Elizabeth A. Newnham

Trauma history and psychopathology in war-affected refugee children referred for trauma-related mental health services in the United States.

There is an increasing need to deliver effective mental health services to refugee children and adolescents across the United States; however, the evidence base needed to guide the design and delivery of services is nascent. We investigated the trauma history profiles, psychopathology, and associated behavioral and functional indicators among war-affected refugee children presenting for psychological treatment. From the National Child Traumatic Stress Networks Core Data Set, 60 war-affected refugee children were identified (51.7% males, mean age = 13.1 years, SD = 4.13). Clinical assessments indicated high rates of probable posttraumatic stress disorder (30.4%), generalized anxiety (26.8%), somatization (26.8%), traumatic grief (21.4%), and general behavioral problems (21.4%). Exposure to war or political violence frequently co-occurred with forced displacement; traumatic loss; bereavement or separation; exposure to community violence; and exposure to domestic violence. Academic problems and behavioral difficulties were prevalent (53.6% and 44.6%, respectively); however, criminal activity, alcohol/drug use, and self-harm were rare (all < 5.45%). These findings highlight the complex trauma profiles, comorbid conditions, and functional problems that are important to consider in providing mental health interventions for refugee children and adolescents. Given the difficulties associated with access to mental health services for refugees, both preventive and community-based interventions within family, school, and peer systems hold particular promise.

Monitoring treatment response and outcomes using the World Health Organization's Wellbeing Index in psychiatric care

BACKGROUND Effective psychiatric care requires reliable measurement of patient progress and outcome. The current study aimed to assess the clinical validity of the WHO Wellbeing Index (WHO-5; Bech, P., Gudex, C., Johansen, K.S., 1996. The WHO (Ten) Wellbeing Index: validation in diabetes. Psychotherapy and Psychosomatics 65, 183-190.) for use as a measure of individual treatment response and outcome in mental health care. METHOD Three hundred and eighteen consecutive inpatients and day patients at an Australian private psychiatric facility completed the WHO-5, SF-36 and DASS-21 routinely during treatment, and 152 undergraduate students completed the WH0-5. RESULTS The WHO-5 was shown to be a measure with high reliability, validity and sensitivity to change, for use with patients who have affective or neurotic primary diagnoses. Further to this, regression analyses demonstrated that early scores on the measure predicted final outcome. Criteria for clinically significant recovery are also presented. LIMITATIONS The results may be generalized to samples with primary diagnoses of affective and anxiety disorders. Assessment of the WHO-5 as a measure of treatment response is warranted in other patient samples. CONCLUSIONS The current findings illustrate the potential of the WHO-5 as a quick, reliable and valid means for assessing patient outcome and monitoring patient response to treatment in psychiatric services.

Post-traumatic stress symptoms among former child soldiers in Sierra Leone: follow-up study

BACKGROUND Former child soldiers are at risk of developing post-traumatic stress disorder (PTSD); however, the trajectory of symptoms has yet to be examined. AIMS The risk and protective factors associated with PTSD symptom change among former child soldiers in Sierra Leone were investigated. METHOD Data from 243 former child soldiers (mean age 16.6 years, 30% female) were analysed. RESULTS Self-reported rates of possible PTSD using standard cut-off points declined from 32% to 16% 4 years later (P<0.05). Symptoms of PTSD at baseline were significantly associated with war experiences (P<0.01) and post-conflict family abuse (P<0.001). Reliable improvement in symptoms was reported by 30%. In growth models examining symptom change, worsening of symptoms was associated with death of a parent (P<0.05) and post-conflict stigma (P<0.001). Protective effects were observed for increases in family acceptance (P<0.001). CONCLUSIONS The findings indicated improvement in PTSD symptoms among former child soldiers despite limited access to care. Family and community support played a vital part in promoting psychological adjustment.

