Gender Differences in Traumatic Experiences and Posttraumatic Stress Symptoms After the Rwandan Genocide Against the Tutsi.

The effects of the 1994 Rwandan Genocide against the Tutsi are widespread and long-lasting, but little is known about how posttraumatic consequences differ regarding gender. In the present study, we estimated the associations between trauma exposure and posttraumatic stress symptoms (PTSS) in a Rwandan community sample and examined whether the associations differed by gender. The sample comprised 498 adults (75.2% women) living in Rwanda's Huye District in 2011. We used a validated self-report checklist to assess the eight most frequent traumatic experiences during the Genocide. The PTSD Checklist-Civilian version (PCL-C) was used to assess PTSS. Associations between trauma exposure and PTSS were estimated using structural equation modeling (SEM), with additional SEMs stratified by gender. The prevalence of exposure to each traumatic event ranged from 15.1% to 64.5%, with more severe PTSS among individuals who reported personal physical injury, ß = .76, 95% CI [0.54, 0.98]; witnessing sexual/physical violence against a loved one, ß = .51, 95% CI [0.20, 0.81]; a close relative/friend's death, ß = .54, 95% CI [0.24, 0.83]; property destruction, ß = .35, 95% CI [0.048, 0.51]; or a family member's death due to illness, ß = .21, 95% CI [0.00, 0.41]. Men who saw people killed and women who witnessed sexual/physical violence against a close family member reported elevated PTSS. The psychiatric impact of the Rwandan Genocide continues into the 21st century. Increased attention should be paid to the long-term and demographic patterns of distress and disorder, especially in the absence of widespread clinical mental health services.

Adherence to childhood religious affiliation and suicide intentions in women exposed to the violence of the 1994 Genocide against the Tutsi in Rwanda.

PURPOSE: To examine the association between adherence to childhood religious affiliations and serious suicide intentions in 371 women exposed to the 1994 Genocide against the Tutsi in Rwanda. METHODS: Participants were randomly sampled in 2011 from households in the Southern Province of Rwanda. Trained interviewers gathered information on socio-economic background, genocide-related trauma exposure, Major Depressive Episode (MDE) and suicide intentions (assessed with the Mini International Neuropsychiatric Interview), and Posttraumatic Stress Disorder (PTSD) (assessed with the PTSD Checklist-Civilian version). RESULTS: In this predominantly Christian sample, 62.8% (233/371) had adhered to their childhood religious affiliation. Adherence was associated with lower odds of serious suicide intentions (OR 0.321, 95% CI 0.13-0.78, P < 0.01) independent of socio-economic factors, court-designated victim status, trauma exposure, MDE, and PTSD; that association held following consideration of specific denomination. CONCLUSION: Women who adhere to their childhood religious affiliation may be less likely to have serious suicide intentions following major catastrophes. Whether that association is attributable to stronger connections with lost and remaining family and friends, or greater faith in the church as a facilitator of reconciliation and coping, requires further study.

Contribution of religion/spirituality and major depressive disorder to altruism.

BACKGROUND: In most studies, religiosity and spirituality (R/S) are positively associated with altruism, whereas depression is negatively associated. However, the cross-sectional designs of these studies limit their epidemiological value. We examine the association of R/S and major depressive disorder (MDD) with altruism in a five year longitudinal study nested in a larger prospective study. METHODS: Depressed and non-depressed individuals and their first- and second-generation offspring were assessed over several decades. At Year30 after baseline, R/S was measured using participants' self-report; MDD, by clinical interview. At Year35, participants completed a measure of altruism. Adjusted odds ratios (AOR) were calculated using multivariate logistic regression; statistical significance, set at p<.05. two-tailed. RESULTS: In the overall sample, both R/S and MDD were significantly associated with altruism, AOR 2.52 (95% CI 1.15-5.49) and AOR 2.43 (95% CI 1.05-5.64), respectively; in the High Risk group alone, the corresponding AORs were 4.69 (95% CI 1.39-15.84) and 4.74 (95% CI 1.92-11.72). Among highly R/S people in the High Risk group, the AOR for MDD with altruism was 22.55 (95% CI 1.23-414.60) p<.04; among the remainder, it was 3.12 (95% CI 0.63-15.30), a substantial but non-significant difference. LIMITATIONS: Altruism is based on self-report, not observation, hence, vulnerable to bias. CONCLUSIONS: MDD's positive association with elevated altruism concurs with studies of posttraumatic growth in finding developmental growth from adversity. The conditions that foster MDD's positive association with altruism and the contribution of R/S to this process requires further study.

