Are Sexual Assaults Related to Functional Somatic Disorders? A Cross-Sectional Study.

An increasing number of sexual assaults (SAs) are being reported. This study investigated associations between SA and FSD, conceptualized as bodily distress syndrome (BDS), and five functional somatic syndromes (FSSs): chronic widespread pain (CWP), irritable bowel (IB), chronic fatigue (CF), multiple chemical sensitivity (MCS), and whiplash-associated disorder (WAD). Participants (n = 7493) from the population-based cohort Danish Study of Functional Disorders (DanFunD) completed questionnaires on FSD, emotional distress, SA, and sociodemographics. Risk ratios (RRs) for each FSD and emotional distress were calculated in nine models with SA as the primary exposure using generalized linear models with binomial family and log link and were adjusted for other potential risk factors. The results showed that SA was associated with single-organ FSD (RR = 1.51; 95% CI = 1.22-1.87), multi-organ FSD (RR = 3.51; 95% CI = 1.89-6.49), CWP (RR = 1.28; 95% CI = 0.83-1.98), IB (RR = 2.00; 95% CI = 1.30-3.07), CF (RR = 1.81; 95% CI = 1.42-2.32), WAD (RR = 2.62; 95% CI = 1.37-5.03), MCS (RR = 3.04; 95% CI = 1.79-5.17), emotional distress (RR = 1.75; 95% CI = 1.21-2.54), and health anxiety (RR = 1.65; 95% CI = 1.10-2.46). Overall, SA victims experienced significantly more somatic symptoms than individuals not exposed to SA. Adjusting for physical and emotional abuse did not change the observed associations. Our results suggest a large impact of SA on the overall somatic and mental health of SA victims. Due to the cross-sectional study design, further studies are required.

Long-term treatment effect of trauma-affected refugees with flexible cognitive behavioural therapy and antidepressants.

Few studies exist on the long-term effect of treatment of trauma-affected refugees. The purpose of this study was to estimate the long-term treatment effects of cognitive behavioural therapy and antidepressants (sertraline and mianserin) in trauma-affected refugees. Follow-ups were conducted 6 and 18 months after a randomised controlled clinical trial. The included patients were refugees with war-related traumatic experiences, PTSD and without psychotic disorders. We found a small improvement over time in PTSD, depression and anxiety symptoms and level of functioning, but the improvement was not associated with any specific treatment. Personality change after catastrophic experiences and life events influenced the symptom level at all follow-ups while depression at completion of treatment was associated with a steeper decline in symptom load at the follow-ups. In spite of the limited decline in symptom scores and treatment effects immediately after treatment, the condition of the treated trauma-affected refugees was significantly improved 6 and 18 months after treatment although the improvement was small.

[Diagnosing and treating post-traumatic stress disorder].

The post-traumatic stress disorder (PTSD) diagnosis has undergone large developments. With the changes in DSM-5 and the proposed changes in ICD-11, the two systems move in different directions. Treatment for PTSD is developing, but the evidence for the effect is lacking behind. Trauma-focused cognitive behavioural therapy and eye movement desensitization and reprocessing remain first choice. Pharmacotherapy is secondary. There is evidence for the effect of paroxetine, venlafaxine and fluoxetine and less so for sertraline.

The effect of flexible cognitive-behavioural therapy and medical treatment, including antidepressants on post-traumatic stress disorder and depression in traumatised refugees: pragmatic randomised controlled clinical trial.

BACKGROUND: Little evidence exists on the treatment of traumatised refugees. AIMS: To estimate treatment effects of flexible cognitive-behavioural therapy (CBT) and antidepressants (sertraline and mianserin) in traumatised refugees. METHOD: Randomised controlled clinical trial with 2 × 2 factorial design (registered with Clinicaltrials.gov, NCT00917397, EUDRACT no. 2008-006714-15). Participants were refugees with war-related traumatic experiences, post-traumatic stress disorder (PTSD) and without psychotic disorder. Treatment was weekly sessions with a physician and/or psychologist over 6 months. RESULTS: A total of 217 of 280 patients completed treatment (78%). There was no effect on PTSD symptoms, no effect of psychotherapy and no interaction between psychotherapy and medicine. A small but significant effect of treatment with antidepressants was found on depression. CONCLUSIONS: In a pragmatic clinical setting, there was no effect of flexible CBT and antidepressants on PTSD, and there was a small-to-moderate effect of antidepressants and psychoeducation on depression in traumatised refugees.