Progress monitoring and feedback in psychiatric care reduces depressive symptoms

BACKGROUND To date, the monitoring of patient progress using standardized assessments has been neglected in hospital-based psychiatric care. Findings in outpatient psychotherapy have demonstrated clinically significant benefits for providing feedback to the sizeable minority of patients who were otherwise unlikely to experience positive outcome (Lambert, 2007). However, a similar system for presenting feedback on patient progress has not yet been assessed for group therapy within psychiatric inpatient settings. The current study aimed to develop and evaluate the effectiveness of a feedback system suitable for use in psychiatric services. METHODS In a nonrandomized trial, 1308 consecutive inpatients and day patients, whose diagnoses were primarily depressive and anxiety disorders, completed the World Health Organizations Wellbeing Index (WHO-5) routinely during a ten-day cognitive behavioral therapy group. The first cohort (n=461) received treatment as usual. The second cohort (n=439) completed monitoring measures without feedback, and for patients in the third cohort (n=408), feedback on progress was provided to both clinicians and patients midway through the treatment period. RESULTS Feedback was effective in reducing depressive symptoms (F(1,649)=6.29, p<.05) for those patients at risk of poor outcome, but not effective in improving wellbeing (F(1,569)=1.14, p>.05). LIMITATIONS The current findings may be generalized to patient samples that exhibit largely depressive disorders, however rigorous follow-up is warranted. CONCLUSIONS Similar to outpatient settings, feedback appears to be beneficial for improving symptom outcomes but further time may be required for wellbeing to be affected.

Moderators of Treatment Effectiveness for War-Affected Youth With Depression in Northern Uganda

PURPOSE As we build the evidence base of interventions for depression among war-affected youth, it is critical to understand factors moderating treatment outcomes. The current study investigated how gender and history of abduction by Lords Resistance Army rebels moderated treatment outcomes for war-affected youth. METHODS The study-a three-armed, randomized, controlled trial-was conducted with internally displaced war-affected adolescents in northern Uganda. Participants with significant depression symptoms (N = 304; 57% female; 14-17 years of age) were randomly assigned to an interpersonal psychotherapy group (IPT-G), a creative play/recreation group, or a wait-list control condition. Secondary analyses were conducted on data from this randomized controlled trial. RESULTS A history of abduction by Lords Resistance Army rebels was reported by 42% of the sample. Gender and abduction history interacted to moderate the effectiveness of IPT-G for the treatment of depression. In the IPT-G intervention arm, treatment effectiveness was greatest among female subjects without an abduction history, with effect size = 1.06. IPT-G was effective for the treatment of depression for both male and female subjects with a history of abduction (effect size = .92 and .50, respectively). Male subjects with no abduction history in IPT-G showed no significant improvement compared with those in the control conditions. CONCLUSIONS Abduction history and gender are potentially important moderators of treatment effects, suggesting that these factors need to be considered when providing interventions for war-affected youth. IPT-G may be an effective intervention for female subjects without an abduction history, as well as for both male and female former child soldiers, but less so for male subjects without an abduction history.

The subscale structure and clinical utility of the Health of the Nation Outcome Scale

Background: The Health of the Nation Outcome Scale (HoNOS) has been adopted with enthusiasm by service providers and clinicians, but criticism regarding the appropriate factor structure has emerged. Aims: The current study aimed to determine an appropriate factor structure that is both psychometrically sound and clinically meaningful. Method: HoNOS data for 6475 inpatients at admission and 6308 at discharge from an Australian psychiatric clinic were assessed in two studies. Results: The results of confirmatory factor analyses support the use of a new four factor model that includes anti-social, physical and psychological impairment, symptom, and socio-economic factors. The four factor structure demonstrated greater sensitivity to change than alternatives and factorial stability. In addition, the model is both parsimonious and clinically useful. Conclusions: When administering the HoNOS for patients with mood and/or anxiety disorders, it appears the new four factor model is an appropriate means of interpreting scores.

The intergenerational impact of war: longitudinal relationships between caregiver and child mental health in postconflict Sierra Leone

BACKGROUND Trauma from witnessing events such as bombings and killings as well as direct victimization or participation in violence has been associated with psychosocial distress and poor mental health among war-exposed children and adolescents. This study examines the relationship between caregiver mental health and child internalizing (anxiety and depression) symptoms over a 4-year period in postconflict Sierra Leone. METHODS The sample included 118 adolescent Sierra Leonean youth (73% male; mean age = 16.5 years at Time 1) and their caregivers (40% male; mean age = 39.0 at Time 1). To measure depression and anxiety symptoms, the Hopkins Symptom Checklist-25 was used with adults and the Oxford Measure of Psychosocial Adjustment - previously validated for use with children and adolescents in the region - was used to assess youth. A multivariate hierarchical linear model (HLM) for studying change within dyads was implemented to study covariation in internalizing symptoms among caregivers and youth over time; these models also included covariates at the individual, family and community levels. The relationship of caregiver mental health to childs internalizing was tested in a latent variable extension of the HLM. RESULTS The latent variable extension estimated that a one standard deviation (SD) change in caregiver anxiety/depression was associated with a .43 SD change in youth internalizing (p < .01) over the 4-year period. Family acceptance was negatively related to youth internalizing (p < .001), while community stigma was positively associated (p < .001). CONCLUSIONS The findings highlight an important interplay between caregiver and child mental health within the postconflict setting and the need for psychosocial interventions to extend beyond the individual to account for family dynamics.

