Verena Ertl

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.

The Risk of Posttraumatic Stress Disorder After Trauma Depends on Traumatic Load and the Catechol-O-Methyltransferase Val158Met Polymorphism

BACKGROUND The risk for posttraumatic stress disorder (PTSD) depends on the number of traumatic event types experienced in a dose-response relationship, but genetic factors are known to also influence the risk of PTSD. The catechol-O-methyltransferase (COMT) Val158Met polymorphism has been found to affect fear extinction and might play a role in the etiology of anxiety disorders. METHODS Traumatic load and lifetime and current diagnosis of PTSD and COMT genotype were assessed in a sample of 424 survivors of the Rwandan Genocide living in the Nakivale refugee camp in southwestern Uganda. RESULTS Higher numbers of different lifetime traumatic event types led to a higher prevalence of lifetime PTSD in a dose-response relationship. However, this effect was modulated by the COMT genotype: whereas Val allele carriers showed the typical dose-response relationship, Met/Met homozygotes exhibited a high risk for PTSD independently of the severity of traumatic load. CONCLUSIONS The present findings indicate a gene-environment interaction between the human COMT Val158Met polymorphism and the number of traumatic event types experienced in the risk of developing PTSD.

A deletion variant of the alpha2b-adrenoceptor is related to emotional memory in Europeans and Africans

Emotionally arousing events are recalled better than neutral events. This phenomenon, which helps us to remember important and potentially vital information, depends on the activation of noradrenergic transmission in the brain. Here we show that a deletion variant of ADRA2B, the gene encoding the α2b-adrenergic receptor, is related to enhanced emotional memory in healthy Swiss subjects and in survivors of the Rwandan civil war who experienced highly aversive emotional situations.

Community-implemented trauma therapy for former child soldiers in northern Uganda : a randomized controlled trial

CONTEXT The psychological rehabilitation of former child soldiers and their successful reintegration into postconflict society present challenges. Despite high rates of impairment, there have been no randomized controlled trials examining the feasibility and efficacy of mental health interventions for former child soldiers. OBJECTIVE To assess the efficacy of a community-based intervention targeting symptoms of posttraumatic stress disorder (PTSD) in formerly abducted individuals. DESIGN, SETTING, AND PARTICIPANTS Randomized controlled trial recruiting 85 former child soldiers with PTSD from a population-based survey of 1113 Northern Ugandans aged 12 to 25 years, conducted between November 2007 and October 2009 in camps for internally displaced persons. Participants were randomized to 1 of 3 groups: narrative exposure therapy (n = 29), an academic catch-up program with elements of supportive counseling (n = 28), or a waiting list (n = 28). Symptoms of PTSD and trauma-related feelings of guilt were measured using the Clinician-Administered PTSD Scale. The respective sections of the Mini International Neuropsychiatric Interview were used to assess depression and suicide risk, and a locally adapted scale was used to measure perceived stigmatization. Symptoms of PTSD, depression, and related impairment were assessed before treatment and at 3 months, 6 months, and 12 months postintervention. INTERVENTION Treatments were carried out in 8 sessions by trained local lay therapists, directly in the communities. MAIN OUTCOME MEASURES Change in PTSD severity, assessed over a 1-year period after treatment. Secondary outcome measures were depression symptoms, severity of suicidal ideation, feelings of guilt, and perceived stigmatization. RESULTS PTSD symptom severity (range, 0-148) was significantly more improved in the narrative exposure therapy group than in the academic catch-up (mean change difference, -14.06 [95% confidence interval, -27.19 to -0.92]) and waiting-list (mean change difference, -13.04 [95% confidence interval, -26.79 to 0.72]) groups. Contrast analyses of the time × treatment interaction of the mixed-effects model on PTSD symptom change over time revealed a superiority of narrative exposure therapy compared with academic catch-up (F(1,234.1) = 5.21, P = .02) and wait-listing (F(1,228.3) = 5.28, P = .02). Narrative exposure therapy produced a larger within-treatment effect size (Cohen d = 1.80) than academic catch-up (d = 0.83) and wait-listing (d = 0.81). CONCLUSION Among former Ugandan child soldiers, short-term trauma-focused treatment compared either with an academic catch-up program including supportive counseling or with wait-listing resulted in greater reduction of PTSD symptoms. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00552006.

