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Refugees typically spend years in a state of protracted displacement prior to permanent resettlement. Little is known about how various prior displacement contexts influence long-term mental health in resettled refugees. In this study, we aimed to determine whether having lived in refugee camps v. community settings prior to resettlement impacted the course of refugees' psychological distress over the 4 years following arrival in Australia.
Participants were 1887 refugees who had taken part in the Building a New Life in Australia study, which comprised of five annual face-to-face or telephone surveys from the year of first arrival in Australia.
Latent growth curve modelling revealed that refugees who had lived in camps showed greater initial psychological distress (as indexed by the K6) and faster decreases in psychological distress in the 4 years after resettling in Australia, compared to those who had lived in community settings. Investigation of refugee camp characteristics revealed that poorer access to services in camps was associated with greater initial distress after resettlement, and greater ability to meet one's basic needs in camps was associated with faster decreases in psychological distress over time.
These findings highlight the importance of the displacement context in influencing the course of post-resettlement mental health. Increasing available services and meeting basic needs in the displacement environment may promote better mental health outcomes in resettled refugees.
Refugees report a diverse array of psychological responses following persecution and displacement. Little is known, however, regarding the mechanisms that underlie differential psychological reactions in refugees. This study investigated the longitudinal impact of negative moral appraisals about one's own actions [i.e. moral injury-self (MI-self) appraisals] and others' actions [i.e. moral injury-other (MI-others) appraisals] on a variety of psychological symptoms over a period of 6 months.
Participants were 1085 Arabic, Farsi, Tamil, or English-speaking refugees who completed a survey at baseline and 6 months later either on-line or via pen-and-paper. The survey indexed demographic factors, exposure to potentially traumatic events (PTEs), exposure to ongoing stressors, MI-other appraisals, MI-self appraisals, re-experiencing and arousal symptoms, and feelings of sadness, anger and shame.
Findings indicated that, after controlling for demographics, PTE exposure and ongoing stressors, MI-other appraisals predicted increased re-experiencing and hyperarousal symptoms, and feelings of sadness and shame. MI-self appraisals predicted decreased feelings of shame, and decreased re-experiencing symptoms. In contrast, psychological symptoms at baseline did not as strongly influence MI appraisals 6 months later.
These findings highlight the important role that cognitive appraisals of adverse events play in the longitudinal course of psychological symptoms. These results thus have important implications for the development of tailored psychological interventions to alleviate the mental health burden held by refugees.
Refugees report elevated rates of posttraumatic stress disorder (PTSD), but are relatively unlikely to seek help for their symptoms. Mental health stigma is a key barrier to help-seeking amongst refugees. We evaluated the efficacy of an online intervention in reducing self-stigma and increasing help-seeking in refugee men.
Participants were 103 refugee men with PTSD symptoms from Arabic, Farsi or Tamil-speaking backgrounds who were randomly assigned to either receive an 11-module online stigma reduction intervention specifically designed for refugees (‘Tell Your Story’, TYS) or to a wait-list control (WLC) group. Participants completed online assessments of self-stigma for PTSD and help-seeking, and help-seeking intentions and behaviors at baseline, post-intervention, and at a 1 month follow-up.
Intent-to-treat analyses indicated that, compared to the WLC, TYS resulted in significantly smaller increases in self-stigma for seeking help from post-treatment to follow-up (d = 0.42, p = 0.008). Further, participants in the TYS conditions showed greater help-seeking behavior from new sources at follow-up (B = 0.69, 95% CI 0.19–1.18, p = 0.007) than those in the WLC. The WLC showed significantly greater increases in help-seeking intentions from post-intervention to follow-up (d = 0.27, p = 0.027), relative to the TYS group.
This is the first investigation of a mental health stigma reduction program specifically designed for refugees. Findings suggest that evidence-based stigma reduction strategies are beneficial in targeting self-stigma related to help-seeking and increasing help-seeking amongst refugees. These results indicate that online interventions focusing on social contact may be a promising avenue for removing barriers to accessing help for mental health symptoms in traumatized refugees.
The mental health and social functioning of millions of forcibly displaced individuals worldwide represents a key public health priority for host governments. This is the first longitudinal study with a representative sample to examine the impact of interpersonal trust and psychological symptoms on community engagement in refugees.
Participants were 1894 resettled refugees, assessed within 6 months of receiving a permanent visa in Australia, and again 2–3 years later. Variables measured included post-traumatic stress disorder symptoms, depression/anxiety symptoms, interpersonal trust and engagement with refugees’ own and other communities.
A multilevel path analysis was conducted, with the final model evidencing good fit (Comparative Fit Index = 0.97, Tucker–Lewis Index = 0.89, Root Mean Square Error of Approximation = 0.05, Standardized Root-Mean-Square-Residual = 0.05). Findings revealed that high levels of depression symptoms were associated with lower subsequent engagement with refugees’ own communities. In contrast, low levels of interpersonal trust were associated with lower engagement with the host community over the same timeframe.
Findings point to differential pathways to social engagement in the medium-term post-resettlement. Results indicate that depression symptoms are linked to reduced engagement with one's own community, while interpersonal trust is implicated in engagement with the broader community in the host country. These findings have potentially important implications for policy and clinical practice, suggesting that clinical and support services should target psychological symptoms and interpersonal processes when fostering positive adaptation in resettled refugees.
Although emergency service personnel experience markedly elevated the rates of post-traumatic stress disorder (PTSD), there are no rigorously conducted trials for PTSD in this population. This study assessed the efficacy of cognitive behaviour therapy (CBT) for PTSD in emergency service personnel, and examined if brief exposure (CBT-B) to trauma memories is no less efficacious as prolonged exposure (CBT-L).
