -March 2020. We used the phenotyping data from a case-control study (NeuroGAP-Psychosis) in Uganda investigating the genetic and environmental risk factors for psychosis spectrum disorders with 4,479 participants (2,375 cases and 2,104 controls). Prevalence for PTEs was determined for all participants and by case-control status. The factor structure of the LEC-5 was assessed using an exploratory factor analysis (EFA) and a confirmatory factor analysis (CFA). The overall prevalence of exposure to one or more types of PTEs was 60.5%. Cases reported more frequency of exposure to PTEs than controls (64.2% vs 55.4%; p<0.001). The most frequently endorsed traumatic event was physical assault (22.8%), while exposure to toxic substances was the least endorsed (1.7%). There were several differences among the types of events experienced between cases and controls, including cases reporting more experiences of physical (28.6% vs. 16.2%, p<0.001) and sexual assault (11.5% vs. 5.0%, p<0.001) than controls. The EFA yielded a six-factor model that explained 49.8% of the total variance. The CFA showed that a theoretical seven-factor model based on the South African Stress and Health survey was a better fitting model (CFI = 0.935; TLI = 0.908; RMSEA = 0.026) than the EFA. This study revealed a high prevalence of PTEs among cases and controls, and the LEC-5 was found to have good psychometric properties among Ugandan adults.

The rationale for South Africa to prioritise mental health care as a critical aspect of overall health care

BACKGROUND

The publication of South Africa's National Mental Health Policy Framework and Strategic Plan 2023-2030 and the proposed National Health Insurance (NHI) make it timely to review that state of mental health services in the country, and to emphasize the importance of prioritising mental health as a pivotal component of holistic healthcare.

METHOD

We searched the published literature on mental health using Google Scholar, Pubmed, and Bing Chat, focusing on these words: epidemiology of mental health disorders, depression and anxiety disorders, mental health services, mental health facilities, human resources, financing and impact of COVID-19 on mental health in South Africa and beyond. We also searched the grey literature on mental health policy that is publicly available on Google.

RESULTS

We provided information on the epidemiology and economic impact of mental health disorders, the availability of mental health services, enabling policies, human resources, financing, and the infrastructure for mental health service delivery in South Africa. We detail the high lifetime prevalence rates of common mental disorders, as well as the profound impact of socioeconomic determinants such as poverty, unemployment, and trauma on mental health disorders. We note the exacerbating effect of the COVID-19 pandemic, and emphasize the pressing need for a robust mental health care system.

CONCLUSION

In addition to outlining the challenges, such as limited mental health service availability, a shortage of mental health professionals, and financial constraints, the review proposes potential solutions, including task-sharing, telehealth, and increasing the production of mental health professionals. The paper underscores the necessity of crafting a comprehensive NHI package of mental health services tailored to the local context. This envisioned package would focus on evidence-based interventions, early identification, and community-based care. By prioritising mental health and addressing its multifaceted challenges, South Africa can aspire to render accessible and equitable mental health services for all its citizens within the framework of the National Health Insurance.

Experiences on the frontline: Qualitative accounts of South African healthcare workers during the COVID-19 pandemic

Background

The COVID-19 pandemic significantly impacted people's mental health significantly. Frontline healthcare workers (HCWs) were arguably most affected, particularly in low-to-middle-income countries like South Africa. Understanding their experiences is important to inform interventions for social and psychological support for future pandemics.

Aim

This study explored the experiences of frontline HCWs in South Africa during the COVID-19 pandemic.

Setting

The sample included HCWs from various professions and health sectors who worked with COVID-19 patients across South Africa.

Methods

An exploratory descriptive qualitative design was used. Semi-structured interviews were conducted with 11 frontline HCWs recruited via purposive sampling. Data were analysed using principles of inductive thematic analysis.

Results

Four major themes were identified in the data: (1) Working during COVID-19 was an emotional rollercoaster; (2) Working during COVID-19 was physically and mentally exhausting; (3) Participants held negative attitudes towards the Department of Health; and (4) COVID-19 had a transformative impact on the daily life of HCWs.

Conclusion

HCWs' experiences were diverse and marked by contradictions. Limited psychological support and resources aggravated experiences. However, a positive narrative of hope and gratitude also resonated with participants. Qualitative methodologies provided depth and insights into the diverse realities of frontline HCWs.

Contribution

This study provides significant insights into the experiences of a diverse group of frontline South African HCWs during COVID-19. It demonstrates a shift in the definition of a 'frontline' HCW and highlights the need for greater psychological support and individualised public health interventions during future pandemics.

Post-traumatic stress disorder as a risk factor for major adverse cardiovascular events: a cohort study of a South African medical insurance scheme

AIMS

Prior research, largely focused on US male veterans, indicates an increased risk of cardiovascular disease among individuals with post-traumatic stress disorder (PTSD). Data from other settings and populations are scarce. The objective of this study is to examine PTSD as a risk factor for incident major adverse cardiovascular events (MACEs) in South Africa.

METHODS

We analysed reimbursement claims (2011-2020) of a cohort of South African medical insurance scheme beneficiaries aged 18 years or older. We calculated adjusted hazard ratios (aHRs) for associations between PTSD and MACEs using Cox proportional hazard models and calculated the effect of PTSD on MACEs using longitudinal targeted maximum likelihood estimation.

RESULTS

We followed 1,009,113 beneficiaries over a median of 3.0 years (IQR 1.1-6.0). During follow-up, 12,662 (1.3%) persons were diagnosed with PTSD and 39,255 (3.9%) had a MACE. After adjustment for sex, HIV status, age, population group, substance use disorders, psychotic disorders, major depressive disorder, sleep disorders and the use of antipsychotic medication, PTSD was associated with a 16% increase in the risk of MACEs (aHR 1.16, 95% confidence interval (CI) 1.05-1.28). The risk ratio for the effect of PTSD on MACEs decreased from 1.59 (95% CI 1.49-1.68) after 1 year of follow-up to 1.14 (95% CI 1.11-1.16) after 8 years of follow-up.

CONCLUSION

Our study provides empirical support for an increased risk of MACEs in males and females with PTSD from a general population sample in South Africa. These findings highlight the importance of monitoring cardiovascular risk among individuals diagnosed with PTSD.

A counsellor-supported 'PTSD Coach' intervention versus enhanced Treatment-as-Usual in a resource-constrained setting: A randomised controlled trial

To widen treatment access for posttraumatic stress disorder (PTSD) in resource-constrained South Africa, we evaluated the feasibility and effectiveness of a counsellor-supported PTSD Coach mobile application (app) (PTSD Coach-CS) intervention on PTSD and associated sequelae in a community sample. Participants (female = 89%; black = 77%; aged 19-61) with PTSD were randomised to PTSD Coach-CS (n = 32) or enhanced Treatment-as-Usual (n = 30), and assessed with the Clinician-Administered PTSD Scale (CAPS-5), PTSD Checklist (PCL-5) and Depression, Anxiety and Stress Scale-21 items, at pre- to post-treatment and follow-up (1 and 3 months). We also collected data on user experiences of the PTSD Coach app with self-administered surveys. We conducted an intent-to-treat analysis and linear mixed models. A significant (group × time) effect for the CAPS-5 (F3.136 = 3.33, p = 0.02) indicated a greater reduction in PTSD symptom severity over time for the intervention group with a significant between-group effect size detected at 3-month follow-up. Significant between-group effect sizes were detected in self-reported stress symptom reduction in the intervention group at post-treatment and 3-month follow-up. Participants perceived the app as helpful and were satisfied with the app. Findings suggest PTSD Coach-CS as a suitable low-cost intervention and potential treatment alternative for adults with PTSD in a resource-constrained country. Replication in larger samples is needed to fully support effectiveness. Pan African Trial Registry: PACTR202108755066871.

Childhood adversity during the post-apartheid transition and COVID-19 stress independently predict adult PTSD risk in urban South Africa: A biocultural analysis of the stress sensitization hypothesis

OBJECTIVES

The COVID-19 pandemic in South Africa introduced new societal adversities and mental health threats in a country where one in three individuals are expected to develop a psychiatric condition sometime in their life. Scientists have suggested that psychosocial stress and trauma during childhood may increase one's vulnerability to the mental health consequences of future stressors-a process known as stress sensitization. This prospective analysis assessed whether childhood adversity experienced among South African children across the first 18 years of life, coinciding with the post-apartheid transition, exacerbates the mental health impacts of psychosocial stress experienced during the 2019 coronavirus (COVID-19) pandemic (ca. 2020-2021).

MATERIALS AND METHODS

Data came from 88 adults who participated in a follow-up study of a longitudinal birth cohort study in Soweto, South Africa. Childhood adversity and COVID-19 psychosocial stress were assessed as primary predictors of adult PTSD risk, and an interaction term between childhood adversity and COVID-19 stress was calculated to evaluate the potential effect of stress sensitization.

