Association of Torture and Other Potentially Traumatic Events With Mental Health Outcomes Among Populations Exposed to Mass Conflict and Displacement: A Systematic Review and Meta-analysis (original) (raw)
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JAMA, 2009
ASS CONFLICT AND DISplacement continue to affect large numbers of people worldwide. 1 In 2007, the United Nations High Commissioner for Refugees documented 16 million refugees, 26 million internally displaced persons, and 12 million stateless persons. 2 Yet controversy about the mental health needs of conflictexposed populations persists, 3 a problem that is magnified by the wide variability in rates of the most commonly studied psychiatric conditions among affected populations, namely, posttraumatic stress disorder (PTSD) and depression. Prevalence rates for PTSD have ranged from 0% in a conflict-affected region of Iran 4 to 99% in Sierra Leone 5 and between 3% and 86% for depression across surveys. 6,7 Identifying the potential methodological and substantive factors that are associated with this variation is vital to determining with any accuracy rates of mental health problems of conflict-affected populations. Methodological factors, particularly the approach used for sampling and diagnosis, appear to exert a large influence on the prevalence rates yielded by surveys. 8 An outstanding question, how-Author Affiliations are listed at the end of this article.
Comorbidity of Posttraumatic Stress Disorder and Depression in Tortured, Treatment-Seeking Refugees
Journal of Traumatic Stress, 2017
There is a growing number of refugees forcibly displaced by persecution across the globe (United Nations High Commissioner for Refugees \[UNHCR\], 2015). A sizeable proportion of refugees suffer from psychological disorders including posttraumatic stress disorder (PTSD) or depression, and these disorders have been demonstrated to commonly co-occur in community studies conducted with refugee groups. Marshall, Schell, Elliott, Berthold, and Chun (2005) found that 71.0% of Cambodian refugees with a diagnosis of PTSD in the previous year met criteria for depression, and 86.0% of those with depression also met criteria for PTSD. Research with Bosnian refugees in Croatia and Australia suggested that 20.6% and 46.03% of participants had comorbid PTSD and depression, respectively (Mollica et al., 1999; Momartin, Silove, Manicavasagar, & Steel, 2004). Comorbidity has also been found to be extremely prevalent in clinical settings. A study conducted in the Netherlands found that 63.9% of treatment-seeking refugees and asylum-seekers with PTSD also had comorbid depression (Haagen, Ter Heide, Mooren, Knipscheer, & Kleber, 2016). Another study conducted in outpatient clinics in Norway found that 80.0% of patients with PTSD also met criteria for major depression (Teodorescu, Heir, Hauff, Wentzel-Larsen, & Lien, 2012). Notably, studies have found that PTSD appears to occur in the absence of depression more frequently than depression occurs in the absence of PTSD (Fazel, Wheeler, & Danesh, 2005; Momartin et al., 2004). Overall, research findings converge to indicate that comorbidity is pervasive among forcibly displaced populations.