Multidimensional understanding of religiosity/spirituality: relationship to major depression and familial risk.

BACKGROUND: Previous research has shown prospectively that religiosity/spirituality protects against depression, but these findings are commonly critiqued on two grounds, namely: (1) apparent religiosity/spirituality reflects merely an original absence of depression or elevated mood and (2) religiosity/spirituality too often is measured as a global construct. The current study investigates the relationship between depression and religiosity/spirituality by examining its multidimensional structural integrity. METHOD: Confirmatory factor analyses with a previously observed cross-cultural factor structure of religiosity/spirituality variables were conducted on an independent sample, diagnostic and familial risk subgroups from this sample, and a subsample of the original cross-cultural sample. Linear regressions onto a previous diagnosis of major depressive disorder (MDD) 5 years prior to assess the potential attenuating impact of a previous depression was explored. RESULTS: Across familial risk groups and clinical subgroups, each of the previously validated religiosity/spirituality domains was confirmed, namely: religious/spiritual commitment, contemplative practice, sense of interconnectedness, the experience of love, and altruistic engagement. Previous MDD diagnosis was associated with a lower religious/spiritual commitment among high-risk individuals, higher contemplation among low-risk individuals, and lower importance of religion or spirituality regardless of risk group. CONCLUSIONS: Structural integrity was found across familial risk groups and diagnostic history for a multidimensional structure of religiosity/spirituality. Differential associations between a previous diagnosis of MDD and level of religiosity/spirituality across domains suggest a complex and interactive relation between depression, familial risk, and religiosity/spirituality. Accounting for an empirically valid, multidimensional understanding of religiosity/spirituality may advance research on mechanisms underlying the relationship between religiosity/spirituality and mental health.

Are Children or Adolescents More at Risk for Posttraumatic Stress Reactions Following Exposure to Violence?: Evidence From Post-Genocide Rwanda.

Whether children or adolescents exhibit higher levels of posttraumatic stress symptoms (PTSS) in response to violence is an unresolved research question. We examine this issue in UNICEF's 1995 National Trauma Survey (NTS) of 8-19-year-olds (n = 942) who survived the Rwandan Genocide and lived and attended schools in the community. PTSS were assessed with a symptom checklist based on DSM-IV indexed using an overall score comprising the sum of scores on all items and mean item scores of each of five distinct factors identified in a factor analysis within this sample. Eighty percent of the sample had witnessed massacres; 25%, rape/sexual mutilation. The overall symptom score among children was significantly (p < 0.05) lower than among adolescents. Among the five separate factors, this direct association of age with symptom levels held for two: re-experiencing (p < 0.001) and dysphoric arousal (p < 0.05), but not for the remaining three: avoidance, numbing, and anxious arousal. This discordance in factorial response to violence may help explain prevailing inconsistencies in the age-PTSS association reported to date.

Predictors of Disclosure of Maternal HIV Status by Caregivers to their Children in an Inner-City Community in the United States.

Disclosure of HIV status to children is a challenge parents living with HIV face. To evaluate predictors of maternal HIV disclosure in a low-income clinic in the U.S. that serves an African American, Hispanic and immigrant population with high HIV prevalence, 172 caregivers with 608 children completed a standardized survey. Caregivers were 93 % female, 84 % biological mothers, and 34 % foreign born. Sixty-two (36 %) caregivers had at least one disclosed child, 42 of whom also had other nondisclosed children. Of all children, 581 (96 %) were uninfected and 181 (30 %) were disclosed. Caregiver's U.S. birth (OR: 2.32, 95 % CI 1.20-4.52), child's age (OR: 1.2/year, 95 % CI 1.16-1.24), and increased HIV-stigma perception by caregiver (1.06/point increase, 95 % CI 1.04-1.09) predicted disclosure. Children were more often disclosed if their caregiver was born in the U.S. or reported higher HIV-related stigma. These findings suggest that complex family context may complicate disclosure, particularly among immigrants.