RESULTS

Fifty-six percent of adults exhibited moderate-to-severe PTSD symptoms. Greater childhood adversity and higher COVID-19 psychosocial stress independently predicted worse post-traumatic stress disorder symptoms in adults. Adults who reported greater childhood adversity exhibited non-significantly worse PTSD symptoms from COVID-19 psychosocial stress.

DISCUSSION

These results highlight the deleterious mental health effects of both childhood trauma and COVID-19 psychosocial stress in our sample and emphasize the need for greater and more accessible mental health support as the pandemic progresses in South Africa.

Validation of the Malay version of the Life Events Checklist for DSM-5 among Malaysian undergraduates

This cross-sectional study aimed to validate the Life Events Checklist for DSM-5 (LEC-5) among Malaysian undergraduates (N = 500; mean age = 21.66 ± 1.57), of which 90.4% had ever experienced a lifetime traumatic event. Cronbach's alpha of .87 (95% CI [.86, .89]) and McDonald's omega of .89 (95% CI [.89, .93]) indicated good reliability. Confirmatory factor analysis based on a six-factor structure showed the best fit. The measurement invariance showed that the six-factor structure was similar across sexes. Therefore, the Malay LEC-5 is a valid and reliable instrument to screen for traumatic events among Malaysian undergraduates.

Early Childhood Violence Exposure Patterns in The Drakenstein Child Health Study (DCHS)

Background: Research has highlighted high rates of exposure to violence among South African youth. However, work to date has been largely cross-sectional, focused on violence exposure during the adolescence period, and has been limited to specific types of violence exposure. We examined violence exposure in South African preschool children between 3 and 6 years of age, capturing both direct and indirect forms of violence, and tested for potential sex differences across the several types of exposures. Methods: Lifetime direct and indirect exposure to domestic and community violence was measured by parental report when children were 3.5 years (N = 530), 4.5 years (N = 749) and 6 years of age (N= 417) in a South African birth cohort located in a peri-urban community. Results: There are three main findings. First, a large proportion of children (72%-75%) were reported as having been exposed to some form of direct or indirect violent experience in their homes or communities from a young age. Second, there was significant polyvictimization,  with 49% of the children being exposed to more than one type of violence by age 6. Third, by 4.5 years of age, there was evidence that boys were more likely than girls to be exposed to domestic victimisation (28% vs. 17%) and polyvictimization (38% vs. 28%). Conclusions: These findings highlight the high levels of violence exposure in young South African children, particularly among boys, and the need for prevention at both the community and individual levels.

Identifying genetic loci that are associated with changes in gene expression in PTSD in a South African cohort

The molecular mechanisms underlying posttraumatic stress disorder (PTSD) are yet to be fully elucidated, especially in underrepresented population groups. Expression quantitative trait loci (eQTLs) are DNA sequence variants that influence gene expression, in a local (cis-) or distal (trans-) manner, and subsequently impact cellular, tissue, and system physiology. This study aims to identify genetic loci associated with gene expression changes in a South African PTSD cohort. Genome-wide genotype and RNA-sequencing data were obtained from 32 trauma-exposed controls and 35 PTSD cases of mixed-ancestry, as part of the SHARED ROOTS project. The first approach utilised 108 937 single-nucleotide polymorphisms (SNPs) (MAF > 10%) and 11 312 genes with Matrix eQTL to map potential eQTLs, while controlling for covariates as appropriate. The second analysis was focused on 5638 SNPs related to a previously calculated PTSD polygenic risk score for this cohort. SNP-gene pairs were considered eQTLs if they surpassed Bonferroni correction and had a false discovery rate <0.05. We did not identify eQTLs that significantly influenced gene expression in a PTSD-dependent manner. However, several known cis-eQTLs, independent of PTSD diagnosis, were observed. rs8521 (C > T) was associated with TAGLN and SIDT2 expression, and rs11085906 (C > T) was associated with ZNF333 expression. This exploratory study provides insight into the molecular mechanisms associated with PTSD in a non-European, admixed sample population. This study was limited by the cross-sectional design and insufficient statistical power. Overall, this study should encourage further multi-omics approaches towards investigating PTSD in diverse populations.

Exposure to self-reported traumatic events and probable PTSD in a national sample of Poles: Why does Poland's PTSD prevalence differ from other national estimates?

BACKGROUND

There is a lack of studies on trauma exposure and PTSD prevalence in Poland on representative samples. Available data from studies on convenient samples show very high rates of probable PTSD compared with relevant estimates in other countries.

OBJECTIVE

This study aimed to measure the exposure to self-report traumatic events (PTEs) and to estimate the current rate of prevalence of probable posttraumatic stress disorder (PTSD) in accordance with DSM-5 criteria in a population-based sample of Poles. Additionally, the link between PTSD intensity and level of life satisfaction was investigated.

METHOD

A representative sample of 1,598 adult Poles was recruited. Probable PTSD was assessed with the Posttraumatic Diagnostic Scale for DSM-5 (PDS-5) and the Satisfaction with Life Scale (SWLS) was also used.

RESULTS

The findings showed that 60.3% of Poles had experienced at least one PTE and 31.1% of those who had been exposed to trauma reported symptoms of PTSD. At the level of the entire sample, the obtained rate for probable PTSD was 18.8%. The traumatic events with the highest probabilities of PTSD symptoms were child abuse and sexual assault. Levels of life satisfaction were significantly lower in the group of participants with probable PTSD.

CONCLUSIONS

We found that the current prevalence of probable PTSD in Poland is intriguingly high relative to rates reported in comparable representative samples from other countries across the world. Possible mechanisms are discussed, including a lack of social acknowledgement of WWII and other traumas as well as poor access to trauma-focused care. We hope that this research may inspire more studies investigating cross-national differences in PTSD and trauma exposure.

Post-traumatic stress disorder and traumatic events in China: a nationally representative cross-sectional epidemiological study

Post-traumatic stress disorder (PTSD) is one of the most severe sequelae of trauma. But a nationally representative epidemiological data for PTSD and trauma events (TEs) was unavailable in China. This article firstly demonstrated detailed epidemiological information on PTSD, TEs, and related comorbidities in the national-wide community-based mental health survey in China. A total of 9,378 participants completed the PTSD-related interview of the CIDI 3.0. Lifetime prevalence and 12-month prevalence of PTSD in total respondents were 0.3% and 0.2%. while the conditional lifetime and 12-month prevalence of PTSD after trauma exposure were 1.8% and 1.1%. The prevalence of exposure to any type of TE was 17.2%. Among individuals with the exposed to TEs, younger, without regular work (being a homemaker or retried), and intimate relationship breakdown (separated/Widowed/Divorced), living rurally were associated with either the lifetime PTSD or the 12-month PTSD, while the count of a specific TE, the unexpected death of loved one, was related to both. Alcohol dependence was the most common comorbidity among male participants with PTSD but major depressive disorder (MDD) for female counterparts. Our study can provide a reliable reference for future identification and intervention for people with PTSD.

Post-traumatic Growth: The Roles of the Sense of Entitlement, Gratitude and hope

People believe that they are entitled to well-being and safety, and their responses to unexpected traumatic events reveal individual differences. Their reactions vary, from feeling blocked and distressed to feeling proactive towards new growth, depending on their personal resources. The current study sought to identify the role of entitlement in explaining post-traumatic growth (PTG) while considering the role of gratitude and hope as personal resources. We used a community-based sample of Israeli adults (n = 182) who reported experiencing a traumatic event during the preceding year. The relationships between PTG and their sense of entitlement, gratitude, and hope were examined. A stepwise multiple hierarchical regression revealed that all the three variables were associated with PTG. However, the effect of hope turned insignificant with the inclusion of sense of entitlement and gratitude in the regression. Sense of entitlement and gratitude were independently associated with PTG. The theoretical contribution of these findings is discussed, as well as their interventional implications and future directions.

Post-traumatic stress disorder and associated factors among adults exposed to stress in Ethiopia: A meta-analysis and systematic review

Objective

Post-traumatic stress disorder is a complex psychiatric disorder that develops after exposure to traumatic events, such as violent physical assaults, accidents, rape, natural disasters, and conflicts, stranger than usual human experiences. The typical presentation of intrusive thoughts, the persistence of the trauma, the avoidance of pertinent stimuli, emotional numbness, and physiological hyperarousal are the characteristics of this anxiety symptom. Despite the presence of a study conducted on this problem, the pooled effect, particularly in Ethiopia, is not known; therefore, this study assessed the allover burden of post-traumatic stress disorder.

