Evaluating the procedural validity of the multilingual computer assisted self interview (MultiCASI) in a refugee population.

Multimedia-based administration of questionnaires, presenting items both in writing and spoken word, offers numerous potential benefits in transcultural psychiatry, such as improved comprehension of each question, ease of administration, prevention of missing or arbitrary responses, and obviating subsequent data entry. The concept has become known as "Computer-Assisted Self Interviewing" (CASI), and while preliminary results are promising, previous studies have not directly compared CASI to paper-and-pen administration in a large and representative sample of refugees. The aim of this study was to evaluate the procedural validity of multilingual CASI in comparison to paper-based-administration. The Hopkins Symptom Checklist-25 anxiety and depression subscales were administered in both modalities with a total of N = 281 participants from sites in Australia, New Zealand, and Denmark. We evaluated potential deviations in both the raw item and scale scores in each modality, while psychometric properties of each subscale were compared for an Arabic-speaking subsample (n = 125). Results showed no significant differences between raw item- or scale score across the two modalities, nor between the level of construct validity. In conclusion, this study supports a wider adaptation of multilingual CASI in the context of transcultural psychiatry, both for purposes of screening and treatment evaluation.

Understanding the pathology of psychiatric disorders in refugees.

Displacement of people from their homes, families and countries is a current global crisis, with over 70 million people forcibly on the move. A substantial proportion of these people will end up in regions with a different language and culture, where they are registered as refugees or asylum seekers. Due to the underlying reasons for displacement (including conflicts, persecution or violation of human rights), displaced people are severely stress-exposed, which continues into their post-migration life and increases risk for developing psychiatric disorders such as post-traumatic stress disorder and other anxiety disorders and mood disorders. While landmark studies have illustrated the increased prevalence of psychopathology in asylum seeker and refugee populations following pre-/post-displacement stress, few studies add to our understanding of the basic biological mechanisms underpinning risk to psychiatric disorders in these populations. Additionally, the mechanisms underlying resilience despite significant adversity remain unclear. Understanding the molecular mechanisms underpinning the development of psychiatric disorders in refugees can propel treatments (both drug and non-drug) that are capable of influencing biology at the molecular level, and the design of interventions. In the following review, we summarise the status quo of research investigating the pathophysiology of psychiatric disorders in refugees, and propose new ways to address gaps in knowledge with multidisciplinary research.

Mental health literacy among refugee communities: differences between the Australian lay public and the Iraqi and Sudanese refugee communities.

PURPOSE: This study investigated differences in mental health knowledge and beliefs between participants from the Iraqi and Sudanese refugee communities, and Australian-born individuals, in Sydney, Australia. METHODS: Ninety-seven participants were given vignettes of characters describing symptoms of major depressive disorder and posttraumatic stress. They were required to identify psychological symptoms as disorders, rate beliefs about the causes of and helpful treatments for these disorders, and rate attitude statements regarding the two characters. RESULTS: Australian participants recognized the presented symptoms as specific mental disorders significantly more than Iraqi and Sudanese participants did, and reported causal and treatment beliefs which were more congruent with expert beliefs as per the western medical model of mental disorder. The Sudanese group endorsed supernatural and religious causal beliefs regarding depression and posttraumatic stress symptoms most often; but both Sudanese and Iraqi participants strongly supported options from the supernatural and religious treatment items. However, evidence for pluralistic belief systems was also found. CONCLUSIONS: Although sampling was non-random, suggesting caution in the interpretation of results, it appears that the mental health literacy of lay Australians may be more aligned with the western medical model of mental disorder than that of Iraqi and Sudanese refugee communities. Mental health literacy support needs of Iraqi and Sudanese refugee communities resettled in western countries such as Australia might include education about specific symptoms and causes of mental disorder and the effectiveness of psychiatric treatments. These findings provide useful directions for the promotion of optimal service utilization among such communities.

Two year psychosocial and mental health outcomes for refugees subjected to restrictive or supportive immigration policies.