Does Nursery-Based Intensified Anticipatory Guidance Reduce Emergency Department Use for Nonurgent Conditions in the First Month of Life? A Randomized Controlled Trial.

Objective. We aimed to evaluate the impact of an intensified anticipatory guidance program in the nursery on Emergency Department (ED) use for nonurgent conditions (NUCs) in the neonatal period. Methods. Parturient mothers of healthy newborns were randomized to an intervention group or control group. Baseline and 1-month follow-up knowledge surveys regarding newborn care were conducted. The primary outcome was the proportion of neonates who used the ED for a NUC. Secondary outcome was change in caregivers' knowledge on NUC. Results. Of a total of 594 mothers, 323 (54%) agreed to participate and were randomized to intervention (n = 170) or control (n = 153) group. Most were Hispanic (68%), single (61%), primiparous (39%), and without high school diploma (44%). 35 (21%) neonates in the intervention group and 41 (27%) in the control group were brought at least once for a NUC to the ED (p = 0.12). There was no statistically significant difference in within subject change on knowledge scores between the two study arms. Conclusions. Neonatal ED visits for NUCs occur frequently. This nursery-based intensified anticipatory guidance program had no statistically significant impact on neonatal ED use for NUC, nor on neonatal care-relevant knowledge among parturient mothers. Alternative modalities and timing of parental educational intervention may need to be considered. This trial is registered with Clinical Trials Number NCT01859065 (Clinicaltrials.gov).

Telephone-Administered Interpersonal Psychotherapy by Nurse-Midwives for Postpartum Depression.

INTRODUCTION: Postpartum depression (PPD) affects 7% to 13% of childbearing women. Access to care may be limited by maternal time constraints and fears of being judged, labeled as mentally ill, and having their infants taken away. The study's objective was to test the feasibility, effectiveness, and acceptability of certified nurse-midwife telephone-administered interpersonal psychotherapy (CNM-IPT) as a treatment for PPD. METHODS: A prospective cohort study was conducted from 2010 to 2014. A sample of women meeting Diagnostic and Statistical Manual of Mental Disorders, Version 4, Text Revision (DSM-IV-TR) criteria for depression was recruited from 8 obstetric practices employing CNMs in the United States. Forty-one women in the treatment group received up to eight 50-minute CNM-IPT sessions, and 20 in the control group were referred to mental health professionals. The main outcome measure was the Hamilton Rating Scale for Depression. Secondary outcomes included maternal and marital functioning, mother-infant bonding, social support, and client satisfaction. RESULTS: The Hamilton Rating Scale for Depression at 8 and 12 weeks was significantly lower among women in the treatment group compared to the control group (Week 8, P = .047; Week 12, P = .029). Client satisfaction was high in both groups. While only 5 out of 8 CNM-IPT counselors continued the intervention until the study's conclusion, CNM-IPT counselor protocol adherence was high. DISCUSSION: CNM-IPT is effective and acceptable as a method of reducing the severity of PPD symptoms. Careful assessment of CNM availability is critical to intervention feasibility. Future research is needed to evaluate translation of this intervention into practice.

Outcomes and risk factors for listing for heart transplantation after the Norwood procedure: An analysis of the Single Ventricle Reconstruction Trial.

