Richard F. Mollica

The Harvard Trauma Questionnaire. Validating a cross-cultural instrument for measuring torture, trauma, and posttraumatic stress disorder in Indochinese refugees.

There are no valid and reliable cross-cultural instruments capable of measuring torture, trauma, and trauma-related symptoms associated with the DSM-III-R diagnosis of posttraumatic stress disorder (PTSD). Generating such standardized instruments for patients from non-Western cultures involves particular methodological challenges. This study describes the development and validation of three Indochinese versions of the Harvard Trauma Questionnaire (HTQ), a simple and reliable screening instrument that is well received by refugee patients and bicultural staff. It identifies for the first time trauma symptoms related to the Indochinese refugee experience that are associated with PTSD criteria. The HTQs cultural sensitivity may make it useful for assessing other highly traumatized non-Western populations.

Mental health in complex emergencies

Mental health is becoming a central issue for public health complex emergencies. In this review we present a culturally valid mental health action plan based on scientific evidence that is capable of addressing the mental health effects of complex emergencies. A mental health system of primary care providers, traditional healers, and relief workers, if properly trained and supported, can provide cost-effective, good mental health care. This plan emphasises the need for standardised approaches to the assessment, monitoring, and outcome of all related activities. Crucial to the improvement of outcomes during crises and the availability to future emergencies of lessons learned from earlier crises is the regular dissemination of the results achieved with the action plan. A research agenda is included that should, in time, fill knowledge gaps and reduce the negative mental health effects of complex emergencies.

Effects of war trauma on Cambodian refugee adolescents' functional health and mental health status

OBJECTIVE To measure the effect of war trauma on the functional health and mental health status of Cambodian adolescents living in a refugee camp on the Thai-Cambodian border. METHOD A multistage probability sample identified 1,000 households in the camp known as Site Two. Interviews were conducted in each household with randomly selected adults 18 years of age and older. All adolescents aged 12 and 13 years old, along with one parent were interviewed. One hundred eighty-two adolescents (94 girls, 88 boys) and their parents participated. Culturally sensitive instruments were used including Cambodian versions of the Child Behavior Checklist (CBCL) and the Youth Self-Report (YSR). RESULTS Parents and adolescents reported the latter having experienced high levels of cumulative trauma, especially lack of food, water, and shelter. Mean Total Problem scores were in ranges similar to those of adolescents receiving clinical care in the United States, Netherlands, and Israel. Nearly 54% (53.8%) had Total Problem scores in the clinical range by parent report on the CBCL and 26.4% by adolescent report on the YSR. The most commonly reported symptoms were somatic complaints social withdrawal attention problems, anxiety, and depression. The dose-effect relationship between cumulative trauma and symptoms was strong for parent reporting on the CBCL; the subscales on both the YSR and CBCL for Anxious/Depressed and Attention Problems revealed dose-effect associations. Dose-effect relationships between cumulative trauma and social functioning or health status were lacking. CONCLUSION The high levels of emotional distress in this population of Cambodian adolescents and corresponding dose-effect relationships reveal the important negative psychosocial impact of violence on Cambodian adolescents. Lack of findings related to physical health status and the presence of positive social functioning of many youths should not deter health care providers and public health officials from diagnosing and treating underlying high levels of psychological distress.

The Harvard Trauma Questionnaire: Adapting a Cross-Cultural Instrument for Measuring Torture, Trauma and Posttraumatic Stress Disorder in Iraqi Refugees

Background: Mental health assessments in post-conflict zones have relied heavily on Western psychiatric scales. Yet, a strict dependence on the paradigms of Western psychiatry risks inappropriately prioritizing syndromes, such as PTSD, which, however important, are eclipsed by local concerns. Material and discussion: In Dearborn, Michigan, home to the largest population of Iraqi refugees in the United States, 60 Iraqi refugee life stories were collected in order to adapt the Harvard Trauma Questionnaire (HTQ) to the Iraqi context. Conclusion: The methodology described proved to be a useful approach to developing a trauma measure that is culturally grounded in a multi-dimensional model of mental health.

From asylum to community. The threatened disintegration of public psychiatry.

Before 1950, publicly supported psychiatric services (i.e., those of so-called public psychiatry) were provided primarily at state hospitals. Over the past 30 years public psychiatry has shifted its emphasis away from long-term custodial care to outpatient and community-based services. Paradoxically, this broadening of focus has become associated with both an expanded use of psychiatric services and a threatened decline in clinical standards and treatment goals. Five areas of policy confusion and contradiction threaten the stability of public mental-health services: the shift in emphasis from public to private services, the issue of rehabilitation and reintegration into society versus custodial care, the differential treatment of the lower-class patient, the demedicalization of public services, and conflict between professionals and blurring of roles within the psychiatric profession. These problems reflect public psychiatrys overemphasis on social reform and political rather than clinical definitions of treatment, its lack of specific treatment and of defined treatment goals, and its inability to change psychiatrys (and societys) historical assignment of low status to the public patient.

