Hope in hardship: charting a new course for mental health in Afghanistan.

The long legacy of upheavals and deprivations in Afghanistan and the associated mental health impacts on its people are well documented. A systematic review undertaken by Alemi et al (2023) presents the most comprehensive synthesis to date on this topic. Drawing on their findings, this editorial examines the complex mental health and psychosocial challenges confronted by neglected vulnerable groups such as pregnant and postnatal women, LGBTQ individuals, older adults, ethnic minority groups and Afghan refugees living overseas. It explores the potential challenges in rebuilding a resilient mental health system following the mass exodus of Afghanis. It calls for a whole-of-society approach that extends beyond clinical interventions to address the broader sociocultural and economic factors influencing mental health.

Correction: COVID-19 stressors and mental health problems amongst women who arrived as refugees and those born in Australia.

[This corrects the article DOI: 10.1371/journal.pgph.0002073.].

Effect of daily stressors and collective efficacy on post-traumatic stress symptoms among internally displaced persons in post-war northern Sri Lanka.

BACKGROUND: Daily stressors have been shown to mediate the relationship of war trauma and trauma-related distress among refugees and internally displaced persons exposed to war and conflict. AIMS: To examine the extent to which the relationship between war-related trauma and mental distress was mediated by daily stressors and collective efficacy among internally displaced communities a decade after exposure to war. METHOD: In a cross-sectional study, we recruited a random sample of residents in villages severely affected by conflict in five districts in the Northern Province of Sri Lanka. Measures of war trauma, daily stressors, collective efficacy and post-traumatic stress symptoms (PTSS) were examined. Statistical analyses of the mediating and moderating effects of daily stressors were conducted using regression based methods. RESULTS: Daily stressors mediated the association of war trauma and PTSS, as both paths of the indirect effect, war trauma to daily stressors and daily stressors to PTSS, were significant. The predictive effect of war trauma on PTSS was positive and significant at moderate and high levels of daily stressors but not at low levels. Higher levels of neighbourhood informal social control, a component of collective efficacy, function as a protective factor to reduce effects of war trauma and daily stressors on mental distress in this population. CONCLUSIONS: Daily stressors are an important mediator in the well-established relationship between war exposure and traumatic stress among internally displaced persons, even a decade after the conflict. Mental health and psychosocial support programmes that aim to address mental distress among war-affected communities could reduce daily stressors and enhance collective efficacy in this context.

COVID-19 stressors and mental health problems amongst women who arrived as refugees and those born in Australia.

Women from refugee background residing in high income countries are at greater mental health risk during the COVID-19 pandemic given their higher baseline prevalence of mental disorders, trauma exposures and social adversities. During the COVID-19 pandemic we drew on data from wave-4 of the WATCH cohort study, collected between October 2019 and June 2021. We conducted a cross-sectional analysis to compare the prevalence of common mental disorders (CMDs) from the sample of 650 consecutively recruited women, 339 (52.2%) from the refugee-background who were resettled in Australia and 311 (48.8%) randomly and contemporaneously selected Australian born women. We assessed COVID-19 psychosocial stressors: 1. COVID-related material hardship and 2. COVID-related fear and stress. We examined for associations between scores on these two items and CMDs in each group respectively. Compared to Australian-born woman, women from refugee background recorded a significantly higher prevalence of Major Depressive Disorder (MDD) (19.8% vs 13.5%), PTSD (9.7% vs 5.1%), Separation Anxiety Disorder (SEPAD) (19.8% vs 13.5%) and Persistent Complicated Bereavement Disorder (PCBD) (6.5% vs 2.9%). In refugee women, associations were found between COVID-related material hardship and CMDs [MDD, Relative Risk (RR) = 1.39, 95%CI: 1.02-1.89, p = 0.02] as well as between COVID-related fear and stress and CMDs (MDD, RR = 1.74, 95%CI: 1.04-2.90, p = 0.02 p = 0.02). For Australian-born women, associations were more commonly found between CMDs and material hardship. Our study demonstrates that both women from refugee background and those born in Australia are experiencing significant rates of CMD during the pandemic and that material hardship is an associated factor. We found that women from refugee background are at greater risk for mental health problems and are more likely to report an association of those problems with fear and stress related to COVID_19. All women, and particularly those from refugee background, require urgent and specialised attention to their mental health and psychosocial problems during this pandemic.

Psychosocial model of burnout among humanitarian aid workers in Bangladesh: role of workplace stressors and emotion coping.

