Beyond Burnout: Responding to the COVID-19 Pandemic Challenges to Self-care.

PURPOSE OF REVIEW: This paper is a review of the self-care challenges of the COVID-19 pandemic on the physical and emotional health and well-being of healthcare providers. New self-care practices are presented. RECENT FINDINGS: Globally, thousands of health care practitioners and staff have been infected; many have died. Research studies reveal that this pandemic has threatened the health of healthcare staff, their families, and communities in many unique ways, such as fear of infecting family (lack of safety at home), moral injury, witnessing the suffering of the "innocent," coping with a problem too big to solve (the enormity problem), and racial trauma. The COVID-19 pandemic has impacted the global population in ways not seen in a century. The unique self-care challenges of COVID-19 while enhancing the symptoms of burnout, i.e., physical, and mental exhaustion, despair, helplessness, and suicidal thinking, need to be addressed directly. This paper offers a new COVID-19 self-care model and approach.

The Role of Telemental Health, Tele-consultation, and Tele-supervision in Post-disaster and Low-resource Settings.

PURPOSE OF REVIEW: The goal of this paper was to review recent literature and provide recommendations regarding the use of telemental health, with a focus on tele-consultation and tele-supervision in post-disaster and low-resource settings, including the impact of COVID-19. RECENT FINDINGS: The latest research on mental health needs in low-resource settings has identified a high need for mental health services for difficult-to-reach and underserved populations. Research on tele-consultation and tele-supervision was reviewed and found that tele-consultation and tele-supervision to be an effective modality for insuring quality mental health care delivery in low-resource settings. Additionally, two case studies were included which illustrate the use of both tele-consultation and tele-supervision in low-resource low- and middle-income settings. The paper concludes that tele-consultation and tele-supervision hold the promise to narrow the gap in quality mental health services in low-resource settings so often impacted by disaster and conflict. The authors recommend that telemental health training be developed that specifically enhances consultants' and supervisors' skills in tele-consultation and tele-supervision.

The HTQ-5: revision of the Harvard Trauma Questionnaire for measuring torture, trauma and DSM-5 PTSD symptoms in refugee populations.

BACKGROUND: The Harvard Trauma Questionnaire (HTQ) was developed 25 years ago as a cross-cultural screening instrument to document trauma exposure, head trauma and trauma-related symptoms in refugees. This article aims to: (i) outline the process of revision of Part IV of the HTQ to (a) include the new DSM-5 diagnostic criteria for PTSD, and (b) separate out and more fully develop the refugee-specific functioning items; and (ii) promote a consistent approach to the validation of the HTQ-5 when adapted for use in other cultures and language groups. METHODS: Our process involved item mapping; expert consultations; generating items according to the new DSM-5 criteria; and drafting, refinement and finalization of the revised measure focusing closely on issues of meaning, future translation into multiple languages and comprehension amongst groups with low literacy and little or no exposure to Western trauma concepts. Validity and reliability testing of the new HTQ-5 is underway. RESULTS: The HTQ symptom checklist was modified consistent with current DSM-5 diagnostic criteria to identify those refugees at risk for mental health and other symptoms associated with traumatic life events, disability and dysfunction. CONCLUSIONS: Accurate screening of post-traumatic distress and dysfunction enables those working with refugees to triage them more effectively to scarce health and mental health resources. When developing screening measures to inform public health policy and practice, it is vital that these measures can bridge the gap between western (etic) nosologies and indigenous (emic) understandings of traumatic stress.

Leveraging Technology in Post-Disaster Settings: the Role of Digital Health/Telemental Health.

THE PURPOSE REVIEW: This paper will review the literature on global disasters and the mental health impact of disasters, and discuss the use of digital health/telemental health in providing care in post-disaster settings. RECENT FINDINGS: Global disasters, natural and manmade, are on the rise. As a consequence, there are increases in the health and mental health impact in the affected populations. We examine the literature on the health and mental health impact of disasters and the role of digital health/telemental health in response to meeting those needs. We examine the use of digital health/telemental health in two case examples, one of a natural disaster and one of a man-made disaster. Finally, we examine a blended telemental health model for collaboration between mental health and primary care providers in post-disaster settings. Digital health/telemental health is positioned on the cusp of the technology explosion, thus bringing much needed medical and mental health care to previously under-served populations.

