Search

Aims: Refugees are confronted with the task of adapting to the long-term erosion of psychosocial systems and institutions that in stable societies support psychological well-being and mental health. We provide an overview of the theoretical principles and practical steps taken to develop a novel psychotherapeutic approach, Integrative Adapt Therapy (IAT), which aims to assist refugees to adapt to these changes. This paper offers the background informing ongoing trials of IAT amongst refugees from Myanmar. Methods: A systematic process was followed in formulating the therapy and devising a treatment manual consistent with the principles of the Adaptation and Development After Persecution and Trauma (ADAPT) model. The process of development and refinement was based on qualitative research amongst 70 refugees (ten from West Papua and 60 Rohingya from Myanmar). The therapeutic process was then piloted by trained interventionists amongst a purposively selected sample of 20 Rohingya refugees in Malaysia. Results: The final formulation of IAT represented an integration of the principles of the ADAPT model and evidence-based techniques of modern therapies in the field, including a transdiagnostic approach and the selective use of cognitive behavioural treatment elements such as problem-solving and emotional regulation techniques. The steps outlined in refining the manual are outlined in relation to work amongst West Papuan refugees, and the process of cultural and contextual modifications described during early piloting with Rohingya refugees in Malaysia. Conclusions: IAT integrates universal principles of the ADAPT model with the particularities of the culture, history of conflict and living context of each refugee community; this synthesis of knowledge forms the basis for participants gaining insights into their personal patterns of psychosocial adaptation to the refugee experience. Participants then apply evidence-based techniques to improve their capacity to adapt to the serial psychosocial changes they have encountered in their lives as refugees. The overarching goal of IAT is to provide refugees with a coherent framework that assists in making sense of their experiences and their emotional and interpersonal reactions to the challenges they confront within the family and community context. As such, the principles of a general model (ADAPT) are used as a springboard for making concrete, manageable and meaningful life changes at the individual level, a potentially novel approach for psychosocial interventions in the field. [ABSTRACT FROM AUTHOR]

Aims: Despite the frequency that refugees suffer bereavement, there is a dearth of research into the prevalence and predictors of problematic grief reactions in refugees. To address this gap, this study reports a nationally representative population-based study of refugees to determine the prevalence of probable prolonged grief disorder (PGD) and its associated problems. Methods: This study recruited participants from the Building a New Life in Australia (BNLA) prospective cohort study of refugees admitted to Australia between October 2013 and February 2014. The current data were collected in 2015–2016, and comprised 1767 adults, as well as 411 children of the adult respondents. Adult refugees were assessed for trauma history, post-migration difficulties, probable PGD, post-traumatic stress disorder (PTSD) and mental illness. Children were administered the Strengths and Difficulties Questionnaire. Results: In this cohort, 38.1% of refugees reported bereavement, of whom 15.8% reported probable PGD; this represents 6.0% of the entire cohort. Probable PGD was associated with a greater likelihood of mental illness, probable PTSD, severe mental illness, currently unemployed and reported disability. Children of refugees with probable PGD reported more psychological difficulties than those whose parents did not have probable PGD. Probable PGD was also associated with the history of imprisonment, torture and separation from family. Only 56.3% of refugees with probable PGD had received psychological assistance. Conclusions: Bereavement and probable PGD appear highly prevalent in refugees, and PGD seems to be associated with disability in the refugees and psychological problems in their children. The low rate of access to mental health assistance for these refugees highlights that there is a need to address this issue in refugee populations. [ABSTRACT FROM AUTHOR]

