• 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.
    • Trauma of Chechnya's ongoing war on internally displaced people.

      de Jong, K; van der Kam, S; Ford, N; Hargreaves, S; van Oosten, R; Cunningham, D; Boots, G (Elsevier, 2004)
    • 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.
    • The trauma of war in Sierra Leone.

      de Jong, K; Mulhern, M; Ford, N; van der Kam, S; Kleber, R; Institute of Psychotrauma, University of Utrecht, The Netherlands. (Elsevier, 2000-06-10)
    • Trauma-related psychological disorders among Palestinian children and adults in Gaza and West Bank, 2005-2008

      Espié, E; Gaboulaud, V; Baubet, T; Casas, G; Mouchenik, Y; Yun, O; Grais, RF; Moro, M R; Epicentre, Paris, France; Hôpital Avicenne, Assistance Publique Hôpitaux de Paris, Bobigny, France; Médecins Sans Frontières, Paris, France; Université Toulouse Le Mirail, Toulouse, France; Médecins Sans Frontières/Doctors Without Borders, New York, USA; Hôpital Cochin, Maison des adolescents, Université Paris Descartes, AP-HP, France (2009-09-23)
      BACKGROUND: Trauma from war and violence has led to psychological disorders in individuals living in the Gaza strip and West Bank. Few reports are available on the psychiatric disorders seen in children and adolescents or the treatment of affected populations. This study was conducted in order to describe the occurrence and treatment of psychiatric disorders in the Palestinian populations of the Gaza strip and Nablus district in the West Bank. METHODS: From 2005 to 2008, 1369 patients aged more than 1 year were identified through a local mental health and counseling health network. All were clinically assessed using a semi-structured interview based on the DSM-IV-TR criteria. RESULTS: Among 1254 patients, 23.2% reported post-traumatic stress disorder [PTSD], 17.3% anxiety disorder (other than PTSD or acute stress disorder), and 15.3% depression. PTSD was more frequently identified in children < or = 15 years old, while depression was the main symptom observed in adults. Among children < or = 15 years old, factors significantly associated with PTSD included being witness to murder or physical abuse, receiving threats, and property destruction or loss (p < 0.03). Psychological care, primarily in the form of individual, short-term psychotherapy, was provided to 65.1% of patients, with about 30.6% required psychotropic medication. Duration of therapy sessions was higher for children < or = 15 years old compared with adults (p = 0.05). Following psychotherapy, 79.0% had improved symptoms, and this improvement was significantly higher in children < or = 15 years old (82.8%) compared with adults (75.3%; p = 0.001). CONCLUSION: These observations suggest that short-term psychotherapy could be an effective treatment for specific psychiatric disorders occurring in vulnerable populations, including children, living in violent conflict zones, such as in Gaza strip and the West Bank.
    • Traumatic Events and Symptoms of Post-Traumatic Stress Disorder Amongst Sudanese Nationals, Refugees and Ugandans in the West Nile.

      Karunakara, U; Neuner, F; Schauer, M; Singh, K; Hill, K; Elbert, T; Burnham, G; Médecins sans Frontières, PO Box 10014, 1001 EA Amsterdam, The Netherlands. (2004-08)
      Objectives: To compare the incidence of traumatic events and its association with symptoms of post-traumatic stress disorder in three population groups in northern Uganda and southern Sudan. Methods: Household and individual level data collected through a single-round cross-sectional demographic survey. Setting: The sub-counties of Yivu, Odupi and Midia in the northern Ugandan district of Arua and of Otogo in Yei River district in southern Sudan. Participants: Residents of these Ugandan and Sudanese sub-counties were categorized on the basis of citizenship and refugee status (i.e. as Ugandan nationals, Sudanese nationals or Sudanese refugees). The random sample population consisted of 3,323 adults (mean age: 30 years; 75% female) from 1,831 national and refugee households. Results: Sudanese refugees reported the highest number of violent events experienced or witnessed ever and in the past one year . Witnessing of traumatic events, ever and in the past year , significantly predicted PTSD in surveyed population. Sex, age, education and occupation were also significantly associated with the development of PTSD symptoms. The population prevalence of PTSD was estimated to be 48% for Sudanese stayees, 46% for Sudanese refugees and 18% for Ugandan nationals. Conclusions: Symptoms of PTSD in war-affected Sudanese populations can be partly explained by traumatic event exposures. The high prevalence of violence and symptoms of PTSD in refugee populations highlight the need for better protection and security in refugee settlements. Humanitarian agencies must consider the provision of mental health services for populations affected by war and forced migration.
    • Treating schizophrenia with DOTS in developing countries: one size does not fit all.

      Souza, R; Yasuda, S; Cristofani, S (BioMed Central, 2007-09)
    • A Two-Phase Approach for the Identification of Refugees with Priority Need for Mental Health Care in Lebanon: A Validation Study

      Llosa, AE; Van Ommeren, M; Kolappa, K; Ghantous, Z; Souza, R; Bastin, P; Slavuckij, A; Grais, RFF (BioMed Central, 2017-01-18)
      Time and resource efficient mental disorder screening mechanisms are not available to identify the growing number of refugees and other forcibly displaced persons in priority need for mental health care. The aim of this study was to identify efficient screening instruments and mechanisms for the detection of moderate and severe mental disorders in a refugee setting.
    • Validation of mental health screening instruments in the Kashmir Valley, India

      Housen, T; Lenglet, A; Ariti, C; Ara, S; Shah, S; Dar, M; Hussain, A; Paul, A; Wagay, Z; Viney, K; et al. (SAGE Publications, 2018-03-19)
      The present study aimed to culturally adapt, translate, and validate the Hopkins Symptom Checklist-25 (HSCL-25) and the Harvard Trauma Questionnaire-Posttraumatic Stress Symptoms Checklist (HTQ-16) prior to use in a cross-sectional mental health population survey in the Kashmir Valley. Cultural adaptation and translation of the HSCL-25 and the HTQ-16 employed multiple forms of transcultural validity check. The HSCL-25 and HTQ-16 were compared against a "gold standard" structured psychiatric interview, the Mini International Neuropsychiatric Interview (MINI). Interviews were conducted with 290 respondents recruited using consecutive sampling from general medical outpatient departments in five districts of the Kashmir Valley. Receiver operating characteristics (ROC) analysis was used to estimate the cut point with optimal discriminatory power based on sensitivity and specificity. Internal reliability of the HSCL-25 was high, Cronbach's alpha (α) = .92, intraclass correlation coefficient (ICC) = 0.75, with an estimated optimal cut point of 1.50, lower than the conventional cut point of 1.75. Separation of the instruments into subscales demonstrated a difference in the estimated cut point for the anxiety subscale and the depression subscale, 1.75 and 1.57, respectively. Too few respondents were diagnosed with posttraumatic stress disorder (PTSD) during structured psychiatric interview, and therefore the HTQ-16 could not be validated despite the fact that high internal reliability was demonstrated (α = .90). This study verified the importance of culturally adapting and validating screening instruments in particular contexts. The use of the conventional cut point of 1.75 would likely have misclassified depression in our survey, leading to an underestimate of this condition.
    • What is a traumatic experience if you live in Mogadishu?

      de Jong, K; Mental Health Specialist, Medecins Sans Frontieres, Amsterdam, Netherlands (BMJ Group Blog, 2012-03)