M. Claire Greene

Sexual and gender-based violence in areas of armed conflict: a systematic review of mental health and psychosocial support interventions

BackgroundSexual and other forms of gender-based violence are common in conflict settings and are known risk factors for mental health and psychosocial wellbeing. We present findings from a systematic review of the academic and grey literature focused on the effectiveness of mental health and psychosocial support interventions for populations exposed to sexual and other forms of gender-based violence in the context of armed conflicts.MethodsWe searched the Cochrane Database of Systematic Reviews, Cochrane Controlled Trials Register, PubMed/ Medline, psycINFO, and PILOTS, as well as grey literature to search for evaluations of interventions, without date limitations.ResultsOut of 5,684 returned records 189 full text papers were assessed for eligibility. Seven studies met inclusion criteria: 1 non-randomized controlled study; 3 non-controlled pre- post-test designs; 1 retrospective cohort with a matched comparison group; and 2 case studies. Studies were conducted in West and Central Africa; Albania; UK and USA, included female participants, and focused on individual and group counseling; combined psychological, medical, social and economic interventions; and cognitive behavioral therapy (two single case studies).ConclusionsThe seven studies, while very limited, tentatively suggest beneficial effects of mental health and psychosocial interventions for this population, and show feasibility of evaluation and implementation of such interventions in real-life settings through partnerships with humanitarian organizations. Robust conclusions on the effectiveness of particular approaches are not possible on the basis of current evidence. More rigorous research is urgently needed.

Beyond motivation: Initial validation of the commitment to sobriety scale

From an addiction treatment and recovery standpoint maladaptive motivational hierarchies lie at the core of the challenge in mobilizing salutary behavior change. Motivation has been conceptualized as dynamic, interactive and modifiable, as well as multidimensional. Measures of recovery motivation have been developed and validated, but are generally only modest and variable predictors of future behavior. A related, but potentially more potent, construct, is that of commitment to sobriety as it denotes a clearer re-ranking of motivational hierarchies such that the recovery task is now given a top priority potentially less susceptible to the risks associated with undulating future circumstance. This study investigated the psychometric properties of a novel commitment to sobriety scale (CSS). Results revealed a coherent, psychometrically valid, and reliable tool that outperformed an existing commitment to abstinence scale (ATAQ; J. Morgenstern, R.M. Frey, B.S. McCrady, E. Labouvie, & C.J. Neighbors, 1996) and a gold standard measure of motivation (SOCRATES; W.R. Miller & J.S. Tonigan, 1996). This study highlights commitment to sobriety as an important addiction construct. Researchers and theoreticians may find the CSS useful in helping to explain how individuals achieve recovery, and practitioners may find clinical utility in the CSS in helping identify patients in need of more intensive or alternative intervention.

Young Adults, Social Networks, and Addiction Recovery: Post Treatment Changes in Social Ties and Their Role as a Mediator of 12-Step Participation

Background Social factors play a key role in addiction recovery. Research with adults indicates individuals with substance use disorder (SUD) benefit from mutual-help organizations (MHOs), such as Alcoholics Anonymous, via their ability to facilitate adaptive network changes. Given the lower prevalence of sobriety-conducive, and sobriety-supportive, social contexts in the general population during the life-stage of young adulthood, however, 12-step MHOs may play an even more crucial recovery-supportive social role for young adults, but have not been investigated. Greater knowledge could enhance understanding of recovery-related change and inform young adults’ continuing care recommendations. Methods Emerging adults (N = 302; 18–24 yrs; 26% female; 95% White) enrolled in a study of residential treatment effectiveness were assessed at intake, 1, 3, 6, and 12 months on 12-step attendance, peer network variables (“high [relapse] risk” and “low [relapse] risk” friends), and treatment outcomes (Percent Days Abstinent; Percent Days Heavy Drinking). Hierarchical linear models tested for change in social risk over time and lagged mediational analyses tested whether 12-step attendance conferred recovery benefits via change in social risk. Results High-risk friends were common at treatment entry, but decreased during follow-up; low-risk friends increased. Contrary to predictions, while substantial recovery-supportive friend network changes were observed, this was unrelated to 12-step participation and, thus, not found to mediate its positive influence on outcome. Conclusions Young adult 12-step participation confers recovery benefit; yet, while encouraging social network change, 12-step MHOs may be less able to provide social network change directly for young adults, perhaps because similar-aged peers are less common in MHOs. Findings highlight the importance of both social networks and 12-step MHOs and raise further questions as to how young adults benefit from 12-step MHOs.