BACKGROUND: While trauma exposure is an established predictor of poor mental health among humanitarian aid workers (HAWs), less is known about the role of psychosocial work-related factors. This study aims to establish a psychosocial model for burnout and psychological distress in HAWs that tests and compares the effects of adversity exposure and workplace stressors in combination, and explores the potential mediating role of individual coping styles. METHODS: Path analysis and model comparison using cross-sectional online survey data were collected from full-time international and local HAWs in Bangladesh between December 2020 and February 2021. HAWs self-reported on exposure to adversities, workplace psychosocial stressors (Third Copenhagen Psychosocial Questionnaire), coping styles (Coping Inventory for Stressful Situations), burnout (Maslach Burnout Inventory-Human Services Survey), and psychological distress (Kessler-6). RESULTS: Among N = 111 HAWs, 30.6%, 16.4%, 12.7%, and 8.2% screened positive for moderate psychological distress (8 ≤ Kessler-6 ≤ 12), emotional exhaustion (EE ≥ 27), depersonalization (DP ≥ 13), and severe psychological distress (K-6 ≥ 13), respectively. 28.8% reported a history of mental disorder. The preferred model showed distinct pathways from adversity exposure and workplace stressors to burnout, with negative emotion-focused coping and psychological distress as significant intervening variables. While greater exposure to both types of stressors were associated with higher levels of burnout and distress, workplace stressors had a stronger association with psychological outcomes than adversity exposure did (ß = .52, p ≤ .001 vs. ß = .20, p = .032). Workplace stressors, but not adversities, directly influenced psychological distress (ß = .45, p ≤ .001 vs. ß = -.01, p = .927). Demographic variables, task-focused and avoidance-focused coping were not significantly associated with psychological outcomes. CONCLUSIONS: Compared to exposure to adversities, workplace stressors primarily influenced occupational stress syndromes. Reducing workplace stressors and enhancing adaptive coping may improve psychological outcomes in humanitarian staff.

Long-term efficacy of brief psychological treatments for common mental disorders in Myanmar refugees in Malaysia: 12-month follow-up of a randomized, active-controlled trial of integrative adapt therapy v. cognitive behavioral therapy.

BACKGROUND: Long-term efficacy of brief psychotherapies for refugees in low-resource settings is insufficiently understood. Integrative adapt therapy (IAT) is a scalable treatment addressing refugee-specific psychosocial challenges. METHODS: We report 12-month post-treatment data from a single-blind, active-controlled trial (October 2017-August 2019) where 327 Myanmar refugees in Malaysia were assigned to either six sessions of IAT (n = 164) or cognitive behavioral treatment (CBT) (n = 163). Primary outcomes were posttraumatic stress disorder (PTSD), depression, anxiety, and persistent complex bereavement disorder (PCBD) symptom scores at treatment end and 12-month post-treatment. Secondary outcome was functional impairment. RESULTS: 282 (86.2%) participants were retained at 12-month follow-up. For both groups, large treatment effects for common mental disorders (CMD) symptoms were maintained at 12-month post-treatment compared to baseline (d = 0.75-1.13). Although participants in IAT had greater symptom reductions and larger effect sizes than CBT participants for all CMDs at treatment end, there were no significant differences between treatment arms at 12-month post-treatment for PTSD [mean difference: -0.9, 95% CI (-2.5 to 0.6), p = 0.25], depression [mean difference: 0.1, 95% CI (-0.6 to 0.7), p = 0.89), anxiety [mean difference: -0.4, 95% CI (-1.4 to 0.6), p = 0.46], and PCBD [mean difference: -0.6, 95% CI (-3.1 to 1.9), p = 0.65]. CBT participants showed greater improvement in functioning than IAT participants at 12-month post-treatment [mean difference: -2.5, 95% CI (-4.7 to -0.3], p = 0.03]. No adverse effects were recorded for either therapy. CONCLUSIONS: Both IAT and CBT showed sustained treatment gains for CMD symptoms amongst refugees over the 12-month period.

Harbingers of Hope: Scientists and the Pursuit of World Peace.

The ongoing wars in many regions-such as the conflict between Israel and Hamas-as well as the effects of war on communities, social services, and mental health are covered in this special editorial. This article emphasizes the need for international efforts to promote peace, offer humanitarian aid, and address the mental health challenges faced by individuals and communities affected by war and violence.

Prevalence and correlates of DSM-IV and DSM-5 Intermittent Explosive Disorder amongst Myanmar refugees living in Malaysia: a population-based study.