Australia has been at the forefront of implementing immigration policies that aim to limit the flow of asylum seekers over recent decades. Two controversial polices have been the use of immigration detention for unauthorized arrivals and the issuing of temporary protection visas (TPVs) for refugees who arrived without valid visas. We conducted a longitudinal survey over 2 years commencing in 2003 of 104 consecutive refugees from Iran and Afghanistan attending a state-wide early intervention program in New South Wales. The sample included those released from immigration detention on TPVs (n = 47) and others granted permanent protection visas prior to entering Australia (PPVs, n = 57). Psychological symptoms were assessed at baseline and follow-up by the Harvard Trauma Questionnaire (HTQ), the Hopkins symptom checklist-25 (HSCL), the GHQ-30 and the Penn State Worry Questionnaires (PSWQ). English language competency, daily living difficulties and coping-related activities were also assessed. The results indicated that TPVs had higher baseline scores than PPVs on the HTQ PTSD scale, the HSCL scales, and the GHQ. ANCOVA models adjusting for baseline symptom scores indicated an increase in anxiety, depression and overall distress for TPVs whereas PPVs showed improvement over time. PTSD remained high at follow-up for TPVs and low amongst PPVs with no significant change over time. The TPVs showed a significant increase in worry at follow-up. TPVs showed no improvement in their English language skills and became increasingly socially withdrawn whereas PPVs exhibited substantial language improvements and became more socially engaged. TPV holders also reported persistently higher levels of distress in relation to a wide range of post-migration living difficulties whereas PPVs reported few problems in meeting these resettlement challenges. The data suggest a pattern of growing mental distress, ongoing resettlement difficulties, social isolation, and difficulty in the acculturation process amongst refugees subject to restrictive immigration policies.

Adult separation anxiety disorder among war-affected Bosnian refugees: comorbidity with PTSD and associations with dimensions of trauma.

Although separation anxiety disorder appears to be common among children exposed to disasters, there are no data focusing on the impact of trauma on adult separation anxiety disorder. The present exploratory study examined the relationship of adult separation anxiety disorder with other psychological reactions (posttraumatic stress disorder [PTSD], complicated grief, depression) and dimensions of trauma among 126 war-affected Bosnian refugees resettled in Australia. Adult separation anxiety disorder was associated with PTSD, but not with complicated grief or depression. Although adult separation anxiety disorder was weakly linked with traumatic losses, this association was nonspecific. Further research is needed to clarify the pathogenic pathways leading to the comorbid PTSD-adult separation anxiety disorder pattern and its clinical implications.

Relationship between recent life events, social supports, and attitudes to domestic violence: predictive roles in behaviors.

The purpose of the study was to assess the relationship between recent life events, attitudes to domestic violence (DV), and DV behaviors among perpetrators of DV in China. A total of 600 participants were assessed for recent life events, psychological functioning, social support, and attitudes to DV. Results demonstrated that recent negative life events (NLE) and attitudes to DV were predictive factors for DV among perpetrators of DV, after controlling for demographic variables, psychological functioning, and social supports. The findings suggest that recent life events are potential factors contributing to behaviors of DV. The importance of changes of negative attitudes to DV among perpetrators was highly emphasized. Intervention and prevention programs based on psychological functioning and social support in relation to perpetrators of DV may be useful to control DV in China.

Child sexual abuse, coping strategies and lifetime posttraumatic stress disorder among female inmates.

The purpose of the study was to assess the relationship between child sexual abuse (CSA) and posttraumatic stress disorder (PTSD) in female inmates in China. A total of 471 participants were assessed for CSA, personality traits, coping strategies, and frequency of lifetime PTSD. Results demonstrated that CSA and negative coping were predictive factors for lifetime PTSD among female inmates after personality traits were controlled. The findings suggest that CSA is one potential factor contributing to lifetime PTSD among female inmates. The importance of screening for CSA among female inmates was highly emphasized. Early intervention and prevention programmes based on coping skills may be useful to forestall the development of chronic PTSD in female inmates.

A comparison of the mental health of refugees with temporary versus permanent protection visas.

