Johannes E. Hovens

Physical and mental health of Afghan, Iranian and Somali asylum seekers and refugees living in the Netherlands

ContextWorldwide, the number of refugees and asylum seekers is estimated to be about 11.5 million plus a much larger number of former refugees who have obtained a residence permit in a new country. Although asylum seekers have been coming to the Netherlands since the 1980s, very few epidemiological studies have focused on this group of inhabitants or on the refugees who have resettled in this country.ObjectivesThe objectives of this study were to estimate the prevalence rates of physical and mental health problems and to identify the risk factors for these complaints.Design, Setting, and ParticipantsA population-based study was conducted in the Netherlands from June 2003 to April 2004 among adult refugees and asylum seekers from Afghanistan, Iran and Somalia. Asylum seekers were living in 14 randomly selected reception centres, and random samples of refugees were obtained from the population registers of three municipalities (Arnhem, Leiden and Zaanstad). A total of 178 refugees and 232 asylum seekers participated (response rates of 59 and 89%, respectively).Main Outcome MeasuresGeneral health and physical health were measured with the Short-Form 36 and a list of 19 chronic conditions, respectively; symptoms of post-traumatic stress disorder (PTSD), depression and anxiety, were measured with the Harvard Trauma Questionnaire and the Hopkins Symptoms Checklist-25.ResultsMore asylum seekers (59.1%) than refugees (42.0%) considered their health to be poor (P=0.001). In both groups, approximately half of the respondents suffered from more than one chronic condition. More asylum seekers than refugees had symptoms of PTSD (28.1 and 10.6%, respectively; P=0.000) and depression/anxiety (68.1 and 39.4, respectively; P=0.000). Respondents from Afghanistan and, in particular, from Iran had a higher risk for PTSD and depression/anxiety. Female gender was associated with chronic conditions, PTSD and depression/anxiety, and higher age was associated with poor general health and chronic conditions. A greater number of traumatic events was associated with all health outcomes, and more post-migration stress and less social support were associated with PTSD and depression/anxiety symptoms.ConclusionsBoth physical and mental health problems are highly prevalent among refugees and asylum seekers in the Netherlands. Although higher prevalence rates for most health outcomes were found among asylum seekers, both the specific health services for asylum seekers and the general health services in the municipalities should be aware of these problems.

The development of the Self-Rating Inventory for Posttraumatic Stress Disorder

In this study a newly developed Self‐rating Inventory for Posttraumatic Stress Disorder (PTSD) is presented. The instrument consists of 47 items, reflecting DSM‐III‐R criteria, associated features and items corresponding to the disorder of extreme stress not otherwise specified. All items are phrased in a trauma‐independent way and are measured on an intensity scale. The instrument was validated on 76 subjects with war‐related trauma and 59 psychiatric outpatients, one third of whom were traumatized. Test‐retest for the scale was 0.90. The coefficient alpha appeared to be 0.96 for the 47‐items scale and 0.92 for the 22 DSM‐III‐R subscale. The scale correlated significantly with the Clinician Administered PTSD Scale, the Mississippi Scale for Combat‐related PTSD, the MMPI PTSD subscale and the Impact of Event Scale. The overall efficiency of the Self‐rating Inventory for PTSD was comparable to the overall efficiency of the Mississippi Scale and superior to the MMPI PTSD subscale. Factor analysis on the 22 DSM‐III‐R items showed 4 factors, representing numbing, intrusion, avoidance and sleeping problems. It is concluded that the Self‐rating Inventory for PTSD is a powerful instrument for diagnosing PTSD in survey research. The instrument appears to be capable of differentiating not only between PTSD and non‐PTSD subjects but also between traumatized non‐PTSD subjects and non‐traumatized psychiatric patients.

