Context Uncertainties continue about the roles that methodological factors and key risk factors, particularly torture and other potentially traumatic events (PTEs), play in the variation of reported prevalence rates of posttraumatic stress disorder (PTSD) and depression across epidemiologic surveys among postconflict populations worldwide. Objective To undertake a systematic review and meta-regression of the prevalence rates of PTSD and depression in the refugee and postconflict mental health field. Data Sources An initial pool of 5904 articles, identified through MEDLINE, PsycINFO and PILOTS, of surveys involving refugee, conflict-affected populations, or both, published in English-language journals between 1980 and May 2009. Study Selection Surveys were limited to those of adult populations (n ≥ 50) reporting PTSD prevalence, depression prevalence, or both. Excluded surveys comprised patients, war veterans, and civilian populations (nonrefugees/asylum seekers) from high-income countries exposed to terrorist attacks or involved in distal conflicts (≥25 years). Data Extraction Methodological factors (response rate, sample size and design, diagnostic method) and substantive factors (sociodemographics, place of survey, torture and other PTEs, Political Terror Scale score, residency status, time since conflict). Data Synthesis A total of 161 articles reporting results of 181 surveys comprising 81 866 refugees and other conflict-affected persons from 40 countries were identified. Rates of reported PTSD and depression showed large intersurvey variability (0%-99% and 3%-85.5%, respectively). The unadjusted weighted prevalence rate reported across all surveys for PTSD was 30.6% (95% CI, 26.3%-35.2%) and for depression was 30.8% (95% CI, 26.3%-35.6%). Methodological factors accounted for 12.9% and 27.7% PTSD and depression, respectively. Nonrandom sampling, small sample sizes, and self-report questionnaires were associated with higher rates of mental disorder. Adjusting for methodological factors, reported torture (Δ total R 2 between base methodological model and base model + substantive factor [ΔR 2 ] = 23.6%; OR, 2.01; 95% CI, 1.52-2.65) emerged as the strongest factor associated with PTSD, followed by cumulative exposure to PTEs (ΔR 2  = 10.8%; OR, 1.52; 95% CI, 1.21-1.91), time since conflict (ΔR 2  = 10%; OR, 0.77; 95% CI, 0.66-0.91), and assessed level of political terror (ΔR 2  = 3.5%; OR, 1.60; 95% CI, 1.03-2.50). For depression, significant factors were number of PTEs (ΔR 2  = 22.0%; OR, 1.64; 95% CI, 1.39-1.93), time since conflict (ΔR 2  = 21.9%; OR, 0.80; 95% CI, 0.69-0.93), reported torture (ΔR 2  = 11.4%; OR, 1.48; 95% CI, 1.07-2.04), and residency status (ΔR 2  = 5.0%; OR, 1.30; 95% CI, 1.07-1.57). Conclusion Methodological factors and substantive population risk factors, such as exposure to torture and other PTEs, after adjusting for methodological factors account for higher rates of reported prevalence of PTSD and depression.

Association of Torture and Other Potentially Traumatic Events With Mental Health Outcomes Among Populations Exposed to Mass Conflict and Displacement: A Systematic Review and Meta-analysis

ContextRefugees experience multiple traumatic events and have significant associated
health problems, but data about refugee trauma and health status are often
conflicting and difficult to interpret.ObjectivesTo assess the characteristics of the literature on refugee trauma and
health, to identify and evaluate instruments used to measure refugee trauma
and health status, and to recommend improvements.Data SourcesMEDLINE, PsychInfo, Health and PsychoSocial Instruments, CINAHL, and
Cochrane Systematic Reviews (searched through OVID from the inception of each
database to October 2001), and the New Mexico Refugee Project database.Study SelectionKey terms and combination operators were applied to identify English-language
publications evaluating measurement of refugee trauma and/or health status.Data ExtractionInformation extracted for each article included author; year of publication;
primary focus; type (empirical, review, or descriptive); and type/name and
properties of instrument(s) included. Articles were excluded from further
analyses if they were review or descriptive, were not primarily about refugee
health status or trauma, or were only about infectious diseases. Instruments
were then evaluated according to 5 criteria (purpose, construct definition,
design, developmental process, reliability and validity) as described in the
published literature.Data SynthesisOf 394 publications identified, 183 were included for further analyses
of their characteristics; 91 (49.7%) included quantitative data but did not
evaluate measurement properties of instruments used in refugee research, 78
(42.6%) reported on statistical relationships between measures (presuming
validity), and 14 (7.7%) were only about statistical properties of instruments.
In these 183 publications, 125 different instruments were used; of these,
12 were developed in refugee research. None of these instruments fully met
all 5 evaluation criteria, 3 met 4 criteria, and 5 met only 1 of the criteria.
Another 8 standard instruments were designed and developed in nonrefugee populations
but adapted for use in refugee research; of these, 2 met all 5 criteria and
6 met 4 criteria.ConclusionsThe majority of articles about refugee trauma or health are either descriptive
or include quantitative data from instruments that have limited or untested
validity and reliability in refugees. Primary limitations to accurate measurement
in refugee research are the lack of theoretical bases to instruments and inattention
to using and reporting sound measurement principles.