OBJECTIVES: To determine the impact of the Australian provisions for temporary rather than permanent protection for asylum seekers found to be genuine refugees. DESIGN AND SETTING: A comparison of the mental health of Persian-speaking refugees with temporary (n = 49) versus permanent (n = 67) protection visas attending an early intervention program in Sydney, New South Wales, 2002-03. MEASURES: Standard measures were used to assess past trauma, detention experiences, postmigration stresses, symptoms of post-traumatic stress disorder (PTSD), anxiety, depression and functional impairment. RESULTS: The two groups had experienced similar levels of past trauma and persecution. Nevertheless, holders of temporary protection visas (TPVs) returned higher scores on three psychiatric symptom measures (P < 0.001). Multivariate analyses showed that TPV status was the strongest predictor of anxiety, depression and particularly PTSD. Further analyses suggested that, for TPV holders, experience of past stresses in detention in Australia and ongoing living difficulties after release contributed to adverse psychiatric outcomes. CONCLUSIONS: The sequence of postmigration stresses experienced by TPV holders appears to impact adversely on their mental health.

Impact of immigration detention and temporary protection on the mental health of refugees.

BACKGROUND: Over the past decade, developed Western countries have supplied increasingly stringent measures to discourage those seeking asylum. AIMS: To investigate the longer-term mental health effects of mandatory detention and subsequent temporary protection on refugees. METHOD: Lists of names provided by community leaders were supplemented by snowball sampling to recruit 241 Arabic-speaking Mandaean refugees in Sydney (60% of the total adult Mandaean population). Interviews assessed post-traumatic stress disorder (PTSD), major depressive episodes, and indices of stress related to past trauma, detention and temporary protection. RESULTS: A multilevel model which included age, gender, family clustering, pre-migration trauma and length of residency revealed that past immigration detention and ongoing temporary protection each contributed independently to risk of ongoing PTSD, depression and mental health-related disability. Longer detention was associated with more severe mental disturbance, an effect that persisted for an average of 3 years after release. CONCLUSIONS: Policies of detention and temporary protection appear to be detrimental to the longer-term mental health of refugees.

Prevalence and characteristics of trauma and posttraumatic stress disorder in female prisoners in China.

OBJECTIVE: Posttraumatic stress disorder (PTSD) and its relationship with a range of traumatic events have previously been documented within various traumatized groups in Western countries. In the present study, the authors investigated the relationship between the frequency and type of traumatic events and the prevalence of PTSD among female prisoners in China. METHOD: A structured psychiatric interview, the self-report Traumatic Life Events Questionnaire, and Symptom Checklist-90-Revised were administered to a subset of 471 female members who were randomly selected from Hunan female prison, China. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) diagnoses were assigned by consensus after the interviews were evaluated by independent raters. RESULTS: The prevalences of lifetime and current PTSD were 15.9% (n = 75) and 10.6% (n = 50), and 82% (n = 386) of the subjects had experienced at least 1 traumatic event. The whole sample was divided into 2 groups according to age: the younger group (age < or =25 years) and the older group (age >25 years) . The most predictive factor for lifetime PTSD among the younger age group was the experience of sudden death of a close friend or a loved one, childhood physical abuse, intimate partner abuse, and sexual abuse before the age of 13 years by someone at least 5 years older. For the older group, the most predictive factors were a history of motor traffic accident, sudden death of a close friend or a loved one, severe assault by acquaintance or stranger, witness to family violence, having experienced more than 5 traumatic events, intimate partner abuse, and sexual abuse before the age of 13 years by someone at least 5 years older. Those females with PTSD tended to demonstrate higher levels of anger/hostility or interpersonal sensitivity than those without either partial or full diagnosis. CONCLUSIONS: In this sample of female prisoners in China, although exposure to traumatic events was common and the rate is nearly as high as that in western countries, the prevalences of lifetime and current PTSD were relatively lower. Moreover, the prevalence of current PTSD among younger prisoners was significantly higher than that among older prisoners. The risk of developing lifetime PTSD was significantly greater only for older prisoners with a history of more than 5 traumatic events, whereas the types of specific traumatic events with the risk of developing lifetime PTSD among younger prisoners were similar to that among older prisoners. Administering specialized treatments for anger dyscontrol and interpersonal sensitivity may be useful for rehabilitation and reform of female prisoners.

Complicated grief in Bosnian refugees: associations with posttraumatic stress disorder and depression.