AIMS: We investigate the prevalence and risk factor profiles of Intermittent Explosive Disorder (IED) and comparison between two diagnostic measures for IED in a large population-based study of three ethnic groups of refugees (Chin, Kachin and Rohingya) from Myanmar resettled in Malaysia. METHODS: Trained field personnel interviewed in total 2058 refugees, applying a clustered, probabilistic, proportional-to-size sampling framework and using the DSM-IV and DSM-5 criteria to diagnose IED. We used descriptive and bivariate analyses to explore associations of IED (using DSM IV or DMS 5) with ethnic group membership, sociodemographic characteristics and exposure to premigration traumatic events (TEs) and postmigration living difficulties (PMLDs). We also examined associations of IED with other common mental disorders (CMDs) (depression, anxiety and posttraumatic stress disorder) and with domains of functional impairment. Finally, we compared whether IED measured using DSM IV or DSM 5 generated the same or different prevalence. RESULTS: For the whole sample (n = 2058), the 12-month prevalence of DSM-IV IED was 5.9% (n = 122) and for DSM-5, 3.4% (n = 71). Across the three ethnic groups, 12-month DSM-5 IED prevalence was 2.1% (Chin), 2.9% (Rohingya) and 8.0% (Kachin), whereas DSM-IV defined IED prevalence was 3.2% (Chin), 7% (Rohingya) and 9.2% (Kachin). Being single, and exposure to greater premigration TEs and PMLDs were each associated with IED. Over 80% of persons with IED recorded one or more comorbid CMDs. Persons with IED also showed greater levels of functional impairment compared with those without IED. CONCLUSIONS: The pooled IED prevalence was higher than global norms but there was substantial variation in prevalence across the three study groups.

Psychosocial treatment outcomes of common mental disorders vary widely in persons in low- and middle-income countries affected by humanitarian crises and refugees in high-income countries.

This commentary discusses methodological and contextual factors that might account for variations in psychosocial treatment outcomes found in persons in low- and middle-income countries affected by humanitarian crises and refugees. Factors discussed are related to cultural adaptations, content and intensity of treatment, population characteristics and factors related to research design.

Variations in prevalence and risk profiles for Common Mental Disorders amongst Rohingya, Chin and Kachin refugees from Myanmar.

BACKGROUND: Large variations in prevalence rates of common mental disorder (CMD) amongst refugees and forcibly displaced populations have raised questions about the accuracy and value of epidemiological surveys in these cross-cultural settings. We examined the associations of sociodemographic indices, premigration traumatic events (TEs), postmigration living difficulties (PMLDs), and psychosocial disruptions based on the Adaptive Stress Index (ASI) in relation to CMD prevalence amongst the Rohingya, Chin and Kachin refugees originating from Myanmar and relocated to Malaysia. METHODS: Parallel epidemiological studies were conducted in areas where the three groups were concentrated in and around Malaysia (response rates: 80-83%). RESULTS: TE exposure, PMLDs and ASI were significantly associated with CMD prevalence in each group but the Rohingya recorded the highest exposure to all three of these former indices relative to Chin and Kachin (TE: mean = 11.1 v. 8.2 v. 11; PMLD: mean = 13.5 v. 7.4 v. 8.7; ASI: mean = 128.9 v. 32.1 v. 35.5). Multiple logistic regression analyses based on the pooled sample (n = 2058) controlling for gender and age, found that ethnic group membership, premigration TEs (16 or more TEs: OR, 2.00; 95% CI, 1.39-2.88; p < 0.001), PMLDs (10-15 PMLDs: OR, 4.19; 95% CI, 3.17-5.54; 16 or more PMLDs: OR, 7.23; 95% CI, 5.24-9.98; p < 0.001) and ASI score (ASI score 100 or greater: OR, 2.19; 95% CI, 1.46-3.30; p < 0.001) contributed to CMD. CONCLUSIONS: Factors specific to each ethnic group and differences in the quantum of exposure to TEs, PMLDs and psychosocial disruptions appeared to account in large part for differences in prevalence rates of CMDs observed across these three groups.

A Naturalistic Evaluation of Group Integrative Adapt Therapy (IAT-G) with Rohingya Refugees During the Emergency Phase of a Mass Humanitarian Crisis in Cox's Bazar, Bangladesh.