https://jamanetwork.com/HttpHandlers/ArticlePdfHandler.ashx?journal=JAMA&articleId=195170&pdfFileName=jrv20018.pdf

Measuring Trauma and Health Status in Refugees: A Critical Review

ContextLittle is known about the long-term mental health of trauma-exposed
refugees years after permanent resettlement in host countries.ObjectiveTo assess the prevalence, comorbidity, and correlates of psychiatric
disorders in the US Cambodian refugee community.Design, Setting, and ParticipantsA cross-sectional, face-to-face interview conducted in Khmer language
on a random sample of households from the Cambodian community in Long Beach,
Calif, the largest such community in the United States, between October 2003
and February 2005. A total of 586 adults aged 35 to 75 years who lived in
Cambodia during the Khmer Rouge reign and immigrated to the United States
prior to 1993 were selected. One eligible individual was randomly sampled
from each household, with an overall response rate (eligibility screening
and interview) of 87% (n = 490).Main Outcome MeasuresExposure to trauma and violence before and after immigration (using
the Harvard Trauma Questionnaire and Survey of Exposure to Community Violence);
weighted past-year prevalence rates of posttraumatic stress disorder (PTSD)
and major depression (using the Composite International Diagnostic Interview
version 2.1); and alcohol use disorder (by the Alcohol Use Disorders Identification
Test).ResultsAll participants had been exposed to trauma before immigration. Ninety-nine
percent (n = 483) experienced near-death due to starvation and 90%
(n = 437) had a family member or friend murdered. Seventy percent
(n = 338) reported exposure to violence after settlement in the
United States. High rates of PTSD (62%, weighted), major depression (51%,
weighted), and low rates of alcohol use disorder were found (4%, weighted).
PTSD and major depression were highly comorbid in this population (n = 209;
42%, weighted) and each showed a strong dose-response relationship with measures
of traumatic exposure. In bivariate analyses, older age, having poor English-speaking
proficiency, unemployment, being retired or disabled, and living in poverty
were also associated with higher rates of PTSD and major depression. Following
multivariate analyses, premigration trauma remained associated with PTSD (odds
ratio [OR], 2.08; 95% CI, 1.37-3.16) and major depression (OR, 1.56; 95% CI,
1.24-1.97); postmigration trauma with PTSD (OR, 1.65; 95% CI, 1.21-2.26) and
major depression (OR, 1.45; 95% CI, 1.12-1.86); and older age with PTSD (OR,
1.76; 95% CI, 1.46-2.13) and major depression (OR, 1.47; 95% CI, 1.15-1.89).ConclusionMore than 2 decades have passed since the end of the Cambodian civil
war and the subsequent resettlement of refugees in the United States; however,
this population continues to have high rates of psychiatric disorders associated
with trauma.

/pdf/mental-health-of-cambodian-refugees-2-decades-after-l4fu039poz.pdf

Mental health of Cambodian refugees 2 decades after resettlement in the United States

Torture is a complex trauma that often occurs within the context of widespread persecution and human rights violations. In addition, the nature of modern warfare is such that whole populations are at risk of suffering extensive trauma, injustices, loss, and displacement. Refugees, in particular, experience sequential stresses that may compound each other over prolonged periods of time. The present overview examines whether contemporary notions of trauma, and especially a focus on the category of posttraumatic stress disorder (PTSD), are adequate in assessing the multiple effects of such experiences. Recent studies are reviewed to indicate the strengths and limitations of current research approaches. Rates of PTSD in such studies have varied with relatively low rates being found in recent epidemiologic studies undertaken on refugee populations. It is suggested that a focus on intervening psychosocial adaptive systems may assist in delineating more clearly the pathways that determine whether traumatized persons achieve psychosocial restitution or are at risk of ongoing psychiatric disability. A model is proposed which suggests that torture and related abuses may challenge five core adaptive systems subserving the functions of "safety," "attachment," "justice," "identity-role," and "existential-meaning." It is argued that a clearer delineation of such adaptive systems may provide a point of convergence that may link research endeavors more closely to the subjective experience of survivors and to the types of clinical interventions offered by trauma treatment services.