Fluvoxamine Treatment for Chronic PTSD: A Pilot Study

A group of 24 Dutch World War II Resistance veterans with a documented traumatic war history and a (partially) positive diagnosis of current posttraumatic stress disorder (PTSD) was studied. This special group of war victims is characterised by chronicity, suffering from intractable posttraumatic complaints for decades. They were treated with fluvoxamine (Fevarin), a selective serotonin reuptake inhibitor with antidepressive and anxiolytic properties. The study was designed as an open-ended, outpatient pilot study, with a treatment period of 12 weeks. Results of clinical examination, and questionnaires investigating PTSD, depression, sleeping problems, anxiety, and vital exhaustion indicate that a significant number of the subjects improved with respect to their PTSD symptomatology, and their symptoms of anxiety and vital exhaustion. However, at the end of the study, quantitative improvement was modest. The results indicate that treatment with fluvoxamine may offer alleviation of chronic PTSD symptoms, in particular insomnia, nightmares, anxiety, intrusive recollections, guilt feelings and tiredness.

Current Posttraumatic Stress Disorder and Cardiovascular Disease Risk Factors in Dutch Resistance Veterans from World War II

The extraordinary trauma experienced by Resistance veterans from World War II (WW II) and other veterans may be associated with an increased incidence of posttraumatic stress disorder (PTSD) and somatic morbidity, including cardiovascular disease (CVD). This study explored some relationships between current PTSD and CVD risk factors in 147 male Dutch WW II Resistance veterans. They were compared to 65 same-aged male patients with a recent myocardial infarction and 79 surgical patients. Of these subjects, WW II Resistance veterans scored highest on CVD risk factors (i.e., angina pectoris, type A behavior, life stressors, and vital exhaustion), except smoking. Fifty-six percent of these veterans were currently suffering from PTSD. They reported CVD risk factors, in particular type A behavior and vital exhaustion, more often than veterans without PTSD; they also reported more premorbid adverse living conditions. These data suggest that early sensitization to environmental stressors may be associated with a high prevalence of current PTSD and excess CVD risk factors in subjects exposed to extraordinary war-time trauma and that this may lead to vital exhaustion.

The assessment of posttraumatic stress disorder: With the clinician administered PTSD scale: Dutch results

The Clinician Administered PTSD Scale was employed with 76 traumatized Dutch subjects from different treatment centers and one social rehabilitation center. Subjects were traumatized either in childhood, in adolescence, or in early adulthood. The CAPS showed an overall agreement with clinical diagnosis of 79%, with a kappa coefficient of .58. Interrater agreement on the CAPS subscales of intensity (intrusion, avoidance, and hyperarousal) varied from .93 to .98. The internal consistency for all core symptoms of DSM-III-R at the CAPS intensity level for current PTSD was .89, and for lifetime PTSD .86. Concurrent validity was established by correlating the CAPS with the Mississippi Scale, the MMPI, and the Impact of Event Scale. All correlations were significant beyond .001. Finally, the CAPS items, both core symptoms and associative features, are discussed in detail at item level.

Self-Rating Inventory for Posttraumatic Stress Disorder: Review of the Psychometric Properties of a New Brief Dutch Screening Instrument

The Self-rating Inventory for Posttraumatic Stress Disorder of 22 items was developed for use with populations without identified traumatic experiences. The inventory has been used extensively in survey research in The Netherlands. This paper examines the psychometric properties. In four different groups (trauma and psychiatric patients, elderly Dutch subjects, former peacekeepers, and medical students) internal consistency, test-retest reliability, concurrent and discriminant validity, and sensitivity and specificity are analyzed. The inventory showed good internal consistency, test-retest reliability, concurrent and discriminant validity, and high sensitivity and specificity. It appears to be valuable for survey research on posttraumatic stress in nonselected populations. As a screening device, high sensitivity for PTSD symptoms is evident even when the traumatic event has not been defined.

Threat/control-override symptoms and emotional reactions to positive symptoms as correlates of aggressive behavior in psychotic patients.