Method

The available study was extracted and conducted on post-traumatic stress disorder and its associated factors in Ethiopia by three independent authors. The data were analyzed by using STATA version 11 after extraction was done on a Microsoft Excel spreadsheet. The random-effect model was used to estimate the pooled effect size of post-traumatic stress disorder and its effect in the previous studies with 95% confidence intervals. Funnel plots analysis and Egger regression tests were conducted to detect the presence of publication bias. A subgroup analysis and a sensitivity analysis were done.

Result

Thirteen (13) studies were included with a total of 5874 study participants in this meta-analysis and systematic reviews. The pooled prevalence of post-traumatic stress disorder in Ethiopia was 39.28% with a 95% confidence interval (26.54, 52.01). Poor social support (adjusted odds ratio = 2.86; 95% confidence interval (1.81, 4.53)), being female (adjusted odds ratio = 1.89; 95% confidence interval (1.53, 2.34)), presence of previous mental illness (adjusted odds ratio = 4.72; 95% confidence interval (2.62, 8.36)), and witness (adjusted odds ratio = 2.01; 95% confidence interval (1.30, 3.11)) were associated with post-traumatic stress disorder.

Conclusion

The burden of post-traumatic stress disorder in this meta-analysis and systematic review is high; therefore, immediate intervention is needed for those specific traumatized individuals.

Early Childhood Violence Exposure Patterns in The Drakenstein Child Health Study (DCHS)

Background: Research has highlighted high rates of exposure to violence among South African youth. However, work to date has been largely cross-sectional, focused on violence exposure during the adolescence period, and has been limited to specific types of violence exposure. We examined violence exposure in South African preschool children between 3 and 6 years of age, capturing both direct and indirect forms of violence, and tested for potential sex differences across the several types of exposures. Methods: Lifetime direct and indirect exposure to domestic and community violence was measured by parental report when children were 3.5 years (N = 530), 4.5 years (N = 749) and 6 years of age (N= 417) in a South African birth cohort located in a peri-urban community. Results: There are three main findings. First, a large proportion of children (72%-75%) were reported as having been exposed to some form of direct or indirect violent experience in their homes or communities from a young age. Second, there was significant polyvictimization,  with 49% of the children being exposed to more than one type of violence by age 6. Third, by 4.5 years of age, there was evidence that boys were more likely than girls to be exposed to domestic victimisation (28% vs. 17%) and polyvictimization (38% vs. 28%). Conclusions: These findings highlight the high levels of violence exposure in young South African children, particularly among boys, and the need for prevention at both the community and individual levels.

Trauma exposure and psychometric properties of the life events checklist among adults in South Africa

Background: Trauma exposure is widespread and linked to chronic physical and mental health conditions including posttraumatic stress disorder. However, there are major gaps in our knowledge of trauma exposure in Africa and on the validity of instruments to assess potentially life-threatening trauma exposure.Objective: The Life Events Checklist for the DSM-5 (LEC-5) is a free, widely used questionnaire to assess traumatic events that can be associated with psychopathology. As part of a case-control study on risk factors for psychosis spectrum disorders, we used the LEC-5 to examine the frequency of traumatic events and to assess the questionnaire's factor structure in South Africa (N = 6,765).Method: The prevalence of traumatic events was measured by individual items on the LEC-5 across the study sample, by case-control status, and by sex. Cumulative trauma burden was calculated by grouping items into 0, 1, 2, 3, and ≥4 traumatic event types. Psychometric properties of the LEC-5 were assessed through exploratory and confirmatory factor analyses.Results: More than 92% of the study sample reported experiencing ≥1 traumatic event; 38.7% reported experiencing ≥4 traumatic event types. The most endorsed item was physical assault (65.0%), followed by assault with a weapon (50.2%). Almost 94% of cases reported ≥1 traumatic event compared to 90.5% of controls (p < .001) and 94% of male participants reported ≥1 traumatic event compared to 89.5% of female participants (p < .001). Exploratory factor analysis revealed a 6-factor model. Confirmatory factor analyses of three models found that a 7-factor model based on the South African Stress and Health survey was the best fit (standardized root mean square residual of 0.024, root mean square error of approximation of 0.029, comparative fit index of 0.910).Conclusion: Participants reported very high exposure to traumatic events. The LEC-5 has good psychometric priorities and is adequate for capturing trauma exposure in South Africa.

Correlates and prevalence of post-traumatic stress disorders in the São Paulo metropolitan area, Brazil

BACKGROUND

Post-traumatic stress disorder (PTSD) is a debilitating condition, which generates an extensive burden. We aimed to investigate in a huge metropolitan area, the prevalence of traumatic experiences, the development of PTSD, and its predictors.

METHODS

Traumatic experiences and PTSD were assessed in 5037 adult individuals of the general population. Cross-tabulations method assessed the prevalence of traumatic events and PTSD. Logistic regression models investigated predictors of lifetime and 12-month odds of PTSD and the conditional probability of developing PTSD for specific traumas.

RESULTS

Lifetime and 12-month diagnoses of PTSD were found in 3.2% and 1.6% of the sample. 'Witnessing anyone being injured or killed, or unexpectedly seeing a dead body' (35,7%) and 'being mugged or threatened with a weapon' (34.0%) were the two most reported traumas. The commonest events before PTSD onset were 'sudden unexpected death of a loved one' (34.0%), 'interpersonal violence' (31.0%), and 'threats to the physical integrity of others' (25.0%). Experiences related to "interpersonal violence" presented the highest conditional probability for PTSD (range 2.2-21.2%). Being 'sexually assaulted or molested' (21.2% total; 22.3% women; 0.0% men) and being 'raped' (18.8% total; 18.4% women; 20.1% men) were the two experiences with the highest odds for PTSD. While being female was a predictor of less exposure to any event (OR = 0.69), females were more prone to develop lifetime PTSD after exposure to an event (OR = 2.38).

CONCLUSION

Traumatic events are frequent in the general population and a small group of traumatic events accounts for most cases of subsequent PTSD.

Still Standing Inside: A Local Idiom Related to Trauma among Namibian Speakers of Khoekhoegowab

Euro-centric psychiatric conceptualizations often ignore the interplay of local with universal factors in psychological suffering. Emic, locally focused perspectives can enrich etic knowledge to provide culturally sensitive care and to better elucidate the role of culture in mental illness. This study explored the idiom Tsûsa ǃNaeǃkhais xa hâǃnâ/mâǃnâ/ǂgâǃnâhe hâ (a terrible event has entered a person and remains standing inside), which was understood to relate to experiences of trauma and post-traumatic stress, among speakers of Khoekhoegowab, a southern-African click language. Semi-structured interviews were conducted with 16 participants from six urban and rural communities in Namibia. Questions probed perceptions of the idiom in terms of etiology, course, and risk and resilience factors from a socio-ecological framework. Five key themes were identified using thematic analysis: origin in a shocking event; intrusive recurrence of memories, "it keeps on coming back"; the close interplay between mental and physical suffering; the importance of active engagement in healing through prayer and acceptance; and the role of the community in both alleviating and amplifying distress. Our findings highlight local norms and strategies for adaptive coping, and the benefits of exploring local idioms to elucidate the braiding together of universal and cultural elements in psychological distress.

The experiences of clinical psychologists in treating traumatic stress at a tertiary psychiatric hospital in the Eastern Cape: A qualitative study

Background

Qualitative data on the experiences of treating post-traumatic stress disorder (PTSD) in a psychiatric setting in a low-resource context is sparse.

Aim

The authors aimed to explore the lived experiences of clinical psychologists who treat patients who are either trauma survivors or perpetrators in a psychiatric hospital.

Setting

A public psychiatric hospital in the Eastern Cape, South Africa.

Method

A total of six individual semi-structured interviews were conducted with three clinical psychologists. Data were analysed using interpretive phenomenological analysis (IPA).

Results

The analysis for each participant identified several significant themes, namely (1) support as a male person, (2) being appreciative, (3) difficult trauma narratives, (4) a mother and a psychologist and (5) fear and hopelessness.

Conclusion

Treating traumatic stress amongst clinical psychologists working in a public psychiatric hospital can lead to experiences of vicarious trauma and traumatic stress. In addition, the participants experienced an added danger in treating high-risk state patients, exposing psychologists to traumatic stress. Furthermore, psychologists recognised the influence of gender and race and its impact on their roles in their personal and professional lives as practitioners treating traumatic stress.

Rates of and factors associated with atopy and allergies in posttraumatic stress disorder as compared to controls

OBJECTIVE

Several studies suggest a relationship between atopy and psychiatric disorders, but few have investigated the association between atopic conditions and posttraumatic stress disorder (PTSD). We sought to compare the rates of atopy and allergies in a South African case-control study of 220 patients with PTSD (mean age 41.7 years, SD = 11.7) and 196 trauma exposed controls (TEC, mean age 45.4 years, SD = 14.7) conducted in Cape Town, South Africa from May 2014 to June 2017.