BACKGROUND: Infants with hypoplastic left heart syndrome after palliation have the worst survival among heart transplant recipients. Heart transplantation is often reserved for use in patients with sub-optimal results after palliative surgery. This study characterized outcomes after listing in infants with a single ventricle who had undergone the Norwood procedure and identified predictors of the decision to list for heart transplantation. METHODS: The public-use database from the multicenter, prospective randomized Single Ventricle Reconstruction trial was used to identify patients who were listed for heart transplantation. Outcomes on the waiting list and after transplantation were determined. Risk factors were compared between those who were listed and those who survived without listing. RESULTS: Among 555 patients, 33 patients (5.9%) were listed and 18 underwent heart transplantation. Mortality was 39% while waiting for a heart and was 33% after heart transplantation. Overall, 1-year survival after listing (including death after transplantation) was 48%. Factors associated with listing were a lower right ventricular fractional area change at birth, non-hypoplastic left heart syndrome diagnosis, and a more complicated post-Norwood course, defined as a higher need for extracorporeal membrane oxygenation, longer intensive care unit stay, more complications, and a higher number of discharge medications. CONCLUSIONS: Worse right ventricular function, non-hypoplastic left heart syndrome diagnosis, and complex intensive care unit stay were significant risk factors for listing for heart transplantation after the Norwood procedure. Heart transplantation as a rescue procedure after the Norwood procedure in the first year of life carries a significant risk of mortality.

The factor structure of posttraumatic stress disorder symptoms among Rwandans exposed to the 1994 genocide: A confirmatory factor analytic study using the PCL-C.

The factor structure of posttraumatic stress disorder (PTSD) symptoms in Euro-American populations has been extensively studied, but confirmatory factor analytic studies from non-Western societies are lacking. Alternative models of DSM-IV symptoms were tested among Rwandan adults (N=465) who experienced trauma during the 1994 genocide. A cluster random survey was conducted with interviews held in Rwandan households. PTSD was assessed with the Posttraumatic Stress Disorder Checklist-Civilian version. Competing models were the DSM-IV, emotional numbing, dysphoria, aroused intrusion, and dysphoric arousal models. Results showed that the emotional numbing, dysphoria, and dysphoric arousal models had almost identical, good fit indices and fit the data significantly better than the other models. The emotional numbing and dysphoric arousal models also exhibited good construct validity. Results suggest that the latent structure of PTSD symptoms in Rwanda are comparable to that found in Euro-American samples, thereby lending further support to the cross-cultural validity of the construct.

Borderline personality disorder, exposure to interpersonal trauma, and psychiatric comorbidity in urban primary care patients.

OBJECTIVE: Few data are available on interpersonal trauma as a risk factor for borderline personality disorder (BPD) and its psychiatric comorbidity in ethnic minority primary care populations. This study aimed to examine the relation between trauma exposure and BPD in low-income, predominantly Hispanic primary care patients. METHOD: Logistic regression was used to analyze data from structured clinical interviews and self-report measures (n = 474). BPD was assessed with the McLean screening scale. Trauma exposure was assessed with the Life Events Checklist (LEC); posttraumatic stress disorder (PTSD) was assessed with the Lifetime Composite International Diagnostic Interview, other psychiatric disorders with the SCID-I, and functional impairment with items from the Sheehan Disability Scale and Social Adjustment Scale Self-Report (SAS-SR). RESULTS: Of the 57 (14%) patients screening positive for BPD, 83% reported a history of interpersonally traumatic events such as sexual and physical assault or abuse. While interpersonal trauma experienced during adulthood was as strongly associated with BPD as interpersonal trauma experienced during childhood, noninterpersonal trauma was associated with BPD only if it had occurred during childhood. The majority (91%) of patients screening positive for BPD met criteria for at least one current DSM-IV Axis I diagnosis and exhibited significant levels of functional impairment. CONCLUSION: Increased awareness of BPD in minority patients attending primary care clinics, high rates of exposure to interpersonal trauma, and elevated risk for psychiatric comorbidity in this population may enhance physicians' understanding, treatment, and referral of BPD patients.

Moderators of treatment effectiveness for war-affected youth with depression in northern Uganda.

