Apolipoprotein E Isoform-specific changes related to stress and trauma exposure

Post-Traumatic Stress Disorder (PTSD) is a highly prevalent mental health disorder. Due to the high level of variability in susceptibility and severity, PTSD therapies are still insufficient. In addition to environmental exposures, genetic risks play a prominent role and one such factor is apolipoprotein E. The protein (apoE) is functionally involved in cholesterol transport and metabolism and exists as 3 major isoforms in humans: E2, E3, and E4. To model the role of apolipoprotein E isoform in stress-related changes in behavior and cognition, female and male mice (3-5 months of age) expressing E2, E3, or E4 were used. Mice were either placed into control groups or exposed to chronic variable stress (CVS), which has been shown to induce PTSD-like behavioral and neuroendocrine changes. E2 mice showed a unique response to CVS compared to E3 and E4 mice that included impaired spatial learning and memory, increased adrenal gland weight, and no increase in glucocorticoid receptor protein levels (normalized to apoE levels). In addition, the cholesterol metabolite 7-ketocholesterol was elevated in the cortex after CVS in E3 and E4, but not E2 female mice. E2 confers unique changes in behavioral, cognitive, and biomarker profiles after stress exposure and identify 7-ketocholesterol as a possible novel biomarker of the traumatic stress response. We further explored the relationship between E2 and PTSD in an understudied population by genotyping 102 patients of Cambodian and Vietnamese ethnicity. E2 carriers demonstrated a higher odds ratio of having a PTSD diagnosis compared to E3/E3 carriers, supporting that the E2 genotype is associated with PTSD diagnosis after trauma exposure in this population.

Refugee Trauma

Epidemiological studies and theoretical models of refugee trauma based on ethnographic, biomedical and sociopolitical perspectives have focused on a variety of cultural and ethnic groups since World War II. Subjective distress and problems in psychosocial functioning are influenced by individual, fam ily, cultural and social variables. Refugees are at risk for developing psychiatric illness resulting from pre-migration, migration and post-migration experiences. This paper reviews biological, psychological and sociocultural models for recog nizing, conceptualizing and treating the psychiatric problems of traumatized refugees. The treatment approach of the Oregon Indochinese Psychiatric Program is summarized.

Prospective one-year treatment outcomes of tortured refugees: a psychiatric approach

The treatment of torture survivors from diverse cultures has been a difficult task involving issues of loss, massive trauma, cultural style, and adjusting to a new country. Research on treatment outcomes has shown inconsistent results. This report presents a prospective one year treatment outcome of 22 severely tortured patients from Ethiopia, Somalia, Iran and Afghanistan. Treatment was provided by psychiatrists and counselors with interpreters from each culture involved. The specific treatment included psychiatric evaluation, medicine, education, supportive psychotherapy and assisting some social needs. All 22 were diagnosed with depression and 17 of these also had posttraumatic stress disorder (PTSD). Twenty of 22 patients showed marked significant improvement on all of the scales for depression, PTSD, disability, and quality of life. Medicine was particularly useful in treating depression and the symptoms of flashbacks, nightmares and irritability. Standard psychiatric treatment with evaluation, diagnosis, appropriate medicine, supportive psychotherapy and counseling by ethnic counselors provided good outcomes.

Pharmacologic reduction of CNS noradrenergic activity in PTSD: the case for clonidine and prazosin

This article reviews the neurobiologic rationale for and presents clinical guidance concerning the use of medications that reduce central nervous system noradrenergic activity in the treatment of intrusive symptoms of posttraumatic stress disorder. The authors reviewed neurobiological studies, nonclinical studies using animal models, clinical case reports, open-label drug studies, and blinded, placebo-controlled drug studies. This review of the basic science and clinical literature, and the authors' clinical experience with culturally and demographically diverse populations, indicate that clonidine and prazosin can play a useful role in treating sleep disturbance and hyperarousal in posttraumatic stress disorder, with minimal adverse effects and low financial cost.

