Robert Brooks

Quality of life outcomes after intensive care

Objective: Compare the health related quality of life of intensive care patients with a community sample. Design: Self-completed questionnaire posted to a consecutive sample of 238 patients 16 months after discharge from an intensive care unit (ICU) and to a random community sample (n = 242). Setting: The Liverpool Hospital is the main referral and teaching hospital in a community of 620,000 people. It has a ten-bed general ICU. Patients and participants: All patients admitted to the ICU over 8 months with a length of stay ≥ 24 h and a sample drawn from the community telephone directory. Measurements and main results: The self completed questionnaire contained physical and psychosocial health and quality of life (QOL) scales. Analysis of variance indicated that ICU patients were more physically ill and anxiously depressed than the community sample. Sixty-three per cent of patients had not attained full health, were functionally impaired and had a poorer QOL than those patients who had returned to full health and the community. Psychosocial health (apart from anxious depression) was related to the level of perceived physical health rather than to whether or not they had been admitted to the ICU. Those subjects not in full health had poorer interpersonal relationships, less positive attitudes about life, more anxious depression and more suicidal depression. Conclusions: ICU patients following discharge have worse perceived health and more anxiety than others in the community. Sixty-three per cent of patients had a poorer QOL and functional health than those who returned to full health and those in the community.

Factor Structure and Interpretation of the K10.

The Kessler 10 Psychological Distress Scale (K10) is a brief 10-item questionnaire designed to measure the level of distress and severity associated with psychological symptoms in population surveys. It is being used widely, including in the World Health Organization World Mental Health Survey, and as a clinical outcome measure, although little information is available about the structure of the measure. The factorial composition of the K10 was examined in a prospective community survey and cross-validated in a separate large community survey. The K10 was found to consist of 4 factors and a 2-factor second-order factor structure. This was stable across the 2 waves of the prospective study and the Australian National Survey of Mental Health and Well-Being. The 4 factors, labeled Nervous, Negative Affect, Fatigue, and Agitation, were consistent with the original scales from which the items were taken. The 2 second-order factors represent Depression and Anxiety.

Estimating clinically relevant mental disorders in a rural and an urban setting in postconflict Timor Leste.

CONTEXTnEpidemiologic studies undertaken in postconflict countries have focused primarily on trauma-related disorders. There is a need to include disabling psychotic disorders in order to plan clinical services in these settings.nnnOBJECTIVESnTo estimate the prevalence of key clinical disorders in Timor Leste (East Timor), and to assess cultural factors that may influence help-seeking patterns.nnnDESIGN, SETTING, PARTICIPANTSnA 2-phase total population survey of 1544 adults in an urban and a rural area of Timor Leste. Phase 1 involved a household informant survey using indigenous terms to detect psychosis and a screen of all adults for posttraumatic stress disorder (PTSD) and symptoms of psychologic distress, including depression and anxiety. In phase 2, clinicians interviewed all those identified by household informants and half of those who screened positive in order to assign DSM-IV diagnoses. Disability, explanatory models, and perceived needs were also assessed.nnnMAIN OUTCOME MEASURESnPhase 1: Demographic characteristics; trauma events and PTSD (Harvard Trauma Questionnaire); psychologic distress (Kessler-10 scale). Phase 2: Structured Clinical Interview for relevant DSM-IV diagnoses; the Global Assessment of Functioning Scale and the World Health Organization Disability Assessment Scales; and the modified Short Explanatory Model Interview.nnnRESULTSnThe household informant method in phase 1 detected mainly psychotic disorders, and the screen method detected PTSD and depression. Phase 2 yielded a DSM-IV point prevalence estimate of 5.1% (including psychosis, 1.35%; and PTSD, 1.47%). Psychotic disorders were most disabling, primarily attributed to supernatural causes and treated mainly by traditional healers. Those with depression and PTSD experienced substantial disability but had received little treatment. They attributed their mental problems to social and traumatic causes.nnnCONCLUSIONSnOur 2-phase method proved effective for identifying the range of disorders relevant to planning clinical services in postconflict developing countries. The unmet needs of the mentally ill in countries such as Timor Leste pose a major challenge to psychiatry.

Explosive anger as a response to human rights violations in post-conflict Timor-Leste

Over several decades, clinicians have documented a pattern of explosive anger amongst survivors of gross human rights violations. Yet there is a dearth of epidemiological research investigating explosive anger in post-conflict countries. In the present study undertaken in Timor-Leste between March and November 2004, we identified an indigenous descriptor for explosive anger, including this index in the East Timor Mental Health Epidemiological Needs Study, a small area total population survey of 1544 adults living in an urban and a rural area. Other measures included indices of past trauma events, post-traumatic stress and general psychological distress, and socio-demographic variables. We found that 38% of the population reached the defined threshold of one attack of explosive anger a month (average=1 episode every 2-3 days). Only a minority of persons with explosive anger reached threshold scores for post-traumatic stress and general psychological distress. High levels of trauma exposure represented the strongest predictor of explosive anger. Latent class analysis identified three sub-groups with explosive anger: young trauma-affected adults living in the capital city who were unemployed; an older group, predominantly men, who had experienced extensive violence, including combat, assault and torture; and a less well characterized group of women. The findings offer support for a sequential model of explosive anger in which experiences of past persecution are compounded by frustrations in the post-conflict environment. The data provide a foundation for exploring further the role of trauma-induced anger in the cycles of violence that are prevalent in post-conflict countries.