Background: Studies of scalable psychological interventions in humanitarian setting are usually carried out when the acute emergency has stabilized. We report the first evaluation of an evidence-based group psychological intervention, Group Integrative Adapt Therapy (IAT-G), during the emergency phase of a mass humanitarian crisis amongst Rohingya refugees in Cox's Bazar, Bangladesh. Methods: We did a pragmatic naturalistic evaluation (2018-2020) of a seven-session group intervention with adult Rohingya refugees with elevated symptoms of depression (≥10 on the Patient Health Questionnaire) and/or posttraumatic stress disorder, PTSD, (≥3 on the Posttraumatic Stress Disorder-8), and functional impairment (≥17 on WHO Disability Assessment Schedule or WHODAS-brief). Screening was done across the most densely populated campsites. Blind assessments were completed at baseline, posttreatment, and at 3-month follow-up using culturally adapted measures of depression, anxiety, posttraumatic stress symptoms, complicated bereavement, adaptive stress associated with disrupted psychosocial support systems, functional impairment, and resilience. Findings: 383 persons were screened and of the 144 persons who met inclusion criteria all participated in the group intervention. Compared to baseline scores, IAT-G participants recorded significantly lower mean scores on key outcome indices (mental health symptoms, adaptive stress, and functional impairment) at posttreatment and 3-month follow-up (all pairwise tests significant Ps<.05). From baseline to 3-month follow-up, score changes were greatest for functional impairment (d = 2.24), anxiety (d = 2.15) and depression (d = 1.9), followed by PTSD symptoms (d = 1.17). Interpretation: A group-based intervention designed specifically to reflect the refugee experience and adapted to the language and culture, showed positive outcomes in the context of a pragmatic, naturalistic trial implemented in a mass humanitarian emergency. Funding: United Nations High Commissioner for Refugees; National Health and Medical Research Council Australia.

Prevalence, predictors and associations of complex post-traumatic stress disorder with common mental disorders in refugees and forcibly displaced populations: a systematic review.

Background: The inclusion of complex post-traumatic stress disorder (CPTSD) in ICD-11 represents a turning point for the field of traumatic stress, with accumulative evidence of this disorder in refugees and displaced populations. Objective: The objectives of this systematic review are to examine, in refugee and displaced populations: 1) the prevalence of CPTSD; 2) factors contributing to CPTSD; and 3) and associations between CPTSD and other common mental disorders including: PTSD, depression, anxiety and somatisation. Method: We followed the Joanna Briggs Institute Methodology for Systematic Reviews. Papers published in English language were included, with date of publication between 1987 and June 2019. We searched six relevant databases: MEDLINE, PsycINFO, Embase, Scopus, CINAHL, and PILOTS, and the grey literature. We included observational studies with prevalence data on CPTSD. Results: 19 articles met all inclusion criteria. Quality assessment was performed on each included study using the Joanna Briggs Institute Critical Appraisal Checklist for Studies Reporting Prevalence Data. Based on this, 13 moderate and high-quality studies were included in our narrative synthesis. The included studies reported prevalence of CPTSD in refugees and displaced populations ranging from 2% to 86%. Conclusions: Reasons for the wide variation in prevalence may include contextual and geographical differences, the influence of post-migration difficulties, and sample population characteristics such as treatment seeking versus general population. We found higher prevalence rates (range: 16-82%) in more studies with treatment seeking samples, followed by convenience and snowball samples (40-51%), and lower rates in more studies utilising random sampling techniques (2-86%). Consistent with the broader literature, the studies in our review supported an association for complex post-traumatic stress disorder with prolonged, repeated trauma, and post-migration living difficulties, with the latter association being specific to refugee and displaced populations. Further research on this construct in this population group, including effective treatments, is required.

