• Brief mental health interventions in conflict and emergency settings: an overview of four Medecins Sans Frontieres -- France programs

      Coldiron, M E; Llosa, A E; Roederer, T; Casas, G; Moro, M-R (BioMed Central, 2013-11-01)
      Mental health problems, particularly anxiety and mood disorders, are prevalent in the setting of humanitarian emergencies, both natural and man-made disasters. Evidence regarding best strategies for therapeutic interventions is sparse. Medecins Sans Frontieres has been providing mental health services during emergencies for over two decades, and here we compare data from four programs.Program Overview: In China, 564 patients were followed for an average of 7 sessions after a major earthquake. The most common diagnoses were PTSD and other anxiety disorders. Between program entry and exit, the median global assessment of functioning increased from 65 to 80. At program entry, 58% were considered moderately, markedly or severely ill; a proportion which fell to 14% at program exit. In Colombia in the setting of chronic violence, 2411 patients were followed for a median of two sessions. Anxiety disorders and major depression were the most common diagnoses, and 76% of patients were moderately or severely ill at program entry. 91% had symptomatic improvement at program exit. In Gaza, 1357 patients were followed for a median of 9 sessions; a majority was under age 15. PTSD and other anxiety disorders were the most common diagnoses, and 91% were moderately or severely ill at entry. 89% had improved symptoms at program exit. In the West Bank, the 1478 patients had similar characteristics to those enrolled in Gaza. 88% were moderately or severely ill at entry; 88% had improved at exit.Discussion and evaluation: It was feasible to implement brief yet effective mental health interventions in a wide variety of humanitarian contexts -- post-natural disaster, during acute violent conflict and during chronic violent conflict. The most common diagnoses were PTSD, other anxiety disorders and mood disorders. The use of local specially-trained counselors who were focused on coping skills and improving functionality over a brief time period, likely contributed to the symptomatic improvement seen in a large majority of patients across the four sites.
    • Characteristics of the Colombian armed conflict and the Mental Health of civilians living in active conflict zones

      Bell, V; Méndez, F; Martínez, C; Palma, P P; Bosch, M; Médicos sin Fronteras España, Misión Colombia, Bogotá, Colombia. msfe-bogota-cg@barcelona.msf.org. (2012-11-21)
    • The Colombian conflict: a description of a mental health program in the Department of Tolima.

      Sanchez-Padilla, E; Casas, G; Grais, RF; Hustache, S; Moro, M-R; Epicentre, 8 rue Saint Sabin, 75011, Paris, France. (2009-12)
      Colombia has been seriously affected by an internal armed conflict for more than 40 years affecting mainly the civilian population, who is forced to displace, suffers kidnapping, extortion, threats and assassinations. Between 2005 and 2008, Médecins Sans Frontières-France provided psychological care and treatment in the region of Tolima, a strategic place in the armed conflict. The mental health program was based on a short-term multi-faceted treatment developed according to the psychological and psychosomatic needs of the population. Here we describe the population attending during 2005-2008, in both urban and rural settings, as well as the psychological treatment provided during this period and its outcomes.We observed differences between the urban and rural settings in the traumatic events reported, the clinical expression of the disorders, the disorders diagnosed, and their severity. Although the duration of the treatment was limited due to security reasons and access difficulties, patient condition at last visit improved in most of the patients. These descriptive results suggest that further studies should be conducted to examine the role of short-term psychotherapy, adapted specifically to the context, can be a useful tool to provide psychological care to population affected by an armed conflict.
    • Conflict in the Indian Kashmir Valley I: exposure to violence.

