Angela Nickerson

A critical review of psychological treatments of posttraumatic stress disorder in refugees.

Despite much research evidence that refugees suffer from elevated rates of posttraumatic stress disorder (PTSD), relatively few studies have examined the effectiveness of psychological treatments for PTSD in refugees. The field of refugee mental health intervention is dominated by two contrasting approaches, namely trauma-focused therapy and multimodal interventions. This article firstly defines these two approaches, then provides a critical review of 19 research studies that have been undertaken to investigate the efficacy of these treatments. Preliminary research evidence suggests that trauma-focused approaches may have some efficacy in treating PTSD in refugees, but limitations in the methodologies of studies caution against drawing definitive inferences. It is clear that research assessing the treatment of PTSD in refugees is lagging behind that available for other traumatized populations. The review examines important considerations in the treatment of refugees. A theoretical framework is offered that outlines contextual issues, maintaining factors, change mechanisms and the distinctive challenges to traditional trauma-focused treatments posed by the needs of refugees with PTSD.

Sudden Gains during Psychological Treatments of Anxiety and Depression: A Meta-Analysis.

OBJECTIVE The present study quantitatively reviewed the literature on sudden gains in psychological treatments for anxiety and depression. The authors examined the short- and long-term effects of sudden gains on treatment outcome as well as moderators of these effects. METHOD The authors conducted a literature search using PubMed, PsycINFO, the Cochrane Library, and manual searches. The meta-analysis was based on 16 studies and included 1,104 participants receiving psychological treatment for major depressive disorder or an anxiety disorder. RESULTS Effect size estimates suggest that sudden gains had a moderate effect on primary outcome measures at posttreatment (Hedgess g = 0.62) and follow-up (Hedgess g = 0.56). These effect sizes were robust and unrelated to publication year or number of treatment sessions. The effect size of sudden gains in cognitive-behavioral therapy was higher (Hedgess g = 0.75) than in other treatments (Hedgess g = 0.23). CONCLUSIONS These results suggest that sudden gains are associated with short-term and long-term improvements in depression and anxiety, especially in cognitive-behavioral therapy.

Functional impairment in social anxiety disorder

The present study examined functional impairment among treatment seekers with social anxiety disorder (SAD). We investigated the effects of diagnostic subtypes of SAD and comorbidity with mood and anxiety disorders on impairment. In addition, we used cluster analysis procedures to empirically identify subgroups of individuals with distinct patterns of impairment. Participants were 216 treatment-seeking individuals with SAD. Clinical interviews were undertaken to determine diagnoses of anxiety disorders and major depressive disorder, and a battery of self-report measures was administered to index symptoms of social anxiety, depression and extent of impairment. Results indicated that individuals with the generalized subtype of SAD had greater impairment in all three life domains compared to individuals with the nongeneralized subtype. Comorbidity with mood disorders was associated with greater impairment than SAD alone, but comorbidity with anxiety disorders was not. Four distinct impairment profiles emerged from the cluster analysis: primary work/studies impairment, primary social life impairment, both work/studies and social impairment, and impairment in all domains. Findings from this study suggest that SAD is associated with substantial impairment across multiple domains, and that individuals with SAD present diverse impairment profiles. These profiles may inform subtyping of the disorder as well as therapeutic interventions.

Patterns of lifetime PTSD comorbidity: a latent class analysis.

Posttraumatic stress disorder (PTSD) is associated with high rates of psychiatric comorbidity, most notably substance use disorders, major depression, and other anxiety disorders. However, little is known about how these disorders cluster together among people with PTSD, if disorder clusters have distinct etiologies in terms of trauma type, and if they confer greater burden over and above PTSD alone.

Impact of the diagnostic changes to post-traumatic stress disorder for DSM-5 and the proposed changes to ICD-11

BACKGROUND There have been changes to the criteria for diagnosing post-traumatic stress disorder (PTSD) in DSM-5 and changes are proposed for ICD-11. AIMS To investigate the impact of the changes to diagnostic criteria for PTSD in DSM-5 and the proposed changes in ICD-11 using a large multisite trauma-exposed sample and structured clinical interviews. METHOD Randomly selected injury patients admitted to four hospitals were assessed 72 months post trauma (n = 510). Structured clinical interviews for PTSD and major depressive episode, as well as self-report measures of disability and quality of life were administered. RESULTS Current prevalence of PTSD under DSM-5 scoring was not significantly different from DSM-IV (6.7% v. 5.9%, z = 0.53, P = 0.59). However, the ICD-11 prevalence was significantly lower than ICD-10 (3.3% v. 9.0%, z = -3.8, P<0.001). The PTSD current prevalence was significantly higher for DSM-5 than ICD-11 (6.7% v. 3.3%, z = 2.5, P = 0.01). Using ICD-11 tended to show lower rates of comorbidity with depression and a slightly lower association with disability. CONCLUSIONS The diagnostic systems performed in different ways in terms of current prevalence rates and levels of comorbidity with depression, but on other broad key indicators they were relatively similar. There was overlap between those with PTSD diagnosed by ICD-11 and DSM-5 but a substantial portion met one but not the other set of criteria. This represents a challenge for research because the phenotype that is studied may be markedly different according to the diagnostic system used.