METHODS

Self-reported atopic conditions and allergies were regressed on PTSD, as determined with the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5), in multivariate logistic regression models, controlling for age, gender, body mass index, physical activity, lifetime and childhood trauma, and time since index trauma.

RESULTS

Rates of lifetime atopy (p = 0.03), current asthma (p = 0.04), lifetime allergic rhinitis (p = 0.002), and current allergic rhinitis (p = 0.004) were significantly higher in patients than TEC on bivariate analysis. On multivariate analysis, rates of current atopy (Cohen's d = 0.26, p = 0.04) and current allergic rhinitis (Cohen's d = 0.34, p = 0.012) were significantly higher in patients with PTSD than in TEC. Current eczema (p = 0.24), current asthma (p = 0.26), and allergies (p = 0.59) were not associated with PTSD.

CONCLUSIONS

Rates of atopy are higher in participants with PTSD than TEC, and this effect is related to higher rates of allergic rhinitis. Further studies are needed to elucidate the pathways linking allergic rhinitis and PTSD.

Childhood Trauma and Mental Health in the Cape Town Adolescent Antiretroviral Cohort

This study aimed to assess the association of childhood trauma, stressful life events and HIV stigma with mental health in South African adolescents from the Cape Town Adolescent Antiretroviral Cohort (CTAAC). The Childhood Trauma Questionnaire, Life Events Questionnaire and the HIV Stigma Scale for South African Adolescents Living with HIV was used to assess childhood trauma, stressful life events and stigma in adolescents living with perinatally acquired HIV and healthy controls enrolled in the CTAAC. These measures were associated with mental health outcomes including the Beck-Youth Inventories, Child Behaviour Checklist, Columbian Impairment Scale, Childrens Motivation Scale, Conners Scale for Attention Deficit Hyperactivity Disorder using Pearson correlations and self-reported alcohol use, using Spearman-rank correlation. 63.7% of adolescents reported at least one childhood trauma on the CTQ. Significant associations were reported between CTQ measures and Beck-Youth Inventories. Emotional abuse was associated with anxiety, anger, depression and disruptive behaviour. Emotional neglect was associated with poor self-concept and disruptive behaviour. LEQ total score was significantly associated with Beck-Youth Inventories including anxiety, depression, anger and disruptive behaviour scales. HIV stigma was significantly associated with Beck-Youth Inventories including depression, anger and disruptive behaviour. Childhood trauma, stressful life events and HIV stigma in South African adolescents are associated with anxiety, depression, anger, disruptive-behaviour and poor self-concept. This study highlights the importance of enquiring about exposure to a variety of traumas, particularly those commonly experienced by South African adolescents. In addition, it is important to understand the impact of trauma exposure on each individuals mental health and functioning.

Insecure attachment styles as predictors of posttraumatic growth in a South African student sample

South Africa, as a developing country, is characterized by high levels of crime, partner violence, and other traumatic experiences. Exposure to these traumas may lead to the development of post-traumatic stress disorder or, conversely, post-traumatic growth. Citizens in developing African countries appear to be at risk for the development of insecure attachment styles due to the cumulative effects of socio-economic risk factors. The prevalence of many possible traumatic experiences along with the risk of more insecure attachments set the stage for investigating the impact of insecure attachment on post-traumatic growth. The aim of this study was thus to determine whether two insecure attachment styles, namely anxious and avoidant attachment, were significant predictors of post-traumatic growth. The sample consisted of 233 undergraduate students from a South African university who had experienced a traumatic event. Participants’ ages ranged from 18 to 33 years ( M = 21 years) and were from various ethnic backgrounds (81.5% Black African, 7.7% White, 9% Coloured, and 3.9% Asian/Indian). Two self-report measures were administered via an online survey to assess attachment styles and post-traumatic growth. Results showed that an anxious attachment style was a significant negative predictor of post-traumatic growth. Furthermore, individuals with an avoidant attachment style were significantly less likely to experience post-traumatic growth through relating to others, than along the other domains of post-traumatic growth. The findings contribute by highlighting the importance of considering how insecure attachment styles may impact post-traumatic growth, as this could inform the treatment of trauma victims.

Symptoms of post-traumatic stress and associations with sexual behaviour and PrEP preferences among young people in South Africa, Uganda and Zimbabwe

BACKGROUND

It is not known whether post-traumatic stress disorder (PTSD) increases HIV-risk behaviours among young people in sub-Saharan Africa. We assessed associations of PTSD symptoms with sexual behaviour, HIV risk perception, and attitudes towards PrEP among young people taking part in the CHAPS community survey. We hypothesised that PTSD symptoms would increase sexual behaviours associated with HIV risk, hinder PrEP uptake and influence preference for daily versus on-demand PrEP.

METHODS

Young people without HIV, aged 13-24 years, were purposively recruited in Johannesburg and Cape Town in South Africa, Wakiso in Uganda, and Chitungwiza in Zimbabwe, and surveyed on socio-demographic characteristics, PrEP knowledge and attitudes, sexual behaviour, HIV perception and salience, and mental health. PTSD symptoms were measured using the Primary Care PTSD Screen for the Diagnostic and Statistical Manual of Mental Disorders 5 (PC-PTSD-5). Logistic and ordinal logistic regression was used to assess associations between PC-PTSD-5 score and socio-demographic characteristics, sexual behaviour, HIV risk perception, PrEP attitudes, and substance use, adjusting for age, sex, setting, depression and anxiety.

RESULTS

Of 1330 young people (51% male, median age 19 years), 522 (39%) reported at least one PTSD symptom. There was strong evidence that having a higher PC-PTSD-5 score was associated with reported forced sex (OR 3.18, 95%CI: 2.05-4.93), self-perception as a person who takes risks (OR 1.12, 95%CI: 1.04-1.20), and increased frequency of thinking about risk of HIV acquisition (OR 1.16, 95%CI: 1.08-1.25). PTSD symptoms were not associated with willingness to take PrEP, preference for on-demand versus daily PrEP, or actual HIV risk behaviour such as condomless sex.

CONCLUSIONS

Symptoms consistent with probable PTSD were common among young people in South Africa, Uganda and Zimbabwe but did not impact PrEP attitudes or PrEP preferences. Evaluation for PTSD might form part of a general assessment in sexual and reproductive health services in these countries. More work is needed to understand the impact of PTSD on HIV-risk behaviour, forced sex and response to preventive strategies including PrEP.

Traumatic experiences assessed with the life events checklist for Kenyan adults

BACKGROUND

Life Events Checklist (LEC-5) has been widely used to assess for exposure to potentially traumatic life events (PTEs), but its psychometric properties have not been evaluated in Kenya. The objectives of this study were to determine the frequency and types of PTEs within this setting and to examine the construct validity of LEC-5 in Kenya.

METHODS

The LEC-5 was administered to 5316 participants in the ongoing multisite case-control study of Neuropsychiatric Genetics of African Populations-Psychosis. We used exploratory factor analysis to assess LEC-5 structure, and conducted confirmatory factor analyses to compare these results with two other models: a six-factor model based on the only prior EFA of the LEC and a theoretical seven-factor model.

RESULTS

The majority (63.4% overall and 64.4% of cases and 62.4% of controls) of participants had experienced at least one PTE in their lifetime. Results of the exploratory factor analyses for LEC-5 yielded a seven-factor solution with eigenvalues greater than one, accounting for 55.3% of the common variance. Based on confirmatory factor analyses, all three models had good fit for our sample, but the theoretical seven-factor model had the best fit.

LIMITATIONS

The study did not assess if the participants perceived experiences as traumatic, we did not carry out test retest reliability or and we did not consider cultural variations in perception of trauma.

CONCLUSION

This study provides evidence of a high prevalence of traumatic life events and for the construct validity of LEC-5 in assessing PTE exposures in a Kenyan setting.

Sex differences in the experience of COVID-19 post-traumatic stress symptoms by adults in South Africa

BACKGROUND

The COVID-19 pandemic has created multiple mental health challenges. Many residents in South Africa face pre-existing elevated levels of stress and the pandemic may have had varying impacts on sub-populations. The aims of this study were to determine: 1) the factors associated with post-traumatic stress symptoms (PTSS) and 2) sex differences in the factors associated with PTSS in adults residing in South Africa during the COVID-19 pandemic.

METHODS

Study participants aged 18 years and above, were recruited for this cross-sectional study through an online survey implemented from June 29, 2020 to December 31, 2020. The outcome variable was PTSS; explanatory variables were sex at birth, COVID-19 status, social isolation and access to emotional support. Confounders considered were age, education level completed and current work status. Logistic regressions were used to determine the association between the outcome and explanatory variables after adjusting for confounders.