Antecedentes: la inclusión del trastorno por estrés postraumático complejo (TEPTC) en la CIE-11 representa un punto de inflexión para el campo del estrés traumático, con evidencia acumulativa de este trastorno en refugiados y poblaciones desplazadas.Objetivo: Los objetivos de esta revisión sistemática son examinar, en poblaciones de refugiados y desplazados: 1) la prevalencia de TEPTC; 2) factores contribuyentes al TEPTC; y 3) y asociaciones entre TEPTC y otros trastornos mentales comunes como: TEPT, depresión, ansiedad y somatización.Método: Seguimos la Metodología del Instituto Joanna Briggs para Revisiones Sistemáticas. Se incluyeron artículos publicados en idioma inglés, con fecha de publicación entre 1987 y junio de 2019. Se buscó en seis bases de datos relevantes: MEDLINE, PsycINFO, Embase, Scopus, CINAHL y PILOTS, y la literatura gris. Se incluyeron estudios observacionales con datos de prevalencia de TEPTC.Resultados: 19 artículos cumplieron con todos los criterios de inclusión. Se realizó una evaluación de calidad en cada estudio incluido utilizando la lista de verificación de apreciación crítica del Instituto Joanna Briggs para estudios que informan datos de prevalencia. Sobre esta base, 13 estudios de calidad moderada y alta fueron incluidos en nuestra síntesis narrativa. Los estudios incluidos informaron sobre la prevalencia de TEPTC en refugiados y poblaciones desplazadas en un rango del 2% al 86%.Conclusiones: Las razones de la amplia variación en la prevalencia pueden incluir diferencias contextuales y geográficas, la influencia de dificultades post-migratorias y características de la muestra de la población, como población general versus en búsqueda de tratamiento. Encontramos tasas de prevalencia más altas (rango: 16-82%) en más estudios con muestras de búsqueda de tratamiento, seguidas de muestras de conveniencia y por bola de nieve (40-51%), y tasas más bajas en más estudios que utilizan técnicas de muestreo aleatorio (2-86%). De forma consistente con la literatura más amplia, los estudios en nuestra revisión apoyaron una asociación para el trastorno de estrés postraumático complejo con trauma prolongado, repetido y dificultades de vida post-migratorias, siendo esta última asociación específica para las poblaciones de refugiados y desplazados. Se requiere mayor investigación sobre este constructo en este grupo de población, incluyendo tratamientos efectivos.

Associations between family-level adversity and society-level trauma with emotional and behavioural problems amongst children of West Papuan refugees.

Few studies have examined associations between family-level parental factors, society-level violence, and the emotional and behavioral status of children of refugee populations. Our study used cross-sectional epidemiological data to test a theoretical model of these key associations amongst a community sample of children (n = 162) of West Papuan refugees living in remote town in Papua New Guinea (PNG), a setting of endemic violence and poverty. Culturally adapted instruments were used to assess three types of intra-familial factors (adverse parenting, physical and/or sexual abuse and emotional abuse) and three types of society-level violence and stressors (exposure to systematic violence, peer violence, living difficulties). Emotional and behavioural problems were assessed using the Youth Self-Report Checklist. Path analysis was used to test theoretical associations. Key findings include direct associations between both family-level physical and/or sexual abuse (ß = .43; p < .001) and adverse parenting (ß = .40; p < .001) with emotional and behavioural problems amongst children. In the broader social domain, peer violence (ß = .29; p < .001) had a direct association with children's emotional and behavioural problems. Several indirect paths demonstrated a chain of relationships involving family- and society-level factors and emotional and behavioural problems in children. Only longitudinal data can provide further support for veridical causal pathways linking family and social factors with adverse emotional and behavioural outcomes in offspring of refugees, thereby supporting mechanisms leading to a transgenerational transmission of adverse mental health outcomes in refugee populations. Such data would give further support for a multisectoral approach to dealing with at risk families in refugee populations, in which attention should focus on supporting parents, and promoting the protection of children from abuse in the family and in the wider society.

Psychosocial mechanisms of change in symptoms of Persistent Complex Bereavement Disorder amongst refugees from Myanmar over the course of Integrative Adapt Therapy.

Background: The ability to adapt to the psychosocial disruptions associated with the refugee experience may influence the course of complicated grief reactions. Objective: We examine these relationships amongst Myanmar refugees relocated to Malaysia who participated in a six-week course of Integrative Adapt Therapy (IAT). Method: Participants (n = 170) included Rohingya, Chin, and Kachin refugees relocated to Malaysia. At baseline and six-week post-treatment, we applied culturally adapted measures to assess symptoms of Prolonged Complex Bereavement Disorder (PCBD) and adaptive capacity to psychosocial disruptions, based on the Adaptive Stress Index (ASI). The ASI comprises five sub-scales of safety/security (ASI-1); bonds and networks (ASI-2); injustice (ASI-3); roles and identity (ASI-4); and existential meaning (ASI-5). Results: Multilevel linear models indicated that the relationship between baseline and posttreatment PCBD symptoms was mediated by the ASI scale scores. Further, ASI scale scores assessed posttreatment mediated the relationship between baseline and posttreatment PCBD symptoms. Mediation of PCBD change was greatest for the ASI II scale representing disrupted bonds and networks. Conclusion: Our findings are consistent with the informing model of IAT in demonstrating that changes in adaptive capacity, and especially in dealing with disrupted bonds and networks, may mediate the process of symptom improvement over the course of therapy.

