Svang Tor

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.

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.

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.

The enduring mental health impact of mass violence: A community comparison study of Cambodian civilians living in Cambodia and Thailand

Background: No population-based studies have directly compared the long-term health and mental health outcomes of conflict- versus non-conflict-affected communities from the same ethnic background. Aims: To identify and compare levels of psychiatric morbidity between a traumatized and non-traumatized civilian community; to investigate the long-term impact of mass violence. Methods: Double-stratified community surveys in Siem Reap and Surin provinces were conducted by highly qualified Cambodian interviewers using culturally validated survey instruments with known psychometric properties. These included Cambodian versions of the Hopkins Symptom Checklist-25, the Harvard Trauma Questionnaire and the Medical Outcome Study Short Form. Results: Siem Reap and Surin respondents experienced 12,266 and 621 major trauma events, respectively; 745 (76.2%) Siem Reap respondents and six (0.6%) Surin respondents reported torture events; 499 (49.5%) Siem Reap respondents and 203 (19.7%) Surin respondents met the clinical threshold for depression (OR 4.01, 95% CI 3.29–4.88); 204 (20.6%) Siem Reap respondents and 23 (2.2%) Surin respondents met the clinical threshold for post-traumatic stress disorder (PTSD) (OR 11.39, 95% CI 7.3–17.7). The MOS physical disability was higher in Siem Reap versus Surin respondents (74 (7.5%) vs 13 (1.3%), χ2 = 47.4 df = 1, p < .001). Health status was poorest among Siem Reap respondents when compared with Surin respondents (mean score 1.59 vs 0.59, respectively; t = 19.85 df = 2018, p < .001). Path analysis reveals that recent and past extreme violence are associated with the health and mental health status of the Siem Reap community. Conclusion: After 25 years, the Khmer civilian population that experienced the Pol Pot genocide continues to suffer psychiatric morbidity and poor health.

Building primary care practitioners' attitudes and confidence in mental health skills in a post-conflict society: a Cambodian example.

Our program attempted to integrate community mental health in primary care settings in Cambodia and to evaluate the effects of training on local providers. The training program underwent an extensive evaluation to determine its impact on the mental health knowledge, confidence in performing medical and psychiatric procedures, skills and attitudes of its trainees. One hundred four Cambodian primary care practitioners (PCPs) were trained in a primary care setting in Siem Reap, Cambodia, over a 2-year period. There was a significant improvement in PCPs’ confidence in all clusters of medical and psychiatric procedures (counseling, medical evaluation, prescribing medications, psychiatric diagnosis, assessing risk for violence, traditional treatments, and treating trauma victims) comparing baseline to posttraining and baseline to 2-year follow-up (p < 0.05). Only confidence in prescribing psychotropic medications improved from posttraining to 2-year follow-up. This study supports the feasibility of training PCPs in a culturally effective manner in a postconflict society.

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.