A review of telemental health in international and post-disaster settings.

Telemental health (TMH) is an important component in meeting critical mental health needs of the global population. Mental health is an issue of global importance; an estimated 450 million people worldwide have mental or behavioural disorders, accounting for 12% of the World Health Organization's (WHO) global burden of disease. However, it is reported that 75% of people suffering from mental disorders in the Developing World receive no treatment or care. In this paper, the authors review global mental health needs with a focus on the use of TMH to meet mental health needs in international and post-disaster settings. Telemedicine and TMH have the capacity to bring evidence-based best practices in medicine and mental health to the under-served and difficult to reach areas of the world, including post-disaster settings. The authors will also report on the mental health impact of the Haiti 2010 earthquake and on the limited use of telemedicine in post-disaster Haiti. The paper will underscore the point that published papers on the use of TMH in post-disaster settings are lacking. Finally, the paper will review considerations before working in TMH in international and post-disaster settings.

The mental health sequelae of traumatic head injury in South Vietnamese ex-political detainees who survived torture.

Little is known about the relationship between traumatic head injury (THI) and psychiatric morbidity in torture survivors. We examine the relationship between THI and depression, PTSD, post-concussive syndrome (PCS), disability and poor health status in Vietnamese ex-political detainees who survived incarceration in Vietnamese re-education camps. A community sample of ex-political detainees (n=337) and a non-THI, non-ex-detainee comparison group (n=82) were surveyed. Seventy-eight percent of the ex-political detainees had experienced THI; 90.6% of the ex-political detainees and 3.6% of the comparison group had experienced 7 or more trauma events. Depression and PTSD were greater in ex-detainees than in the comparison group (40.9% vs 23.2% and 13.4% vs 0%). Dose-effect relationships for THI and trauma/torture in the ex-political detainee group were significant. Logistic regression in the pooled sample of ex-detainees and the comparison group confirmed the independent impact of THI from trauma/torture on psychiatric morbidity (OR for PTSD=22.4; 95% CI: 3.0-165.8). These results demonstrate important effects of THI on depression and PTSD in Vietnamese ex-detainees who have survived torture.

Overview of research on the mental health impact of violence in the Middle East in light of the Arab Spring.

This is a baseline of published research in the trauma field by Arab researchers. It highlights groundbreaking attempts by Arab researchers to investigate the mental health impact of violence in their countries before the Arab Spring. Peer-reviewed articles (N = 157) were identified through computerized searches in PubMed, PsycINFO, Google Scholar, and Pilots Database, 1995 to 2012. A synopsis of the published research included (a) country, (b) screening instruments, (c) sample size, (d) methods, and (e) results. The findings reveal that domestic violence attracted most attention after civil strife in Palestine and Lebanon. Torture survivors and victims of sexual violence received little attention. Study instruments were borrowed from Western researchers without being validated within local Arab cultures. No clinical outcome studies were found. In light of the Arab Spring, it is urgent that Arab researchers conduct studies that are evidence based and culturally valid addressing the mental health care of all traumatized citizens.

Comorbid mental and physical health and health access in Cambodian refugees in the US.

Little research has been conducted on the prevalence of physical health problems in Cambodian refugees and the relationship between their mental and physical health. We identified the relationship between mental and physical health problems and barriers to healthcare access in Cambodian refugee adults. We used a cross-sectional survey design with a snowball sample of 136 Cambodian refugee adult residents of Connecticut and Western Massachusetts. 61% reported being diagnosed with three or more physical conditions and 73% with depression, posttraumatic stress disorder (PTSD) or both. Language and transportation problems were the primary barriers to accessing care. Participants with probable comorbid PTSD and depression had 1.850 times more physical health problems than those without either condition (p > .001; CI 1.334-2.566). Age moderated this relationship. Participants who had been diagnosed with both depression and PTSD reported a consistent number of health conditions across the age span while those who had no mental health conditions or only one of the two reported fewer health conditions when they were younger and more when they were older. These two groups were significantly different from the group reporting both. There is a significant relationship between chronic comorbid mental and physical health diseases affecting Cambodian refugees resettled in the US Having comorbid depression and PTSD puts Cambodian refugees at risk for physical health problems no matter their age. It is vital that those treating Cambodian genocide survivors identify and treat their prevalent comorbid health conditions. Language and transportation barriers must be addressed to improve access to mental and physical health care in this population.