Association study of trauma load and SLC6A4 promoter polymorphism in posttraumatic stress disorder : evidence from survivors of the Rwandan genocide

OBJECTIVE As exposure to different types of traumatic stressors increases, the occurrence of posttraumatic stress disorder (PTSD) increases. However, because some people exhibit either surprising resilience or high vulnerability, further influencing factors have been conjectured, such as gene-environment interactions. The SLC6A4 gene, which encodes serotonin transporter, has been identified as predisposing toward differential emotional processing between genotypes of its promoter polymorphism. METHOD We investigated 408 refugees from the Rwandan genocide and assessed lifetime exposure to traumatic events, PTSD (according to DSM-IV) status, and genotype of the SLC6A4 promoter polymorphism. The study was conducted from March 2006 to February 2007. RESULTS The prevalence of PTSD approached 100% when traumatic exposure reached extreme levels. However, persons homozygous for the short allele of the SLC6A4 promoter polymorphism showed no dose-response relationship but were at high risk for developing PTSD after very few traumatic events. This genotype influence vanished with increasing exposure to traumatic stressors. CONCLUSION We find evidence for a gene-environment interplay for PTSD and show that genetic influences lose importance when environmental factors cause an extremely high trauma burden to an individual. In the future, it may be important to determine whether the effectiveness of therapeutic interventions in PTSD is also modulated by the SLC6A4 genotype.

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.

Validation of a Mental Health Assessment in an African Conflict Population.

We studied the validity of the assessment of posttraumatic stress disorder (PTSD) and depression within the context of an epidemiological mental health survey among war-affected adolescents and young adults in northern Uganda. Local language versions of the Posttraumatic Diagnostic Scale (PDS) and the Depression section of the Hopkins Symptom Checklist (DHSCL) were administered by trained local interviewers. Correlations with probable predictor variables (i.e., trauma exposure), outcomes (e.g., impaired functioning), and local idioms of distress (i.e., spirit possession) were determined to estimate criterion-related construct validity. To assess convergent validity, expert clinicians reinterviewed a subsample using structured interviews (the Clinician Administered PTSD Scale [CAPS] and the Mini International Neuropsychiatric Interview [MINI]). Depression and PTSD symptoms as assessed by the local interviewers correlated with the context variables as predicted. After optimizing the scoring algorithm, we found good agreement between the PDS-based diagnoses and expert diagnoses. However, the concordance for depression diagnoses was not satisfactory. Results show that mental health assessments in African languages can produce reliable and valid data but that caution is warranted in the unevaluated transfer of cutoff scores and scoring algorithms.

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.

Prevalence and predictors of partner violence against women in the aftermath of war: A survey among couples in Northern Uganda

Violence against women that is perpetrated by an intimate partner prevails as one of the most widespread human rights violations in virtually all societies of the world. Women in resource-poor countries, in particular those affected by recent war, appear to be at high risk of experiencing partner violence. Although there has been a longstanding assumption that organised violence at a societal level is transmitted to an interpersonal level, little is known about the link between exposure to war and familial violence. We conducted an epidemiological survey in 2010 with 2nd-grade students and their male and female guardians from nine heavily war-affected communities in Northern Uganda employing structured interviews and standardized questionnaires. The present study analysed a subsample of 235 guardian couples from seven rural communities in order to determine the prevalence and predictors of current partner violence experienced by women in the context of the past war. Study results revealed a high prevalence of ongoing partner violence experienced by female partners. In the past year, 80% of women reported at least one type of verbal/psychological abuse, 71% were exposed to at least one type of physical abuse, 52% suffered isolation and 23% fell victim to sexual violence. Findings from linear regression analyses showed that womens prior exposure to war-related traumatic events, womens re-experiencing symptoms and mens level of alcohol-related problems were associated with higher levels of partner violence against women. Differential effects of the predictor variables emerged with respect to different subtypes of partner violence. The findings suggest that partner violence against women constitutes a major problem in rural Northern Uganda. Programmes for the prevention and reduction of partner violence against women need to address high levels of hazardous drinking in men as well as womens prior traumatisation. In addition, different patterns of partner violence should be taken into account.

PKCα is genetically linked to memory capacity in healthy subjects and to risk for posttraumatic stress disorder in genocide survivors

Strong memory of a traumatic event is thought to contribute to the development and symptoms of posttraumatic stress disorder (PTSD). Therefore, a genetic predisposition to build strong memories could lead to increased risk for PTSD after a traumatic event. Here we show that genetic variability of the gene encoding PKCα (PRKCA) was associated with memory capacity—including aversive memory—in nontraumatized subjects of European descent. This finding was replicated in an independent sample of nontraumatized subjects, who additionally underwent functional magnetic resonance imaging (fMRI). fMRI analysis revealed PRKCA genotype-dependent brain activation differences during successful encoding of aversive information. Further, the identified genetic variant was also related to traumatic memory and to the risk for PTSD in heavily traumatized survivors of the Rwandan genocide. Our results indicate a role for PKCα in memory and suggest a genetic link between memory and the risk for PTSD.