The familial influence of loss and trauma on refugee mental health: A multilevel path analysis

Although the impact of human rights violations on the mental health of refugees has been well documented, little is known about these effects at a family level. In this study the authors examined the relationships among loss, trauma, and mental health at the individual and family levels in resettled Mandaean refugees (N = 315). Trauma, loss, posttraumatic stress disorder, depression, complicated grief, and mental health-related quality of life were assessed. A multilevel path analysis revealed that loss and trauma significantly impacted on psychological outcomes at both the individual and family levels. Effect sizes ranged from .21 to .68 at the individual level, and .38 to .99 at the family level, highlighting the importance of the family when considering the psychological impact of refugee-related trauma.

Predictors of mental disorders and their outcome in a community based cohort.

BackgroundOnly a limited number of population-based studies have been able to prospectively follow the mental health of their participants. We aimed to describe diagnostic changes in a population based cohort over a two year period, and to explore associations between a range of individual factors and recovery from, or onset of, disorders.MethodsTwo year, face-to-face follow-up of a community-based cohort drawn from random telephone screening using the CIDI as diagnostic instrument. Unlike most similar research we did not exclude individuals with prior history from analysis.Results1407 participants were administered face-to-face interviews and 968 were re-interviewed. In multivariate analysis, recent adverse life events, poor physical health, and high neuroticism score were significant predictors of developing a mental disorder in participants who were disorder free at baseline. Higher baseline levels of physical activity were protective of new disorders in univariate analysis. Most participants with a baseline disorder and not lost to follow-up were disorder-free two years later. For participants with a disorder at both interviews, there was marked lability in diagnoses, with only a small minority having an unchanged diagnosis at both baseline and follow-up. Factors predicting a poor outcome in participants with a disorder included the number of baseline diagnoses, high neuroticism score and adverse life events.ConclusionsThese findings suggest that the diagnosis of common mental disorders is complex and that diagnoses are relatively unstable. The factors that influence the emergence of mental disorders in individuals who may, or may not, have had a disorder in the past, are similar to those associated with the development of new disorders in subjects without a lifetime history.

Torture, Mental Health Status and the Outcomes of Refugee Applications among Recently Arrived Asylum Seekers in Australia

There are ongoing concerns that asylum seekers who have been tortured and who suffer trauma‐related mental disorders are being refused protection by countries in which they seek asylum. The study described here assessed a consecutive sample of recently arrived asylum seekers attending immigration agents in Sydney, Australia, using a series of structured measures. Participants were followed up to assess the outcomes of their refugee applications. The 73 participants, who had resided in Australia for an average of 4.3 months, reported high rates of torture (51%), and that group was at highest risk of suffering a combination of post‐traumatic stress disorder (PTSD) and major depression, a response pattern associated with substantial levels of psychosocial disability. Neither past torture nor current psychiatric disorder influenced the outcomes of refugee applications. The study raises further concerns that tortured asylum seekers and others with trauma‐related mental disorder may be at risk of repatriation to their countries of origin.

Achieving convergence between a community-based measure of explosive anger and a clinical interview for intermittent explosive disorder in Timor-Leste

BACKGROUNDnThere is growing research interest in understanding and analyzing explosive forms of anger. General epidemiological studies have focused on the DSM-IV category of Intermittent Explosive Disorder (IED), while refugee and post-conflict research have used culturally-based indices of explosive anger. The aim of this study was to test the convergence of a culturally-sensitive community measure of explosive anger with a structured clinical interview diagnosis of IED in Timor-Leste, a country with a history of significant mass violence and displacement.nnnMETHODSnA double-blind clinical concordance study was conducted amongst a stratified community sample in post-conflict Timor-Leste (n=85) to compare a community measure of anger against the Structured Clinical Interview (SCID) module for IED.nnnRESULTSnClinical concordance between the two measures was high: the area under the curve (AUC) index was 0.90 (95% CI: 0.83-0.98); sensitivity and specificity were 93.3% and 87.5% respectively.nnnLIMITATIONSnResponse rates were modest due to the participants time commitments.nnnCONCLUSIONSnIt is possible to achieve convergence between culturally-sensitive measures of explosive anger and the DSM-IV construct of IED, allowing comparison of findings across settings and populations.

Social and trauma-related pathways leading to psychological distress and functional limitations four years after the humanitarian emergency in Timor-Leste.

There is growing acknowledgment that research in the postconflict field needs to include a focus on social conditions. The authors applied structural equation modeling to epidemiologic data obtained from postconflict Timor-Leste, to examine for links involving potentially traumatic events and sociodemographic factors (age, gender, educational levels, and unemployment) with psychological symptoms and functioning. Exposure to trauma and lack of education emerged as most relevant with psychological distress impacting on education in the urban area. Age and gender exerted influences at different points in the model consistent with the known history of Timor. Although based on cross-sectional data, the model supports the relevance of past trauma, posttraumatic distress, and postconflict social conditions to functioning in societies such as Timor-Leste.

Mental health survey among landmine survivors in Siem Reap province, Cambodia

Many survivors of the Khmer Rouge period in Cambodia and the subsequent war with Vietnam have now returned to Cambodia. In this two-stage household cluster survey in Siem Reap Province in Cambodia, we explored the mental health consequences on 166 landmine injury survivors selected from 1000 household in 50 clusters and an oversample of all landmine survivors. We found a prevalence of anxiety of 62% for all respondents, 74% for depression, and 34% for post-traumatic stress disorder (PTSD). These prevalences were statistically significantly higher than among the adult population who had not been injured by landmines. These data underscore the importance of providing mental health care services for the people in Siem Reap Province in Cambodia who have been injured by landmines.