Youth mental health after civil war: the importance of daily stressors

Background Recent evidence suggests that post-conflict stressors in addition to war trauma play an important role in the development of psychopathology. Aims To investigate whether daily stressors mediate the association between war exposure and symptoms of post-traumatic stress and depression among war-affected youth. Method Standardised assessments were conducted with 363 Sierra Leonean youth (26.7% female, mean age 20.9, s.d. = 3.38) 6 years post-war. Results The extent of war exposures was significantly associated with post-traumatic stress symptoms (P<0.05) and a significant proportion was explained by indirect pathways through daily stressors (0.089, 95% CI 0.04–0.138, P<0.001). In contrast, there was little evidence for an association from war exposure to depression scores (P = 0.127); rather any association was explained via indirect pathways through daily stressors (0.103, 95% CI 0.048–0.158, P<0.001). Conclusions Among war-affected youth, the association between war exposure and psychological distress was largely mediated by daily stressors, which have potential for modification with evidence-based intervention.

The effects of progress monitoring on subsequent readmission to psychiatric care: A six-month follow-up

BACKGROUND Monitoring patient progress and providing feedback to clinicians and patients about progress during therapy reduce depressive symptoms at treatment completion. However, the effects of feedback on patient outcomes following treatment completion are unknown. Accordingly, the current study aimed to examine the effect of feedback on readmission to psychiatric hospital following completion of a group psychotherapy program. METHOD This naturalistic historical follow-up study compared the risk of readmission to a psychiatric hospital for two patient cohorts examined by Newnham et al. (2010a,b); the first cohort received feedback (n=408) during a group psychotherapy program, whereas the second cohort did not receive feedback (n=439). The sample included inpatients and day patients, with primarily depressive and anxiety disorders who routinely completed the World Health Organizations Wellbeing Index. RESULTS Feedback was associated with fewer readmissions over the six months following completion of the therapy program for patients who, at the point of feedback, were on track to make clinically meaningful improvement by treatment termination. DISCUSSION The findings suggest feedback could result in cost saving and is associated with improved outcomes following treatment completion for patients deemed on track during therapy.

A pilot randomized controlled trial of an early multidisciplinary model to prevent disability following traumatic injury

Purpose: Chronic pain, posttraumatic stress disorder (PTSD), and depression are common outcomes following traumatic injury. Yet, screening and early intervention to prevent the onset of these disorders do not occur routinely in acute trauma settings. This pilot study examined the clinical utility of screening and early multidisciplinary intervention for reducing disability following traumatic injury. Method: 142 non-severe head injured trauma inpatients (26% female, Injury Severity Score M = 9.65, M age = 36 years) were assessed for injury-related factors, pain, and psychological function within 4 weeks post injury. Patients were randomly allocated to a Multidisciplinary Intervention (MI) or Usual Care (UC) group. MI patients received assessment and treatment at one and 3 months post injury from pain and rehabilitation medicine doctors, physiotherapists, occupational therapists, and clinical psychologists. Outcomes at 6 months were then compared. Results: Acute pain intensity, posttraumatic adjustment, depression and acute trauma symptoms, and alcohol use predicted a significant 26%, 49%, 56%, and 30% of the variance in pain, depressive, and PTSD severity, and physical mobility respectively at 6 months. Despite MI group patients reporting no improvement in the severity of pain and psychological symptoms, these patients reported significantly improved relief from pain symptoms as a result of treatment at 6 months. Twenty four per cent of the UC group initially below the cut-off for being at risk of developing PTSD/Depression received new clinical diagnoses at 6 months compared with none of the ‘not at risk’ MI group attendees who remained asymptomatic. Conclusions: Early findings point to the value of early screening to identify patients at risk of treatable pain, physical, and psychological impairments. Moreover, early multidisciplinary intervention models following traumatic injury show promise for protecting against the onset of posttraumatic psychological disorders. Implications for Rehabilitation The prevalence of chronic pain, posttraumatic stress and depressive disorders, and functional disability is high following traumatic injury. Standardized screening within acute trauma settings can identify patients are highest risk of long-term physical and psychological disability. Coordinated early interventions conducted by acute trauma, pain and rehabilitation teams working in collaboration show promise for reducing long-term disability among recently injured trauma patients.