Measuring Health: A Guide to Rating Scales and Questionnaires

国際生活機能分類(International Classification of Functioning, Disability and Health: ICF)にみた福祉・保健・医療の専門職協働における連携に関する貢献と課題

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

Systematic violence is a long-standing problem in Iraq. Research indicates that survivors often experience multiple mental health problems, and that there is a need for more rigorous research that targets symptoms beyond post-traumatic stress (PTS). Our objective was to test the effectiveness of two counseling therapies in Southern Iraq in addressing multiple mental health problems among survivors of systematic violence: (1) a transdiagnostic intervention (Common Elements Treatment Approach or CETA); and (2) cognitive processing therapy (CPT). The therapies were provided by non-specialized health workers since few MH professionals are available to provide therapy in Iraq. This was a randomized, parallel, two site, two-arm (1:1 allocation), single-blinded, wait-list controlled (WLC) trial of CETA in one site (99 CETA, 50 WLC), and CPT in a second site (129 CPT, 64 WLC). Eligibility criteria were elevated trauma symptoms and experience of systematic violence. The primary and secondary outcomes were trauma symptoms and dysfunction, respectively, with additional assessment of depression and anxiety symptoms. Non-specialized health workers (community mental health worker, CMHW) provided the interventions in government-run primary health centers. Treatment effects were determined using longitudinal, multilevel models with CMHW and client as random effects, and a time by group interaction with robust variance estimation, to test for the net difference in mean score for each outcome between the baseline and follow up interview. Multiple imputation techniques were used to account for missingness at the item level and the participant level. All analyses were conducted using Stata 12. The CETA intervention showed large effect sizes for all outcomes. The CPT intervention showed moderate effects sizes for trauma and depression, with small to no effect for anxiety or dysfunction, respectively. Both CETA and CPT appear to benefit survivors of systematic violence in Southern Iraq by reducing multiple mental health symptoms, with CETA providing a very large benefit across a range of symptoms. Non-specialized health workers were able to treat comorbid symptoms of trauma, depression and anxiety, and dysfunction among survivors of systematic violence who have limited access to mental health professionals. The trial further supports the use of evidence-based therapies in lower-resource settings. This trial was registered at ClinicalTrials.gov on 16 July 2010 with an identifier of NCT01177072
 as the Study of Effectiveness of Mental Health Interventions among Torture Survivors in Southern Iraq. The study protocol can be downloaded from the following website: http://tinyurl.com/CETA-Iraq-Protocol
 . In the protocol, the CETA intervention is given a different name: components-based intervention or CBI.

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Community-based mental health treatments for survivors of torture and militant attacks in Southern Iraq: a randomized control trial.

In this paper we review research evidence on psychosocial interventions for adult survivors of torture and trauma. We identified 40 studies from 1980 to 2010 that investigated interventions for adult survivors of torture and trauma. Population subtypes include resettled refugees, asylum seekers, displaced persons, and persons resident in their country of origin. Settings include specialized services for torture and trauma, specialized tertiary referral clinics, community settings, university settings, as well as psychiatric and multidisciplinary mental health services. Interventions were delivered as individual or group treatments and lasted from a single session to 19 years duration. The studies employed randomized controlled trials, nonrandomized comparison studies and single cohort follow-up studies. In all, 36 of the 40 studies (90%) demonstrated significant improvements on at least one outcome indicator after an intervention. Most studies (60%) included participants who had high levels of posttraumatic stress symptomatology. Improvements in symptoms of posttraumatic stress, depression, anxiety, and somatic symptoms were found following a range of interventions. Little evidence was available with regard to the effect on treatment outcomes of the amount, type, or length of treatment, the influence of patient characteristics, maintenance of treatment effects, and treatment outcomes other than psychiatric symptomatology. The review highlights the need for more carefully designed research that addresses the shortcomings of current studies and that integrates the experience of expert practitioners.

Evidence-based psychological interventions for adult survivors of torture and trauma: A 30-year review:

Objective This desk study intends to update and complement the desk study review of the torture rehabilitation literature completed in 1998 (Gurr and Quiroga, 2001), emphasizing areas not covered by the original study but updating the torture rehabilitation literature from the publication of the original desk study. Some selected earlier references have been retained, but the focus remains primarily on the published literature from 1998 through mid-2004. This paper intends to stand alone but will refer back to original study. The target audience is those working in or interested in the field of rehabilitation of politically motivated torture survivors. Findings since 1998 Perhaps the most important finding is that either torture has increased worldwide or the exposure of torture events has improved. Publications: Much has been written about trauma and torture, especially since the terrorist attacks on New York City and Washington, D.C. on September 11, 2001 (9/11) and the Abu Ghraib prison abuses in Iraq. The print and visual media has fostered a virtual explosion of information about torture and terrorism. Even in the professional literature, the relevant books are too numerous to catalogue here and beyond our scope. Research on PTSD and on the prevalence of torture has been notable. In addition, much information is more readily available with the increased access and availability of internet resources and publications. Changing Nature of Torture: After 9/11, terrorism and its relationship to torture became an issue.The use of torture methods to extract information from suspected terrorists became controversial. Evidence of torture by "civilized" western countries was uncovered. Worldwide, the context of torture has broadened to include many aspects of organized violence, often occurring during war. Antiimmigrant sentiment has not improved and, if anything, has worsened in the US Europe, and in many other Western countries. METHODS: The Abu Ghraib prison abuses and alleged torture by coalition forces in Iraq has fueled an international discussion about what methods constitute torture. Assessment: Progress has been made on the legal and forensic evaluation of torture survivors, notably publication of the Istanbul Protocol. Questions raised regarding the validity of memory recall have implications for assessment of torture survivors. Prevention: Passage of the UN Optional Protocol and formation of the International Criminal Court are significant advances in the effort to prevent and eradicate torture. Gaps in the literature since 1998 After a quarter of a century and dramatic expansion of rehabilitation efforts worldwide, there is still no consensus about the efficacy of treatment interventions for torture survivors. There is little additional literature about treatment outcome, models and structure of rehabilitation services, design of services, cost-effectiveness, or sustainability of services. General principles of assessment and treatment remain virtually unchanged. Controversies over PTSD applicability for torture survivors persist. Restructuring of the desk study New Structure: In order to focus the desk study on health issues, the sections with this emphasis will be presented as chapters while the remaining topics, which are more political, research, or prevention oriented will be included as appendices. Language: en

Politically-motivated torture and its survivors:

Table of contents Introduction Background and history The complexity of rehabilitation: Some of the variables The challenges Designing outcome studies: study validity Programme definitions and examples Outcomes and indicators Research strategies Literature review Examples of instruments available Recommendations for the future Acronyms Website resources References Introduction The authors of this document intend to review the history of evaluation of torture treatment programmes, discuss the challenges, and identify the research conducted to evaluate services. We outline research designs to measure outcome, including symptoms, level of function, and satisfaction. Research design, not data analysis, is the focus of this desk study. The outcomes research literature is summarized and categorized. Finally, we discuss the advantages and limitations of the most commonly used assessment instruments, some of them culturally-appropriate, and recommend the best approaches to measure outcomes of treatment for torture survivors. This document intends not only to provide the context in which outcome research has been conducted in the past, but how centres can move forward today despite limitations and obstacles.

James M. Jaranson

Papers

Politically-motivated torture and its survivors:

Evaluating the services of torture rehabilitation programmes: history and recommendations.