A dual diagnosis of PTSD and depression (i.e., comorbidity) is associated with substantially greater disability and impairment in refugees than a single or no diagnosis (Mollica et al., 1999; Momartin et al., 2004). Mollica and colleagues (1999) found that refugees with comorbid PTSD and depression were 5 times more likely to report significant disability than those with no diagnosis, even after controlling for demographic and contextual This article is protected by copyright. All rights reserved. variables. In addition, comorbid depression has been found to reduce treatment response among refugees with PTSD (Haagen et al., 2016; Silove, Manicavasagar, Coello, & Aroche, 2005). Despite this, little is known about the predictors and correlates of comorbidity among treatment-seeking refugees. Momartin and colleagues (2004) found that, among
European Journal of Psychotraumatology, 2021
Background: The inclusion of complex post-traumatic stress disorder (CPTSD) in ICD-11 represents a turning point for the field of traumatic stress, with accumulative evidence of this disorder in refugees and displaced populations. Objective: The objectives of this systematic review are to examine, in refugee and displaced populations: 1) the prevalence of CPTSD; 2) factors contributing to CPTSD; and 3) and associations between CPTSD and other common mental disorders including: PTSD, depression, anxiety and somatisation. Method: We followed the Joanna Briggs Institute Methodology for Systematic Reviews. Papers published in English language were included, with date of publication between 1987 and June 2019. We searched six relevant databases: MEDLINE, PsycINFO, Embase, Scopus, CINAHL, and PILOTS, and the grey literature. We included observational studies with prevalence data on CPTSD. Results: 19 articles met all inclusion criteria. Quality assessment was performed on each included study using the Joanna Briggs Institute Critical Appraisal Checklist for Studies Reporting Prevalence Data. Based on this, 13 moderate and high-quality studies were included in our narrative synthesis. The included studies reported prevalence of CPTSD in refugees and displaced populations ranging from 2% to 86%. Conclusions: Reasons for the wide variation in prevalence may include contextual and geographical differences, the influence of post-migration difficulties, and sample population characteristics such as treatment seeking versus general population. We found higher prevalence rates (range: 16-82%) in more studies with treatment seeking samples, followed by convenience and snowball samples (40-51%), and lower rates in more studies utilising random sampling techniques (2-86%). Consistent with the broader literature, the studies in our review supported an association for complex post-traumatic stress disorder with prolonged, repeated trauma, and post-migration living difficulties, with the latter association being specific to refugee and displaced populations. Further research on this construct in this population group, including effective treatments, is required.
The Journal of Nervous and Mental Disease, 2018
Turkey is hosting the majority of Syrian refugees. The current study investigates the prevalence of probable posttraumatic stress disorder (PTSD) and depression among adult Syrians residing in a camp (N = 781) and potential predictors. The Impact of Event Scale–Revised was used to measure PTSD and the Beck Depression Inventory depression. Probable PTSD prevalence was 83.4%, with predictors being female sex (odds ratio [OR], 4.1), previous mental health problems (OR, 4.5), life threat (OR, 3.0), and injury of a loved one (OR, 1.8). Probable depression prevalence was 37.4%, with predictors being female sex (OR, 5.1), previous mental health problems (OR, 2.9), having a loved one who was tortured (OR, 1.7), and not being satisfied at the camp (OR, 1.7). The current study reveals high rates of probable PTSD and depression among Syrian refugees and highlights vulnerabilities such as great risk for women of having psychopathology.
Long-term mental health of war-refugees: a systematic literature review
BMC international health and human rights, 2015
There are several million war-refugees worldwide, majority of whom stay in the recipient countries for years. However, little is known about their long-term mental health. This review aimed to assess prevalence of mental disorders and to identify their correlates among long-settled war-refugees. We conducted a systematic review of studies that assessed current prevalence and/or factors associated with depression and anxiety disorders in adult war-refugees 5 years or longer after displacement. We searched Medline, Embase, CINAHL, PsycINFO, and PILOTS from their inception to October 2014, searched reference lists, and contacted experts. Because of a high heterogeneity between studies, overall estimates of mental disorders were not discussed. Instead, prevalence rates were reviewed narratively and possible sources of heterogeneity between studies were investigated both by subgroup analysis and narratively. A descriptive analysis examined pre-migration and post-migration factors associa...
Frontiers in Psychiatry, 2018
Background: Protracted armed conflicts not only shape political, legal, and socioeconomic structures, but also have a lasting impact on people's human migration. In 2017, the United Nations High Commissioner for Refugees reported an unprecedented number of 65.6 million individuals who were displaced worldwide as a result of armed conflicts. To date, however, little is known about these people's mental health status. Therefore, we conducted a systematic review of the prevalence of psychiatric disorders among forcibly displaced populations in settings of armed conflicts. Methods: We undertook a database search using Medline, PsycINFO, PILOTS, and the Cochrane Library, using the following keywords and their appropriate synonyms to identify relevant articles for possible inclusion: "mental health," "refugees," "internally displaced people," "survey," and "war." This search was limited to original articles, systematic reviews, and meta-analyses published after 1980. We reviewed studies with prevalence rates of common psychiatric disorders-mood and anxiety disorders, psychotic disorders, personality disorders, substance abuse, and suicidality-among adult internally displaced persons (IDPs) and refugees afflicted by armed conflicts. Results: The search initially yielded 915 articles. Of these references 38 studies were eligible and provided data for a total of 39,518 adult IDPs and refugees from 21 countries. The highest prevalence were for reported for post-traumatic stress disorder (3-88%), depression (5-80%), and anxiety disorders (1-81%) with large variation. Only 12 original articles reported about other mental disorders. Conclusions: These results show a substantial lack of data concerning the wider extent of psychiatric disability among people living in protracted displacement situations. Ambitious assessment programs are needed to support the implementation of sustainable global mental health policies in wartorn countries. Finally, there is an urgent need for large-scale interventions that address psychiatric disorders in refugees and internally displaced persons after displacement.