Immigrants and refugees: the psychiatric perspective

Psychiatric studies of immigrants have yielded contradictory findings regarding rates of mental illness. Current evidence suggests that rates of schizophrenia (and probably other disorders) among immigrant groups are low compared with native-born populations when sending and receiving countries are socially and culturally similar. The rates for immigrants are higher when sending and receiving countries are dissimilar, probably because of multiple social problems faced by immigrants in the receiving country. Refugees who flee their own country because of fears of violence or starvation often have had extremely traumatic experiences, which may result in PTSD and sometimes chronic impairment. Asylum seekers who arrive illegally to seek refuge in a foreign country also may have multiple traumas and experience further distress from their uncertain residency and legal status. Although much is known about the effects of migration, competent culturally sensitive services for migrants remain inadequate to meet the need.

Cortisol production rate in posttraumatic stress disorder

CONTEXT

Several authors have reported the unsuspected finding of low cortisol levels (urinary, salivary, and serum) in patients with posttraumatic stress disorder (PTSD).

OBJECTIVE

Our objective was to assess concentrations of cortisol and its predominant metabolites, cortisol production rate (CPR), and glucocorticoid receptor (GR) binding characteristics in PTSD compared with normal subjects.

DESIGN

Matched PTSD patients and control subjects had CPR determined by a stable isotope dilution technique after infusion of deuterated cortisol. Serum cortisol, urinary cortisol, and its metabolites were measured by gas chromatography/mass spectrometry. GR binding capacity (R(o)) and ligand binding affinity (K(d)) were measured in mononuclear leukocytes.

SETTING

All subjects were tested during a 40-h admission in an inpatient clinical research center.

PATIENTS AND PARTICIPANTS

Ten patients with PTSD were matched by age and gender with 10 controls.

OUTCOME MEASURES

Statistical comparison was conducted for various measures of cortisol in PTSD patients and normal subjects.

RESULTS

No statistical difference was found in mean level or circadian pattern of cortisol secretion using serum or salivary immunoassay detection methods. Although in the normal range, urinary cortisol by immunoassay showed statistically lower values over a 24-h period in PTSD patients compared with controls. This finding was not confirmed by gas chromatography/mass spectrometry determination of cortisol or its metabolites. CPR was not statistically different between these groups. GR also showed no alteration in R(o) or K(d) between the groups.

CONCLUSION

The data indicate that PTSD in the chronic and unprovoked state is not characterized by an acute biological stress response.

Traumatized refugee children: the case for individualized diagnosis and treatment

The first 131 traumatized refugee children evaluated and treated in a child specialty clinic indicated a wide variety of trauma including war-related traumas (21%) for areas of recent conflict and domestic violence (28%) predominantly occurring in patients from Mexico and Latin America. Clinical diagnoses indicate PTSD was common (63%) in the war trauma group but was found less (25%) in the domestic violence group. Otherwise, the refugee clinic population showed a wide variety of diagnoses, including 20% having learning or cognitive disability or clear mental retardation. The traumatized refugee children had a similar prevalence of PTSD and depression to a comparable group of American child psychiatry patients. Refugee children have faced a variety of traumas and have a variety of diagnoses. All traumatized refugee children need an individualized evaluation and treatment plan. Trauma focused therapy is not appropriate for all refugee children.

Psychological distress among recent Russian immigrants in the United States

BACKGROUND

The purpose of this study was to examine the psychological status of Russian immigrants who have recently come to the United States.

AIMS

The project included creation of a Russian version of the Hopkins Symptom Checklist-25 (HSCL-25) in order to identify anxiety and depression in members of the Russian-speaking immigrant population.

METHODS

Translation and adaptation included (a) cross-cultural adaptation; (b) translation; (c) pre-testing; and (d) analysis of validity, reliability and internal consistency. Seventeen Russian-speaking patients at a Russian psychiatric clinic were recruited for the study and were compared with a sample of 42 Russian-speaking members of the community.