Traumatized refugees: morbidity, treatment and predictors of outcome.

INTRODUCTION: Despite large numbers of traumatized refugees, little is known about effective treatment of war trauma in refugees and immigrants. Few studies evaluating treatment have been published and most studies are follow-up studies with methodological limitations and little comparability across studies. PURPOSE: The purpose of the PhD is to characterize transcultural trauma patients in Denmark needing psychiatric treatment with regards to psychopathology and predictors of mental health and to evaluate the effects of the treatment. METHODS: Two studies reported in 4 papers form the basis of the thesis. FORLOB (Paper 1-3) was a follow-up study that included all patients receiving treatment at the Competence Center for Transcultural Psychiatry in Copenhagen from April 2008 to February 2010. Patients completed self-ratings of symptoms of PTSD, depression and anxiety as well as level of functioning and quality of life (HTQ, HSCL-25, SDS & WHO-5) before treatment and after treatment. Associations of co-morbid diagnoses and predictors of the patients' health condition were examined with linear and logistic regression and Pearson's correlation coefficients. Treatment in FORLOB consisted of a combination of Sertraline, Mianserin, psycho-education and Trauma-Focused Cognitive Behavioral Therapy (TFCBT). The treatment administered to each patient was monitored in detail and changes in outcome and predictors of change were analyzed. PTF1 (Paper 4) was a randomized controlled clinical trial with 2x2 factorial design (antidepressants, TFCBT, antidepressants & TFCBT, waiting list). Potential participants were screened amongst adult patients referred to the Competence Center for Transcultural Psychiatry in the period June 2009-2011. Patients with PTSD, war trauma and without a psychotic disorder were included. The manualized treatment consisted of weekly sessions with a physician and/or psychologist over a period of 6 months. The treatment effect was evaluated with a combination of self-ratings and blinded and non-blinded observer ratings. Outcome measures included symptoms of PTSD, depression, anxiety, pain and somatization, quality of life and level of functioning (HTQ, HSCL-25, SCL-90, WHO-5, SDS, VAS, Hamilton, GAF). Treatment was offered with translation and screening instruments were translated to the six most common languages in the patient group covering the needs of 92% of patients. RESULTS: In FORLOB, patients had several co-morbidities and not just PTSD. Almost all patients had depression, pain and untreated somatic complaints in addition to PTSD. Furthermore, 36-58% had physical problems they were in treatment for, 9-16% of patients had psychotic symptoms mainly related to their trauma, 27% had enduring personality change due to catastrophic events according to ICD-10 and 46% reported traumatic brain injury. Patients reporting chronic pain had higher symptom scores on HSCL-25 and HTQ and patients with psychotic symptoms scored higher on all symptom clusters on HTQ. At pre-treatment assessment, the patients' level of functioning and quality of life were very low, the majority of patients lived on public subsidies, education levels were low and most patients had a limited social network. In FORLOB, we found a moderate significant change (Cohen's d 0.44-0.67) on all self-report outcome measures (HTQ, HSCL-25, SDS and WHO-5) after combination treatment. We found less improvement in PTSD when patients were receiving public subsidies and less improvement of depression when patients reported pain in the upper extremities. We found a positive association between systematic use of CBT methods and improvement in patient condition. In PTF1, the randomized clinical trial, we found a small, but significant effect of treatment with medicine on blinded observer-ratings of depression and anxiety (Ham-D and Ham-A) and a large effect on non-blinded ratings of level of functioning (GAF-F and GAF-S), in addition to a small effect on self-reported level of functioning and headache (SDS and VAS). Cohen's d calculated as the differences between randomization groups receiving medicine and not receiving medicine ranged from 0.91-1.01 on GAF-F and GAF-S, whereas on the other ratings showing significant change Cohen's d was 0.31-0.41. We did not find any effect of psychotherapy on any outcomes nor any effect of psycho-therapy or medicine on the primary outcome measure, PTSD. CONCLUSION: Traditionally, treatment of traumatized refugees have focused on PTSD, but this study demonstrates that patients suffer from numerous psychiatric and somatic co-morbidities and the comprehensiveness of PTSD in explaining symptoms of traumatized refugees is questionable. This has implications for the type and implementation of treatment. PTF1 is the largest randomized clinical trial published on the treatment of traumatized refugees. It is a strength of PTF1 that it includes a waiting list control group thereby accounting for any effects due to spontaneous recovery and that treatment modalities are examined separately and in combination. In both FORLOB and PTF1, treatment adherence and patient compliance with treatment was thoroughly documented. Effect sizes were moderate in FORLOB and small in PTF1. There were discrepancies between the results in FORLOB and PTF1 with regards to the effect measured on self-ratings that can only partially be explained by methodological limitations of the follow-up study. Both studies are undertaken under pragmatic and realistic circumstances and the results are therefore relevant to other contexts. Patients are representative of patients in other North-European studies of traumatized refugees but differ from patients in trials published on culturally adapted CBT and Narrative Exposure Therapy.

