Michael Odenwald

Treatment of posttraumatic stress disorder by trained lay counselors in an African refugee settlement: a randomized controlled trial.

Traumatic stress due to conflict and war causes major mental health problems in many resource-poor countries. The objective of this study was to examine whether trained lay counselors can carry out effective treatment of posttraumatic stress disorder (PTSD) in a refugee settlement. In a randomized controlled dissemination trial in Uganda with 277 Rwandan and Somalian refugees who were diagnosed with PTSD the authors investigated the effectiveness of psychotherapy administered by lay counselors. Strictly manualized narrative exposure therapy (NET) was compared with more flexible trauma counseling (TC) and a no-treatment monitoring group (MG). Fewer participants (4%) dropped out of NET treatment than TC (21%). Both active treatment groups were statistically and clinically superior to MG on PTSD symptoms and physical health but did not differ from each other. At follow-up, a PTSD diagnosis could not be established anymore in 70% of NET and 65% TC participants, whereas only 37% in MG did not meet PTSD criteria anymore. Short-term psychotherapy carried out by lay counselors with limited training can be effective to treat war-related PTSD in a refugee settlement.

Can Asylum-Seekers with Posttraumatic Stress Disorder Be Successfully Treated? : A Randomized Controlled Pilot Study

Rates of posttraumatic stress disorder (PTSD) are exceptionally high among asylum-seekers. Reportedly, stressors caused by the asylum procedure and psychological consequences of torture contribute to the maintenance of symptoms and interfere with treatment. In a pilot randomized controlled trial, the authors examined the efficacy of trauma-focused treatment in 32 asylum-seekers with PTSD resulting from state-sponsored violence and other traumatic events. Narrative exposure therapy (NET) was compared with treatment as usual (TAU), with a focus on stabilization and psychoactive medication. Six months after treatment, a significant reduction of posttraumatic stress symptoms was found in the NET participants but not in the TAU group. Although treatment gains were moderate, these results indicate that NET is a promising approach for the treatment of PTSD in asylum-seekers living in unstable conditions.

Narrative Exposure Therapy as a treatment for child war survivors with posttraumatic stress disorder: Two case reports and a pilot study in an African refugee settlement

BackgroundLittle data exists on the effectiveness of psychological interventions for children with posttraumatic stress disorder (PTSD) that has resulted from exposure to war or conflict-related violence, especially in non-industrialized countries. We created and evaluated the efficacy of KIDNET, a child-friendly version of Narrative Exposure Therapy (NET), as a short-term treatment for children.MethodsSix Somali children suffering from PTSD aged 12–17 years resident in a refugee settlement in Uganda were treated with four to six individual sessions of KIDNET by expert clinicians. Symptoms of PTSD and depression were assessed pre-treatment, post-treatment and at nine months follow-up using the CIDI Sections K and E.ResultsImportant symptom reduction was evident immediately after treatment and treatment outcomes were sustained at the 9-month follow-up. All patients completed therapy, reported functioning gains and could be helped to reconstruct their traumatic experiences into a narrative with the use of illustrative material.ConclusionsNET may be safe and effective to treat children with war related PTSD in the setting of refugee settlements in developing countries.

Trauma, poverty and mental health among Somali and Rwandese refugees living in an African refugee settlement – an epidemiological study

BackgroundThe aim of this study was to establish the prevalence of posttraumatic stress disorder (PTSD) and depression among Rwandese and Somali refugees resident in a Ugandan refugee settlement, as a measure of the mental health consequences of armed conflict, as well as to inform a subsequent mental health outreach program. The study population comprised a sample from 14400 (n = 519 Somali and n = 906 Rwandese) refugees resident in Nakivale refugee settlement in South Western Uganda during the year 2003.MethodsThe Posttraumatic Diagnostic Scale (PDS) and the Hopkins Symptom Checklist 25 were used to screen for posttraumatic stress disorder and depression.ResultsThirty two percent of the Rwandese and 48.1% of the Somali refugees were found to suffer from PTSD. The Somalis refugees had a mean of 11.95 (SD = 6.17) separate traumatic event types while the Rwandese had 8.86 (SD = 5.05). The Somalis scored a mean sum score of 21.17 (SD = 16.19) on the PDS while the Rwandese had a mean sum score of 10.05 (SD = 9.7).ConclusionMental health consequences of conflict remain long after the events are over, and therefore mental health intervention is as urgent for post-conflict migrant populations as physical health and other emergency interventions. A mental health outreach program was initiated based on this study.