      de Jong, K; Ford, N; Kam, S; Lokuge, K; Fromm, S; van Galen, R; Reilley, B; Kleber, R; Médecins Sans Frontières, Plantage Middenlaan 14, 1018 DD Amsterdam, the Netherlands. kaz.de.jong@amsterdam.msf.org. (2008-10-14)
      ABSTRACT: BACKGROUND: India and Pakistan have disputed ownership of the Kashmir Valley region for many years, resulting in several conflicts since the end of partition in 1947. Very little is known about the prevalence of violence and insecurity in this population. METHODS: We undertook a two-stage cluster household survey in two districts (30 villages) of the Indian part of Kashmir to assess experiences with violence and mental health status among the conflict-affected Kashmiri population. The article presents our findings for confrontations with violence. Data were collected for recent events (last 3 months) and those occurring since the start of the conflict. Informed consent was obtained for all interviews. RESULTS: 510 interviews were completed. Respondents reported frequent direct confrontations with violence since the start of conflict, including exposure to crossfire (85.7%), round up raids (82.7%), the witnessing of torture (66.9%), rape (13.3%), and self-experience of forced labour (33.7%), arrests/kidnapping (16.9%), torture (12.9%), and sexual violence (11.6%). Males reported more confrontations with violence than females, and had an increased likelihood of having directly experienced physical/mental maltreatment (OR 3.9, CI: 2.7-5.7), violation of their modesty (OR 3.6, CI: 1.9-6.8) and injury (OR 3.5, CI: 1.4-8.7). Males also had high odds of self-being arrested/kidnapped (OR 8.0, CI: 4.1-15.5). CONCLUSION: The civilian population in Kashmir is exposed to high levels of violence, as demonstrated by the high frequency of deliberate events as detention, hostage, and torture. The reported violence may result in substantial health, including mental health problems. Males reported significantly more confrontations with almost all violent events; this can be explained by higher participation in outdoor activities.
    • Conflict in the Indian Kashmir Valley II: psychosocial impact.

      de Jong, K; van der Kam, S; Ford, N; Lokuge, K; Fromm, S; van Galen, R; Reilley, B; Kleber, R (2008-10-14)
      ABSTRACT: BACKGROUND: India and Pakistan have disputed ownership of the Kashmir Valley region for many years, resulting in high level of exposure to violence among the civilian population of Kashmir (India). A survey was done as part of routine programme evaluation to assess confrontation with violence and its consequences on mental health, health service usage, and socio-economic functioning. METHODS: We undertook a two-stage cluster household survey in two districts of Kashmir (India) using questionnaires adapted from other conflict areas. Analysis was stratified for gender. RESULTS: Over one-third of respondents (n=510) were found to have symptoms of psychological distress (33.3%, CI: 28.3-38.4); women scored significantly higher (OR 2.5; CI: 1.7-3.6). A third of respondents had contemplated suicide (33.3%, CI: 28.3-38.4). Feelings of insecurity were associated with higher levels of psychological distress for both genders (males: OR 2.4, CI: 1.3-4.4; females: OR 1.9, CI: 1.1-3.3). Among males, violation of modesty, (OR 3.3, CI: 1.6-6.8), forced displacement, (OR 3.5, CI: 1.7-7.1), and physical disability resulting from violence (OR 2.7, CI: 1.2-5.9) were associated with greater levels of psychological distress; for women, risk factors for psychological distress included dependency on others for daily living (OR 2.4, CI: 1.3-4.8), the witnessing of killing (OR 1.9, CI: 1.1-3.4), and torture (OR 2.1, CI: 1.2-3.7). Self-rated poor health (male: OR 4.4, CI: 2.4-8.1; female: OR 3.4, CI: 2.0-5.8) and being unable to work (male: OR 6.7, CI: 3.5-13.0; female: OR 2.6, CI: 1.5-4.4) were associated with mental distress. CONCLUSIONS: The ongoing conflict exacts a huge toll on the communities' mental well-being. We found high levels of psychological distress that impacts on daily life and places a burden on the health system. Ongoing feelings of personal vulnerability (not feeling safe) were associated with high levels of psychological distress. Community mental health programmes should be considered as a way reduce the pressure on the health system and improve socio-economic functioning of those suffering from mental health problems.
    • Counselling in humanitarian settings: a retrospective analysis of 18 individual-focused non-specialised counselling programmes

      Shanks, L; Ariti, C; Siddiqui, R; Pintaldi, G; Venis, S; de Jong, K; Denault, M (BioMed Central, 2013-09-16)
      Medecins Sans Frontieres (MSF) provides individual counselling interventions in medical humanitarian programmes in contexts affected by conflict and violence. Although mental health and psychosocial interventions are a common part of the humanitarian response, little is known about how the profile and outcomes for individuals seeking care differs across contexts. We did a retrospective analysis of routine programme data to determine who accessed MSF counselling services and why, and the individual and programmatic risk factors for poor outcomes.
    • "I prefer dying fast than dying slowly", how institutional abuse worsens the mental health of stranded Syrian, Afghan and Congolese migrants on Lesbos island following the implementation of EU-Turkey deal