Aims: Despite the magnitude and protracted nature of the Rohingya refugee situation, there is limited information on the culture, mental health and psychosocial wellbeing of this group. This paper, drawing on a report commissioned by the United Nations High Commissioner for Refugees (UNHCR), aims to provide a comprehensive synthesis of the literature on mental health and psychosocial wellbeing of Rohingya refugees, including an examination of associated cultural factors. The ultimate objective is to assist humanitarian actors and agencies in providing culturally relevant Mental Health and Psychosocial Support (MHPSS) for Rohingya refugees displaced to Bangladesh and other neighbouring countries. Methods: We conducted a systematic search across multiple sources of information with reference to the contextual, social, economic, cultural, mental health and health-related factors amongst Rohingya refugees living in the Asia-Pacific and other regions. The search covered online databases of diverse disciplines (e.g. medicine, psychology, anthropology), grey literature, as well as unpublished reports from non-profit organisations and United Nations agencies published until 2018. Results: The legacy of prolonged exposure to conflict and persecution compounded by protracted conditions of deprivations and displacement is likely to increase the refugees' vulnerability to wide array of mental health problems including posttraumatic stress disorder, anxiety, depression and suicidal ideation. High rates of sexual and gender-based violence, lack of privacy and safe spaces and limited access to integrated psychosocial and mental health support remain issues of concern within the emergency operation in Bangladesh. Another challenge is the limited understanding amongst the MHPSS personnel in Bangladesh and elsewhere of the language, culture and help-seeking behaviour of Rohingya refugees. While the Rohingya language has a considerable vocabulary for emotional and behavioural problems, there is limited correspondence between these Rohingya terms and western concepts of mental disorders. This hampers the provision of culturally sensitive and contextually relevant MHPSS services to these refugees. Conclusions: The knowledge about the culture, context, migration history, idioms of distress, help-seeking behaviour and traditional healing methods, obtained from diverse sources can be applied in the design and delivery of culturally appropriate interventions. Attention to past exposure to traumatic events and losses need to be paired with attention for ongoing stressors and issues related to worries about the future. It is important to design MHPSS interventions in ways that mobilise the individual and collective strengths of Rohingya refugees and build on their resilience. [ABSTRACT FROM AUTHOR]

Background. Prolonged separation from parental support is a risk factor for psychopathology. This study assessed the impact of brief separation from parents during childhood trauma on adult attachment tendencies and post-traumatic stress. Method. Children (n = 806) exposed to a major Australian bushfire disaster in 1983 and matched controls (n = 725) were assessed in the aftermath of the fires (mean age 7-8 years) via parent reports of trauma exposure and separation from parents during the fires. Participants (n = 500) were subsequently assessed 28 years after initial assessment on the Experiences in Close Relationships scale to assess attachment security and post-traumatic stress disorder (PTSD) was assessed using the PTSD checklist. Results. Being separated from parents was significantly related to having an avoidant attachment style as an adult (B =-3.69, S.E. = 1.48, β =-0.23, p = 0.013). Avoidant attachment was associated with re-experiencing (B = 0.03, S.E. = 0.01, β = 0.31, p = 0.045), avoidance (B = 0.03, S.E. = 0.01, β = 0.30, p = 0.001) and numbing (B = 0.03, S.E. = 0.01, β = 0.30, p < 0.001) symptoms. Anxious attachment was associated with re-experiencing (B = 0.03, S.E. = 0.01, β = 0.18, p = 0.001), numbing (B = 0.03, β = 0.30, S.E. = 0.01, p < 0.001) and arousal (B = 0.04, S.E. = 0.01, β = 0.43, p < 0.001) symptoms. Conclusions. These findings demonstrate that brief separation from attachments during childhood trauma can have longlasting effects on one's attachment security and that this can be associated with adult post-traumatic psychopathology. [ABSTRACT FROM AUTHOR]

Objectives: To identify the 6-year trajectories of posttraumatic stress symptoms (PTSS) and psychological distress symptoms, and examine for associations with timing of trauma exposure, ongoing adversity and with the sense of injustice in conflict-affected Timor-Leste. Setting: A whole-of-household survey was conducted in 2004 and 2010 in Dili, the capital of Timor-Leste. Participants: 1022 adults were followed up over 6 years (retention rate 84.5%). Interviews were conducted by field workers applying measures of traumatic events (TEs), ongoing adversity, a sense of injustice, PTS symptoms and psychological distress. Results: Latent transition analysis supported a 3-class longitudinal model (psychological distress, comorbid symptoms and low symptoms). We derived 4 composite trajectories comprising recovery (20.8%), a persisting morbidity trajectory (7.2%), an incident trajectory (37.2%) and a low-symptom trajectory (34.7%). Compared with the low-symptom trajectory, the persistent and incident trajectories reported greater stress arising from poverty and family conflict, higher TE exposure for 2 historical periods, and a sense of injustice for 2 historical periods. The persistent trajectory was unique in reporting greater TE exposure in the Indonesian occupation, whereas the incident trajectory reported greater TE exposure during the later internal conflict that occurred between baseline and follow-up. Compared with the low-symptom trajectory, the incident trajectory reported a greater sense of injustice relating to the periods of the Indonesian occupation and independence. The persistent trajectory was characterised by a sense of injustice relating to the internal conflict and contemporary times. The recovery trajectory was characterised by the absence of these risk factors, the only difference from the low-symptom trajectory being that the former reported a sense of injustice for the period surrounding independence. Conclusions: Our findings suggest that the timing of both TE exposure and the focus of a sense of injustice may differentiate those with persisting and new-onset mental health morbidity in settings of recurrent conflict. [ABSTRACT FROM AUTHOR]

