Edvard Hauff

Mental health of recently resettled refugees from the Middle East in Sweden: the impact of pre-resettlement trauma, resettlement stress and capacity to handle stress

The pathways to symptoms of common mental disorder and post-traumatic stress symptoms among refugees during resettlement need to be better specified. We aim to identify models of these different mental health outcomes among refugees during resettlement, taking pre-migration, migration and post-migration stress conditions, a person’s capacity to handle such stress and socio-demographic variables into consideration. A new questionnaire developed to better cover resettlement stress, as well as pre-resettlement trauma exposures and different measures of a person’s capacity to handle stress, was administered to 124 Middle Eastern refugees that had been granted permanent residency in Sweden only a few months before responding. We found four dimensions of resettlement stress: social and economic strain, alienation, discrimination and status loss and violence and threats in Sweden, that account for 62% of the total variance in resettlement stress. Social and economic strain and alienation are important for explaining symptoms of common mental disorder. In the model of core post-traumatic stress symptoms, pre-resettlement trauma exposure seems to have the strongest impact. A person’s capacity to handle stress plays significant, direct and mediating roles in both models. The impact of resettlement stressors in the context of the whole migration process for different mental health outcomes is discussed.

Psychological distress among displaced persons during an armed conflict in Nepal

Most internally displaced persons (IDPs) live in low-income countries experiencing a war; their psychosocial health has not been well addressed. We carried out a comprehensive assessment of traumatic experiences, distress symptomatology, and factors independently associated with distress among IDPs in Nepal. A cross-sectional survey was conducted among 290 IDPs in Nepal during June–July 2003. We used the Hopkins Symptom Checklist-25 (HSCL-25) to assess depression and anxiety symptoms, and the Posttraumatic Stress Disorder (PTSD) Checklist—Civilian Version (PCL-C) to assess PTSD symptoms. All these instruments were validated against local corresponding syndromes and diagnoses of Composite International Diagnostic Interviews (CIDIs) as well. Almost everyone reported trauma and 53.4% had PTSD symptomatology. The rates of anxiety and depression symptomatology were 80.7 and 80.3%, respectively. Factors independently associated with anxiety symptomatology were illiteracy and feeling miserable on arrival at a new place. Female gender, age 41–50, and feeling miserable on arrival at a new place were associated with depression symptomatology. On the other hand, experiencing greater than three traumatic events and feeling miserable on arrival at a new place were associated with PTSD symptomatology, whereas evacuation after a weeklong preparation and lower caste appeared as protective factors. High rates of psychological distress and associated factors were identified among highly traumatized IDPs in Nepal, thereby underlining the need for collective assistance, not only for refugees, but also for IDPs. Risk and protective factors that we have identified can thus be utilized for any kind of psychosocial interventions among these IDPs.

Chronic posttraumatic stress disorder in Vietnamese refugees : a prospective community study of prevalence, course, psychopathology, and stressors

A community cohort of 145 Vietnamese boat refugees in Norway was prospectively studied for presence of chronic posttraumatic stress disorder (PTSD) after resettlement. Ten percent had PTSD on arrival and/or after 3 years. This group had been exposed to significantly more traumatic stress before their escape (e.g., reeducation camps, combat, and other war incidents) and had more psychopathology (SCL-90-R Global Assessment Scale) after resettlement. A logistic regression analysis indicated that different types of traumatic stress had an independent relationship with chronic PTSD. Nine SCL-90-R items discriminated between the PTSD group and the rest both on arrival and follow-up. These were not anxiety items, but related to interpersonal sensitivity, somatization, and aggression. The inclusion of additional diagnostic features in the criteria for chronic PTSD is indicated.

Gender differences in factors associated with psychological distress among immigrants from low- and middle-income countries--findings from the Oslo Health Study.

Despite the high rate of migration from low- and middle-income countries to high-income countries, there is still a lack of comprehensive studies of gender-specific differences in psychological distress in a diverse group of immigrants. We compared psychological distress between male and female immigrants from low- and middle-income countries living in Oslo, and identified factors associated with distress for men and women, separately. A cross-sectional survey with self-administered questionnaires was conducted among 1536 immigrants from low- and middle-income countries living in Oslo. The Hopkins Symptom Checklist (HSCL-10) was used to measure psychological distress. Data on their sociodemographic characteristics, negative and traumatic life events, and social integration and possible discrimination in the Norwegian society were also collected. One-fourth of the study population was found to be psychologically distressed, with almost equal levels among men and women. Lack of salaried job and recent negative life events were independently associated with psychological distress for both genders. Furthermore, experience of denial of job and past traumatic experiences were other associated negative factors among men, while visits made by Norwegians appeared as a protective factor against distress among men. Older age, Middle East background, living without a partner, and experiencing denial of housing were other associated negative factors among women. Our findings show that, except for adverse living conditions, there are gender differences with regard to factors associated with psychological distress among immigrants living in Oslo. Such gender issues are relevant for assisting immigrants in the integration process as well as for future research in migration and health.

