Jeroen W. Knipscheer

The efficacy of recommended treatments for veterans with PTSD: A metaregression analysis.

Soldiers and veterans diagnosed with PTSD benefit less from psychotherapy than non-military populations. The current meta-analysis identified treatment predictors for traumatised soldiers and veterans, using data from studies examining guideline recommended interventions, namely: EMDR, exposure, cognitive, cognitive restructuring, cognitive processing, trauma-focused cognitive behavioural, and stress management therapies. A systematic search identified 57 eligible studies reporting on 69 treated samples. Exposure therapy and cognitive processing therapy were more effective than EMDR and stress management therapy. Group-only therapy formats performed worse compared with individual-only formats, or a combination of both formats. After controlling for study design variables, EMDR no longer negatively predicted treatment outcome. The number of trauma-focused sessions, unlike the total number of psychotherapy sessions, positively predicted treatment outcome. We found a relationship between PTSD pretreatment severity levels and treatment outcome, indicating lower treatment gains at low and high PTSD severity levels compared with moderate severity levels. Demographic variables did not influence treatment outcome. Consequently, soldiers and veterans are best served using exposure interventions to target PTSD. Our results did not support a group-only therapy format. Recommended interventions appear less effective at relatively low and high patient PTSD severity levels. Future high-quality studies are needed to determine the efficacy of EMDR.

Coping and chronic psychosocial consequences of female genital mutilation in the Netherlands

Objective. The study presented in this article explored psychosocial and relational problems of African immigrant women in the Netherlands who underwent female genital mutilation/cutting (FGM/C), the causes they attribute to these problems – in particular, their opinions about the relationship between these problems and their circumcision – and the way they cope with these health complaints. Design. This mixed-methods study used standardised questionnaires as well as in-depth interviews among a purposive sample of 66 women who had migrated from Somalia, Sudan, Eritrea, Ethiopia or Sierra Leone to the Netherlands. Data were collected by ethnically similar female interviewers; interviews were coded and analysed by two independent researchers. Results. One in six respondents suffered from post-traumatic stress disorder (PTSD), and one-third reported symptoms related to depression or anxiety. The negative feelings caused by FGM/C became more prominent during childbirth or when suffering from physical problems. Migration to the Netherlands led to a shift in how women perceive FGM, making them more aware of the negative consequences of FGM. Many women felt ashamed to be examined by a physician and avoided visiting doctors who did not conceal their astonishment about the FGM. Conclusion. FGM/C had a lifelong impact on the majority of the women participating in the study, causing chronic mental and psychosocial problems. Migration made women who underwent FGM/C more aware of their condition. Three types of women could be distinguished according to their coping style: the adaptives, the disempowered and the traumatised. Health care providers should become more aware of their problems and more sensitive in addressing them.

Late-Onset PTSD in Unaccompanied Refugee Minors: Exploring the Predictive Utility of Depression and Anxiety Symptoms

Following resettlement in Western countries, unaccompanied refugee minors (URM) are at risk of developing posttraumatic stress disorder (PTSD). It is unclear to what extent PTSD in this group may become manifest at later stages following resettlement and which factors are associated with late onset. We examined data from URM collected 1 (T1) and 2 years (T2) following resettlement for differences between groups with no PTSD, PTSD at T1, and late-onset PTSD (at T2 only) using multinomial regression and path analysis. Of the children and adolescents (ages 12–18) completing both assessments (N = 554), 223 (40%) met criteria for PTSD at T1, and 88 (16%) endorsed late-onset PTSD. Late-onset PTSD was associated with traumatic event exposure, older age, and low education. In the late-onset PTSD group, the predictive effects of traumatic event exposure on symptom severity at T2 were fully mediated by depression and anxiety symptoms at T1. These results suggest that late-onset PTSD is a clinically relevant problem among URM that may be heralded by early depression and anxiety symptoms.

Acculturation and psychological distress among non-Western muslim migrants: a population-based survey.

Background: Political and social developments point at increasing marginalization of Muslim migrants, but little is known about its consequences for the mental health of this particular group. Aim: To explore the relationship between acculturation and psychological distress among first-generation Muslim migrants from Turkey and Morocco in the Netherlands. Methods: A cross-sectional study. Respondents were interviewed in their preferred language. Acculturation was measured with the Lowlands Acculturation Scale (LAS) and psychological distress with the Kessler Psychological Distress Scale (K10). Data were complete for 321 subjects and analyzed with multivariate linear regression. Results: Less skills for living in Dutch society was associated with distress (p = 0.032). Feelings of loss were related to distress among Moroccans (p = 0.037). There was an interaction between traditionalism and ethnic background ( p = 0.037); traditionalism was related to less distress among Moroccans (p = 0.020), but not among Turkish. Finally, there was an interaction by gender among Turks (p = 0.029); conservative norms and values seemed to be related to distress among men (p = 0.062), not women. Conclusion: Successful contact and participation in Dutch society, and maintenance of heritage culture and identity were moderately associated with less psychological distress. Improving mastery of the dominant language in host societies, and allowing migrants to preserve their traditions, might be effective measures in improving the mental well-being of migrants.

Help-seeking behaviour regarding mental health problems of Mediterranean migrants in the Netherlands: familiarity with care, consultation attitude and use of services.