RESULTS

The instrument showed internal consistency when evaluated with coefficient alpha. Clinic patients had significantly higher anxiety and depression symptom scores than community subjects. Russian immigrants' scores on the anxiety and depression scales were less than comparative data for the United States and notably less than similar measures for Russian immigrants to Israel.

CONCLUSIONS

Recent Russian immigrants to the United States appear to have low prevalences of anxiety and depression.

Psychometric properties of a Russian version of the SF-12 Health Survey in a refugee population

This project examined psychometric properties of a Russian translation of the 12-item Short-Form health survey questionnaire (SF-12) to assess physical and mental health status in members of the Russian-speaking refugee population. Translation and adaptation included (a) cross-cultural adaptation; (b) translation; (c) pre-testing; and (d) analysis of validity, reliability, and internal consistency. Seventeen Russian-speaking patients at a Russian psychiatric clinic were recruited for the study and were compared to a sample of 42 Russian-speaking members of the community. The instrument showed internal consistency when evaluated with coefficient alpha. As compared with community subjects, clinic patients had significantly lower scores, reflecting poorer physical and mental well being.

A ten-year treatment outcome study of traumatized Cambodian refugees

The purpose of this study was to assess treatment outcome among 23 severely traumatized Cambodian refugee patients with posttraumatic stress disorder who had been in continuous treatment for 10 or more years. Primary outcome parameters were symptom severity, social and vocational disability, and subjective quality of life. All patients were interviewed using standard assessment tools by a research psychiatrist not connected with the treatment, and charts were reviewed for past and current traumas and for treatment history. There was a wide range of current posttraumatic stress disorder symptom scores, but current depression scores were very low. Thirteen patients were judged to have good outcomes, and 10 had relatively poor outcomes. Reported degree of previous trauma and demographic factors did not distinguish between the two outcome groups. Sixty percent of patients greatly improved. However, even with comprehensive continuous treatment over a period of 10 or more years, a substantial minority was still impaired.

Review of child and adolescent refugee mental health

OBJECTIVE

To review stressful experiences and stress reactions among child and adolescent refugees, as well as interventions and ethical considerations in research and clinical work, within the framework of the chronological experiences of child refugees; namely, the phases of preflight, flight, and resettlement. Highlighted are special refugee populations such as unaccompanied minors, asylum seekers, and former child soldiers. Pertinent medical findings are summarized.

METHOD

The authors reviewed articles from 1990 to 2003 addressing the topics above. Literature was gathered from databases including PsycINFO, Medline, and SocioFile. Pertinent earlier papers and those from other disciplines cited in database-identified articles were also included.

RESULTS

Child and adolescent refugees suffer from significant conflict-related exposures. Reactions to stress may be mediated by coping strategies, belief systems, and social relations.

CONCLUSIONS

More research is needed on interventions, specifically on efficacy and cultural relevance. Interventions that have an impact on multiple ecological levels need further development and evaluation.

The effects of September 11 on traumatized refugees: reactivation of posttraumatic stress disorder

Secondary traumatization from the tragic events of September 11, 2001 was studied among an ethnically diverse group of refugees who had been previously traumatized in their native war torn countries. A brief clinically oriented questionnaire was developed and administered to a clinic population of Vietnamese, Cambodian, Laotian, Bosnian and Somalian refugees in the Intercultural Psychiatric Program at Oregon Health & Science University. Traumatic symptoms and responses to the widely televised images from September 11 were assessed among the five ethnic groups, and the differential responses among patients with posttraumatic stress disorder (PTSD), depression, and schizophrenia also were assessed. The strongest responses were among Bosnian and Somalian patients with PTSD, and the Somalis had the greatest deterioration in their subjective sense of safety and security. Regardless of ethnic group, PTSD patients reacted most intensely, and patients with schizophrenia the least. Although patients largely returned to their baseline clinical status after two to three months, this study shows that cross-cultural reactivation of trauma has a significant clinical impact. It is essential that clinicians anticipate PTSD symptom reactivation among refugees when they are reexposed to significant traumatic stimuli.