Prävalenz der Posttraumatischen Belastungsstörung (PTSD) und Möglichkeiten der Ermittlung in der Asylverfahrenspraxis

Zusammenfassung. Theoretischer Hintergrund: Posttraumatische Belastungsstorungen (PTSD) spielen in der Asylverfahrenspraxis eine zunehmende Rolle. Dennoch liegen bislang keine Daten zur Pravalenz unter Asylbewerbern in Deutschland vor. Auch ist nicht bekannt, inwieweit Einzelentscheider des Bundesamtes fur die Anerkennung auslandischer Fluchtlinge (BAFl) Anzeichen auf eine Traumatisierung bei der Anhorung erkennen konnen. Fragestellungen: Stellt PTSD eine relevante Grose unter Asylbewerbern in Deutschland dar? Konnen Einzelentscheider mit Hilfe von Kurzinstrumenten Anzeichen auf eine PTSD erkennen? Methode: eigens geschulte Einzelentscheider befragten 76 Asyl-Erstantragsteller mit der eng am DSM-IV orientierten PDS (Posttraumatic Diagnostic Scale). 42 dieser Personen wurden in einem klinisch strukturierten Interview anhand der Sektion N des M-CIDI ausfuhrlich nachuntersucht. Ergebnisse: Bei Asylsuchenden betragt die PTSD-Punkt-Pravalenz ca. 40%. Es ergab sich keine uberzufallige Erkennung dieser psychisch...

The Consumption of Khat and Other Drugs in Somali Combatants: A Cross-Sectional Study

Background For more than a decade, most parts of Somalia have not been under the control of any type of government. This “failure of state” is complete in the central and southern regions and most apparent in Mogadishu, which had been for a long period in the hands of warlords deploying their private militias in a battle for resources. In contrast, the northern part of Somalia has had relatively stable control under regional administrations, which are, however, not internationally recognized. The present study provides information about drug abuse among active security personnel and militia with an emphasis on regional differences in relation to the lack of central governmental control—to our knowledge the first account on this topic. Methods and Findings Trained local interviewers conducted a total of 8,723 interviews of armed personnel in seven convenience samples in different regions of Somalia; 587 (6.3%) respondents discontinued the interview and 12 (0.001%) were excluded for other reasons. We assessed basic sociodemographic information, self-reported khat use, and how respondents perceived the use of khat, cannabis (which includes both hashish and marijuana), psychoactive tablets (e.g., benzodiazepines), alcohol, solvents, and hemp seeds in their units. The cautious interpretation of our data suggest that sociodemographic characteristics and drug use among military personnel differ substantially between northern and southern/central Somalia. In total, 36.4% (99% confidence interval [CI] 19.3%–57.7%) of respondents reported khat use in the week before the interview, whereas in some regions of southern/central Somalia khat use, especially excessive use, was reported more frequently. Self-reported khat use differed substantially from the perceived use in units. According to the perception of respondents, the most frequent form of drug use is khat chewing (on average, 70.1% in previous week, 99% CI 63.6%–76.5%), followed by smoking cannabis (10.7%, 99% CI 0%–30.4%), ingesting psychoactive tablets (8.5%, 99% CI 0%–24.4%), drinking alcohol (5.3%, 99% CI 0%–13.8%), inhaling solvents (1.8%, 99% CI 0%–5.1%), and eating hemp seeds (0.6%, 99% CI 0%–2.0%). Perceived use of khat differs little between northern and southern Somalia, but perceived use of other drugs reaches alarmingly high levels in some regions of the south, especially related to smoking cannabis and using psychoactive tablets. Conclusions Our data suggest that drug use has quantitatively and qualitatively changed over the course of conflicts in southern Somalia, as current patterns are in contrast to traditional use. Although future studies using random sampling methods need to confirm our results, we hypothesize that drug-related problems of armed staff and other vulnerable groups in southern Somalia has reached proportions formerly unknown to the country, especially as we believe that any biases in our data would lead to an underestimation of actual drug use. We recommend that future disarmament, demobilization, and reintegration (DDR) programs need to be prepared to deal with significant drug-related problems in Somalia.

Treatment of traumatized victims of war and torture: a randomized controlled comparison of narrative exposure therapy and stress inoculation training.

Background: The aim of the present randomized controlled trial was to compare the outcome of 2 active treatments for posttraumatic stress disorder (PTSD) as a consequence of war and torture: narrative exposure therapy (NET) and stress inoculation training (SIT). Methods: Twenty-eight PTSD patients who had experienced war and torture, most of them asylum seekers, received 10 treatment sessions of either NET or SIT at the Outpatient Clinic for Refugees, University of Konstanz, Germany. Posttests were carried out 4 weeks after treatment, and follow-up tests were performed 6 months and 1 year after treatment. The main outcome measure was the PTSD severity score according to the Clinician-Administered PTSD Scale (CAPS) at each time point. Results: A significant reduction in PTSD severity was found for NET, but not for SIT. A symptom reduction in the NET group occurred between pretest and the 6-month follow-up examination, the effect size being d = 1.42 (for SIT: d = 0.12), and between pretest and the 1-year follow-up, the effect size being d = 1.59 (for SIT: d = 0.19). The rates and scores of major depression and other comorbid disorders did not decrease significantly over time in either of the 2 treatment groups. Conclusions: The results indicate that exposure treatments like NET lead to a significant PTSD symptom reduction even in severely traumatized refugees and asylum seekers.