PURPOSE: As we build the evidence base of interventions for depression among war-affected youth, it is critical to understand factors moderating treatment outcomes. The current study investigated how gender and history of abduction by Lord's Resistance Army rebels moderated treatment outcomes for war-affected youth. METHODS: The study-a three-armed, randomized, controlled trial-was conducted with internally displaced war-affected adolescents in northern Uganda. Participants with significant depression symptoms (N = 304; 57% female; 14-17 years of age) were randomly assigned to an interpersonal psychotherapy group (IPT-G), a creative play/recreation group, or a wait-list control condition. Secondary analyses were conducted on data from this randomized controlled trial. RESULTS: A history of abduction by Lord's Resistance Army rebels was reported by 42% of the sample. Gender and abduction history interacted to moderate the effectiveness of IPT-G for the treatment of depression. In the IPT-G intervention arm, treatment effectiveness was greatest among female subjects without an abduction history, with effect size = 1.06. IPT-G was effective for the treatment of depression for both male and female subjects with a history of abduction (effect size = .92 and .50, respectively). Male subjects with no abduction history in IPT-G showed no significant improvement compared with those in the control conditions. CONCLUSIONS: Abduction history and gender are potentially important moderators of treatment effects, suggesting that these factors need to be considered when providing interventions for war-affected youth. IPT-G may be an effective intervention for female subjects without an abduction history, as well as for both male and female former child soldiers, but less so for male subjects without an abduction history.

Functional impairment in adults with past posttraumatic stress disorder: findings from primary care.

BACKGROUND: Although many patients with posttraumatic stress disorder (PTSD) experience a reduction in posttraumatic symptoms over time, little is currently known about the extent of their residual functional impairment. This study examines functional impairment in primary care patients with a history of PTSD as compared to patients with current PTSD, and those who never developed PTSD following exposure to trauma. METHODS: The sample consisted of 321 trauma-exposed low-income, predominantly Hispanic adults attending a large urban primary care practice. PTSD was assessed with the Lifetime Composite International Diagnostic Interview and other psychiatric disorders with the SCID-I. Physical and mental health-related quality of life was assessed with the Medical Outcome Health Survey (SF-12), and functional impairment with items from the Sheehan Disability Scale and Social Adjustment Scale Self-Report. RESULTS: Logistic regression analyses controlling for gender, psychiatric comorbidity, and interpersonal traumas showed that although patients with past PTSD function significantly better than patients with current PTSD, they experience persisting deficits in mental health-related quality of life compared to trauma-exposed patients who never developed PTSD. Overall, results revealed a continuum of severity in psychiatric comorbidity, functioning, and quality of life, with current PTSD associated with the most impairment, never having met criteria for PTSD with the least impairment, and history of PTSD falling in between. CONCLUSIONS: In this primary care sample, adults with a history of past PTSD but no current PTSD continued to report enduring functional deficits, suggesting a need for ongoing clinical attention.

Sociocultural domains of depression among indigenous populations in Latin America.

Not enough research has been carried out on depression up to now in Latin America. The knowledge that has resulted from research activities in the USA or Europe offers limited generalizability to other regions of the world, including Latin America. In the Andean highlands of Ecuador, we found very high rates of moderate and severe depressive symptoms, a finding that must be interpreted within its cultural context. Somatic manifestations of depression predominated over cognitive manifestations, and higher education level was protective against depression. These findings call for an appreciation of culturally specific manifestations of depression and the social factors that influence them. These factors must be further studied in order to give them the deserved priority, allocate resources appropriately, and formulate innovative psychosocial interventions.

Identifying future VFR travelers among immigrant families in the Bronx, New York.

Travelers visiting friends and relatives (VFR) have low rates of pre-travel health encounters. In 2006 in the Bronx, New York, a convenience sample of 129 families originating in malaria-endemic countries and presenting for a routine pediatric outpatient evaluation completed a standardized questionnaire regarding future travel plans to their country of origin. Pro-active screening for intended travel activities can identify future VFR travelers and ascertain potentially high-risk itineraries, thereby enabling education regarding the importance of accessing competent pre-travel medicine services.

Illness in children after international travel: analysis from the GeoSentinel Surveillance Network.