Mental Health and Social Support Among HIV-Positive Injection Drug Users and Their Caregivers in China

The burden of HIV/AIDS in China is due to injection drug use. Non-clinical caregivers provide much of the care for HIV patients but are often not included in HIV care or research. The objective of this study is to examine the relationships between the caregiver context and mental health of HIV-positive injection drug users and their caregivers. We interviewed 96 patient–caregiver dyads using quantitative methods. A conceptual model was developed as a framework for multivariate linear regression modeling. The strongest predictor of poor patient mental health was lack of social support, which was largely determined by the caregiver’s stigma towards HIV/AIDS and caregiver burden. Patient disability and caregiver burden were the primary predictors of poor caregiver mental health. The interrelated nature of caregiver and patient mental health supports the inclusion of caregiver health into the patient’s HIV/AIDS treatment to maximize support provision and health for the patient and caregiver.

Challenges for the implementation of World Health Organization guidelines for acute stress, PTSD, and bereavement: a qualitative study in Uganda

BackgroundIn 2013, the World Health Organization (WHO) published new guidelines for the management of conditions specifically related to stress, including symptoms of acute stress, bereavement, and post-traumatic stress disorder (PTSD). It is important to evaluate potential challenges for the implementation of these guidelines in low-resource settings, however, there is a dearth of research in this area. The current qualitative study aimed to assess perspectives on the feasibility and acceptability of the new guidelines in four clinics that provide mental health services in post-conflict northern Uganda.MethodsIn-depth interviews were conducted with 19 mental health-care providers and program developers in northern Uganda to address three major research objectives: (1) describe the current standard practices and guidelines used for treating conditions related to stress in Uganda; (2) identify barriers and challenges associated with implementing the new WHO guidelines; and (3) identify and describe potential strategies for overcoming these barriers and challenges. An emergent thematic analysis was used to develop a coding scheme for the transcribed interviews.ResultsPractices for managing conditions related to stress included group psychological interventions, psychoeducation, and medication for clients with severe signs and symptoms. Several themes were identified from the interviews on barriers to guideline implementation. These included (1) a lack of trained and qualified mental health professionals to deliver WHO-recommended psychological interventions; (2) a perception that psychological interventions developed in high-income countries would not be culturally adaptable in Uganda; and (3) reluctance about blanket statements regarding medication for the management of acute stress symptoms and PTSD. Identified strategies for overcoming these barriers included (1) training and capacity building for current mental health staff; (2) a stepped care approach to mental health services; and (3) cultural modification of psychological interventions to improve treatment acceptability by clients.ConclusionsGuidelines were viewed positively by mental health professionals in Uganda, but barriers to implementation were expressed. Recommendations for implementation include (1) strengthening knowledge on effectiveness of existing cultural practices for improving mental health; (2) improving supervision capacity of current mental health staff to address shortage in human resources; and (3) increasing awareness of help-seeking clients on the potential effectiveness of psychological vs. pharmacological interventions.

Toward an Enhanced Understanding of the Psychological Mechanisms by which Spirituality Aids Recovery in Alcoholics Anonymous

Alcoholics Anonymous (AA) is based on a spiritual program of action. In keeping with AAs spiritually based recovery theory, rigorous studies have revealed that spirituality may be one of the mechanisms through which AA aids recovery. A question that has lingered, however, is how exactly does an increase in spiritual beliefs and practices translate into more abstinence and remission? To help answer this question, this article reviews theory and research related to AA and spirituality as a mechanism of behavior change and offers five possible psychological pathways that may help explain how increases in spirituality may translate into enhanced abstinence and remission rates.