Antecedentes: La capacidad de adaptarse a las alteraciones psicosociales asociadas con la experiencia de los refugiados puede influir en el curso de las reacciones de duelo complicadas.Objetivo: Examinamos estas relaciones entre los refugiados de Myanmar reubicados en Malasia que participaron en un proceso de seis semanas de Terapia de Adaptación Integrativa (IAT por sus siglas en ingles).Método: Los participantes (n = 170) incluyeron refugiados rohingya, chin y kachin reubicados en Malasia. Al inicio y seis semanas después del tratamiento, aplicamos instrumentos adaptados culturalmente para evaluar los síntomas del trastorno de duelo complejo prolongado (PCBD por sus siglas en ingles) y la capacidad de adaptación a las alteraciones psicosociales, según el índice de estrés adaptativo (ASI). El ASI comprende cinco subescalas de seguridad/protección (ASI-1); lazos y redes (ASI-2); injusticia (ASI-3); roles e identidad (ASI-4); y significado existencial (ASI-5).Resultados: Los modelos lineales multinivel indicaron que la relación entre los síntomas de PCBD basales y posteriores al tratamiento estuvo mediada por las puntuaciones de la escala ASI. Además, los puntajes de la escala ASI evaluados después del tratamiento median la relación entre los síntomas de PCBD basales y posteriores al tratamiento. La mediación del cambio de PCBD fue mayor para la escala ASI II que representa los lazos y redes interrumpidos.Conclusión: Nuestros hallazgos son consistentes con el modelo informativo de IAT al demostrar que los cambios en la capacidad de adaptación, y especialmente al tratar con los lazos y las redes interrumpidas, pueden mediar el proceso de mejora de los síntomas durante el curso de la terapia.

An Integrative Adapt Therapy for common mental health symptoms and adaptive stress amongst Rohingya, Chin, and Kachin refugees living in Malaysia: A randomized controlled trial.

BACKGROUND: This randomised controlled trial (RCT) aims to compare 6-week posttreatment outcomes of an Integrative Adapt Therapy (IAT) to a Cognitive Behavioural Therapy (CBT) on common mental health symptoms and adaptive capacity amongst refugees from Myanmar. IAT is grounded on psychotherapeutic elements specific to the refugee experience. METHODS AND FINDINGS: We conducted a single-blind RCT (October 2017 -May 2019) with Chin (39.3%), Kachin (15.7%), and Rohingya (45%) refugees living in Kuala Lumpur, Malaysia. The trial included 170 participants receiving six 45-minute weekly sessions of IAT (97.6% retention, 4 lost to follow-up) and 161 receiving a multicomponent CBT also involving six 45-minute weekly sessions (96.8% retention, 5 lost to follow-up). Participants (mean age: 30.8 years, SD = 9.6) had experienced and/or witnessed an average 10.1 types (SD = 5.9, range = 1-27) of traumatic events. We applied a single-blind design in which independent assessors of pre- and posttreatment indices were masked in relation to participants' treatment allocation status. Primary outcomes were symptom scores of Post Traumatic Stress Disorder (PTSD), Complex PTSD (CPTSD), Major Depressive Disorder (MDD), the 5 scales of the Adaptive Stress Index (ASI), and a measure of resilience (the Connor-Davidson Resilience Scale [CDRS]). Compared to CBT, an intention-to-treat analysis (n = 331) at 6-week posttreatment follow-up demonstrated greater reductions in the IAT arm for all common mental disorder (CMD) symptoms and ASI domains except for ASI-3 (injustice), as well as increases in the resilience scores. Adjusted average treatment effects assessing the differences in posttreatment scores between IAT and CBT (with baseline scores as covariates) were -0.08 (95% CI: -0.14 to -0.02, p = 0.012) for PTSD, -0.07 (95% CI: -0.14 to -0.01) for CPTSD, -0.07 for MDD (95% CI: -0.13 to -0.01, p = 0.025), 0.16 for CDRS (95% CI: 0.06-0.026, p ≤ 0.001), -0.12 (95% CI: -0.20 to -0.03, p ≤ 0.001) for ASI-1 (safety/security), -0.10 for ASI-2 (traumatic losses; 95% CI: -0.18 to -0.02, p = 0.02), -0.03 for ASI-3 (injustice; (95% CI: -0.11 to 0.06, p = 0.513), -0.12 for ASI-4 (role/identity disruptions; 95% CI: -0.21 to -0.04, p ≤ 0.001), and -0.18 for ASI-5 (existential meaning; 95% CI: -0.19 to -0.05, p ≤ 0.001). Compared to CBT, the IAT group had larger effect sizes for all indices (except for resilience) including PTSD (IAT, d = 0.93 versus CBT, d = 0.87), CPTSD (d = 1.27 versus d = 1.02), MDD (d = 1.4 versus d = 1.11), ASI-1 (d = 1.1 versus d = 0.85), ASI-2 (d = 0.81 versus d = 0.66), ASI-3 (d = 0.49 versus d = 0.42), ASI-4 (d = 0.86 versus d = 0.67), and ASI-5 (d = 0.72 versus d = 0.53). No adverse events were recorded for either therapy. Limitations include a possible allegiance effect (the authors inadvertently conveying disproportionate enthusiasm for IAT in training and supervision), cross-over effects (counsellors applying elements of one therapy in delivering the other), and the brief period of follow-up. CONCLUSIONS: Compared to CBT, IAT showed superiority in improving mental health symptoms and adaptative stress from baseline to 6-week posttreatment. The differences in scores between IAT and CBT were modest and future studies conducted by independent research teams need to confirm the findings. TRIAL REGISTRATION: The study is registered under Australian New Zealand Clinical Trials Registry (ANZCTR) (http://www.anzctr.org.au/). The trial registration number is: ACTRN12617001452381.