Use of khat and posttraumatic stress disorder as risk factors for psychotic symptoms: A study of Somali combatants

The chewing of the khat leaves, which contain the amphetamine-like cathinone, is a traditional habit in Somalia. Our objective was to explore the effects of khat use and Posttraumatic Stress Disorder (PTSD) on paranoid symptoms and to test a potential causal chain. We report on a cross-sectional study in Somalia that was conducted in 2003. Trained local staff interviewed 8723 personnel of armed groups in seven regional convenience samples. Of them, 8124 were included in the analysis. We assessed current khat use, PTSD symptoms, functional drug use and paranoid ideation using items from the Composite International Diagnostic Interview (CIDI) and the Somali version of the Posttraumatic Stress Diagnostic Scale (PDS). Applying the causal steps approach, in a series of logistic regression models, we used PTSD as independent and paranoia as outcome variable; the quantity of khat use was defined as mediator variable and functional drug use as moderator. The results showed that respondents with PTSD used khat more frequently. Khat chewers with PTSD reported a higher intake compared to khat chewers without PTSD. Among excessive khat chewers with PTSD, paranoia was most frequent. The greatest amount of khat use was among respondents with PTSD who indicated that they found drugs help them to forget war experiences. The proposed mediated moderation model was supported by the data, i.e. besides the direct effects of PTSD and functional drug use on paranoia, the amount of khat use appeared to be a mechanism, by which paranoia is caused. We conclude that in our data we have uncovered a relationship between khat, PTSD and paranoia. Khat is functionally used by respondents with PTSD. Findings support a dose effect: the more khat consumption and when a respondent has PTSD, the higher the odds for paranoid ideation. However, the proposed causal chain needs to be confirmed in longitudinal studies. Demobilization and reintegration programs in Somalia need to be prepared to deal with complex psychological problems.

Altered oscillatory brain dynamics after repeated traumatic stress.

BackgroundRepeated traumatic experiences, e.g. torture and war, lead to functional and structural cerebral changes, which should be detectable in cortical dynamics. Abnormal slow waves produced within circumscribed brain regions during a resting state have been associated with lesioned neural circuitry in neurological disorders and more recently also in mental illness.MethodsUsing magnetoencephalographic (MEG-based) source imaging, we mapped abnormal distributions of generators of slow waves in 97 survivors of torture and war with posttraumatic stress disorder (PTSD) in comparison to 97 controls.ResultsPTSD patients showed elevated production of focally generated slow waves (1–4 Hz), particularly in left temporal brain regions, with peak activities in the region of the insula. Furthermore, differential slow wave activity in right frontal areas was found in PTSD patients compared to controls.ConclusionThe insula, as a site of multimodal convergence, could play a key role in understanding the pathophysiology of PTSD, possibly accounting for what has been called posttraumatic alexithymia, i.e., reduced ability to identify, express and regulate emotional responses to reminders of traumatic events. Differences in activity in right frontal areas may indicate a dysfunctional PFC, which may lead to diminished extinction of conditioned fear and reduced inhibition of the amygdala.

Screening for Posttraumatic Stress Disorder among Somali ex-combatants: A validation study

BackgroundIn Somalia, a large number of active and former combatants are affected by psychological problems such as Posttraumatic Stress Disorder (PTSD). This disorder impairs their ability to re-integrate into civilian life. However, many screening instruments for Posttraumatic Stress Disorder used in post-conflict settings have limited validity. Here we report on development and validation of a screening tool for PTSD in Somali language with a sample of ex-combatants.MethodsWe adapted the Posttraumatic Diagnostic Scale (PDS) to reflect linguistic and cultural differences within the Somali community so that local interviewers could be trained to administer the scale. For validation purposes, a randomly selected group of 135 Somali ex-combatants was screened by trained local interviewers; 64 of them were then re-assessed by trained clinical psychologists using the Composite International Diagnostic Interview (CIDI) and the Self-Report Questionnaire (SRQ-20).ResultsThe screening instrument showed good internal consistency (Cronbachs α = .86), convergent validity with the CIDI (sensitivity = .90; specificity = .90) as well as concurrent validity: positive cases showed higher SRQ-20 scores, higher prevalence of psychotic symptoms, and higher levels of intake of the local stimulant drug khat. Compared to a single cut-off score, the multi-criteria scoring, in keeping with the DSM-IV, produced more diagnostic specificity.ConclusionThe results provide evidence that our screening instrument is a reliable and valid method to detect PTSD among Somali ex-combatants. A future Disarmament, Demobilization and Reintegration Program in Somalia is recommended to screen for PTSD in order to identify ex-combatants with special psycho-social needs.