Educational potential of a virtual patient system for caring for traumatized patients in primary care.

BACKGROUND: Virtual Patients (VPs) have been used in undergraduate healthcare education for many years. This project is focused on using VPs for training professionals to care for highly vulnerable patient populations. The aim of the study was to evaluate if Refugee Trauma VPs was perceived as an effective and engaging learning tool by primary care professionals (PCPs) in a Primary Health Care Centre (PHC). METHODS: A VP system was designed to create realistic and engaging VP cases for Refugee Trauma for training refugee patient interview, use of established trauma and mental health instruments as well as to give feedback to the learners. The patient interview section was based on video clips with a Bosnian actor with a trauma story and mental health problems. The video clips were recorded in Bosnian language to further increase the realism, but also subtitled in English. The system was evaluated by 11 volunteering primary health clinicians at the Lynn Community Health Centre, Lynn, Massachusetts, USA. The participants were invited to provide insights/feedback about the system's usefulness and educational value. A mixed methodological approach was used, generating both quantitative and qualitative data. RESULTS: Self-reported dimensions of clinical care, pre and post questionnaire questions on the PCPs clinical worldview, motivation to use the VP, and IT Proficiency. Construct items used in these questionnaires had previously demonstrated high face and construct validity. The participants ranked the mental status examination more positively after the simulation exercise compared to before the simulation. Follow up interviews supported the results. CONCLUSIONS: Even though virtual clinical encounters are quite a new paradigm in PHC, the participants in the present study considered our VP case to be a relevant and promising educational tool. Next phase of our project will be a RCT study including comparison with specially prepared paper-cases and determinative input on improving clinical diagnosis and treatment of the traumatized refugee patient.

Women health: Psychological and most prominent somatic problems in 3-year follow-up in Bosnian refugees.

BACKGROUND: Little is known about gender differences among people exposed to war related trauma. Aim of this study is to explore gender differences in health status and comorbidity of mental and physical disorders in a cohort of Bosnian refugees followed up for 3 years (1996-1999). METHODS: This longitudinal study included 534 subjects followed up for 3 years. The interviews were conducted in refugee camps in Varazdin, Croatia in Bosnian language. Data were collected using Harvard Trauma Questionnaire (Bosnian version) and Hopkins Checklist-25, respectively. Physical health disorders were self-reported. RESULTS: In both assessments there was a statistically significant difference between men and women in the number of physical health disorders, even when results were controlled for educational status. Although there was no difference in total number of symptoms in both assessments (F = 0.32; df = 1; p > 0.05 and F = 1.15; df = 1; p > 0.05), important physical health disorders were significantly more frequent among women than in men in different educational groups, namely high blood pressure and cardiovascular diseases, arthritis, and anaemia. Asthma, tuberculosis, cirrhosis of the liver, ulcer and epilepsy were more frequent in men than in women. There were no differences in frequencies of psychiatric disorders at baseline, but frequency of psychiatric disorders in women was higher at endpoint for uneducated respondents. There was significant difference compared to men in group of respondents without formal education, but only in comorbidity of PTSD and depression which was more often present in females (22.1%) than in males (3.6%). CONCLUSION: Our findings indicate the importance of gender and education on mental and physical health of people exposed to warrelated trauma. Long term health monitoring and programs, especially related to women's health are needed in order to avoid lasting consequences.

Trauma-Informed Care Survey of Psychiatrists and Primary Care Physicians in the Middle East.