Functional impairment as a proxy measure indicating high rates of trauma exposure, post-migration living difficulties, common mental disorders, and poor health amongst Rohingya refugees in Malaysia.

A major challenge in the refugee field is to ensure that scarce mental health resources are directed to those in greatest need. Based on data from an epidemiological survey of 959 adult Rohingya refugees in Malaysia (response rate: 83%), we examine whether a brief screening instrument of functional impairment, the WHO Disability Assessment Schedule (WHODAS), prove useful as a proxy measure to identify refugees who typically attend community mental health services. Based on estimates of mental disorder requiring interventions from analyses of epidemiological studies conducted worldwide, we selected a WHODAS cutoff that identified the top one-fifth of refugees according to severity of functional impairment, the remainder being distributed to moderate and lower impairment groupings, respectively. Compared to the lower impairment grouping, the severe impairment category comprised more boat arrivals (AOR: 5.96 [95% CI 1.34-26.43); stateless persons (A20·11 [95% CI 7.14-10); those with high exposure to pre-migration traumas (AOR: 4.76 [95% CI 1.64-13.73), peri-migration stressors (AOR: 1.26 [95% CI 1.14-1.39]) and postmigration living difficulties (AOR: 1.43 [95% CI 1.32-1.55); persons with single (AOR: 7.48 [95% CI 4.25-13.17]) and comorbid (AOR: 13.54 [95% CI 6.22-29.45]) common mental disorders; and those reporting poorer general health (AOR: 2.23 [95% CI 1-5.02]). In addition, half of the severe impairment grouping (50.6%) expressed suicidal ideas compared to one in six (16.2 percent) of the lower impairment grouping (OR: 2.39 [95% CI 1.94-2.93]). Differences between the severe and moderate impairment groups were similar but less extreme. In settings where large-scale epidemiological studies are not feasible, the WHODAS may serve as readily administered and brief public health screening tool that assists in stratifying the population according to urgency of mental health needs.

Prevalence and Risk Factors of Major Depressive Disorder Among Women at Public Antenatal Clinics From Refugee, Conflict-Affected, and Australian-Born Backgrounds.

