Melanie Abas

The Relationship of Trauma to Mental Disorders Among Trafficked and Sexually Exploited Girls and Women

OBJECTIVES We explored the association between traumatic events and mental health among girls and women trafficked for sexual exploitation. METHODS We used subscales of the Brief Symptom Inventory and Harvard Trauma Questionnaire to interview 204 trafficked girls and women in 7 posttrafficking service settings. Multivariate logistic regression models based on interview data were fitted for depression, anxiety, and posttraumatic stress disorder (PTSD) separately and adjusted for pretrafficking abuse to determine impact of trafficking-related trauma exposures. RESULTS Injuries and sexual violence during trafficking were associated with higher levels of PTSD, depression, and anxiety. Sexual violence was associated with higher levels of PTSD (adjusted odds ratio [AOR] = 5.6; 95% confidence interval [CI] = 1.3, 25.4). More time in trafficking was associated with higher levels of depression and anxiety (AOR = 2.2; 95% CI = 1.1, 4.5). More time since trafficking was associated with lower levels of depression and anxiety but not of PTSD. CONCLUSIONS Our findings inform the emerging field of mental health care for trafficked persons by highlighting the importance of assessing severity and duration of trafficking-related abuses and need for adequate recovery time. Therapies for anxiety, PTSD, and mood disorders in low-resource settings should be evaluated.

Life events, difficulties and depression among women in an urban setting in Zimbabwe.

BACKGROUND A previous paper (Abas & Broadhead, 1997) reported that among 172 women randomly selected from a Zimbabwean township 30.8% had a depressive or anxiety disorder during the previous year. Compared with London, the higher annual prevalence of disorders in Harare could mostly be accounted for by an excess of onset cases in the study year (annual incidence of depression 18%). This paper reports on the role of life events and difficulties in the aetiology of depression among these women. METHOD Randomly selected women (N = 172) from a township in Harare were interviewed with a Zimbabwean modification of the Bedford College Life Events and Difficulties Schedule (LEDS). RESULTS Events and difficulties proved critical in provoking the onset of depression in Harare. Far more events occurring in Harare were severe or disruptive. Furthermore, a proportion of the Harare severe events were more threatening than have been described in London. As in London, certain types of severe event were particularly depressogenic, i.e. those involving the womans humiliation, her entrapment in an ongoing difficult situation, or bereavement. However, more severe events in Harare involved these specific dimensions. CONCLUSIONS Results indicate a common mechanism for the development of depression, as defined by international criteria, between Zimbabwe and London. The high frequency of severe events, and their especially adverse qualities, offer an explanation for the high incidence of depression in Harare.

Risk factors for mental disorders in women survivors of human trafficking: a historical cohort study.

BackgroundPrevious studies have found high levels of symptoms of depression, anxiety, and post-traumatic stress disorder among women survivors of human trafficking. No previous research has described risk factors for diagnosed mental disorders in this population.MethodsA historical cohort study of women survivors of trafficked women aged 18 and over who returned to Moldova and registered for assistance with the International Organisation for Migration (IOM). Women were approached by IOM social workers and, if they gave informed consented to participate in the study, interviewed by the research team. At 2–12 months post-return to Moldova, a psychiatrist assessed DSM-IV mental disorders blind to information about women’s pre-trafficking and post-trafficking experiences using the Structured Clinical Interview for DSM-IV (SCID). A backwards stepwise selection procedure was used to create a multivariable regression model of risk factors for DSM-IV mental disorder measured at an average of 6 months post-return.Results120/176 (68%) eligible women participated. At an average of 6 months post-return, 54% met criteria for any DSM-IV mental disorder: 35.8% of women had PTSD (alone or co-morbid), 12.5% had depression without PTSD and 5.8% had another anxiety disorder. Multivariable regression analysis found that childhood sexual abuse (Adjusted Odds Ratio [AOR] 4.68, 95% CI 1.04-20.92), increased number of post-trafficking unmet needs (AOR 1.80; 95% CI 1.28-2.52) and post-trafficking social support (AOR 0.64; 95% CI 0.52-0.79) were independent risk factors for mental disorder, and that duration of trafficking showed a borderline association with mental disorder (AOR 1.12, 95% CI 0.98-1.29).ConclusionsAssessment for mental disorders should be part of re-integration follow-up care for women survivors of human trafficking. Mental disorders at that time, most commonly PTSD and depression, are likely to be influenced by a range of predisposing, precipitating and maintaining factors. Care plans for survivors of trafficking must be based on individual needs, and must apply clinical guidelines for the treatment of PTSD and of depression. Evidence is needed on the effectiveness of therapy for PTSD in survivors of human trafficking.

Enhancing psychosocial support for HIV positive adolescents in Harare, Zimbabwe.