Psychotherapy for massively traumatized refugees: the therapist variable

In the treatment of severe posttraumatic stress disorder (PTSD), much emphasis is put on techniques, especially behavioral therapies. Such techniques negate the importance of the therapist as an individual in the treatment of complex PTSD as presented in severely traumatized refugees. The specific difficulties encountered by this population and the therapist responses are discussed: the need to tell the trauma story and the therapist's ability to listen; the patient's need for constancy and therapist's ability to stay; the patient's need to give and the therapist's ability to receive; the patient's problem with evil and the therapist's ability to believe. Case examples illustrate the approach and then discuss how generalizable this experience is to other populations. Research implications are suggested.

Treating traumatized patients and victims of violence

This chapter presents a thorough exposition of treating traumatized patients and victims of violence, addressing many aspects of trauma and victimization critical to a vast proportion of the work that mental health professionals find themselves doing.

A cross-cultural study of reactivation of posttraumatic stress disorder symptoms: American and Cambodian psychophysiological response to viewing traumatic video scenes

A physiological hyperarousal state, which can be reactivated by traumatic stimuli, occurs frequently in patients with posttraumatic stress disorder (PTSD). The goals of this study were to determine whether physiological hyperarousal measured by increased heart rate is a specific response to reminders of a patient's own traumatic events or a more generalized hyperarousal state. Five brief videotape scenes of traumatic events (hurricane, auto accident, Cambodian refugee camp, domestic violence, and Vietnam War) were shown to two patient groups with PTSD (Vietnam veterans and Cambodian refugees) and three control groups (Vietnam veterans, Cambodian refugees, and nonpatient Americans). Observations of subjects' behavior, subjective ratings of distress, and heart rate change were recorded and evaluated. The results indicated that Cambodians with PTSD had the most reactions as measured by behavior and heart rate changes. These tended to occur during all scenes, not just the specific Cambodian scene, indicating a general nonspecific arousal. The Vietnam veterans had the fewest changes implying an inhibition of response. The control groups were intermediate in physiological response. The response in PTSD patients to reactivation scenes is complex and probably relates to type and degree of trauma, as well as to culture.

The history and future of cross-cultural psychiatric services

With cultural issues prominent in the United States today and with ongoing rapid changes in health care management and delivery, this paper discusses the shift from a genetic-type psychiatry (i.e., assuming that humans the world over are no different, and will react to given stressors in life in the same manner) to one recognizing that cultural beliefs, mores, peer pressure, family expectations, and other ingredients operate in unique combinations in various cultures and ethnic groups. These social and cultural factors can and will impact treatment modalities and outcomes. Literature reviewed herein illustrates the progressive stages of awareness and incorporation of cultural differences and the many ways they impact treatment. Unfortunately, the rise in managed, rationed health care threatens the future of this progression. It is essential that culturally-based managed care programs be developed and funded to ensure the availability of cost-effective treatment, through an integrated system of services, to patients of all cultural and economic backgrounds.

A century of controversy surrounding posttraumatic stress stress-spectrum syndromes: the impact on DSM-III and DSM-IV

The authors describe historical clinical reports that preceded the development of criteria for posttraumatic stress disorder (PTSD) and influenced the formation of PTSD in DSM-IV. These reports were identified from extensive search of 19th- and 20th-century American and European medical literature. Relevant findings from the most representative reports are described and discussed. Since the mid-19th century, clinical syndromes resembling PTSD have been described. However, understanding of PTSD has been complicated by questions of nomenclature, etiology, and compensation. Nomenclature placed PTSD syndromes under existing psychiatric disorders: traumatic hysteria, traumatic neurasthenia, or traumatic neurosis. Etiological issues have been concerned often solely with organic factors, pre-existing personality impairments, intrapsychiatric conflicts, and social factors. Only after World War II and the concentration camp experiences did the role of severe trauma in PTSD become recognized. Even though controversy remains, much progress in understanding PTSD has been made.