Complicated grief is likely to be common among refugee populations exposed to war trauma. However, there have been few studies investigating the traumatic antecedents and correlates of complicated grief in refugees, and the relationship of that symptom pattern with other common disorders such as posttraumatic stress disorder (PTSD) and depression. We studied Bosnian refugees recruited from a community center in Sydney, Australia, with the sample being supplemented by a snowball method (N = 126; response rate, 86%). Measures included a trauma inventory, the Clinician Administered PTSD Scale (CAPS), the depression module of the Structured Clinical Interview (SCID), and the Core Bereavement Items (CBI). A dimension of traumatic loss derived from the trauma inventory was a specific predictor of complicated grief, with exposure to human rights violations being associated with images of the traumatic events surrounding the lost person. There was no link between PTSD and grief other than for a low-order association with the PTSD intrusion dimension. In contrast, depression was strongly associated with grief and its subscales. Only the subgroup with comorbid grief and depression reported higher levels of traumatic loss. The results suggest that complicated grief in refugees can become persistent and associated with depression. While PTSD and grief share common symptoms of intrusion, the two symptom domains are sufficiently distinct to warrant independent assessment of grief in refugee populations.

Comorbidity of PTSD and depression: associations with trauma exposure, symptom severity and functional impairment in Bosnian refugees resettled in Australia.

BACKGROUND: Posttraumatic stress disorder (PTSD) is common in refugees but its association with longer-term psychosocial dysfunction remains unclear. We examined whether a subgroup of refugees with comorbid PTSD and depression were at particularly high risk of disability. We also investigated whether specific trauma experiences were linked to this comorbid pattern. METHODS: Consecutive Bosnians (and one or two compatriots nominated by them) were recruited from a community centre, yielding a total sample of 126 participants (response rate 86%). Measures included a trauma inventory, the Clinician Administered PTSD Scale (CAPS) (Blake et al., 1995) and the depression module of the Structured Clinical Interview (SCID) (First et al., 1997). RESULTS: Three diagnostic groupings emerged: normals (n=39), pure PTSD (n=29), and comorbid PTSD and depression (n=58). Of four trauma dimensions derived from principle components analysis (human rights violations, dispossession and eviction, life threat and traumatic loss), life threat alone was associated with pure PTSD, with life threat and traumatic loss both being associated with comorbidity. Compared to normals and those with pure PTSD, the comorbid group manifested more severe PTSD symptoms as well as higher levels of disability on all indices (global dysfunction: odds ratio=5.0, P<0.001, distress: odds ratio=6.0, P<0.001, social impairment: odds ratio 5.9, P<0.001, and occupational disability: odds ratio 5.0, P<0.001). LIMITATIONS: Recruitment was not random, the sample size was modest, and trauma event endorsement was based on retrospective accounts. CONCLUSIONS: The combination of life threat and traumatic loss may be particularly undermining to the psychological well-being of refugees and consequent comorbidity of PTSD and depression may be associated with longer-term psychosocial dysfunction. The findings raise the question whether the comorbid pattern identified should be given more recognition as a core posttraumatic affective disorder.

Psychiatric status of asylum seeker families held for a protracted period in a remote detention centre in Australia.

OBJECTIVE: To document the psychiatric status of a near complete sample of children and their families from one ethnic group held for an extended period of time in a remote immigration detention facility in Australia. METHOD: Structured psychiatric interviews were administered by three same-language speaking psychologists by phone to assess the lifetime and current psychiatric disorders among 10 families (14 adults and 20 children) held in immigration detention for more than two years. RESULTS: All adults and children met diagnostic criteria for at least one current psychiatric disorder with 26 disorders identified among 14 adults, and 52 disorders among 20 children. Retrospective comparisons indicated that adults displayed a threefold and children a tenfold increase in psychiatric disorder subsequent to detention. Exposure to trauma within detention was commonplace. All adults and the majority of children were regularly distressed by sudden and upsetting memories about detention, intrusive images of events that had occurred, and feelings of sadness and hopelessness. The majority of parents felt they were no longer able to care for, support, or control their children. CONCLUSIONS: Detention appears to be injurious to the mental health of asylum seekers. IMPLICATIONS: The level of exposure to violence and the high level of mental illness identified among detained families provides a warning to policy makers about the potentially damaging effects of prolonged detention on asylum seekers. In their attempt to manage the international asylum crisis, it is important that Western countries do not inadvertently implement policies that cause further harm.