[Insufficient documentation of mortality in war]. / Utilstraekkelig dokumentation af dødelighed ved krig.

Mortality estimates can be used for research, to inform or influence policy, for reconciliation processes, to plan health delivery and relief operations and for legal purposes. Many different methods have been applied and each has strengths and weaknesses. Recent years have seen an international effort in various disciplines like humanitarian actors, demographers and forensic anthropologists to cooperate, and efforts are being made to make data collection more systematic and valid. However, there are political, methodological and security-related challenges that must be overcome.

The nuclear weapons inheritance project: student-to-student dialogues and interactive peer education in disarmament activism.

The Nuclear Weapons Inheritance Project is a student run and student initiated project founded in 2001 with the purpose of increasing awareness of health effects of nuclear policies and empowering university students to take action in a local and international context. The project uses dialogues to discuss nuclear disarmament with university students and a method of interactive peer education to train new trainers. The project has met more than 1500 students in nuclear weapon states in dialogue and trained about 400 students from all over the world. This article describes the methods and results of the project and discuss how the experience of the project can be used in other projects seeking to increase awareness of a topic and to initiate action on social injustice.

[Possibility for the health sector to actively contribute to peace-making and peace-keeping]. / Sundhedssektorens mulighed for aktivt at bidrage til fredsskabende og fredsbevarende processer.

Conflict is one of the leading causes of death, disease and suffering. In the past, physicians mainly contributed to peace processes through humanitarian relief of suffering. Physicians can also play an active role in the prevention of violent conflict and in rehabilitation in post-conflict societies. This article is a brief overview of current knowledge about the active role which health personnel can play in peace processes. This is described in more detail in international scientific journals under the terms ''Peace through Health'' and ''Health as a Bridge to Peace''.

The role of health professionals in preventing and mediating conflict.

Since the early 1980s academics, governmental and non-governmental organisations have undertaken field projects inspired by the Peace through Health and similar concepts formulated by the World Health Organisation and the Department of Peace Studies at McMaster University, Canada. These have been criticised for lack of proper evaluation, the appropriateness of the skills of health workers involved, and the overall usefulness of the approach. This article, based on a literature review, compares existing evidence with the theoretical framework. There is still a lack of systematic evaluation, but no direct disproof of Peace through Health theory. It is concluded that the Peace through Health approach can have a positive impact on healing and reconciliation on a community scale, but there is no evidence of a peace impact on a larger scale.