Screening for depression among newly arrived Vietnamese refugees in primary care settings

A brief, culture-specific, self-report screening measure for depression, the Vietnamese Depression Scale, was used to determine the prevalence of depressive symptoms among 1,998 consecutive adult Vietnamese refugees who presented at 10 public health clinics within 2 months of their arrival in the United States. Of these patients, 6% met the criterion for a probable case of depression ("positive"). Being divorced, separated, or widowed and poorly educated were strongly associated with a greater likelihood of screening positive. Somatic complaints were common and induced considerable anxiety about physical health status. Nearly a third of the patients reported sadness and dysphoria; culture-specific symptoms of depression also were prevalent. Our findings document the feasibility of screening for depression using the Vietnamese Depression Scale among Vietnamese refugees, particularly in primary care settings where they are first likely to be seen by health professionals after arrival in their host country.

A prospective study of the natural course of alcoholism in a Native American village

This study examines the natural course of alcoholism in a Native American village. We found that the remission rates of alcoholism were quite similar despite the different methods used: life histories (SADS-L interview) showed a 63% remission rate; a 19-year follow-up prospective showed 60% in remission; and following a cohort of all those who developed alcoholism in the village over the previous 19 years revealed a 60.9% remission rate. The data also showed vast differences in drinking problems between men and women. In the span of 19 years, the differences of point prevalence rates of alcoholism between men and women have jumped from that of two times (52% vs 26%) to five times (36.4% vs 7%). Furthermore, the results showed women had a higher rate of alcohol abuse (8.4% vs 3.6%) and a far higher remission rate (82% vs 52%) when compared to men. Three-fourths of the men in the studied sample had a lifetime history of alcohol dependence. They usually began drinking in their teens and developed dependency by their early twenties. About half stopped after an average of 15 years of drinking. The majority (83%) of the subjects who stopped drinking did so spontaneously or for specific personal-related reasons rather than because they received alcohol treatment.

Criterion validity of the Center for Epidemiologic Studies Depression Scale in a population sample from an American Indian village

The criterion validity of the Center for Epidemiologic Studies Depression Scale (CES-D) is examined in 120 adult Northwest Coast American Indians. The criterion was a DSM-III-R diagnosis derived from the Lifetime version of the Schedule for Affective Disorders and Schizophrenia. Sensitivity for major depression was 100% (95% confidence limits 36%, 100%); specificity was 82.1% (75.1%; 89%). For a broad category of depressive disorders (n = 9), sensitivity was 77.8% and specificity was 84.7%. Cut points based on receiver operating characteristic analyses did not greatly improve the performance of the CES-D. The use of factor scores instead of total scores made little difference.

A 6-year follow-up study of Cambodian refugee adolescents traumatized as children

Seventy-three percent of a sample of 46 Cambodian youth interviewed in 1984 and 1987 were reinterviewed in 1990 as part of a pretest for a multisite study of Cambodian refugee trauma now under way. An additional sample of convenience of 38 youth were also interviewed to determine reliability and validity of the diagnostic instruments chosen for the larger study. The DSM-III-R diagnosis of post-traumatic stress disorder (PTSD) was found to persist, but the symptoms appeared less intense over time. In contrast, the prevalence of depression dropped markedly since 1987. Subjects remained largely free of comorbid conditions. Diagnostic reliability and validity were satisfactory. The follow-up sample appeared to be functioning well despite their PTSD profiles. The findings are discussed in light of several current controversies surrounding the concept and measurement of PTSD.

Prevalence of depressive symptoms among established Vietnamese refugees in the United States: detection in a primary care setting

OBJECTIVE

To determine the prevalence of depressive symptoms among Vietnamese refugees who have lived in the United States for at least two months.