One hundred emergency service personnel with PTSD were randomised to either immediate CBT-L, CBT-B or wait-list (WL). Following post-treatment assessment, WL participants were randomised to an active treatment. Participants randomised to CBT-L or CBT-B were assessed at baseline, post-treatment and at 6-month follow-up. Both CBT conditions involved 12 weekly individual sessions comprising education, CBT skills building, imaginal exposure, in vivo exposure, cognitive restructuring and relapse prevention. Imaginal exposure occurred for 40 min per session in CBT-L and for 10 min in CBT-B.
At post-treatment, participants in WL had smaller reductions in PTSD severity (Clinician Administered PTSD Scale), depression, maladaptive appraisals about oneself and the world, and smaller improvements on psychological and social quality of life than CBT-L and CBT-B. There were no differences between CBT-L and CBT-B at follow-up on primary or secondary outcome measures but both CBT-L and CBT-B had large baseline to follow-up effect sizes for reduction of PTSD symptoms.
This study highlights that CBT, which can include either long or brief imaginal exposure, is efficacious in reducing PTSD in emergency service personnel.
The majority of survivors of mass violence live in low- and middle-income countries (LMICs).
To synthesise empirical findings for psychological interventions for children and adolescents with post-traumatic stress disorder (PTSD) and/or depression in LMICs affected by mass violence.
Randomised controlled trials with children and adolescents with symptoms of PTSD and/or depression in LMICs were identified. Overall, 21812 records were found through July 2016 in the Medline, PsycINFO and PILOTS databases; 21 met the inclusion criteria and were reviewed according to recommended guidelines.
Twenty-one studies were included. Active treatments for PTSD yielded large pre-treatment to post-treatment changes (g = 1.15) and a medium controlled effect size (g = 0.57). Effect sizes were similar at follow-up. Active treatments for depression produced small to medium effect sizes. Finally, after adjustment for publication bias, the imputed uncontrolled and controlled effect sizes for PTSD were medium and small respectively.
Psychological interventions may be effective in treating paediatric PTSD in LMICs. It appears that more targeted approaches are needed for depressive responses.
Traumatic injuries affect millions of patients each year, and resulting post-traumatic stress disorder (PTSD) significantly contributes to subsequent impairment.
To map the distinctive long-term trajectories of PTSD responses over 6 years by using latent growth mixture modelling.
Randomly selected injury patients (n = 1084) admitted to four hospitals around Australia were assessed in hospital, and at 3, 12, 24 and 72 months. Lifetime psychiatric history and current PTSD severity and functioning were assessed.
Five trajectories of PTSD response were noted across the 6 years: (a) chronic (4%), (b) recovery (6%), (c) worsening/recovery (8%), (d) worsening (10%) and (e) resilient (73%). A poorer trajectory was predicted by female gender, recent life stressors, presence of mild traumatic brain injury and admission to intensive care unit.
These findings demonstrate the long-term PTSD effects that can occur following traumatic injury. The different trajectories highlight that monitoring a subset of patients over time is probably a more accurate means of identifying PTSD rather than relying on factors that can be assessed during hospital admission.
The latent structure of the proposed ICD-11 post-traumatic stress
disorder (PTSD) symptoms has not been explored.
To investigate the latent structure of the proposed ICD-11 PTSD
Confirmatory factor analyses using data from structured clinical
interviews administered to injury patients (n = 613) 6
years post-trauma. Measures of disability and psychological quality of
life (QoL) were also administered.
Although the three-factor model implied by the ICD-11 diagnostic criteria
fit the data well, a two-factor model provided equivalent, if not
superior, fit. Whereas diagnostic criteria based on this two-factor model
resulted in an increase in PTSD point prevalence (5.1%
v. 3.4%; z = 2.32,
P<0.05), they identified individuals with similar
levels of disability (P = 0.933) and QoL
(P = 0.591) to those identified by the ICD-11
Consistent with theorised reciprocal relationships between
re-experiencing and avoidance in PTSD, these findings support an
alternative diagnostic algorithm requiring at least two of any of the
four re-experiencing/avoidance symptoms and at least one of the two
There have been changes to the criteria for diagnosing post-traumatic
stress disorder (PTSD) in DSM-5 and changes are proposed for ICD-11.
To investigate the impact of the changes to diagnostic criteria for PTSD
in DSM-5 and the proposed changes in ICD-11 using a large multisite
trauma-exposed sample and structured clinical interviews.
Randomly selected injury patients admitted to four hospitals were
assessed 72 months post trauma (n = 510). Structured
clinical interviews for PTSD and major depressive episode, as well as
self-report measures of disability and quality of life were
Current prevalence of PTSD under DSM-5 scoring was not significantly
different from DSM-IV (6.7% v. 5.9%, z
= 0.53, P = 0.59). However, the ICD-11 prevalence was
significantly lower than ICD-10 (3.3% v. 9.0%,
z =–3.8, P<0.001). The PTSD
current prevalence was significantly higher for DSM-5 than ICD-11 (6.7%
v. 3.3%, z = 2.5, P
= 0.01). Using ICD-11 tended to show lower rates of comorbidity with
depression and a slightly lower association with disability.
The diagnostic systems performed in different ways in terms of current
prevalence rates and levels of comorbidity with depression, but on other
broad key indicators they were relatively similar. There was overlap
between those with PTSD diagnosed by ICD-11 and DSM-5 but a substantial
portion met one but not the other set of criteria. This represents a
challenge for research because the phenotype that is studied may be
markedly different according to the diagnostic system used.
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