The psychosocial effects of torture, mass human rights violations, and refugee trauma : Toward an integrated conceptual framework

Context The relationship between psychiatric symptoms and disability in refugee
survivors of mass violence is not known. Objective To determine if risk factors, such as demographics, trauma, health status,
and psychiatric illness, are associated with disability in Bosnian refugees. Design, Setting, and Participants Cross-sectional survey conducted in 1996 of Bosnian refugee adults living
in a camp established by the Croatian government near the city of Varaždin.
One adult aged 18 years or older was randomly selected from each of 573 camp
families; 534 (93%) agreed to participate (mean age, 50 years; 41% male). Main Outcome Measures Culturally validated measures for depression and posttraumatic stress
disorder (ptsd) included the Hopkins Symptom Checklist 25 and the Harvard
Trauma Questionnaire, respectively. Disability measures included the Medical
Outcomes Study Short-Form 20, a physical functioning scale based on World
Health Organization criteria, and self-reports of socioeconomic activity,
levels of physical energy, and perceived health status. Results Respondents reported a mean (sd) of 6.5 (4.7) unduplicated trauma events;
18% (n=95) had experienced 1 or more torture events. While 55.2% reported
no psychiatric symptoms, 39.2% and 26.3% reported symptoms that meet dsm-iv criteria for depression and ptsd, respectively;
20.6% reported symptoms comorbid for both disorders. a total of 25.5% reported
having a disability. Refugees who reported symptoms comorbid for both depression
and ptsd were associated with an increased risk for disability compared with
asymptomatic refugees (unadjusted odds ratio [OR], 5.02; 95% confidence interval
χ, 3.05-8.26; adjusted or, 2.06; 95% ci, 1.10-3.86). Older age, cumulative
trauma, and chronic medical illness were also associated with disability. Conclusions In a population of Bosnian refugees who had recently fled from the war
in Bosnia and Herzegovina, psychiatric comorbidity was associated with disability
independent of the effects of age, trauma, and health status.

https://jamanetwork.com/journals/jama/articlepdf/191006/joc90966.pdf

Disability associated with psychiatric comorbidity and health status in Bosnian refugees living in Croatia

Context.—Most of the world's refugees are displaced within the developing world.
The impact of torture on such refugees is unknown.Objective.—To examine the impact of torture on Bhutanese refugees in Nepal.Design.—Case-control survey. Interviews were conducted by local physicians and
included demographics, questions related to the torture experienced, a checklist
of 40 medical complaints, and measures of posttraumatic stress disorder (PTSD),
anxiety, and depression.Setting.—Bhutanese refugee community in the United Nations refugee camps in the
Terai in eastern Nepal.Participants.—A random sample of 526 tortured refugees and a control group of 526
nontortured refugees matched for age and sex.Main Outcome Measures.—The Diagnostic and Statistical Manual of Mental Disorders,
Revised Third Edition (DSM-III-R) criteria
for PTSD and the Hopkins Symptom Checklist-25 (HSCL-25) for depression and
anxiety.Results.—The 2 groups were similar on most demographic variables. The tortured
refugees, as a group, suffered more on 15 of 17 DSM-III-R PTSD symptoms (P<.005) and had higher
HSCL-25 anxiety and depression scores (P<.001)
than nontortured refugees. Logistic regression analysis showed that history
of torture predicted PTSD symptoms (odds ratio [OR], 4.6; 95% confidence interval
[CI], 2.7-8.0), depression symptoms (OR, 1.9; 95% CI, 1.4-2.6), and anxiety
symptoms (OR, 1.5; 95% CI, 1.1-1.9). Torture survivors who were Buddhist were
less likely to be depressed (OR, 0.5; 95% CI, 0.3-0.9) or anxious (OR, 0.7;
95% CI, 0.4-1.0). Those who were male were less likely to experience anxiety
(OR, 0.66; 95% CI, 0.44-1.00). Tortured refugees also presented more musculoskeletal
system– and respiratory system–related complaints (P<.001 for both).Conclusion.—Torture plays a significant role in the development of PTSD, depression,
and anxiety symptoms among refugees from Bhutan living in the developing world.

/pdf/impact-of-torture-on-refugees-displaced-within-the-2cj8jd2sqn.pdf

G B Shrestha

Papers

Impact of Torture on Refugees Displaced Within the Developing World Symptomatology Among Bhutanese Refugees in Nepal