OUTCOMES

There were 489 respondents. Among all respondents, those who were older (AOR: 0.97; 95% CI: 0.95 - 0.99) and had access to emotional support from family and relatives (AOR: 0.27; 95% CI: 0.14 - 0.53) had significantly lower odds of PTSS. Respondents who felt socially isolated had higher odds of PTSS (AOR: 1.17; 95% CI: 1.08 - 1.27). Females had higher PTSS scores and higher odds of PTSS compared to males (AOR: 2.18; 95% CI: 1.41-3.39). Females (AOR: 0.27; 95% CI: 0.08 - 0.95) and males (AOR: 0.26; 95% CI: 0.11, 0.59) who had access to emotional support had significantly lower odds of PTSS than those who had no support. Females (AOR: 1.15; 95% CI: 1.04 -1.27) and males (AOR: 1.19; 95% CI: 0.11, 0.59) who felt socially isolated had higher odds of PTSS compared to those who did not feel socially isolated.

INTERPRETATION

Compared to males, females had higher scores and higher odds of reporting PTSS during the COVID-19 pandemic. Access to emotional support ameliorated the odds of having PTSS for both sexes, while feeling socially isolated worsened the odds for both sexes.

Predicting Posttraumatic Stress Disorder Caseness Using the PTSD Checklist for DSM-5 Among Patients Receiving Care for HIV

This study assessed the ability of the Posttraumatic Stress Disorder (PTSD) Checklist for the DSM-5 (PCL-5) to distinguish between caseness and noncaseness for PTSD among South Africans receiving care for HIV. The PCL-5 and the Structured Clinical Interview for DSM-5-Research Version (SCID-RV) module for PTSD were administered to 688 patients receiving antiretroviral therapy (ART) at two HIV care clinics in the greater Cape Town (South Africa) area. In total, nearly half of the sample (n = 324, 47.1%) reported experiencing an index traumatic event, and 101 participants (14.74%, 95% CI [12.17%, 17.62%]) met the diagnostic criteria for PTSD as measured using the SCID-RV. An ROC curve analysis suggested that a PCL-5 cutoff score of 32 yielded optimal sensitivity (0.88) and specificity (0.88), indicating that the measure was successful in determining caseness for PTSD 88% of the time and noncaseness 88% of the time. The AUC was 94.3%, 95% CI [92.6% to 96.1%], indicating high accuracy. The positive predictive value and negative predictive values were 56.3% and 97.7%, respectively, which suggests that the PCL-5 is an effective screening instrument to determine the presence of PTSD among South African ART users. Undetected and, thus, untreated PTSD may reduce quality of life, impede optimal adherence to ART, and increase the likelihood of risk behaviors among individuals living with HIV, contributing to further infections. The PCL-5 may be used for detection, referral, and treatment of PTSD as a way to enhance its management among individuals receiving HIV care.

Posttraumatic Stress Disorder, Suicidal Behavior, Substance Use, and Sexual Victimization Among Adolescent Girls Aged 10-19 Years Living Under Ethnic-Based Civil War in Ethiopia

BACKGROUND

Posttraumatic stress disorder (PTSD) is a chronic, impairing mental disorder that develops after exposure to a traumatic event. Despite many factors putting adolescent girls at risk of PTSD, little is known about the prevalence and how adolescent girls cope with the PTSD burden. So, this study aimed to investigate the prevalence of PTSD and associated factors among adolescent girls in three selected towns in Southwest Ethiopia.

METHODS

A community-based cross-sectional study was conducted among 397 adolescent girls from May 27 to July 27, 2021. The participants were selected by a systematic random sampling method. PTSD and substance use disorder were assessed by DSM V criteria for mental disorders. The data was entered into Epi Data Manager Version 4.0.2 before being exported to SPSS Version 25 for analysis. A logistic regression model was used, and variables with a p-value less than 0.05 in the final fitting model were stated as independent predictors of PTSD.

RESULTS

The prevalence of PTSD among the adolescent girls was 22%, and about three in four (72.7%) of the adolescent girls developed PTSD after exposure to sexual violence. Furthermore, PTSD was associated with Khat use disorder (AOR, 95% CI: 2.79 (1.47-5.30), alcohol use disorder (AOR, 95% CI: 5.27 (2.21-12.60), and suicidal behavior (AOR, 95% CI: 2.12 (1.20-3.74)).

CONCLUSION

The prevalence of PTSD was high among adolescent girls, and suicidal ideation or attempt, khat use disorder, and alcohol use disorder were risk factors for PTSD. Therefore, early screening for PTSD and comorbid risk factors among this particular age group and managing accordingly is warranted.

Racial disparities in psychological distress in post-apartheid South Africa: results from the SANHANES-1 survey

PURPOSE

South Africa has long endured a high prevalence of mental disorders at the national level, and its unique social and historical context could be a contributor to an increased risk of mental health problems. Our current understanding is limited regarding the relative importance of various social determinants to mental health challenges in South Africa, and how existing racial inequities may be explained by these determinants.

METHODS

This study attempted to elucidate potential social determinants of mental health in South Africa using data from the nationally representative South African National Health and Nutrition Examination Survey (SANHANES-1). The main outcome of interest was psychological distress, measured with the Kessler-10 scale. Hierarchical linear regression models included covariates for demographic and socioeconomic factors, count of traumatic events, and a series of stress-related constructs. Analyses were conducted on two populations: the entire sample (n = 15,981), and the African subpopulation (n = 10,723).

RESULTS

Regression models on the entire sample indicated racial disparities in psychological distress, with Africans experiencing higher distress than White and Coloured individuals. Results within the African sub-population indicated geo-spatial disparities, with Africans in formal urban settings experiencing higher psychological distress than those living in formal and informal rural locales. Across both samples, results indicated a cumulative association between count of stressors and traumatic events and distress.

CONCLUSION

We found racial disparities across several mental health-related domains. Africans had greater exposure to traumatic events, social stressors, and psychological distress. This research is a necessary foundation for public health interventions and policy change to effectively reduce inequities in psychological distress.

The prevalence of hope, subjective well-being, and psychopathology among trauma survivors at community-based clinics in Gauteng

This study examined the prevalence of hope and subjective well-being as well as symptoms of depression and post-traumatic stress disorder among trauma survivors at community-based clinics in Gauteng. We further explored traumatic events and help-seeking behaviour in this context. Using a cross-sectional survey design, we collected demographic information and administered questionnaires measuring hope, well-being, depression, and post-traumatic stress. The sample comprised 120 adults, of whom the majority were Black females. Results showed that participants experienced low levels of hope, positive affect, and life satisfaction as well as high levels of negative affect, depression, and post-traumatic stress. In addition, the majority of participants experienced multiple traumatic events in the past 5 years, which had a negative impact on their well-being. However, receiving professional help and being able to cope in the aftermath of trauma may contribute towards higher levels of well-being and fewer psychopathological symptoms. Our findings thus highlighted the need for effective therapeutic interventions among trauma survivors.

Prevalence and factors associated with PTSD among female urban slum dwellers in Ibadan, Nigeria: a cross-sectional study

BACKGROUND

Little is known about the prevalence of and factors associated with PTSD among adult females in Nigeria, particularly those who live in slums. PTSD is a mental health condition that develops among some individuals who experience or witness a traumatic event. Several other factors could place individuals at heightened risk of PTSD including stress and comorbid mental disorders. Therefore, this study aimed to examine the prevalence and factors associated with PTSD among female urban slum dwellers in Ibadan, Nigeria.

METHODS

We conducted a cross sectional survey using multistage sampling of 550 women aged 18 and above from selected slums. Interviewer administered questionnaires were used to elicit information on experience of childhood trauma, recent stressors, intimate partner violence, other mental disorders, sociodemographic characteristics and PTSD. PTSD was measured using the Harvard Trauma Questionnaire (HTQ) which is based on DSM IV. A multivariable linear regression model was built to test associations between PTSD and independent variables.

RESULTS

The prevalence for PTSD was found to be 4.18% and the mean PTSD score was 5.80 ± 7.11. Sexual abuse in childhood, past year intimate partner violence and anxiety were significantly associated with higher PTSD scores. PTSD was not significantly associated with a history of recent stressors. Education, employment and marital status were not associated with PTSD however, age and wealth index showed marginal association with PTSD.

CONCLUSION

The prevalence of PTSD among women living in Ibadan slums was relatively low. Both child sexual abuse and intimate partner violence can be prevented. We also recommend longitudinal studies to better understand risk and protective factors.