The validity of screening for post‐traumatic stress disorder and major depression among Vietnamese former political prisoners

The aim of this study was to investigate the validity of the Harvard Trauma Questionnaire (HTQ) and the depression sub‐scale of the Hopkins Symptom Checklist‐25 (HSCL‐25) in screening for post‐traumatic stress disorder (PTSD) and major depressive disorder (MDD) among Vietnamese former political prisoners (POWs). The study population included Vietnamese POWs (n= 51) who migrated to the Boston metropolitan area between January 1990 and July 1992 under the Special Released Re‐education Center Detainees Resettlement Program. The criterion validity of the HTQ in assessing PTSD and of the depression sub‐scale of the HSCL‐25 in assessing MDD is supported by the results. Consideration of an appropriate cut‐off score should include examination of the utility of a given screening instrument for PTSD or MDD within different settings, such as refugee camps vs. countries of third asylum.

Burmese political dissidents in Thailand: trauma and survival among young adults in exile.

OBJECTIVES This study assessed the self-reported mental health, physical health, and social functioning of young adult political exiles and relates their psychiatric symptoms to their trauma and survival strategies. METHODS A 1992/93 survey of Burmese who fled to Bangkok, Thailand, after participating in a 1988 uprising against Burmas government elicited information on employment, education, disability, trauma, survival strategies, and depressive and posttraumatic stress symptoms. RESULTS The 104 participants reported a mean of 30 trauma events, including interrogation (89%), imprisonment (78%), threats of deportation (70%), and torture (38%). Many reported poor health and lack of social supports, but few reported substantial social disability. The prevalence of elevated symptom scores was 38% for depressive symptoms and 23% for criterion symptoms of posttraumatic stress disorder. Symptoms of avoidance and of increased arousal were the most strongly related to cumulative trauma. Two survival strategies, camaraderie and a Buddhist concept of self-confidence (weria), were associated with somewhat reduced levels of both classes of symptoms. CONCLUSIONS Burmese political exiles in Thailand are young adults adversely affected by severe trauma. Their psychosocial well-being may deteriorate further without legal protections to reduce the continuing stress and violence.

The Validity of Posttraumatic Stress Disorder Among Vietnamese Refugees

The aim of this study was to examine the validity of posttraumatic stress disorder (PTSD) among Vietnamese refugees. The study population included 74 Vietnamese refugees who had resettled in the metropolitan Boston area. The previously validated Harvard Trauma Questionnaire was used to assess traumatic events and trauma-related symptoms. The number of traumatic events experienced was positively correlated with the severity of PTSD-related symptoms in this population. Internal consistency estimates and principal components analysis provided results that generally supported DSM-IV symptom dimensions of arousal, avoidance, and reexperiencing. However, the emergence of two separate dimensions of avoidance reflected the important contribution of depression to the traumatic response.

Detention of asylum seekers: assault on health, human rights, and social development

The end of World War II ushered in a new era of international commitment to provide humane protection to all people fleeing persecution. This decade, however, has witnessed a steady erosion of that ethos, the most disturbing change being the tendency to confine asylum seekers in detention centres in countries of the West. Many of these people have suffered torture and other abuses, raising particular concerns that the anxiety, fear, and frustration provoked by detention may prolong and exacerbate underlying traumatic stress reactions and thereby create long-term psychosocial disability. Of the five million people seeking asylum in the moredeveloped world during 1980–99, the majority have been allowed to live in the community while awaiting the outcome of their refugee claims. Increasingly, however, industrialised countries are building or extending facilities to detain asylum seekers. In 2000, the USA detained about 5000 asylum seekers at any one time. Australia stands alone in mandating the detention of all individuals entering the country without valid visas irrespective of whether or not they are seeking asylum. About 3500 asylum seekers, including 450 children, were held in detention in that country as of June, 2000. More than 300 were detained for longer Detention of asylum seekers: assault on health, human rights, and social development

Screening for depression and PTSD in a Cambodian population unaffected by war comparing the Hopkins Symptom Checklist and Harvard Trauma Questionnaire with the Structured Clinical Interview

The Hopkins Symptom Checklist depression scale (HSCL-D) and the Harvard Trauma Questionnaire (HTQ) have been used extensively in international studies, particularly among refugees and conflict-affected populations. Like many other screening measures, however, the HSCL-D and HTQ have not been subjected to extensive epidemiologic testing, particularly among communities not affected by war. The present study examined the psychometric properties of the HSCL-D and HTQ by comparing the measures with the Structured Clinical Interview for DSM-IV (SCID) among ethnic Cambodians living in Surin, Thailand, a community that was spared the long period of mass violence that affected Cambodia proper. The PTSD data of the HTQ were then contrasted with those obtained from a refugee clinic. The main finding was that in the Surin study, the screening measures showed greater agreement with the SCID in identifying noncases (negative prediction) than cases (positive prediction). In contrast, in the earlier clinic study, the HTQ showed high positive and moderately low negative prediction. The results support previous observations that clinical interviews such as the SCID may be more conservative in identifying cases. We raise the possibility, however, that structured interviews may perform differently across clinic and community populations. In particular, clinicians may be more accurate in identifying cases than noncases in highly symptomatic clinic populations, with the converse applying in low prevalence community populations. These issues warrant further investigation to specify more clearly the value of using the two approaches to case identification.