There is growing acknowledgment that research in the postconflict field needs to include a focus on social conditions. The authors applied structural equation modeling to epidemiologic data obtained from postconflict Timor-Leste, to examine for links involving potentially traumatic events and sociodemographic factors (age, gender, educational levels, and unemployment) with psychological symptoms and functioning. Exposure to trauma and lack of education emerged as most relevant with psychological distress impacting on education in the urban area. Age and gender exerted influences at different points in the model consistent with the known history of Timor. Although based on cross-sectional data, the model supports the relevance of past trauma, posttraumatic distress, and postconflict social conditions to functioning in societies such as Timor-Leste. [ABSTRACT FROM AUTHOR]

Context: Uncertainties continue about the roles that methodological factors and key risk factors, particularly torture and other potentially traumatic events (PTEs), play in the variation of reported prevalence rates of posttraumatic stress disorder (PTSD) and depression across epidemiologic surveys among postconflict populations worldwide.Objective: To undertake a systematic review and meta-regression of the prevalence rates of PTSD and depression in the refugee and postconflict mental health field.Data Sources: An initial pool of 5904 articles, identified through MEDLINE, PsycINFO and PILOTS, of surveys involving refugee, conflict-affected populations, or both, published in English-language journals between 1980 and May 2009.Study Selection: Surveys were limited to those of adult populations (n > or = 50) reporting PTSD prevalence, depression prevalence, or both. Excluded surveys comprised patients, war veterans, and civilian populations (nonrefugees/asylum seekers) from high-income countries exposed to terrorist attacks or involved in distal conflicts (> or = 25 years).Data Extraction: Methodological factors (response rate, sample size and design, diagnostic method) and substantive factors (sociodemographics, place of survey, torture and other PTEs, Political Terror Scale score, residency status, time since conflict).Data Synthesis: A total of 161 articles reporting results of 181 surveys comprising 81,866 refugees and other conflict-affected persons from 40 countries were identified. Rates of reported PTSD and depression showed large intersurvey variability (0%-99% and 3%-85.5%, respectively). The unadjusted weighted prevalence rate reported across all surveys for PTSD was 30.6% (95% CI, 26.3%-35.2%) and for depression was 30.8% (95% CI, 26.3%-35.6%). Methodological factors accounted for 12.9% and 27.7% PTSD and depression, respectively. Nonrandom sampling, small sample sizes, and self-report questionnaires were associated with higher rates of mental disorder. Adjusting for methodological factors, reported torture (Delta total R(2) between base methodological model and base model + substantive factor [DeltaR(2)] = 23.6%; OR, 2.01; 95% CI, 1.52-2.65) emerged as the strongest factor associated with PTSD, followed by cumulative exposure to PTEs (DeltaR(2) = 10.8%; OR, 1.52; 95% CI, 1.21-1.91), time since conflict (DeltaR(2) = 10%; OR, 0.77; 95% CI, 0.66-0.91), and assessed level of political terror (DeltaR(2) = 3.5%; OR, 1.60; 95% CI, 1.03-2.50). For depression, significant factors were number of PTEs (DeltaR(2) = 22.0%; OR, 1.64; 95% CI, 1.39-1.93), time since conflict (DeltaR(2) = 21.9%; OR, 0.80; 95% CI, 0.69-0.93), reported torture (DeltaR(2) = 11.4%; OR, 1.48; 95% CI, 1.07-2.04), and residency status (DeltaR(2) = 5.0%; OR, 1.30; 95% CI, 1.07-1.57).Conclusion: Methodological factors and substantive population risk factors, such as exposure to torture and other PTEs, after adjusting for methodological factors account for higher rates of reported prevalence of PTSD and depression. [ABSTRACT FROM AUTHOR]