Mental health and psychosocial support interventions for survivors of sexual and gender-based violence during armed conflict: a systematic review

Sexual violence has been defined as “any sexual act, attempt to obtain a sexual act, unwanted sexual comments or advances, or acts to traffic, or otherwise directed, against a persons sexuality using coercion, by any person regardless of their relationship to the victim, in any setting, including but not limited to home and work” 1. Gender-based violence is a broader umbrella term referring to any harmful act that is perpetrated against a person based on socially ascribed (gender) differences between males and females. Rates of sexual and other forms of gender-based violence are typically higher in areas of armed conflict than in non-conflict settings 2. Sexual and gender-based violence during conflict is not restricted to rape, nor does conflict-related violence end when conflicts do. Furthermore, the prevalence of sexual violence by intimate partners is usually higher than that of sexual violence by strangers 3. Sexual and gender-based violence has been associated with a high prevalence of social problems (such as social exclusion), psychological distress and mental disorders, including anxiety disorders (such as post-traumatic stress disorder), mood disorders, and substance use disorders 4. International consensus guidelines for prevention and response to sexual and gender-based violence and for mental health and psychosocial support in emergency settings exist 5,6. However, despite the increasing implementation of these interventions, there is a wide gap between popular practices and knowledge on effectiveness of interventions 7. We conducted a systematic review on the impact of mental health and psychosocial support interventions for survivors of sexual and gender-based violence during armed conflict. Grey (i.e., evaluations published on websites, humanitarian reports, etc.) and academic literature were searched between May 13 and August 30, 2011. With regard to grey literature, we searched the Internet (Google) using identified territories where armed conflicts were recorded between 2001 and 2009 as keywords, in combination with Boolean phrases (available upon request) to narrow the search to: sexual and gender-based violence, mental health and psychosocial well-being outcomes, and a broad range of interventions. In addition, we searched 14 websites of key agencies and initiatives in this field for relevant reports. For the academic literature we searched the Cochrane Database of Systematic Reviews, Cochrane Controlled Trials Register, PubMed/Medline, PsycINFO, and PILOTS. We examined reference lists of a number of relevant reviews and of included evaluation studies. We contacted key authors in the field to find out whether they were aware of further studies that would meet inclusion criteria. Studies were included if they were conducted with survivors of sexual or gender-based violence in areas of armed conflict, described a mental health or psychosocial support intervention, and reported evaluation methodology. We searched without date limitations and limited our search to reports in English. Quality of papers was assessed using the Downs & Blacks checklist for the assessment of the methodological quality of studies of health care interventions 8. Out of 5,684 returned records, 189 full text papers were assessed for eligibility and seven studies met inclusion criteria 9–15. One was a non-randomized controlled study; three applied non-controlled pre-posttest designs; one was a retrospective cohort study with a comparison group; and two were single case studies. Four studies were conducted in West and Central Africa, two were conducted with refugees in the USA, and one was conducted in Albania. Studies included women exclusively and evaluated more generic multidisciplinary interventions (e.g., group counseling or support groups, combined psychosocial and economic interventions, medical care and psychological support) or specialized psychotherapeutic interventions (such as cognitive behavioral therapy). The quality of studies ranged from 12 to 16 out of 27 items on the Downs & Blacks checklist 8, indicating substantial limitations in study design and reporting. An obvious conclusion from this systematic review is that the number and quality of conducted studies does not match the significance of the problem. The extent to which knowledge from other types of populations, for example those affected by disasters 7, is generalizable is not known. No studies were found with children below 14 years of age, male participants, and survivors of intimate partner/domestic violence in conflict-affected areas, despite this being a more common form of violence than rape by armed groups. In addition to their relative scarcity, it is difficult to draw any robust conclusions from the identified evaluation studies because of serious methodological limitations. Nonetheless, the seven studies together point to potential beneficial effects of intervention, and no harmful effects of treatment were reported. Despite their limitations, the studies suggest that evaluations of popular interventions can be conducted in challenging situations through partnerships between academia and implementing organizations. Such efforts are crucial to strengthen evidence of effectiveness or potential harm and provide accountability to stakeholders in real-world settings. More focused research efforts are urgently needed to isolate the effects of specific strategies that improve well-being and prevent or manage mental disorders and psychosocial problems in people who have survived sexual and gender-based violence in conflict settings 16.