DESIGN

A prospective and descriptive study using the Vietnamese Depression Scale (VDS). Scores of > or = 13 on the VDS were considered indicative of depression.

SETTING

Ten public health clinics in four states.

PATIENTS/PARTICIPANTS

Four hundred seventy-six consecutive adult Vietnamese refugees presenting for primary care.

INTERVENTIONS

The VDS, an 18-item culture-specific self-report measure, was used to screen for depressive symptoms.

MEASUREMENTS AND MAIN RESULTS

Twenty percent of these patients had scores of 13 or above. Although being female; being older; being divorced, separated, or widowed; and being poorly educated were significant univariate risk factors for screening positive, only the latter two were significant in a multivariate model. Physical complaints were common and induced considerable anxiety about health status, but psychological and emotional symptoms were even more prevalent. Patients scoring 13 or higher had a higher rate of endorsement for every item in the scale than did those scoring lower than 13.

CONCLUSIONS

This study substantiates the feasibility and importance of screening for depressive symptoms among Vietnamese refugees, particularly in primary care settings where they are most likely to seek care for both medical and psychological problems.

Psychotherapy of the victims of massive violence: countertransference and ethical issues

Psychotherapy with severely traumatized patients is a long, draining process that often produces strong countertransference reactions. It is difficult to therapeutically and ethically handle these personal responses. We feel that at different stages in therapy different ethical principles should guide the therapy. At the early stages, fidelity and nonmaleficence should be the guiding principles. As trust and confidence develop, therapists may have more personal freedom to act; beneficence, i.e., providing specific confident care then becomes the primary ethical principle. In later stages of therapy, promoting the principles of autonomy and justice come into play. As therapy further progresses, therapists' own needs, the principle of self-interest, may be utilized in the therapeutic relationship. Throughout therapeutic contacts with traumatized patients, therapists need to monitor their own needs, and find appropriate ways outside of therapy to cope with these often intense feelings. Continuing to feel therapeutically competent and ethically grounded, yet maintaining the personal strength and balance to treat traumatized patients, pose major challenges for therapists.

Improving quality assurance through psychiatric mortality and morbidity conferences in a university hospital

To make quality assurance more outcome oriented, the department of psychiatry in a university hospital developed a program of psychiatric mortality and morbidity conferences for reviewing cases with undesirable outcomes. The conference combines aspects of a traditional medical mortality and morbidity conference with features of utilization review and risk management. Case review is focused on mortality, morbidity, or specific indicators developed by the departmental services involved and on a determination of whether an adverse outcome was avoidable, possibly avoidable, or unavoidable. The authors summarize the 100 cases reviewed in the first seven months. They believe the focus on outcome gives the method a useful role in quality assurance; advantages include its recognizable contributions to continuing education and training.

Use of the CES-D in an American Indian village

In this paper, we examine the performance of a pencil-and-paper screening questionnaire on depressive symptoms (the Center for Epidemiologic Studies Depression Scale, or CES-D) in a sample of 120 adult American Indians belonging to a single Northwest Coast tribe. Results of factor analyses suggest that somatic complaints and emotional distress are not well differentiated from each other in this population. CES-D scores (which have shown good sensitivity and specificity for depressive disorders in this sample) also show weak and apparently nonsignificant trends to be elevated in the presence of other psychiatric diagnoses (including alcoholism) or general impairment. However, because of the use of a convenience sample (rather than a probability sample), analyses of associations between study factors--including comorbidity--are liable to produce spurious results due to selection bias (including Berkson bias). On this basis, we suggest that the use of probability samples should assume a high priority in cross-cultural studies. The study of the entire population of interest is another solution to the sampling problem, particularly in small communities.