Maternal psychosocial risk factors and child gestational epigenetic age in a South African birth cohort study

Accelerated epigenetic aging relative to chronological age has been found to be associated with higher risk of mortality in adults. However, little is known about whether and how in utero exposures might shape child gestational epigenetic age (EA) at birth. We aimed to explore associations between maternal psychosocial risk factors and deviation in child gestational EA at birth (i.e., greater or lower EA relative to chronological age) in a South African birth cohort study-the Drakenstein Child Health Study. Maternal psychosocial risk factors included trauma/stressor exposure; posttraumatic stress disorder (PTSD); depression; psychological distress; and alcohol/tobacco use. Child gestational EA at birth was calculated using an epigenetic clock previously devised for neonates; and gestational EA deviation was calculated as the residuals of the linear model between EA and chronological gestational age. Bivariate linear regression was then used to explore unadjusted associations between maternal/child risk factors and child gestational EA residuals at birth. Thereafter, a multivariable regression method was used to determine adjusted associations. Data from 271 maternal-child dyads were included in the current analysis. In the multivariable regression model, maternal PTSD was significantly and negatively associated with child gestational EA residuals at birth (β = -1.95; p = 0.018), controlling for study site, sex of the child, head circumference at birth, birthweight, mode of delivery, maternal estimated household income, body mass index (BMI) at enrolment, HIV status, anaemia, psychological distress, and prenatal tobacco or alcohol use. Given the novelty of this preliminary finding, and its potential translational relevance, further studies to delineate underlying biological pathways and to explore clinical implications of EA deviation are warranted.

Psychological treatments for post-traumatic stress disorder, anxiety and depression following major physical civilian trauma: A systematic review and meta-analysis

Introduction

Approximately 16% of the world’s burden of disease is attributable to traumatic injury. Psychological symptoms, including post-traumatic stress disorder (PTSD), are prevalent in this population and impact recovery from physical injury. Nevertheless, mental health has not been considered to the same degree as physical health. Psychological interventions are used widely as treatments for PTSD.

Methods

Systematic searches of computerised databases were conducted. Randomised controlled trials of psychological treatments for PTSD following major physical civilian trauma were included. The main outcome measure was clinician-assessed symptoms of PTSD (CAPS), with findings for anxiety and depression also reported. Included studies data were extracted and entered using RevMan 5.3 software. Quality assessments were performed, and data were analysed for summary effects.

Results

10 studies were included. With regard to CAPS <6 months, individual CBT did significantly better than usual care/wait list (SMD (95% CI) = −1.24 [−1.82, −0.67]) and non-CBT treatments (SMD (95% CI) = −1.32 [−2.64, −0.04]). Non-CBT treatments were not significantly better than usual care/wait list (SMD (95% CI) −1.40 [−2.91, 0.11]). CBT was superior to usual care/wait list for reducing depressive (SMD (95% CI) −0.67 [−0.98, −0.37]) and anxiety (SMD (95% CI) −0.70 [−1.22, −0.18]) symptoms both in the shorter and longer term.

Conclusion

Individual CBT was superior to wait list/usual care, and there was limited evidence for non-CBT treatments in reducing clinician and self-rated PTSD, depressive and anxiety symptoms in the shorter term; however, the latter comparison was based on few studies with small sample sizes. Longer-term effects of treatments remain uncertain. There is a need for adequately powered RCTs investigating PTSD treatments following major physical civilian trauma in the longer term. There was considerable heterogeneity in the studies, so care must be taken in interpreting the results of this review.

A Genome-Wide Association Study and Polygenic Risk Score Analysis of Posttraumatic Stress Disorder and Metabolic Syndrome in a South African Population

Posttraumatic stress disorder (PTSD) is a trauma-related disorder that frequently co-occurs with metabolic syndrome (MetS). MetS is characterized by obesity, dyslipidemia, and insulin resistance. To provide insight into these co-morbidities, we performed a genome-wide association study (GWAS) meta-analysis to identify genetic variants associated with PTSD, and determined if PTSD polygenic risk scores (PRS) could predict PTSD and MetS in a South African mixed-ancestry sample. The GWAS meta-analysis of PTSD participants (n = 260) and controls (n = 343) revealed no SNPs of genome-wide significance. However, several independent loci, as well as five SNPs in the PARK2 gene, were suggestively associated with PTSD (p < 5 × 10-6). PTSD-PRS was associated with PTSD diagnosis (Nagelkerke's pseudo R 2 = 0.0131, p = 0.00786), PTSD symptom severity [as measured by CAPS-5 total score (R 2 = 0.00856, p = 0.0367) and PCL-5 score (R 2 = 0.00737, p = 0.0353)], and MetS (Nagelkerke's pseudo R 2 = 0.00969, p = 0.0217). These findings suggest an association between PTSD and PARK2, corresponding with results from the largest PTSD-GWAS conducted to date. PRS analysis suggests that genetic variants associated with PTSD are also involved in the development of MetS. Overall, the results contribute to a broader goal of increasing diversity in psychiatric genetics.

Mental illness attitudes and knowledge in non-specialist medical doctors working in state and private sectors

BACKGROUND

An increasing number of South Africans utilise primary healthcare services (either in the state or private sector) for mental health concerns; hence, there is a need to objectively assess these doctors' attitudes and knowledge of mental illness.

AIM

To investigate aspects of knowledge and attitudes towards mental illness of a group of private and state-employed non-specialist medical doctors.

METHOD

Doctors in the state sector who were working at a primary healthcare level and who were not working towards, or did not hold, a specialist qualification were considered eligible for the study. Doctors in the private sector who were working as general practitioners and who did not hold a specialist qualification were considered eligible for the study. Data were collected by means of a self-administered questionnaire. A link to the study questionnaire, information about the study, details of the researcher and matters pertaining to informed consent were emailed to potential participants.

RESULTS

Of the 140 practitioners who responded to the survey, 51.4% (n = 72) worked in the state sector, 41.4% (n = 58) worked in the private sector and 7.1% (n = 10) worked in both the state and private sectors (χ2 1 = 45.31, p < 0.010). The majority (> 50%) of participants in all three groups had a positive attitude towards mental illness (χ2 2 = 1.52, p = 0.468). Although there were no significant associations between attitude and socio-demographic characteristics (p > 0.05), male SS doctors reported feeling less comfortable when dealing with mentally ill patients (p = 0.015); SS doctors who did not have family contact with mental illness were less likely to feel that mentally ill patients did not pose a risk to others (p = 0.007), and PS doctors under the age of 35 years were more likely to feel adequately trained to treat mental illness (p = 0.026). The majority (> 50%) of participants in all three groups had an adequate level of knowledge of mental illness (modal scores = 10). There were no significant associations between knowledge and socio-demographic characteristics (p > 0.05).

CONCLUSION

Despite the findings of a positive attitude and adequate knowledge of mental illness amongst the participants of this study, it is recommended that more targeted interventions are established to further improve mental health awareness and knowledge of doctors at both undergraduate and postgraduate levels of study.

Internet-based cognitive and behavioural therapies for post-traumatic stress disorder (PTSD) in adults

BACKGROUND

Therapist-delivered trauma-focused psychological therapies are effective for post-traumatic stress disorder (PTSD) and have become the accepted first-line treatments. Despite the established evidence-base for these therapies, they are not always widely available or accessible. Many barriers limit treatment uptake, such as the number of qualified therapists available to deliver the interventions; cost; and compliance issues, such as time off work, childcare, and transportation, associated with the need to attend weekly appointments. Delivering Internet-based cognitive and behavioural therapy (I-C/BT) is an effective and acceptable alternative to therapist-delivered treatments for anxiety and depression.

OBJECTIVES

To assess the effects of I-C/BT for PTSD in adults.

SEARCH METHODS

We searched MEDLINE, Embase, PsycINFO and the Cochrane Central Register of Controlled Trials to June 2020. We also searched online clinical trial registries and reference lists of included studies and contacted the authors of included studies and other researchers in the field to identify additional and ongoing studies.

SELECTION CRITERIA

We searched for RCTs of I-C/BT compared to face-to-face or Internet-based psychological treatment, psychoeducation, wait list, or care as usual. We included studies of adults (aged over 16 years), in which at least 70% of the participants met the diagnostic criteria for PTSD, according to the Diagnostic and Statistical Manual (DSM) or the International Classification of Diseases (ICD).

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed abstracts, extracted data, and entered data into Review Manager 5. The primary outcomes were severity of PTSD symptoms and dropouts. Secondary outcomes included diagnosis of PTSD after treatment, severity of depressive and anxiety symptoms, cost-effectiveness, adverse events, treatment acceptability, and quality of life. We analysed categorical outcomes as risk ratios (RRs), and continuous outcomes as mean differences (MD) or standardised mean differences (SMDs), with 95% confidence intervals (CI). We pooled data using a fixed-effect meta-analysis, except where heterogeneity was present, in which case we used a random-effects model. We independently assessed the included studies for risk of bias and we evaluated the certainty of available evidence using the GRADE approach; we discussed any conflicts with at least one other review author, with the aim of reaching a unanimous decision.