This cross-sectional multicenter study was carried out to examine whether the experience of threat/control-override symptoms and emotional reactions to positive symptoms (e.g., anger, anxiety) are related to aggressive behavior. Patients diagnosed with schizophrenia, delusional disorder, psychotic disorder not otherwise specified, or a schizoaffective disorder (N = 124) were interviewed and filled out self-report questionnaires. Results indicated that, in particular, threat/control-override symptoms were significantly related to aggressive behavior in psychotic patients. Further analysis revealed that the threat symptoms especially, but not the control-override symptoms, carried this effect. Anger disposition also accounted for a significant and unique proportion of the variance in the aggressive behavior of psychotic patients, whereas state anger and anxiety in reaction to positive symptoms did not. These results seem to suggest that feeling threatened by positive psychotic symptoms and anger disposition play a role in the origins of aggressive behavior of psychotic patients.

Oral risperidone with lorazepam versus oral zuclopenthixol with lorazepam in the treatment of acute psychosis in emergency psychiatry: a prospective, comparative, open-label study

Acutely psychotic patients presenting as psychiatric emergencies with aggression or agitation are often administered conventional antipsychotics intramuscularly. However, patients view intramuscular administration as coercive, and conventional antipsychotics are often associated with adverse events. In this open study, consecutive adult patients presenting with an acute exacerbation of schizophrenia or other psychotic disorder were assigned to oral risperidone 2-6 mg/day (n = 48) or oral zuclopenthixol 20-50 mg/day (n = 27) for 7-14 days. Lorazepam (either oral or intramuscular) was administered to both groups as needed. Patients were assessed regularly until day 14 or discharge. Mean Positive And Negative Syndrome Scale (PANSS) aggression scores (sum of item scores on excitement, poor impulse control, hostility and uncooperativeness) decreased steadily and similarly in both groups; the mean changes from baseline were statistically significant at days 10 and 14 and at study end-point. The mean decrease at study end-point in the PANSS component score for hostility was statistically significant in the risperidone group, but not in the zuclopenthixol group. Social Dysfunction and Aggression Scale aggression scores and Clinical Global Impression scores decreased significantly and similarly in both groups. Overall, 18.7% of patients showed minor extrapyramidal symptoms during the study, but only 16.7% of risperidone-treated patients, compared to 59.3% of zuclopenthixol-treated patients, received anti-parkinsonian medication (p< 0.001). Lorazepam was administered to all of the patients assigned to risperidone and to 89% of those assigned to zuclopenthixol. Oral risperidone plus lorazepam is a convenient, effective and well-tolerated alternative to conventional antipsychotics for the treatment of acute psychosis in emergency psychiatry.

PREVALENCE AND COURSE OF POSTTRAUMATIC STRESS DISORDER IN DUTCH VETERANS OF THE CIVILIAN RESISTANCE DURING WORLD WAR II: AN OVERVIEW

This study concerns the prevalence of current and lifetime Posttraumatic Stress Disorder (PTSD) in various groups of officially recognized Veterans of the Dutch civilian Resistance against the Nazi occupation during World War II. In total, 1046 Resistance veterans living in The Netherlands and 52 who emmigrated to the United States after the war were examined. Between four and five decades after the end of WW 11, between 25 and 50% were suffering from current PTSD. The life-time prevalence is estimated to be substantially higher. The course of PTSD proved highly variable. There had often been a delay of several decades between the end of the war and reoccurrence or first onset of posttraumatic symptoms. The prevalence of PTSD in Resistance veterans who emigrated to the United States was hardly different from that of the veterans still living in The Netherlands.

A self-rating scale for the assessment of posttraumatic stress disorder in Dutch Resistance veterans of World War II.

The present study reports on the development of a Dutch PTSD scale based on the DSM-III criteria for PTSD. Test-retest reliability was .91. The scale showed an internal consistency with a coefficient alpha of .88. Factor analysis on a large sample of Resistance veterans (N = 967) yielded six factors, which represent intrusive thoughts, physiological reactions, detachment, rage, active confrontation, and guilt.