Background There is a recognized gap in the evidence base relating to the nature and components of interventions to address the psycho-social needs of HIV positive young people. We used mixed methods research to strengthen a community support group intervention for HIV positive young people based in Harare, Zimbabwe. Methods A quantitative questionnaire was administered to HIV positive Africaid support group attendees. Afterwards, qualitative data were collected from young people aged 15–18 through tape-recorded in-depth interviews (n = 10), 3 focus group discussions (FGDs) and 16 life history narratives. Data were also collected from caregivers, health care workers, and community members through FGDs (n = 6 groups) and in-depth interviews (n = 12). Quantitative data were processed and analysed using STATA 10. Qualitative data were analysed using thematic analysis. Results 229/310 young people completed the quantitative questionnaire (74% participation). Median age was 14 (range 6–18 years); 59% were female. Self-reported adherence to antiretrovirals was sub-optimal. Psychological well being was poor (median score on Shona Symptom Questionnaire 9/14); 63% were at risk of depression. Qualitative findings suggested that challenges faced by positive children include verbal abuse, stigma, and discrimination. While data showed that support group attendance is helpful, young people stressed that life outside the confines of the group was more challenging. Caregivers felt ill-equipped to support the children in their care. These data, combined with a previously validated conceptual framework for family-centred interventions, were used to guide the development of the existing programme of adolescent support groups into a more comprehensive evidence-based psychosocial support programme encompassing caregiver and household members. Conclusions This study allowed us to describe the lived experiences of HIV positive young people and their caregivers in Zimbabwe. The findings contributed to the enhancement of Africaid’s existing programme of support to better promote psychological well being and ART adherence.

Mental, Neurological, and Substance Use Disorders in People Living With HIV/AIDS in Low- and Middle-Income Countries

Abstract:Depression, alcohol use disorders (AUD), and neurocognitive disorders are the 3 most prevalent mental, neurological, and substance use disorders in people living with HIV infection in low- and middle-income countries (LMICs). Importantly, they have an impact on everyday functions and on HIV outcomes. Many LMICs have validated tools to screen for and diagnose depression and AUD in the general population that can be used among people living with HIV infection. Current screening and diagnostic methods for HIV-associated neurocognitive disorders in the era of antiretroviral therapy are suboptimal and require further research. In our view, 2 research priorities are most critical. One is the development of an integrated screening approach for depression, AUD, and neurocognitive disorders that can be used by nonspecialists in LMICs. Second, research is needed on interventions for depression and AUD that also target behavior change, as these could impact on adherence to antiretroviral therapy and improve mental symptoms. Mentorship and fellowship schemes at an individual and institutional level need to be further supported to build capacity and provide platforms for research on HIV and mental, neurological, and substance use disorders in LMICs.

Rural-urban migration and depression in ageing family members left behind.

Background It has been suggested that rural–urban migration will have adverse consequences for older parents left behind. Aims To describe correlates of outmigration and to estimate any association between outmigration of children and depression in rural-dwelling older parents. Method Population-based survey of 1147 parents aged 60 and over in rural Thailand. We randomly oversampled parents living without children. We defined an outmigrant child as living outside their parent’s district, and measured depression as a continuous outcome with a Thai version of the EURO–D. Results Outmigration of all children, compared with outmigration of some or no children, was independently associated with less depression in parents. This association remained after taking account of social support, parent characteristics, health and wealth. Parents with all children outmigrated received more economic remittances and they perceived support to be as good as that of those with children close by. Conclusions Outmigration of children was not associated with greater depression in older parents and, after taking account of a range of possible covariables, was actually associated with less parental depression. This could be explained by pre-existing advantages in families sending more migrants and by the economic benefits of migration.

Psychiatric hospitalization: reasons for admission and alternatives to admission in South Auckland, New Zealand

Objective: To describe reasons for admission and alternatives to admission in a government funded acute inpatient unit. Method: Reasons for admission and alternatives to admission were rated for a consecutive sample of 255 admissions to an acute psychiatric unit in Auckland, using interviews with staff and case note review. Result: Most patients had a functional psychosis and were admitted involuntarily. Forty percent came from areas of marked social deprivation. The major reasons for admission were for reinstatement of medication (mainly linked to non-concordance with prescribed medication), intensive observation, risk to self and risk to others. Only 12% of admissions could have been diverted, of whom most would have required daily home treatment. For those still admitted at 5 weeks, 26% could have been discharged, mainly to 24 h nurse-staffed accommodation. If the alternatives had all been available, simulated bed-day savings were 11 bed years per year. Simulated bed day savings were greater through implementing early discharge than by diverting new admissions. Conclusion: Greater availability of assertive community treatment and of interventions to improve medication concordance may have prevented a small number of admissions. For patients admitted longer than 5 weeks, it appeared that greater availability of 24 h nursestaffed accommodation would have allowed considerable bed-day savings.