MAIN RESULTS

We included 13 studies with 808 participants. Ten studies compared I-C/BT delivered with therapist guidance to a wait list control. Two studies compared guided I-C/BT with I-non-C/BT. One study compared guided I-C/BT with face-to-face non-C/BT. There was substantial heterogeneity among the included studies. I-C/BT compared with face-to-face non-CBT Very low-certainty evidence based on one small study suggested face-to-face non-CBT may be more effective than I-C/BT at reducing PTSD symptoms post-treatment (MD 10.90, 95% CI 6.57 to 15.23; studies = 1, participants = 40). There may be no evidence of a difference in dropout rates between treatments (RR 2.49, 95% CI 0.91 to 6.77; studies = 1, participants = 40; very low-certainty evidence). The study did not measure diagnosis of PTSD, severity of depressive or anxiety symptoms, cost-effectiveness, or adverse events. I-C/BT compared with wait list Very low-certainty evidence showed that, compared with wait list, I-C/BT may be associated with a clinically important reduction in PTSD post-treatment (SMD -0.61, 95% CI -0.93 to -0.29; studies = 10, participants = 608). There may be no evidence of a difference in dropout rates between the I-C/BT and wait list groups (RR 1.25, 95% CI 0.97 to 1.60; studies = 9, participants = 634; low-certainty evidence). I-C/BT may be no more effective than wait list at reducing the risk of a diagnosis of PTSD after treatment (RR 0.53, 95% CI 0.28 to 1.00; studies = 1, participants = 62; very low-certainty evidence). I-C/BT may be associated with a clinically important reduction in symptoms of depression post-treatment (SMD -0.51, 95% CI -0.97 to -0.06; studies = 7, participants = 473; very low-certainty evidence). Very low-certainty evidence also suggested that I-C/BT may be associated with a clinically important reduction in symptoms of anxiety post-treatment (SMD -0.61, 95% CI -0.89 to -0.33; studies = 5, participants = 345). There were no data regarding cost-effectiveness. Data regarding adverse events were uncertain, as only one study reported an absence of adverse events. I-C/BT compared with I-non-C/BT There may be no evidence of a difference in PTSD symptoms post-treatment between the I-C/BT and I-non-C/BT groups (SMD -0.08, 95% CI -0.52 to 0.35; studies = 2, participants = 82; very low-certainty evidence). There may be no evidence of a difference between dropout rates from the I-C/BT and I-non-C/BT groups (RR 2.14, 95% CI 0.97 to 4.73; studies = 2, participants = 132; I² = 0%; very low-certainty evidence). Two studies found no evidence of a difference in post-treatment depressive symptoms between the I-C/BT and I-non-C/BT groups (SMD -0.12, 95% CI -0.78 to 0.54; studies = 2, participants = 84; very low-certainty evidence). Two studies found no evidence of a difference in post-treatment symptoms of anxiety between the I-C/BT and I-non-C/BT groups (SMD 0.08, 95% CI -0.78 to 0.95; studies = 2, participants = 74; very low-certainty evidence). There were no data regarding cost-effectiveness. Data regarding adverse effects were uncertain, as it was not discernible whether adverse effects reported were attributable to the intervention.

AUTHORS' CONCLUSIONS

While the review found some beneficial effects of I-C/BT for PTSD, the certainty of the evidence was very low due to the small number of included trials. This review update found many planned and ongoing studies, which is encouraging since further work is required to establish non-inferiority to current first-line interventions, explore mechanisms of change, establish optimal levels of guidance, explore cost-effectiveness, measure adverse events, and determine predictors of efficacy and dropout.

The impact of trauma on South African women with HIV: The role of anxiety and physical symptomology

Rates of trauma and HIV are high in South Africa, and those who experience more trauma have higher levels of psychological distress. This cross-sectional study examined trauma, physical, and mental health among black South African women living with HIV (WLH). We hypothesised that WLH would have higher rates of trauma than women not living with HIV (WNLH). We also hypothesised that there would be a relationship between trauma, anxiety, and physical symptoms, such that anxiety would mediate the relationship between trauma and physical symptoms for WLH. This study enrolled 242 women, 99 WLH. Women were individually interviewed, completing the Life Stressor Checklist (trauma history), the Physical Symptom Inventory, and the IPAT Anxiety Scale. WLH reported significantly more traumatic life events (M = 3.69, SD = 2.32) than WNLH (M = 3.06, SD = 2.42), t = -2.07, p = 0.04. Additionally, traumatic life events were positively associated with physical symptoms. Further, there was an indirect effect of trauma history on physical symptoms through anxiety, b = 0.97, 95% BC CI [0.29, 1.89], such that the direct effect of trauma on physical symptoms was no longer significant, b = 0.87, 95% BC CI [-0.83, 2.56] when anxiety was added to the model. This pattern of findings suggests that anxiety is a key mechanism through which trauma history is associated with more physical symptoms in WLH. Future research should focus on the effect of interventions alleviating the impact that trauma may have on the mental and physical health of WLH.

Cultural Adaptations of the Standard EMDR Protocol in Five African Countries

Since 2007, mental health workers in sub-Saharan Africa have been trained in eye movement desensitization and reprocessing (EMDR) therapy. This qualitative study used an Afrocentric design with thematic analysis to investigate adaptations to the EMDR standard protocol that make it culturally relevant for African clients. Participants were 25 EMDR therapists (three male, age range 32–60 years, x̄ = 44) from five African countries, who practiced EMDR for 1–11 years (x̄ = 7). All answered a survey questionnaire, eight participated in a focus group discussion, and two provided a supervision notes analysis. Participants found EMDR a useful and beneficial therapy and preferred it over other therapies because of its nonnarrative nature and quick results. We identified four areas in which African therapists consistently made adaptations to the standard protocol: wording of the protocol text, cultural expression of thoughts and emotions, stimulation choice, and simplification of quantitative scales. Based on the study results, we make numerous recommendations for cultural adaptions to the EMDR protocol. These include language changes to take into account the clients' “we oriented” communication; cultural interpretations of positive and negative thoughts and events; adding cultural activities such as dance, music, and religious practices as resourcing exercises; using hand gestures or the pictorial faces scale instead of ordinal scales; and using tapping for bilateral stimulation instead of eye movements, which were sometimes seen as “witchcraft.” The relevance of the findings for EMDR practice and training are discussed. We recommend that African researchers further study the acceptability, use, and effectiveness of EMDR in their countries.

Post-traumatic stress disorder and its associated factors among people who experienced traumatic events in east African countries, 2020: a protocol for systematic review and meta-analysis

BACKGROUND

Post-traumatic stress disorder (PTSD) is the most commonly reported mental health consequence following disasters and traumatic events, either natural or man-made. Nothing is written regarding its pooled prevalence and pooled estimate of factors. Therefore, this study aimed to determine the pooled prevalence of PTSD and estimate the pooled effect of associated factors.

METHODS

An English version of published articles will be retrieved using the following; PubMed/Medline, Africa-wides, Science Direct, Cochrane Library, Global Health, Google Scholar, EMBASE, and psycINFO. Research reports will be searched from October 10/2020 to November 10/2020. The research reports quality will be assessed using the Newcastle-Ottawa Scale. Relevant information from the searched research reports will be extracted in a Microsoft Excel format. After extraction, the data will be imported to STATA version 14.0 for analysis. An appropriate guideline for a systematic review and meta-analysis report will be used, i.e. the Preferred Reporting Items for Systematic reviews and Meta-Analyses. A random-effects meta-analysis model will be used to estimate the Der Simonian and Laird's pooled prevalence of PTSD and its associated factors.

DISCUSSION

This study aims to determine the pooled prevalence of PTSD and estimate the pooled effect of associated factors. Several kinds of research have reported the increasing magnitude of PTSD and its determinants in a different population. This might be due to reasons, such as little attention being given to the issue. Therefore, this study will try to fill this gap by giving new evidence-based results to attract policymakers' attention.

Rape survivors in South Africa: analysis of the baseline socio-demographic and health characteristics of a rape cohort

BACKGROUND

Little is known about women who have experienced a recent rape, and how they differ from women without this exposure. Identifying factors linked to rape is important for preventing rape and developing effective responses in countries like South Africa with high levels of sexual violence.

OBJECTIVE

To describe the socio-demographic and health profile of women recently exposed to rape and to compare them with a non-rape-exposed group.

METHODS

The Rape Impact Cohort Evaluation Study (RICE) enrolled 852 women age 16-40 years exposed to rape from post-rape care centres in Durban (South Africa) and a control group of 853 women of the same age range who have never been exposed to rape recruited from public health services. Descriptive analyses include logistic regression modelling of socio-demographic characteristics associated with recent rape exposure.