      Eleftherakos, C; van den Boogaard, W; Barry, D; Severy, N; Kotsioni, I; Roland-Gosselin, L (BioMed Central, 2018-09-05)
      Background In 2015 and early 2016, close to 1 million migrants transited through Greece, on their way to Western Europe. In early 2016, the closure of the “Balkan-route” and the EU/Turkey-deal led to a drastic reduction in the flow of migrants arriving to the Greek islands. The islands became open detention centers, where people would spend months or years under the constant fear of being returned to Turkey. Syrians were generally granted refugee status in Greece and those arrived before the 20th of March 2016 had the option of being relocated to other European countries. Afghans had some chances of being granted asylum in Greece, whilst most migrants from the Democratic Republic of Congo were refused asylum. In a clinic run by Médecins sans Frontières on Lesbos Island, psychologists observed a deterioration of the migrant’s mental health (MH) since March 2016. In order to understand the MH needs for this stranded population it was essential to explore how, and by what factors, their mental health (MH) has been affected on Lesbos Island due to the EU/Turkey-deal. Methods This was a qualitative study in which eight service providers’ interviews and 12 focus group discussions with male and female Syrian, Afghan and Congolese migrants in two refugee camps on Lesbos Island. Thematic-content analysis was manually applied and triangulation of findings was undertaken to enhance the interpretation of data. Results Three main themes were generated: 1) Institutional abuse, 2) Continuous traumatic stress (CTS) and 3) MH service provision. Institutional abuse was expressed by inhumane living conditions, lack of information in order to make future decisions, humiliation and depersonalization. This led to CTS that was expressed through being in a state of permanent emergency under lack of protective measures. Delays in appointments, lack of psychiatric care and differences in MH perceptions amongst migrants highlighted the provision of MH services. Conclusion The EU/Turkey-deal reduced migrant flows at a very high price. Decongestion of the camps and the elimination of institutional abuse is urgently needed to reduce CTS and improve migrants’ MH.
    • Integrating mental health into primary care for displaced populations: the experience of Mindanao, Philippines

      Mueller, Y; Cristofani, S; Rodriguez, C; Malaguiok, R; Gil, T; Grais, RF; Souza, R; Epicentre, Paris, France; Médecins Sans Frontières, Geneva, Switzerland; Médecins Sans Frontières, Mindanao, Philippines (2011-03-07)
      ABSTRACT:
    • Mental Health and Trauma in Asylum Seekers Landing in Sicily in 2015: A Descriptive Study of Neglected Invisible Wounds

      Crepet, A; Rita, F; Reid, A; Van den Boogaard, W; Deiana, P; Quaranta, G; Barbieri, A; Bongiorno, F; Di Carlo, S (BioMed Central, 2017-01-13)
      In 2015, Italy was the second most common point of entry for asylum seekers into Europe after Greece. The vast majority embarked from war-torn Libya; 80,000 people claimed asylum that year. Their medical conditions were assessed on arrival but their mental health needs were not addressed in any way, despite the likelihood of serious trauma before and during migration. Médecins sans Frontières (MSF), in agreement with the Italian Ministry of Health, provided mental health (MH) assessment and care for recently-landed asylum seekers in Sicily. This study documents mental health conditions, potentially traumatic events and post-migratory living difficulties experienced by asylum seekers in the MSF programme in 2014-15.
    • Mental Health Problems Among Conflict-Affected Adults in Grozny, Chechnya: a Qualitative Study

      Nguyen, AJ; Feo, C; Idrisov, K; Pintaldi, G; Lenglet, A; Tsatsaeva, Z; Bolton, P; Bass, J (BioMed Central, 2016-08-03)
      A decade of conflict in Chechnya destroyed infrastructure and resulted in widespread exposure to violence. Amidst substantial reconstruction, periodic violence has contributed to an ongoing atmosphere of insecurity. We conducted a qualitative study to understand the mental health and psychosocial problems affecting adult Chechens in this context to inform development of assessment tools for an evaluation study related to individual counseling.
    • Short and Longer-term Psychological Consequences of Operation Cast Lead: documentation from a Mental Health program in the Gaza Strip

      Llosa, A E; Casas, G; Thomas, H; Mairal, A; Grais, RF; Moro, M-R; Epicentre, 8 rue Saint Sabin, Paris, 75011, France. Augusto.Llosa@epicentre.msf.org. (2012-10-23)
    • Trauma in the Kashmir Valley and the mediating effect of stressors of daily life on symptoms of posttraumatic stress disorder, depression and anxiety