Treating Prolonged Grief Disorder: A Randomized Clinical Trial

IMPORTANCE Prolonged grief disorder (PGD) is a potentially disabling condition that affects approximately 10% of bereaved people. Grief-focused cognitive behavior therapy (CBT) has been shown to be effective in treating PGD. Although treatments for PGD have focused on exposure therapy, much debate remains about whether exposure therapy is optimal for PGD. OBJECTIVE To determine the relative efficacies of CBT with exposure therapy (CBT/exposure) or CBT alone for PGD. DESIGN, SETTING, AND PARTICIPANTS A randomized clinical trial of 80 patients with PGD attending the outpatient University of New South Wales Traumatic Stress Clinic from September 17, 2007, through June 7, 2010. INTERVENTIONS All patients received 10 weekly 2-hour group therapy sessions that consisted of CBT techniques. Patients also received 4 individual sessions, in which they were randomized to receive exposure therapy for memories of the death or supportive counseling. MAIN OUTCOMES AND MEASURES Measures of PGD by clinical interview and self-reported measures of depression, cognitive appraisals, and functioning at the 6-month follow-up. RESULTS Intention-to-treat analyses at follow-up indicated a significant quadratic time×treatment condition interaction effect (B [SE], 0.49 [0.16]; t120.16=3.08 [95% CI, 0.18-0.81]; P=.003), indicating that CBT/exposure led to greater PGD reductions than CBT alone. At follow-up, CBT/exposure led to greater reductions in depression (B [SE], 0.35 [0.12]; t112.65=2.83 [95% CI, 0.11-0.60]; P=.005), negative appraisals (B [SE], 0.68 [0.25]; t109.98=2.66 [95% CI, 0.17-1.18]; P=.009), and functional impairment (B [SE], 0.24 [0.08]; t111.40=3.01 [95% CI, 0.08-0.40]; P=.003) than CBT alone. In terms of treatment completers, fewer patients in the CBT/exposure condition at follow-up (14.8%) met criteria for PGD than those in the CBT condition (37.9%) (odds ratio, 3.51; 95% CI, 0.96-12.89; χ2=3.81; P=.04). CONCLUSIONS AND RELEVANCE Including exposure therapy that promotes emotional processing of memories of the death is an important component to achieve optimal reductions in PGD severity. Facilitating emotional responses to the death may promote greater changes in appraisals about the loss, which are associated with symptom reduction. Promotion of emotional processing techniques in therapies to treat patients with PGD is needed. TRIAL REGISTRATION anzctr.org.au Identifier: ACTRN12609000229279.

The impact of fear for family on mental health in a resettled Iraqi refugee community.

The current study aimed to evaluate the impact of fear for family remaining in the country of origin and under potential threat on the mental health of refugees. Adult Mandaean refugees (N=315) from Iraq, living in Sydney, Australia, were interviewed regarding fear for family in Iraq, fear of genocide, pre-migration trauma, post-migration living difficulties and psychological outcomes. Participants with immediate family in Iraq reported higher levels of symptoms of PTSD and depression, and greater mental health-related disability than those without family in Iraq. Intrusive fears about family independently predicted risk of PTSD, depression and disability after controlling for trauma exposure and current living difficulties. Threat to family members living in a context of ongoing threat predicted psychopathology and disability in Mandaean refugees. The effect of ongoing threat to family still living in conflict-ridden countries on the mental health of refugees should be further considered in the context of healthcare.