Issue Addressed: To assess the adherence and acceptability of a physical activity program delivered as an adjunct to the usual cognitive behavioural group therapy (CBGT) for adults with anxiety disorders.Methods: Seventy-three participants with either a generalised anxiety disorder, social phobia or panic disorder were randomised to either exercise-enhanced CBGT (CBGT+EX) or the usual CBGT plus nutrition education (CBGT+ED) group. Physical activity, stress, anxiety, depression were assessed at baseline; session attendance, compliance and satisfaction were assessed during the eight-week intervention.Results: Forty-five per cent of participants achieved the recommended levels of physical activity for health at baseline. The proportions of participants attending group meetings declined over time across both groups. In the intervention groups (CBGT+EX), a slightly higher proportion of participants attended the CBGT session than the physical activity sessions. Individuals with social phobia were significantly more likely than those with panic or generalised anxiety disorder to adhere to the physical activity program. Among the remaining adherers, most reported satisfaction with their skills development and better understanding of the benefits of physical activity.Conclusions: Time constraints and participants viewing physical activities as irrelevant or detracting them from their psychological treatment are potential factors contributing to low adherence and present as challenges in implementing a physical activity program as adjunctive to psychological treatment. Process evaluation data helped profile participants who adhered or not adhered to the physical activity program and will inform future physical activity promotion to individuals with anxiety disorders. [ABSTRACT FROM AUTHOR]

To offer optimal psychological treatment, psychologists need to understand patients' own perceptions of their psychological problems, a task that is more challenging if the psychologist and patient are of different cultural backgrounds. This study examined differences in the symptom descriptions and treatment outcomes of panic disorder patients of Arabic and Australian backgrounds attending a psychological treatment facility. Arab patients were found to express more fear of dying and experience less sweating during panic attacks compared to the Australian patients. Treatment outcomes were similar across the two groups at 2-month follow-up, although not immediately after treatment. Limitations of the study that may potentially have affected this unexpected outcome are discussed, although it appears that any cultural differences are not impediments to the effectiveness of cognitive behavioural therapy. [ABSTRACT FROM AUTHOR]

The Hopkins Symptom Checklist depression scale (HSCL-D) and the Harvard Trauma Questionnaire (HTQ) have been used extensively in international studies, particularly among refugees and conflict-affected populations. Like many other screening measures, however, the HSCL-D and HTQ have not been subjected to extensive epidemiologic testing, particularly among communities not affected by war. The present study examined the psychometric properties of the HSCL-D and HTQ by comparing the measures with the Structured Clinical Interview for DSM-IV (SCID) among ethnic Cambodians living in Surin, Thailand, a community that was spared the long period of mass violence that affected Cambodia proper. The PTSD data of the HTQ were then contrasted with those obtained from a refugee clinic. The main finding was that in the Surin study, the screening measures showed greater agreement with the SCID in identifying noncases (negative prediction) than cases (positive prediction). In contrast, in the earlier clinic study, the HTQ showed high positive and moderately low negative prediction. The results support previous observations that clinical interviews such as the SCID may be more conservative in identifying cases. We raise the possibility, however, that structured interviews may perform differently across clinic and community populations. In particular, clinicians may be more accurate in identifying cases than noncases in highly symptomatic clinic populations, with the converse applying in low prevalence community populations. These issues warrant further investigation to specify more clearly the value of using the two approaches to case identification. [ABSTRACT FROM AUTHOR]

Issues of power and consent, confidentiality, trust, and benefit, risks to researchers, and potential harm to participants, are all contested when working with different cultures and within environments marked by violence and insecurity. Difficulty resolving these dilemmas may paralyse ethics committees, may fail to give the guidance sought by researchers, and will not help populations who are among the world's most vulnerable. Even where efforts are made to respond to ethical guidelines and to improve practice, considerable impediments are present in many developing countries, including lack of formal ethical review structures in unstable settings, lack of required skills, limited political and institutional recognition of ethical issues, competing interests, and limitations in clinical and research practice (Elsayed 2004, Macklin 2004). In conflict settings, these limitations are more marked, and the responsibilities of the researcher for ethical practice are greater, but the mechanisms for oversight are weaker. Moreover, the constant focus on vulnerabilities and problems, and the often almost total lack of recognition of strengths and resilience, can further disempower already exploited groups and individuals. The capacity of refugees and communities in conflict to take an active role in the research process is seldom acknowledged, and undermines the potential for more innovative research which can help generate the evidence for better policy and practice. [ABSTRACT FROM AUTHOR]