Background: Ethnic minority groups differ in the pattern of their seeking help, and in their use of and attitude towards mental health systems. To meet the mental health needs of ethnic minority populations, insights into determinants of their help-seeking orientations are of great concern. Aim: To investigate help-seeking behaviour regarding mental health problems in terms of familiarity, attitude and service use among Mediterranean migrants in the Netherlands. Methods: Samples of Mediterranean citizens in the general population (N 1/4 292) and of Mediterranean (N 1/4 114) and indigenous Dutch outpatients (N 1/4 59) currently treated in mental health care were included. Data were acquired by administering a semi-structured interview. Quantified data were analysed using multivariate techniques. Results: More recently arrived participants were less familiar with mental health services. Moroccan, lower educated and recently arrived respondents reported a more negative attitude towards consulting these agencies. The help-seeking behaviour of the Mediterranean participants was relatively similar to that of the indigenous Dutch subjects. Conclusions: With regard to care-seeking routes and use of mental health services, more inter-ethnic similarities than differences emerged. Sociodemo-raphic variables like age, education and length of residence shape the process of help-seeking and service use.

Stress sensitization following a disaster: a prospective study.

BACKGROUND According to the stress sensitization hypothesis, prior exposure to extreme stressors may lead to increased responsiveness to subsequent stressors. It is unclear whether disaster exposure is associated with stress sensitization and, if so, whether this effect is lasting or temporary. This study aimed to investigate the occurrence and duration of stress sensitization prospectively following a major disaster. METHOD Residents affected by a fireworks disaster (n=1083) participated in surveys 2-3 weeks (T1), 18-20 months (T2) and almost 4 years (T3) after the disaster. Participants reported disaster exposure, including direct exposure, injury and damage to their home at T1, and also stressful life events (SLEs) at T2 and T3. Feelings of anxiety and depression, concentration difficulty, hostility, sleep disturbance, and intrusion and avoidance of disaster-related memories were used as indicators of distress. RESULTS Residents whose home was completely destroyed responded with greater distress to SLEs reported 18-20 months following the disaster than residents whose home was less damaged. There were no differences in stress responsiveness almost 4 years after the disaster. CONCLUSIONS During the first years after a disaster, stress sensitization may occur in disaster survivors who experienced extreme disaster exposure. Stress sensitization may explain the persistence or progression of distress over time following extreme stressor exposure.

GHANAIAN MIGRANTS IN THE NETHERLANDS: GENERAL HEALTH, ACCULTURATIVE STRESS AND UTILIZATION OF MENTAL HEALTH CARE

Ghanaians are a relatively unknown migrant group in the Netherlands. Due to a plane crash in a densely populated suburb of Amsterdam, the Ghanaian population in 1992 suddenly became a “hot item” in national media. It was assumed that they would be a group at risk: many Ghanaians were either directly or indirectly victims of this disaster. Moreover, Ghanaians were assumed to be unfamiliar with the Dutch society and the health care system.A study was conducted using self-report questionnaires to investigate mental health and help-seeking orientation. Findings show that migration factors, acculturative stress, and legal status have an impact on health status.However, Ghanaians do not report more health problems than the Dutch norm group. Furthermore, results indicate that the help-seeking orientation of the Ghanaians differs less from the Dutch than was supposed: the Ghanaian participants consult clergy and traditional healers for their problems as well as the regional ambulatory mental health care center. Satisfaction with the services provided was seen to be quite high. However, more practical help with regard to financial problems and housing facilities is wanted. Implications for improving the mental health care system for migrants and ethnic minorities are discussed.

Use of the cultural formulation with refugees.

This article discusses the experiences of mental health professionals who applied the Cultural Formulation (CF) of the DSM-IV for assessment of psychopathology and treatment needs of refugees in the Netherlands. The CF approach proved to be a useful tool in the assessment and diagnostic phase of clinical treatment. However, patients reported problems with defining their own culture and providing explanations of illness and therapists had difficulty identifying culturally-based difficulties in the clinical relationship. Additional information was needed about working with interpreters, therapists’ attitudes towards the culture of the patient and towards their own culture, patients’ previous experiences with discrimination and inaccessibility of care, gender issues, and specific cultures and subcultures. A more structured approach to conducting the CF is recommended. We developed the “Cultural Formulation Interview” for this purpose. The adaptations are aimed at improving the CF for use with refugee populations, as well as for more general use in transcultural psychiatry.

Somatization in refugees: a review

PurposeTo present a review of the literature concerning medically unexplained physical symptoms in refugees.MethodsWe outline a variety of definitions and explanations of somatization, as well as the role of culture in the concept of disease. In addition, we present a review of the epidemiological literature about somatization in refugees.ResultsRefugees from non-Western countries exhibit more unexplained somatic symptoms than the general Western population. Although different studies have employed different methodologies and are therefore difficult to compare, it can be concluded that refugees form a particular population in which somatization is prominent.ConclusionsPotential, not mutually exclusive, explanations of the high number of somatic symptoms in the refugee population include general psychopathology, specifically traumatisation, results of torture, and stigmatisation of psychiatric care. There are implications for assessment, clinical treatment and further research concerning somatization in refugees.

The importance of ethnic similarity in the therapist-patient dyad among Surinamese migrants in Dutch mental health care

Empirical evidence is equivocal on whether ethnic matching in the therapist-patient dyad is preferred by ethnic minority patients and whether it leads to treatment satisfaction. The aim of this study was to establish the importance of ethnic similarity in mental health care among Surinamese migrants in the Netherlands. A convenience sample of Surinamese out-patients in community mental health care (N = 96) was interviewed. Data were analysed using logistic multivariate techniques. The majority of the Surinamese out-patients (in particular recently residing participants) rated ethnic matching as relevant; a considerable minority considered compassion and expertise to be more relevant than ethnic background. Most out-patients reported to be satisfied with the services, especially females and respondents treated by an ethnically similar therapist. Ethnic similarity in the patient-therapist dyad is a strong predictor for satisfaction with mental health care services. However, although it is preferred by many, ethnic matching per se is no must - empathy, expertise and world view sharing are reported to be of considerable importance as well.