OBJECTIVE: To explore in Arab communities the prevalence, dynamics, and resources available to address the physical and psychological consequences that may arise from psychiatric disorders. METHODS: An online survey of psychiatrists and primary care physicians from 17 Arab countries was conducted between September 2011 and June 2012. The survey serves as a needs assessment in a scientifically valid and culturally sensitive manner. Additionally, it focuses attention on the clinical strengths and weaknesses of Middle Eastern primary health care and mental health centers in identifying and treating trauma-related health and mental health issues. RESULTS: The 90 survey respondents comprised psychiatrists (n = 53) and primary care physicians (n = 37). They practiced in 3 clinical settings: primary mental health (27%), inpatient mental health (43%), and primary health care (29%). Traumas frequently reported by their patients were attributed to recent death of a close relative or friend (62.3%), domestic violence (41.4%), divorce/separation (72.1%), serious traffic accident (45.6%), sexual assault/rape (20.3%), child abuse (20.3%), psychological effects of war (30.9%), victims of crime (15.9%), refugees/internally displaced persons (20.6%), physical effects of war (19.1%), torture (13.2%), elderly abuse (11.6%), psychological effects of a natural disaster (7.4%), physical effect of a natural disaster (7.2%), and child soldiers (4.3%). Psychiatrists had significantly more patients with the following traumatic experiences: divorce/separation (81.4% vs 57.1%, P = .039), recent death of a close relative or friend (72.7% vs 47.6%, P = .048), and domestic violence (51.1% vs 19.0%, P = .014). Clinical teams comprised substantial numbers of students but small numbers of community volunteers and school counselors. CONCLUSIONS: This study highlights the need to develop awareness and training programs in Arab communities to identify and properly treat traumatized individuals in psychiatric and primary care settings.

High Prevalence of Post-Traumatic Stress Symptoms in Relation to Social Factors in Affected Population One Year after the Fukushima Nuclear Disaster.

OBJECTIVE: This study investigated post-traumatic stress symptoms in relation to the population affected by the Fukushima Nuclear Disaster, one year after the disaster. Additionally, we investigated social factors, such as forced displacement, which we hypothesize contributed to the high prevalence of post-traumatic stress. Finally, we report of written narratives that were collected from the impacted population. DESIGN AND SETTINGS: Using the Impact of Event Scale-Revised (IES-R), questionnaires were sent to 2,011 households of those displaced from Fukushima prefecture living temporarily in Saitama prefecture. Of the 490 replies; 350 met the criteria for inclusion in the study. Multiple logistic regression analysis was performed to examine several characteristics and variables of social factors as predictors of probable post-traumatic stress disorder, PTSD. RESULTS: The mean score of IES-R was 36.15±21.55, with 59.4% having scores of 30 or higher, thus indicating a probable PTSD. No significant differences in percentages of high-risk subjects were found among sex, age, evacuation area, housing damages, tsunami affected, family split-up, and acquaintance support. By the result of multiple logistic regression analysis, the significant predictors of probable PTSD were chronic physical diseases (OR = 1.97), chronic mental diseases (OR = 6.25), worries about livelihood (OR = 2.27), lost jobs (OR = 1.71), lost social ties (OR = 2.27), and concerns about compensation (OR = 3.74). CONCLUSION: Although there are limitations in assuming a diagnosis of PTSD based on self-report IES-R, our findings indicate that there was a high-risk of PTSD strongly related to the nuclear disaster and its consequent evacuation and displacement. Therefore, recovery efforts must focus not only on medical and psychological treatment alone, but also on social and economic issues related to the displacement, as well.

The enduring mental health impact of mass violence: a community comparison study of Cambodian civilians living in Cambodia and Thailand.

BACKGROUND: No population-based studies have directly compared the long-term health and mental health outcomes of conflict- versus non-conflict-affected communities from the same ethnic background. AIMS: To identify and compare levels of psychiatric morbidity between a traumatized and non-traumatized civilian community; to investigate the long-term impact of mass violence. METHODS: Double-stratified community surveys in Siem Reap and Surin provinces were conducted by highly qualified Cambodian interviewers using culturally validated survey instruments with known psychometric properties. These included Cambodian versions of the Hopkins Symptom Checklist-25, the Harvard Trauma Questionnaire and the Medical Outcome Study Short Form. RESULTS: Siem Reap and Surin respondents experienced 12,266 and 621 major trauma events, respectively; 745 (76.2%) Siem Reap respondents and six (0.6%) Surin respondents reported torture events; 499 (49.5%) Siem Reap respondents and 203 (19.7%) Surin respondents met the clinical threshold for depression (OR 4.01, 95% CI 3.29-4.88); 204 (20.6%) Siem Reap respondents and 23 (2.2%) Surin respondents met the clinical threshold for post-traumatic stress disorder (PTSD) (OR 11.39, 95% CI 7.3-17.7). The MOS physical disability was higher in Siem Reap versus Surin respondents (74 (7.5%) vs 13 (1.3%), χ(2) = 47.4 df = 1, p < .001). Health status was poorest among Siem Reap respondents when compared with Surin respondents (mean score 1.59 vs 0.59, respectively; t = 19.85 df = 2018, p < .001). Path analysis reveals that recent and past extreme violence are associated with the health and mental health status of the Siem Reap community. CONCLUSION: After 25 years, the Khmer civilian population that experienced the Pol Pot genocide continues to suffer psychiatric morbidity and poor health.