Is residential treatment effective for opioid use disorders? A longitudinal comparison of treatment outcomes among opioid dependent, opioid misusing, and non-opioid using emerging adults with substance use disorder

BACKGROUND Opioid misuse and dependence rates among emerging adults have increased substantially. While office-based opioid treatments (e.g., buprenorphine/naloxone) have shown overall efficacy, discontinuation rates among emerging adults are high. Abstinence-based residential treatment may serve as a viable alternative, but has seldom been investigated in this age group. METHODS Emerging adults attending 12-step-oriented residential treatment (N=292; 18-24 years, 74% male, 95% White) were classified into opioid dependent (OD; 25%), opioid misuse (OM; 20%), and no opiate use (NO; 55%) groups. Paired t-tests and ANOVAs tested baseline differences and whether groups differed in their during-treatment response. Longitudinal multilevel models tested whether groups differed on substance use outcomes and treatment utilization during the year following the index treatment episode. RESULTS Despite a more severe clinical profile at baseline among OD, all groups experienced similar during-treatment increases on therapeutic targets (e.g., abstinence self-efficacy), while OD showed a greater decline in psychiatric symptoms. During follow-up relative to OM, both NO and OD had significantly greater Percent Days Abstinent, and significantly less cannabis use. OD attended significantly more outpatient treatment sessions than OM or NO; 29% of OD was completely abstinent at 12-month follow-up. CONCLUSIONS Findings here suggest that residential treatment may be helpful for emerging adults with opioid dependence. This benefit may be less prominent, though, among non-dependent opioid misusers. Randomized trials are needed to compare more directly the relative benefits of outpatient agonist-based treatment to abstinence-based, residential care in this vulnerable age-group, and to examine the feasibility of an integrated model.

Fear factor: The unseen perils of the Ebola outbreak

ABSTRACT As illustrated powerfully by the 2013–2016 Ebola outbreak in western Africa, infectious diseases create fear and psychological reactions. Frequently, fear transforms into action – or inaction – and manifests as “fear-related behaviors” capable of amplifying the spread of disease, impeding life-saving medical care for Ebola-infected persons and patients with other serious medical conditions, increasing psychological distress and disorder, and exacerbating social problems. And as the case of the US micro-outbreak shows, fear of an infectious-disease threat can spread explosively even when an epidemic has little chance of materializing. Authorities must take these realities into account if they hope to reduce the deadly effects of fear during future outbreaks.

Posttraumatic stress disorder symptoms and social and occupational functioning of people with schizophrenia

Abstract This study sought to clarify the contribution of posttraumatic stress disorder (PTSD) to interpersonal and occupational functioning in people with schizophrenia. Self-report questionnaires and semistructured interviews were used to evaluate PTSD and brain injury, positive symptoms, depression, substance abuse, occupational and social functioning, and intelligence. Multiple regressions assessed the relationship between predictors and functional impairment. Posttraumatic stress disorder symptoms were present in 76% of participants, with 12% of participants meeting diagnostic criteria for PTSD. Participants with PTSD had higher rates of depression and more severe positive symptoms. Results of multiple regressions indicated that PTSD symptoms were the only significant predictor of patient-rated interpersonal and occupational functioning. Posttraumatic stress disorder symptoms were not associated with interviewer-rated interpersonal or occupational functioning or employment. While more research is needed, screening and treatment for exposure to traumatic events and PTSD symptoms might be indicated for individuals with schizophrenia. Availability of PTSD assessment and evidence-based treatments for people with schizophrenia is a crucial and often unmet health service need.