Importance: Pregnancy may increase the risk of depression among women who self-identify as refugees and have resettled in high-income countries. To our knowledge, no large systematic studies among women with refugee backgrounds in the antenatal period have been conducted. Objectives: To compare the prevalence of major depressive disorder (MDD), trauma exposure, and other psychosocial risk factors among women who identify as refugees, women from the same conflict-affected countries, and women from the host nation and to test whether self-identification as a refugee indicates greater likelihood of prevalence and risk. Design, Setting, and Participants: This cross-sectional study was undertaken in 3 public antenatal clinics in Sydney and Melbourne, Australia, between January 2015 and December 2016. Overall, 1335 women (685 consecutively enrolled from conflict-affected backgrounds and 650 randomly selected from the host nation) participated. Data analysis was undertaken between June and September 2018. Exposures: One-hour interviews covering mental health, intimate partner violence, and other social measures. Main Outcome and Measures: World Health Organization measure for intimate partner violence and the Mini-International Neuropsychiatric Interview from the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) for MDD. To make a diagnosis, 1 of 2 items relating to being consistently depressed for 2 weeks and 3 further symptoms that cause personal distress or psychosocial dysfunction were endorsed. Results: Overall, 1335 women (84.8% overall response rate), comprising 685 (51.3%) from conflict-affected countries (women self-identifying as refugees: 289 [42.2%]) and 650 (48.7%) from the host nation, participated. The mean (SD) age was 29.7 (5.4) years among women from conflict-affected backgrounds and 29.0 (5.5) years among women born in the host nation. Conflict-affected countries included Iraq (260 [38.0%]), Lebanon (125 [18.2%]), Sri Lanka (71 [10.4%]), and Sudan (66 [9.6%]). Women who identified as refugees reported higher exposure to 2 to 3 (67 [23.2%]) and 4 or more (19 [6.6%]) general traumatic events compared with women from the host nation (103 [15.8%] and 21 [3.2%], respectively). Women who identified as refugees also reported higher exposure to 1 (147 [50.9%]) and 2 or more (97 [33.6%]) refugee-related traumatic events compared with women from the host nation (86 [13.2%] and 20 [3.1%], respectively). Women who identified as refugees reported higher rates of psychological intimate partner violence than women born in the host nation (124 [42.9%] vs 133 [20.5%]; P < .001). Women who identified as refugees were less likely to identify 5 or more supportive family or friends compared with women born in the host nation (36 [12.5%] vs 297 [45.7%]; P < .001). A greater proportion of women who identified as refugees reported experiencing 3 or more financial stressors compared with women born in the host nation (65 [22.5%] vs 41 [6.3%]; P < .001). Women who identified as refugees had the highest prevalence of MDD (94 [32.5%]), followed by women from other conflict-affected backgrounds (78 [19.7%]), and women born in the host nation (94 [14.5%]). Conclusion and Relevance: Women identifying as refugees reported a higher prevalence of MDD and all the indicators of adversity related to that disorder. Even after risk factors were accounted for, refugee status was associated with risk of MDD. Assessing whether women attending an antenatal clinic self-identify as refugees may offer an important indicator of risk of MDD and a range of associated psychosocial adversities.

The structure and psychosocial correlates of complicated bereavement amongst refugees from West Papua.

PURPOSE: Refugees may be at risk of experiencing a complicated form of bereavement. As yet, however, the nosological status of this putative category across cultures remains in question. We apply qualitative and quantitative methods to investigate the manifestations, prevalence, factorial structure and psychosocial correlates of complicated bereavement amongst refugees from West Papua, a population with no past exposure to western concepts of grief or to formal mental health services. METHODS: Qualitative methods (focus groups and informant interviews) were used to identify cultural expressions of complicated bereavement derived from international classification systems, that is, DSM 5 persistent complex bereavement disorder (PCBD) and ICD-11 prolonged grief disorder (PGD) in developing a structured interview applied by trained field workers. Participants were adult West Papuan refugees and their offspring recruited from households (n = 486, response 85.8%) across nine villages in a remote town in Papua New Guinea. RESULTS: The qualitative data obtained from focus groups (n = 20) and informant interviews (n = 4) with local psychiatrists supported the cultural validity of complicated bereavement. 16% (n = 78) of the sample met criteria for PCBD based on DSM-5 criteria and 103 (21%) met criteria for PGD based on ICD-11 criteria. Confirmatory factor analysis yielded a six-factor model of complicated bereavement with a moderately good fit to the data. The model included dimensions of anger/negative appraisal (AN), avoidance/giving up, estrangement from others, and confusion and diminished identity. In contrast, the DSM-5 three-factor model and the ICD-11 two-factor model each yielded a poor fit. Cumulative traumatic losses (ß = 0.16, P = 0.03), duration since displacement [(ß = 0.10, P = 0.02)] and postmigration living difficulties (ß = 0.20, P = 0.01) were associated with an aggregated index of complicated bereavement, supporting the concurrent validity of the structure identified. CONCLUSIONS: Culture and exposure to persecution and displacement may contribute to the content and configuration of the complicated bereavement reaction, an issue that requires recognition in international classification systems and clinical practice.