In the past, most refugees who permanently resettled in the traditional recipient countries of North America, Europe, and Australasia were screened prior to arrival in a host country. In the last decade, increasing numbers of unauthorized refugees or asylum seekers, those who formally lodge application for refugee status in the country in which they are residing, have applied for protection after crossing the borders of these countries. Concerns about uncontrolled migration have encouraged host countries to adopt policies of deterrence in which increasingly restrictive measures are being imposed on persons seeking asylum. These measures include, variously, confinement in detention centers, enforced dispersal within the community, the implementation of more stringent refugee determination procedures, and temporary forms of asylum. In several countries, asylum seekers living in the community face restricted access to work, education, housing, welfare, and, in some situations, to basic health care services. Allegations of abuse, untreated medical and psychiatric illnesses, suicidal behavior, hunger strikes, and outbreaks of violence among asylum seekers in detention centers have been reported. Although systematic research into the mental health of asylum seekers is in its infancy, and methods are limited by sampling difficulties, there is growing evidence that salient postmigration stress facing asylum seekers adds to the effect of previous trauma in creating risk of ongoing posttraumatic stress disorder and other psychiatric symptoms. The medical profession has a role in educating governments and the public about the potential risks of imposing excessively harsh policies of deterrence on the mental health of asylum seekers. JAMA. 2000;284:604-611 [ABSTRACT FROM AUTHOR]

OBJECTIVE: Early bonding abnormalities have been associated with a range of anxiety and depressive disorders in adulthood, but no specific parental patterns have emerged for particular disorders. The present study investigated the possibility that parental overprotectiveness may be linked to a risk of separation anxiety (SA) in adulthood. METHOD: Two samples were recruited: volunteers (n = 34) whose major anxieties focused on separation concerns, and adult anxiety clinic patients (n = 37) who were diagnosed with panic disorder. Parental characteristics and early SA were assessed by dichotomising the combined sample first according to adult SA categorisation and then by panic disorder status. RESULTS: Subjects assigned to the adult SA category reported high levels of juvenile SA and exposure to maternal overprotectiveness, whereas patients diagnosed with panic disorder reported few differences in their bonding histories compared to residual anxious patients. CONCLUSIONS: The findings of this study suggest that early SA and parental overprotectiveness may not be associated with panic disorder per se, but rather with persisting SA symptoms in adulthood. The overlapping samples and retrospectivity of some measures are important limitations of the study. [ABSTRACT FROM AUTHOR]

Background: Research into the mental health of refugees has burgeoned in recent times, but there is a dearth of studies focusing specifically on the factors associated with psychiatric distress in asylum-seekers who have not been accorded residency status.Method: Forty consecutive asylum-seekers attending a community resource centre in Sydney, Australia, were interviewed using structured instruments and questionnaires.Results: Anxiety scores were associated with female gender, poverty, and conflict with immigration officials, while loneliness and boredom were linked with both anxiety and depression. Thirty subjects (79%) had experienced a traumatic event such as witnessing killings, being assaulted, or suffering torture and captivity, and 14 subjects (37%) met full criteria for PTSD. A diagnosis of PTSD was associated with greater exposure to pre-migration trauma, delays in processing refugee applications, difficulties in dealing with immigration officials, obstacles to employment, racial discrimination, and loneliness and boredom.Conclusions: Although based on correlational data derived from'a convenient' sample, our findings raise the possibility that current procedures for dealing with asylum-seekers may contribute to high levels of stress and psychiatric symptoms in those who have been previously traumatised. [ABSTRACT FROM AUTHOR]

Previous attempts to establish a relationship between impaired cell-mediated immunity (CMI) and major mood disorders have been limited by a failure to explore the relevance of depressive subcategories or to assess CMI by in vivo methods. In this case-control study CMI was assessed in 57 patients with major depression (31 with melancholic, 26 with non-melancholic disorders), and in age- and sex-matched controls by both in vitro and in vivo immunological techniques. Compared with control subjects and patients with non-melancholic depression, patients with melancholia demonstrated reduced in vivo CMI as assessed by delayed-type hypersensitivity (DTH) skin responses. Although increasing age, severity of depression, hospital admission for treatment, and reported weight loss are correlates of melancholia, none of these factors alone, or in combination, accounted for the differences in DTH responses observed between the two depressive subtypes. These data suggest that impaired CMI in vivo may be limited to those with melancholic disorders. At this stage the factors which account for this effect are unclear. [ABSTRACT FROM AUTHOR]