Trajectory of post-traumatic stress following traumatic injury: 6-year follow-up

BACKGROUND Traumatic injuries affect millions of patients each year, and resulting post-traumatic stress disorder (PTSD) significantly contributes to subsequent impairment. AIMS To map the distinctive long-term trajectories of PTSD responses over 6 years by using latent growth mixture modelling. METHOD Randomly selected injury patients (n = 1084) admitted to four hospitals around Australia were assessed in hospital, and at 3, 12, 24 and 72 months. Lifetime psychiatric history and current PTSD severity and funxctioning were assessed. RESULTS Five trajectories of PTSD response were noted across the 6 years: (a) chronic (4%), (b) recovery (6%), (c) worsening/recovery (8%), (d) worsening (10%) and (e) resilient (73%). A poorer trajectory was predicted by female gender, recent life stressors, presence of mild traumatic brain injury and admission to intensive care unit. CONCLUSIONS These findings demonstrate the long-term PTSD effects that can occur following traumatic injury. The different trajectories highlight that monitoring a subset of patients over time is probably a more accurate means of identifying PTSD rather than relying on factors that can be assessed during hospital admission.

Change in visa status amongst Mandaean refugees: Relationship to psychological symptoms and living difficulties

Policies of deterrence, including the use of detention and temporary visas, have been widely implemented to dissuade asylum seekers from seeking protection in Western countries. The present study examined the impact of visa status change on the mental health of 97 Mandaean refugees resettled in Australia. At the time of the first survey (2004), 68 (70%) participants held temporary protection visas (TPVs) and 29 (30%) held permanent residency (PR) status, whereas by the second survey (2007), 97 (100%) participants held PR status. We tested a meditational model to determine whether the relationship between change in visa status and change in psychological symptoms was mediated by change in living difficulties associated with the visa categories. The conversion of visa status from TPV to PR status was associated with significant improvements in PTSD and depression symptoms, and increases in mental health-related quality of life (MHR-QOL). The relationship between change in visa status and reduced PTSD and depression symptoms was mediated by reductions in living difficulties. In contrast, the relationship between change in visa status and increased MHR-QOL was not mediated by changes in living difficulties. These results suggest that restriction of rights and access to services related to visa status negatively affect the mental health of refugees. Implications for government policies regarding refugees are discussed.

Effects of recurrent violence on post-traumatic stress disorder and severe distress in conflict-affected Timor-Leste: a 6-year longitudinal study

BACKGROUND Little is known about the effect of recurrent episodes of communal violence on mental health in countries recovering from mass conflict. We report results of a 6-year longitudinal study in post-conflict Timor-Leste assessing changes in mental health after a period of communal violence. METHODS We assessed 1022 adults (600 from a rural village, 422 from an urban district) exposed to mass conflict during the Indonesian occupation after independence in 2004, and again in 2010-11, following a period of internal conflict. We took a census of all adults living at the two sites. The survey included measures of post-traumatic stress disorder, severe distress, traumatic events, poverty, ongoing conflict, and injustice. FINDINGS 1247 (80%) of 1554 invited adults participated in the baseline survey. 1038 (89% of those eligible) were followed up. The analysis included 1022 people who had sufficient data at baseline and follow-up. The prevalence of post-traumatic stress disorder increased from 23 of 1022 (2.3%) in 2004, to 171 of 1022 (16.7%) in 2010. The prevalence of severe distress also increased, from 57 of 1022 (5.6%) in 2004, to 162 of 1022 (15.9%) in 2010. Both these outcomes were associated with disability at follow-up. Having post-traumatic stress at follow-up was associated with being a woman (odds ratio [OR] 1.63, 95% CI 1.14-2.32), experience of human rights trauma (OR 1.25, 95% CI 1.07-1.47), or exposure to murder (OR 1.71, 95% CI 1.38-2.10) during the Indonesian occupation (1975-99), human rights trauma during the period of internal violence in 2006-07 (OR 1.46, 95% CI 1.04-2.03), and ongoing family or community conflict (OR 1.80, 95% CI 1.15-2.80) or preoccupations with injustice for two or three historical periods (OR 4.06, 2.63-6.28). Severe distress at follow-up was associated with health stress (OR 1.47, 1.14-1.90), exposure to murder (OR 1.57, 1.27-1.95), and natural disaster (OR 1.65, 1.03-2.64) during the Indonesian occupation, conflict-related trauma during the internal violence (OR 1.33, 1.02-1.74), and ongoing poverty (OR 1.53, 1.36-1.72) or preoccupations with injustice for two or three historical periods (OR 2.09, 1.25-3.50). INTERPRETATION Recurrent violence resulted in a major increase in post-traumatic stress disorder and severe distress in a community previously exposed to mass conflict. Poverty, ongoing community tensions, and persisting feelings of injustice contributed to mental disorders. The findings underscore the importance of preventing recurrent violence, alleviating poverty, and addressing injustices in countries emerging from conflict. FUNDING Australian National Health and Medical Research Council.