Psychiatric epidemiology of an Indian village. A 19-year replication study

This 1988 study reports the point and lifetime prevalence of psychiatric disorders, using DSM-III-R criteria, of a sample (approximately 25%) of adult members of an Indian village previously studied in 1969. The basic instrument was the Schedule for Affective Disorders and Schizophrenia, augmented by available medical information and administered by experienced psychiatrists. Subjects were interviewed and results were weighed for the age- and sex-distributed population. The results indicated a high point prevalence of alcohol dependence (32.8%), with a lifetime prevalence of 72.8%, among males. The lifetime prevalence of affective disorders among women was also high (36.8%), but less so among men (19.3%). When compared with the DSM-III-R diagnoses of the 1969 study, the point prevalence rates of alcohol dependence and abuse disorders fell from 39% to 21%. Also, fewer subjects were judged to be psychiatrically impaired. Even though the prevalence of psychiatric disorders was lower in the current study, the rates for alcohol disorders and affective disorders were still far higher than those reported in Epidemiologic Catchment Area studies. Alcohol dependence (especially among young men) and affective disorder (among women) were major problems.

The prevalence of posttraumatic stress disorder and its clinical significance among Southeast Asian refugees

All 322 patients at a psychiatric clinic for Indochinese refugees were surveyed to determine the presence of posttraumatic stress disorder (PTSD). If PTSD was not diagnosed at the time of initial evaluation, a structured reinterview was performed. Seventy percent of the patients (N = 226) met the criteria for a current diagnosis of PTSD, and an additional 5% (N = 15) met the criteria for a past diagnosis. The Mein had the highest rate of PTSD (93%) and the Vietnamese the lowest (54%). Of the patients with PTSD who were enrolled in the clinic before March 1988, 46% (N = 87) were given a diagnosis of PTSD only after the reinterview. PTSD is a common disorder among Indochinese refugees, but the diagnosis is often difficult to make.

Clonidine in Cambodian patients with posttraumatic stress disorder

Some symptoms of posttraumatic stress disorder (PTSD) are related to central nervous system adrenergic hyperarousal. It has been suggested that an adrenergic receptor-blocker could be used to diminish, if not alleviate, the target symptoms of PTSD. Severely traumatized Cambodian refugee patients (N = 68) who suffered from chronic PTSD and major depression improved symptomatically when treated with a combination of clonidine and imipramine. A prospective pilot study of nine patients using this combination of an alpha-2 adrenergic agonist and a tricyclic antidepressant resulted in improved symptoms of depression in six patients, five to the point that DSM-III-R diagnoses were no longer met. The average decrease in the Hamilton Rating Scale for Depression score was 16. PTSD global symptoms improved in six patients but only in two to the point that DSM-III-R diagnoses were not met. There was no further sleep disorder in five and the frequency of nightmares lessened in seven patients. Startle reaction improved only in four patients; avoidance behavior showed little improvement in any of the nine. The imipramine-clonidine combination was well tolerated and presents a promising treatment for severely depressed and traumatized patients, although further studies are needed.

A three-year follow-up of Cambodian young people traumatized as children

Twenty-seven Cambodian young people, who were severely traumatized at ages 8 to 12, were followed up 3 years after an original study. A structured interview and self-rating scales showed that post-traumatic stress disorders (PTSD) were still highly prevalent (48%). Depression existed in 41%. Those with PTSD differed significantly from those without PTSD on the Global Adjustment Scale, the Social Adjustment Scale, the Beck Depression Inventory, and the Impact of Event Scale. Eight subjects had PTSD at both interviews, while 11 had none at either time. Eight showed a variable course. Avoidance behavior was highly prevalent, even among those without PTSD diagnosis. Although functioning relatively well, these youths continued to show symptoms related to their trauma of 8 to 12 years before.