Care providers' needs and perspectives on suffering and care in Bosnia and Herzegovina and Cambodia.

This exploratory study aimed to obtain insight into field-level care providers' views on suffering and healing as well as existing obstacles and needs related to providing care to their clients. This research provides a "snapshot" for a better understanding of existing care systems in two post-conflict settings. By identifying existing approaches to care and the needs of the care provider community, this research might be useful in guiding psychosocial assistance programming in post-conflict settings. Utilizing a semi-structured questionnaire, 45 care providers were interviewed, including local health care practitioners, traditional/ spiritual healers, and humanitarian relief workers, in Bosnia and Herzegovina and Cambodia. This study found that the majority of care providers in both settings perceived poverty and violence as significant causes and consequences of human suffering and, at the same time, felt ill-equipped in addressing these issues and related problems. Other issues that hindered these healers in providing care included: limited government/institutional support; lack of training; material resources and funding. Study findings point to a new framework for developing effective interventions and the need for further emphasis on supporting care providers in their work, and most specifically, in identifying and responding to poverty and violence.

Brain structural abnormalities and mental health sequelae in South Vietnamese ex-political detainees who survived traumatic head injury and torture.

CONTEXT: A pilot study of South Vietnamese ex-political detainees who had been incarcerated in Vietnamese reeducation camps and resettled in the United States disclosed significant mental health problems associated with torture and traumatic head injury (THI). OBJECTIVES: To identify structural brain alterations associated with THI and to investigate whether these deficits are associated with posttraumatic stress disorder and depression. DESIGN: Cross-sectional neuroimaging study. SETTING: Massachusetts General Hospital and McLean Hospital. PARTICIPANTS: A subsample of Vietnamese ex-political detainees (n = 42) and comparison subjects (n = 16) selected from a community study of 337 ex-political detainees and 82 comparison subjects. MAIN OUTCOME MEASURES: Scores on the Vietnamese versions of the Hopkins Symptom Checklist-25 (HSCL) and Harvard Trauma Questionnaire for depression and posttraumatic stress disorder, respectively; cerebral regional cortical thickness; and manual volumetric morphometry of the amygdala, hippocampus, and thalamus. RESULTS: Ex-political detainees exposed to THI (n = 16) showed a higher rate of depression (odds ratio, 10.2; 95% confidence interval, 1.2-90.0) than those without THI exposure (n = 26). Ex-political detainees with THI had thinner prefrontotemporal cortices than those without THI exposure (P < .001 by the statistical difference brain map) in the left dorsolateral prefrontal and bilateral superior temporal cortices, controlling for age, handedness, and number of trauma/torture events (left superior frontal cortex [SFC], P = .006; left middle frontal cortex, P = .01; left superior temporal cortex [STC], P = .007; right STC, P = .01). Trauma/torture events were associated with bilateral amygdala volume loss (left, P = .045; right, P = .003). Cortical thinning associated with THI in the left SFC and bilateral STC was related to HSCL depression scores in THI-exposed (vs non-THI-exposed) ex-political detainees (left SFC, P for interaction = .007; left STC, P for interaction = .03; right STC, P for interaction = .02). CONCLUSIONS: Structural deficits in prefrontotemporal brain regions are linked to THI exposures. These brain lesions are associated with the symptom severity of depression in Vietnamese ex-political detainees.