Characteristics of trafficked adults and children with severe mental illness: a historical cohort study

BACKGROUND Evidence regarding the mental health needs of trafficked people is limited; however, prevalence of depression and post-traumatic stress disorder is high among trafficked people who are in contact with shelter services. We aimed to investigate the sociodemographic and clinical characteristics of trafficked people with severe mental illness. METHODS We did a historical cohort study of trafficked people in contact with secondary mental health services in South London, UK, between Jan 1, 2006, and July 31, 2012. We searched and retrieved comprehensive clinical electronic health records for over 200 000 patients from the Case Register Interactive Search database to identify trafficked patients. A matched cohort of non-trafficked adults was generated by simple computer-generated random selection of potential controls for each case within the parameters of matching criteria. We extracted data on sociodemographic and clinical characteristics and abuse history, and used multiple imputation to deal with missing data. We fitted logistic regression models to compare trafficked and non-trafficked patients. FINDINGS We identified 133 trafficked patients, including 37 children. 78 (81%) of 96 adults and 25 (68%) of 37 children were female. 19 (51%) of 37 children were trafficked for sexual exploitation. Among both adults and children, the most commonly recorded diagnoses were post-traumatic stress disorder, severe stress, or adjustment disorder (27 adults [28%] and ten children [27%]) and affective disorders (33 adults [34%] and ten children [27%]). Records documented childhood physical or sexual abuse among trafficked adults (41 [43%]) and children (28 [76%]), and adulthood abuse among trafficked adults (58 [60%]). Trafficked adults were more likely to be compulsorily admitted as a psychiatric inpatient than non-trafficked adults (adjusted odds ratio 7·61, 95% CI 2·18-26·60; p=0·002) and had longer admissions (1·48, 1·01-2·15; p=0·045). No association was found between trafficking status and either adverse pathway into care (adjusted odds ratio 0·91, 95% CI 0·40-2·05; p=0·82) or substance misuse problems (0·55, 0·27-1·17; p=0·12). INTERPRETATION Severe mental illness in trafficked people is associated with longer admissions and high levels of abuse before and after trafficking. Evidence is needed on the effectiveness of interventions to promote recovery for this vulnerable group. FUNDING Department of Health Policy Research Programme.

Women in post-trafficking services in Moldova: diagnostic interviews over two time periods to assess returning women's mental health.

BackgroundTrafficking in women is a widespread human rights violation commonly associated with poor mental health. Yet, to date, no studies have used psychiatric diagnostic assessment to identify common forms of mental distress among survivors returning to their home country.MethodsA longitudinal study was conducted of women aged 18 and over who returned to Moldova between December 2007 and December 2008 registered by the International Organisation for Migration as a survivor of human trafficking. Psychiatric diagnoses in women at a mean of 6 months after return (range 2-12 months) were made by a trained Moldavian psychiatrist using the Structured Clinical Interview for DSM-IV, and compared with diagnoses recorded in the same women within 5 days of return. We described the socio-demographic characteristics of the women in the sample including both pre and post-trafficking information. We then described the distribution of mental health diagnoses recorded during the crisis intervention phase (1-5 days after return) and the re-integration phase (2-12 months after return). We compared diagnoses at the patient level between the two time points by tabulating the diagnoses and carrying out a kappa test of agreement and the Stuart-Maxwell test for marginal homogeneity (an extension of the McNemar test to kxk table).Results120/176 (68%) eligible women participated. At 2-12 months after their return, 54% met criteria for at least one psychiatric diagnoses comprising post-traumatic stress disorder (PTSD) alone (16%); co-morbid PTSD (20%); other anxiety or mood disorder (18%). 85% of women who had been diagnosed in the crisis phase with co-morbid PTSD or with another anxiety or mood disorder sustained a diagnosis of any psychiatric disorder when followed up during rehabilitation.ConclusionsTrafficked women returning to their country of origin are likely to suffer serious psychological distress that may endure well beyond the time they return. Women found to have co-morbid PTSD or other forms of anxiety and depression immediately post-return should be offered evidenced-based mental health treatment for at least the standard 12-month period of rehabilitation.

Impairment, disability, social support and depression among older parents in rural Thailand.

Background It is not known whether social support modifies the association between depression and impairment or disability in older people from developing countries in Asia. Method We used a Thai version of the EURO-D scale to measure depression in 1104 Thai rural community-dwelling parents aged ⩾60 years. These were all those providing data on depression who were recruited as part of a study of older adults with at least one living child (biological, stepchild or adopted child). Logistic regression modelling was used to determine: (a) whether impairment, disability and social support deficits were associated with depression; (b) whether social support modified this association. Results There were strong graded relationships between impairment, disability, social support deficits and EURO-D caseness. Level of impairment, but not disability, interacted with poor social support in that depression was especially likely in those who had more physical impairments as well as one or more social support deficits (p value for interaction=0.018), even after full adjustment. Conclusions Social support is important in reducing the association between physical impairment and depression in Thai older adults, especially for those with a large number of impairments. Enhancing social support as well as improving healthcare and disability facilities should be emphasized in interventions to prevent depression in older adults.