RESULTS

Women with recent rape reported poorer health and more intimate partner violence than those who were not raped. They had a lower likelihood of having completed school (Odds Ratio [OR] 0.46 95% Confidence Interval (CI): 0.24-0.87) and dependence on a government grant as a main source of income (OR 0.61: 95%CI 0.49-0.77). They were more likely to live in informal housing (OR 1.88 95%CI: 1.43-2.46) or rural areas (OR 2.24: 95%CI 1.61-3.07) than formal housing areas - however they were also more likely to report full-time employment (OR 4.24: 95%CI 2.73-6.57).

CONCLUSION

The study shows that structural factors, such as lower levels of education, poverty, and living in areas of poor infrastructure are associated with women's vulnerability to rape. It also shows possible protection from rape afforded by the national financial safety net. It highlights the importance of safe transportation in commuting to work. Preventing rape is critical for enabling women's full social and economic development, and structural interventions are key for reducing women's vulnerability.

Evidence of distinct profiles of ICD-11 post-traumatic stress disorder (PTSD) and complex PTSD in a South African sample

Background: Both post-traumatic stress disorder (PTSD) and complex post-traumatic stress disorder (CPTSD) have been included in the 11th edition of the International Classification of Diseases (ICD-11). Although the validity of CPTSD has been controversial, a growing number of studies support the distinction between PTSD and CPTSD. However, the majority of this research has originated in high-income countries (HICs), whereas the prevalence of trauma experience associated with PTSD/CPTSD diagnosis is significantly higher in low- and middle-income countries (LMICs). Objective: This study assessed whether a sample from an LMIC setting produced distinct classes that reflect ICD-11 criteria for PTSD and CPTSD. Furthermore, this study investigated whether childhood trauma distinguished between PTSD and CPTSD. Method: International Trauma Questionnaire responses from a sample of South African university undergraduates were used as indicator variables in a latent class analysis (LCA). Chi-squared tests of independence and Kruskal-Wallis H tests were used to assess between-class differences. Results: The LCA identified four distinct classes: a PTSD class with elevated symptoms of PTSD, but low endorsement of disturbances in self-organization (DSO; symptoms that are specific to CPTSD); a CPTSD class with elevated symptoms of PTSD and DSO; a DSO class with low symptoms of PTSD, but elevated symptoms of DSO; and a Low class with low endorsements on all symptoms. Regarding childhood trauma, participants in the CPTSD class had more severe childhood abuse and neglect, specifically emotional abuse and neglect, than participants in the PTSD class. Conclusions: Findings were consistent with the distinction between PTSD and CPTSD symptom profiles in the ICD-11. Our findings support a similar qualitative distinction between PTSD and CPTSD in our LMIC context, as previously reported in HICs. This distinction is especially relevant in LMICs because of the significant number of individuals vulnerable to these disorders.

Adverse childhood experiences and domain-specific cognitive function in a population-based study of older adults in rural South Africa

Research on early life adversity and later-life cognitive function is conflicting, with little evidence from low-income settings. We investigated associations between adverse childhood experiences and cognitive function in an older population who grew up under racial segregation during South African apartheid. Data were from 1,871 adults aged 40-79 in the population-representative "Health and Ageing in Africa: A Longitudinal Study of an INDEPTH Community in South Africa" in 2015. The adverse childhood experiences were having a parent unemployed for > 6 months; having parents who argued or fought often; having a parent who drank excessively, used drugs, or had mental health problems; and physical abuse from parents. Executive function, language, visuospatial ability, and memory were assessed with the Oxford Cognitive Screen-Plus, a validated cognitive assessment designed for low-income, low-literacy settings. We estimated associations between adverse childhood experiences and latent cognitive domain z-scores using multiple-indicator, multiple-cause structural equation models. Childhood adversities were reported by 15% (parental unemployment for > 6 months), 25% (parents argued or fought often), 25% (a parent drank excessively, used drugs, or had mental health problems), and 35% (physical abuse from parent) of respondents. They were not associated with cognition, except that having a parent who drank excessively, used drugs, or had mental health problems was associated with lower memory z-scores (-0.07; 95% CI [-0.13, -0.01]). This is one of the first investigations into later-life cognitive outcomes associated with early adversity in a population with a historical context of pervasive trauma, and suggests that later-life memory may be vulnerable to early adversity. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Trauma related psychiatric disorders and their correlates in a clinical sample: A cross-sectional study in trauma affected patients visiting a psychiatric clinic in Nepal

BACKGROUND

Nepal, like many other low-income countries, has a great burden of mental health issues but few resources to meet them. In addition, Nepal has endured several traumatic events in recent decades but the impact on mental health has not been studied in clinical settings. This study explores trauma-related psychiatric disorders and their correlates.

METHODS

100 patients with a history of trauma who visited the outpatient psychiatry clinic at a University hospital in Kathmandu were assessed. The Composite International Diagnostic Interview 2.1 (CIDI) was used to evaluate lifetime and current depressive disorder, generalized anxiety disorder (GAD) and lifetime post-traumatic stress disorder (PTSD). Current PTSD was evaluated using PSTD Checklist-Civilian Version (PCL-C).

RESULTS

The median number of lifetime traumatic events was two. Natural disaster was the most common trauma type (84%) compared to other types of trauma. Rape was reported as the most traumatizing. Current PTSD was found in 15%, depression in 33% and GAD in 38% of the patients. The lifetime rates were PTSD 83%, depression 45% and GAD 40%. There was high comorbidity between the disorders. The 31 to 45 years age group, above high school education level and trauma types other than earthquake were independently associated with current PTSD. Marital status and upper socioeconomic status (SES) compared to upper-middle SES were independently associated with lifetime PTSD. Both lifetime and current depression rates were independently associated with the upper SES compared to upper-middle SES. Place of living, education above high school and lower-middle SES were significantly associated with lifetime and current GAD.

CONCLUSION

PTSD, depression and GAD were prevalent in a trauma exposed patient population visiting a psychiatric clinic in Nepal. High rates of comorbidities and several risk factors were identified. Our findings highlight the need for addressing trauma related disorders in clinical settings in developing countries.

National and regional prevalence of posttraumatic stress disorder in sub-Saharan Africa: A systematic review and meta-analysis

BACKGROUND

People living in sub-Saharan Africa (SSA) are disproportionately exposed to trauma and may be at increased risk for posttraumatic stress disorder (PTSD). However, a dearth of population-level representative data from SSA is a barrier to assessing PTSD. This manuscript sought to calculate pooled PTSD prevalence estimates from nationally and regionally representative surveys in SSA.

METHODS AND FINDINGS

The search was conducted in PubMed, Embase, PsycINFO, and PTSDpubs and was last run between October 18, 2019, and November 11, 2019. We included studies that were published in peer-reviewed journals; used probabilistic sampling methods and systematic PTSD assessments; and included ≥ 450 participants who were current residents of an SSA country, at least 50% of whom were aged between 15 and 65 years. The primary outcomes were point prevalence estimates of PTSD across all studies, and then within subgroups. The protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO) (registration number CRD42016029441). Out of 2,825 unique articles reviewed, 25 studies including a total of 58,887 eligible participants (54% female) in 10 out of the 48 countries in SSA were identified. Most studies enrolled any adult aged 18 years or older. However, some studies only enrolled specific age brackets or persons as young as 15 years old. Six studies were national surveys, and 19 were regional. There were 4 key findings in the meta-analysis: (1) the overall pooled prevalence of probable PTSD was 22% (95% CI 13%-32%), while the current prevalence-defined as 1 week to 1 month-was 25% (95% CI 16%-36%); (2) prevalence estimates were highly variable, ranging from 0% (95% CI 0%-0%) to 74% (95% CI 72%-76%); (3) conflict-unexposed regions had a pooled prevalence of probable PTSD of 8% (95% CI 3%-15%), while conflict-exposed regions had a pooled prevalence of probable PTSD of 30% (95% CI 21%-40%; p < 0.001); and (4) there was no significant difference in the pooled prevalence of PTSD for men and women. The primary limitations of our methodology are our exclusion of the following study types: those published in languages other than English, French, and Portuguese; smaller studies; those that focused on key populations; those that reported only on continuous measures of PTSD symptoms; and unpublished or non-peer-reviewed studies.

CONCLUSIONS

In this study, PTSD symptoms consistent with a probable diagnosis were found to be common in SSA, especially in regions exposed to armed conflict. However, these studies only represent data from 10 of the 48 SSA countries, and only 6 studies provided national-level data. Given the enormous heterogeneity expected across the continent, and also within countries and regions, this review cannot speak to rates of PTSD in any regions not included in this review. Thus, substantial gaps in our knowledge of PTSD prevalence in SSA remain. More research on population-level prevalence is needed to determine the burden of trauma symptoms and PTSD in SSA and to identify acceptable and feasible approaches to address this burden given limited mental healthcare resources.