Preventing the mental health consequences of war in refugee populations
Epidemiology and Psychiatric Sciences
The refugee experience is associated with several potentially traumatic events that increase the risk of developing mental health consequences, including worsening of subjective wellbeing and quality of life, and risk of developing mental disorders. Here we present actions that countries hosting forcibly displaced refugees may implement to decrease exposure to potentially traumatic stressors, enhance subjective wellbeing and prevent the onset of mental disorders. A first set of actions refers to the development of reception conditions aiming to decrease exposure to post-migration stressors, and a second set of actions refers to the implementation of evidence-based psychological interventions aimed at reducing stress, preventing the development of mental disorders and enhancing subjective wellbeing.
Torture Journal
An increasing number of refugees and survivors of torture resettled in the United States are presenting to clinics for treatment related to trauma and postmigration difficulties. Although clinicians experienced in treating trauma with diverse populations may recognize the limitations of a PTSD diagnosis, one of the primary diagnoses received by refugees and survivors of torture remains post-traumatic stress disorder (PTSD). A variety of interventions exist (e.g., supportive, trauma specific, interdisciplinary including physical, social and psychological) for survivors of torture and trauma that move beyond this diagnosis, however, a unifying conceptual model is needed to guide treatment and further the empirical investigation and evidence base in this growing field. In this paper, we propose a broader biopsychosocial framework of the impact of traumatic war events including the measurement of stress related to post migration living difficulties, and daily hassles while highlighting ...
Predicting post-traumatic stress disorder treatment response in refugees: Multilevel analysis
British Journal of Clinical Psychology, 2016
Objectives. Given the recent peak in refugee numbers and refugees' high odds of developing post-traumatic stress disorder (PTSD), finding ways to alleviate PTSD in refugees is of vital importance. However, there are major differences in PTSD treatment response between refugees, the determinants of which are largely unknown. This study aimed at improving PTSD treatment for adult refugees by identifying PTSD treatment response predictors. Design. A prospective longitudinal multilevel modelling design was used to predict PTSD severity scores over time. We analysed data from a randomized controlled trial with pre-, post-, and follow-up measurements of the safety and efficacy of eye movement desensitization and reprocessing and stabilization in asylum seekers and refugees suffering from PTSD. Methods. Lack of refugee status, comorbid depression, demographic, trauma-related and treatment-related variables were analysed as potential predictors of PTSD treatment outcome. Treatment outcome data from 72 participants were used. Results. The presence (B = 6.5, p = .03) and severity (B = 6.3, p < .01) of a pretreatment depressive disorder predicted poor treatment response and explained 39% of the variance between individuals. Conclusions. Refugee patients who suffer from PTSD and severe comorbid depression benefit less from treatment aimed at alleviating PTSD. Results highlight the need for treatment adaptations for PTSD and comorbid severe depression in traumatized refugees, including testing whether initial targeting of severe depressive symptoms increases PTSD treatment effectiveness. Practitioner points There are differences in post-traumatic stress disorder (PTSD) treatment response between traumatized refugees. Comorbid depressive disorder and depression severity predict poor PTSD response. Refugees with PTSD and severe depression may not benefit from PTSD treatment. Targeting comorbid severe depression before PTSD treatment is warranted. This study did not correct for multiple hypothesis testing. Comorbid depression may differentially impact alternative PTSD treatments.