Vietnamese boat refugees : the influence of war and flight traumatization on mental health on arrival in the country of resettlement : a community cohort study of Vietnamese refugees in Norway

A consecutive cohort of 145 adult Vietnamese refugees were personally interviewed and completed the Symptom Checklist 90 R self‐rating scale on arrival in Norway. Sixty‐two percent had witnessed bombing, fires and shooting, 48% had witnessed other people being wounded or killed and 36% had been involved in life‐threatening situations or had been wounded in the war. Nearly all war trauma variables but none of the escape or refugee camp variables were significantly related to mental health 7 years after the end of the war. War trauma was significantly associated with mental health, also when age, gender and previous mental problems were controlled for. These results and our clinical experience indicate that clinicians treating refugees should address such traumatic experiences specifically.

The use of self-reports in psychiatric studies of traumatized refugees: Validation and analysis of HSCL-25

A consecutive sample of 231 refugee patients referred to the outpatient unit at the Psychosocial Centre for Refugees, University of Oslo, were examined by means of a semistructured clinical interview, the Brief Psychiatric Rating Scale (BPRS), and the self-reports Hopkins Symptoms Check List (HSCL-25) and a checklist for post-traumatic symptoms (PTSS-10). A significant relation was found between the self-report scores on the HSCL-25 and ratings made by the clinician on Global Assessment of Function Scale (GAF) and Global Rating on Brief Psychiatric Rating Scale (BPRS). A further analysis showed that HSCL-25 had a significant relation with mainly two of the four symptom patterns identified in a factor analysis of BPRS, namely Factor II (emotional withdrawal/retardation) and Factor III (anxiety/depression). Multiple regression analyses based on HSCL-25 scores for age, sex, nationality of origin, stay in prison, torture, exposure to war actions, refugee status, and employment situation in Norway showed a sig...

Mental health problems and post-migration stress among multi-traumatized refugees attending outpatient clinics upon resettlement to Norway.

Refugees have often been exposed to multiple traumas making them prone to mental health problems later. The aim of this study is to describe the prevalence and symptom load of psychiatric disorders in refugees admitted to psychiatric outpatient clinics and to investigate the relationship between multiple exposure to traumatic events, the severity of traumatic symptoms and post-migration stressors. A clinical sample of 61 refugee outpatients from psychiatric clinics in Southern Norway was cross-sectionally examined using three structured clinical interviews (SCID-PTSD, SIDES and MINI) and self-report psychometric instruments (HSCL-25, IES-R). Post-traumatic Stress Disorder (PTSD) was diagnosed in 82% of the patients, while Disorders of Extreme Stress Not Otherwise Specified (DESNOS) was present in 16% of them. Comorbidity was considerable; 64% of the patients had both PTSD and major depression disorder (MDD) and 80% of those who had PTSD had three or more additional diagnoses. Multi-traumatized refugees in outpatient clinics have high prevalence of PTSD, DESNOS, comorbid depression and anxiety disorders. A more severe symptomatology was found in patients diagnosed with both PTSD and DESNOS, than in those diagnosed with only PTSD. Higher rates of unemployment, weak social network and weak social integration were also prevalent in these outpatients, and related to increased psychiatric comorbidity and severity of symptoms. Further research may clarify the existence of a cumulative relationship between pre-resettlement traumas and post-resettlement stressors in the mental health of refugees, which in turn may help to improve therapeutic interventions.

Posttraumatic growth, depressive symptoms, posttraumatic stress symptoms, post-migration stressors and quality of life in multi-traumatized psychiatric outpatients with a refugee background in Norway