Medication-associated depression: a two and one-half year follow-up of a community sample

A community sample of forty subjects (of a total of 50) were followed up an average of two and one-half years after a SADS/RDC diagnosis of depression. The group was composed of twenty-one subjects whose depressions were judged to be associated with a medical illness or medication use and nineteen without this association. There was no difference in outcome as measured by persistence or recurrence of depression when groups were defined by associated medical illness. There was a significant difference when groups were defined by association with medication use. Of the nine subjects whose depressions were associated with medication, six were still depressed at follow-up; all six had continued to use implicated "depressogenic" medications. The three who were not depressed at follow-up were no longer using the originally implicated medications. The use of depressogenic medication appears to influence the course and/or duration of depression and must be accounted for in epidemiological studies and clinical practices.

Group therapy with Southeast Asian refugees

This report describes a one-year experience with a new program of group therapy for Southeast Asians who were treated in a psychiatric program for Indochinese refugees. Cultural factors involving communication styles, respect for authority, and traditional social relationships greatly influence the group process. Socialization experiences which encouraged traditional activities and practical information were the most acceptable medium by all the groups. Psychological issues of losses, cultural conflicts, and persistent discussion of somatic symptoms were voiced throughout the activities. Formal group psychotherapy was periodically useful in some groups. Flexibility, meeting concrete needs, keeping a bicultural focus, and maintaining the individual therapy sessions contributed to the acceptance by the patient.

Antidepressant blood levels in Southeast Asians. Clinical and cultural implications

After long-term treatment with tricyclic antidepressants (TCA), the TCA blood levels of 41 depressed Southeast Asian patients were determined by high-pressure liquid chromatography. No detectable medicine level was found in 25 (61%) of the patients and a therapeutic level by American standards was found in only six (15%), indicating a high incidence of noncompliance. A Cambodian subgroup, however, was significantly more compliant than either the Vietnamese or Mein patients. After patient education and a discussion of problems and benefits of medicine, compliance improved with Vietnamese and Cambodians but not with the Mien. Cultural and educational factors influence compliance with medicine and responsiveness to education. Because the Cambodians also suffered from posttraumatic stress disorder, it is probable that the presence of this illness increased compliance. Preliminary data among these patients indicate that Asians probably need the same dose of imipramine as Americans to achieve a "therapeutic" level. Reports that Asians need lower doses of TCA medicine are limited by the high noncompliance rates with Asians. These high rates probably reflect cultural beliefs about illness and medication usage. It is valuable to perform TCA blood levels on Asian patients for whom antidepressants have been prescribed to monitor compliance and to lead into a discussion of benefits and side effects of the medicine. Evidence of noncompliance can lead to a productive doctor-patient discussion about beliefs and effects of the medication.

Psychiatry: current perspectives in posttraumatic stress disorders

The Scientific Board of the California Medical Association presents the following inventory of items of progress in psychiatry. Each item, in the judgment of a panel of knowledgeable physicians, has recently become reasonably firmly established, both as to scientific fact and important clinical significance. The items are presented in simple epitome and an authoritative reference, both to the item itself and to the subject as a whole, is generally given for those who may be unfamiliar with a particular item. The purpose is to assist busy practitioners, students, research workers or scholars to stay abreast of these items of progress in psychiatry that have recently achieved a substantial degree of authoritative acceptance, whether in their own field of special interest or another.The items of progress listed below were selected by the Advisory Panel to the Section on Psychiatry of the California Medical Association and the summaries were prepared under its direction.

The use of self-rating scales in cross-cultural psychiatry

The authors review the use of seven psychiatric self-rating scales in cross-cultural research and practice and discuss some of the issues that limit their usefulness in cross-cultural settings. It is unclear whether any one scale can accurately assess the presence of psychiatric illness in different cultures because different cultures have specific ways of experiencing and reporting psychiatric disturbances. This limitation may be overcome through the use of culture-specific rating scales, such as the Vietnamese Depression Scale (VDS), whose development is described here. The authors' work on the VDS suggests that certain biological symptoms of depression may be universal but that psychological symptoms tend to be culturally rooted. The paper includes guidelines for using self-rating scales in cross-cultural psychiatry.