OBJECTIVE: By using a large, multicenter database, we investigated the characteristics and morbidities of 1591 children returning from 218 global destinations and presenting for care in 19 countries. METHODS: Data reported to the GeoSentinel Surveillance Network between January 1997 and November 2007 were analyzed, to assess demographic features, travel characteristics, and clinical diagnoses of ill pediatric travelers. Data were compared between children and adults and among 3 pediatric age groups (0-5 years, 6-11 years, and 12-17 years). RESULTS: Children were predominantly tourist travelers returning from Asia, sub-Saharan Africa, or Latin America. Compared with adults, children disproportionately presented within 7 days after return, required hospitalization, lacked pretravel health advice, and had traveled for the purpose of visiting friends and relatives. Diarrhea (28%), dermatologic conditions (25%), systemic febrile illnesses (23%), and respiratory disorders (11%) accounted for the majority of diagnoses reported for children. No fatalities were reported. Diarrhea occurred disproportionately among children after exposure to the Middle East/North Africa, dermatologic conditions after exposure to Latin America, systemic febrile illnesses after exposure to sub-Saharan Africa or Asia, and respiratory disorders after exposure to Europe or North America. The proportionate morbidity rates of travel-associated diseases differed among the pediatric age groups and between children and adults. CONCLUSIONS: The health care utilization patterns before and after travel and the profiles of travel-associated health problems differed between children and adults. Health professionals providing pretravel advice need to consider destination- and age-specific susceptibility to travel-related morbidities and develop prevention strategies accordingly.

Travel health care for immigrant children visiting friends and relatives abroad: retrospective analysis of a hospital-based travel health service in a US urban underserved area.

BACKGROUND: There is a lack of studies evaluating pre-travel health care for children who travel to visit friends and relatives (VFR). We evaluated travel health services provided to children VFR travelers (CVFRs) as compared with adult VFR travelers (AVFRs). CVFRs and AVFRs were also compared with children and with adults traveling as tourists (CTs and ATs, respectively), to explore relevant differences within each age group between VFRs and tourist travelers. METHODS: Retrospective chart review of all pre-travel consultations from March 2005 to July 2006 at the Bronx-Lebanon Hospital Center travel health clinic, Bronx, New York. RESULTS: Of 204 pre-travel consultations, 51% comprised CVFRs, 20% AVFRs, 7% CTs, and 23% ATs. About 54, 44, 57, and 30% of CVFRs, AVFRs, CTs, and ATs, respectively, presented within 14 days of departure. CVFRs were more likely than AVFRs and CTs to plan long-term travel (> 6 months). CVFRs and AVFRs traveled mostly to West Africa (75 and 73%) in contrast to CTs and ATs (7 and 35%). Mefloquine was the most frequently prescribed antimalarial medication overall (70%) and among CVFRs (94%). Yellow fever vaccine was most frequently administered overall and to CVFRs and AVFRs followed by hepatitis A, typhoid fever, and meningococcal vaccine. CTs were more likely than CVFRs to receive rabies vaccine. Delayed yellow fever administration (< 10 d before departure) was noted for 48% of CVFRs and 33% of AVFRs. CONCLUSIONS: CVFRs frequently plan to travel for long-term trips to West Africa and present late for pre-travel care. Routine screen for high-risk travel activities and coordination of pre-travel care within the routine preventive health care may improve the effectiveness of the travel health services.

Somatic and cognitive domains of depression in an underserved region of Ecuador: some cultural considerations.

Not enough research efforts on depression have been carried out up to now in Latin America. The knowledge that has resulted from research activities in the United States or Europe offers limited generalizability to other regions of the world, including Latin America. In the Andean highlands of Ecuador, we found very high rates of moderate and severe depressive symptoms, a finding that must be interpreted within its cultural context. Somatic manifestations of depression predominated over cognitive manifestations, and higher education level was protective against depression. These findings call for an appreciation of culturally-specific manifestations of depression and the social factors that influence them. These factors must be further studied in order to give them the deserved priority, allocate resources appropriately, and formulate innovative psychosocial interventions.