BackgroundPsychiatric outpatients with a refugee background have often been exposed to a variety of potentially traumatizing events, with numerous negative consequences for their mental health and quality of life. However, some patients also report positive personal changes, posttraumatic growth, related to these potentially traumatic events. This study describes posttraumatic growth, posttraumatic stress symptoms, depressive symptoms, post-migration stressors, and their association with quality of life in an outpatient psychiatric population with a refugee background in Norway.MethodsFifty five psychiatric outpatients with a refugee background participated in a cross-sectional study using clinical interviews to measure psychopathology (SCID-PTSD, MINI), and four self-report instruments measuring posttraumatic growth, posttraumatic stress symptoms, depressive symptoms, and quality of life (PTGI-SF, IES-R, HSCL-25-depression scale, and WHOQOL-Bref) as well as measures of social integration, social network and employment status.ResultsAll patients reported some degree of posttraumatic growth, while only 31% reported greater amounts of growth. Eighty percent of the patients had posttraumatic stress symptoms above the cut-off point, and 93% reported clinical levels of depressive symptoms. Quality of life in the four domains of the WHOQOL-Bref levels were low, well below the threshold for the’life satisfaction’ standard proposed by Cummins.A hierarchic regression model including depressive symptoms, posttraumatic stress symptoms, posttraumatic growth, and unemployment explained 56% of the total variance found in the psychological health domain of the WHOQOL-Bref scale. Posttraumatic growth made the strongest contribution to the model, greater than posttraumatic stress symptoms or depressive symptoms. Post-migration stressors like unemployment, weak social network and poor social integration were moderately negatively correlated with posttraumatic growth and quality of life, and positively correlated with psychopathological symptoms. Sixty percent of the outpatients were unemployed.ConclusionsMulti-traumatized refugees in outpatient clinics reported both symptoms of psychopathology and posttraumatic growth after exposure to multiple traumatic events. Symptoms of psychopathology were negatively related to the quality of life, and positively related to post-migration stressors such as unemployment, weak social network and poor social integration. Posttraumatic growth was positively associated with quality of life, and negatively associated with post-migration stressors. Hierarchical regression modeling showed that posttraumatic growth explained more of the variance in quality of life than did posttraumatic stress symptoms, depressive symptoms or unemployment. It may therefore be necessary to address both positive changes and psychopathological symptoms when assessing and treating multi-traumatized outpatients with a refugee background.

A cross-sectional study of vitamin D deficiency among immigrants and Norwegians with psychosis compared to the general population.

OBJECTIVE Vitamin D deficiency is common among immigrants, who, as a group, have heightened risk of psychosis. This study aimed to determine vitamin D levels among immigrants and Norwegians with psychosis compared to the general population and their association to clinical characteristics. METHOD This study compared vitamin D levels between immigrants and Norwegians within and between samples of patients with psychosis from a catchment area-based cross-sectional study (2002-2007) with a sample from a population-based health study from the same catchment area (2000-2001). The psychosis sample included patients with a Structured Clinical Interview for DSM-IV Axis I Disorders diagnosis of psychotic disorder (67 immigrants, 66 Norwegians). The reference sample consisted of 1,046 subjects (177 immigrants, 869 Norwegians). Serum levels of vitamin D were measured by radioimmunoassay, and results were presented as 25-hydroxyvitamin D levels. RESULTS Over 80% (n = 55) of immigrant patients with psychosis had insufficient/deficient serum levels of 25-hydroxyvitamin D (< 50 nmol/L). Immigrants had higher rates of 25-hydroxyvitamin D deficiency than Norwegians (P < .001). Norwegians with psychosis had lower serum levels of 25-hydroxyvitamin D than Norwegians in the reference sample from the general public (P < .001). 25-hydroxyvitamin D levels correlated with certain negative/depressive symptoms among patients with psychosis. CONCLUSIONS An alarmingly high percentage of immigrants and Norwegians with psychotic disorders have 25-hydroxyvitamin D deficiency. This has important clinical implications as it suggests possible beneficial effects of vitamin D medication/heliotherapy within this group.

Long-term mental health of Vietnamese refugees in the aftermath of trauma.

BACKGROUND There is no long-term prospective study (>20 years) of the mental health of any refugee group. AIMS To investigate the long-term course and predictors of psychological distress among Vietnamese refugees in Norway. METHOD Eighty Vietnamese refugees, 57% of the original cohort previously interviewed in 1982 (T(1)) and 1985 (T(2)), completed a self-report questionnaire prior to a semi-structured interview. Mental health was measured using the Symptom Checklist-90-Revised (SCL-90-R). RESULTS The SCL-90-R mean Global Severity Index (GSI) decreased significantly from T(1) to T(3) (2005-6), but there was no significant change in the percentage reaching threshold scores (GSI =1.00). Trauma-related mental disorder on arrival and the trajectory of symptoms over the first 3 years of resettlement predicted mental health after 23 years. CONCLUSIONS Although the self-reported psychological distress decreased significantly over time, a substantial higher proportion of the refugee group still remained reaching threshold scores after 23 years of resettlement compared with the Norwegian population. The data suggest that refugees reaching threshold scores on measures such as the SCL-90-R soon after arrival warrant comprehensive clinical assessment.