      Housen, T; Lenglet, A; Shah, S; Sha, H; Richardson, A; Pintaldi, G; Shabnum, A; MSF OCA and MSF India (Springer Science and Business Media LLC, 2019-12-12)
      Background The negative psychological impact of living in a setting of protracted conflict has been well studied, however there is a recognized need to understand the role that non-conflict related factors have on mediating exposure to trauma and signs of psychological distress. Methods We used data from the 2015 Kashmir Mental Health Survey and conducted mediation analysis to assess the extent to which daily stressors mediated the effect of traumatic experiences on poor mental health outcomes. Outcomes of interest were probable diagnosis of anxiety, depression, or PTSD; measured using the pre-validated Hopkins Symptoms Checklist (HSCL-25) and the Harvard Trauma Questionnaire (HTQ). Results Total effect mediated were statistically significant but the proportions of effect mediated were found to be small in practical terms. Financial stress mediated 6.8% [95% Confidence Interval (CI) 6∙0–8∙4], 6.7% [CI 6.2–7∙7] and 3.6% [CI 3∙4–4∙0] of the effect of experiencing multiple traumaticogenic events on symptoms of anxiety, depression and PTSD, respectively. Family stress mediated 11.3% [CI 10.3–13.8], 10.3% [CI 9.5–11.9] and 6.1% [CI 5.7–6.7] of the effect of experiencing multiple traumatogenic events on symptoms of anxiety, depression and PTSD, respectively. Poor physical health mediated 10.0% [CI 9.1–12∙0], 7.2% [CI 6.6–8.2] and 4.0% [CI 3.8,4.4] of the effect of experiencing more than seven traumatic events on symptoms of anxiety, depression and PTSD, respectively. Conclusion Our findings highlight that not only do we need to move beyond a trauma-focussed approach to addressing psychological distress in populations affected by protracted conflict but we must also move beyond focussing on daily stressors as explanatory mediators.
    • The Trauma of Ongoing Conflict and Displacement in Chechnya: Quantitative Assessment of Living Conditions, and Psychosocial and General Health Status Among War Displaced in Chechnya and Ingushetia.

      de Jong, K; van der Kam, S; Ford, N; Hargreaves, S; van Oosten, R; Cunningham, D; Boots, G; Andrault, E; Kleber, R; Médecins Sans Frontières, Plantage Middenlaan 14, 1018 DD Amsterdam, The Netherlands. kaz.de.jong@amsterdam.msf.org. (2007)
      ABSTRACT: BACKGROUND: Conflict in Chechnya has resulted in over a decade of violence, human rights abuses, criminality and poverty, and a steady flow of displaced seeking refuge throughout the region. At the beginning of 2004 MSF undertook quantitative surveys among the displaced populations in Chechnya and neighbouring Ingushetia. METHODS: Surveys were carried out in Ingushetia (January 2004) and Chechnya (February 2004) through systematic sampling. Various conflict-related factors contributing to ill health were researched to obtain information on displacement history, living conditions, and psychosocial and general health status. RESULTS: The average length of displacement was five years. Conditions in both locations were poor, and people in both locations indicated food shortages (Chechnya (C): 13.3%, Ingushetia (I): 11.3%), and there was a high degree of dependency on outside help (C: 95.4%, I: 94.3%). Most people (C: 94%, I: 98%) were confronted with violence in the past. Many respondents had witnessed the killing of people (C: 22.7%, I: 24.1%) and nearly half of people interviewed witnessed arrests (C: 53.1%, I: 48.4%) and maltreatment (C: 56.2%, I: 44.5%). Approximately one third of those interviewed had directly experienced war-related violence. A substantial number of people interviewed - one third in Ingushetia (37.5%) and two-thirds in Chechnya (66.8%) - rarely felt safe. The violence was ongoing, with respondents reporting violence in the month before the survey (C: 12.5%, I: 4.6%). Results of the general health questionnaire (GHQ 28) showed that nearly all internally displaced persons interviewed were suffering from health complaints such as somatic complaints, anxiety/insomnia, depressive feelings or social dysfunction (C: 201, 78.5%, CI: 73.0% - 83.4%; I: 230, 81.3%, CI: 76.2% - 85.6%). Poor health status was reflected in other survey questions, but health services were difficult to access for around half the population (C: 54.3%, I: 46.6%). DISCUSSION: The study demonstrates that the health needs of internally displaced in both locations are similarly high and equally unaddressed. The high levels of past confrontation with violence and ongoing exposure in both locations is likely to contribute to a further deterioration of the health status of internally displaced. As of March 2007, concerns remain about how the return process is being managed by the authorities.