Risk and protective factors associated with comorbid PTSD and depression in U.S. military veterans: Results from the National Health and Resilience in Veterans Study.

Converging evidence suggests that veterans with co-occurring PTSD/MDD represent a high-risk group for poor mental health compared to those with PTSD alone. To date, however, little is known about the specific factors that may increase vulnerability for and buffer risk for comorbid PTSD/MDD. The purpose of this study was to provide a population-based characterization of sociodemographic, risk, and protective variables associated with comorbid PTSD/MDD among U.S. military veterans. Data were analyzed from the National Health and Resilience in Veterans Study, a nationally representative survey of U.S. military veterans (n = 2,732). Analyses (1) compared veterans with PTSD alone and co-occurring PTSD/MDD on sociodemographic, military, and psychosocial characteristics; and (2) examined variables independently associated with PTSD/MDD status. Multivariable logistic regression analyses revealed that racial/ethnic minority status (odds ratio [OR] = 12.5), number of lifetime traumas (OR = 1.3), and time spent engaged in private religious/spiritual activities (OR = 1.8) were associated with PTSD/MDD status, while higher scores on measures of community integration (OR = 0.6) and dispositional optimism (OR = 0.7) were negatively associated with comorbid PTSD/MDD status. Relative importance analyses revealed that dispositional optimism (34%) and community integration (24%) explained the largest proportions of variance in PTSD/MDD comorbidity. Taken together, results of this study suggest that racial/ethnic minority status, greater lifetime trauma burden, and engagement in private religious/spiritual activities are key distinguishing characteristics of U.S. military veterans with comorbid PTSD/MDD vs. PTSD alone. They further underscore the need to study whether targeting community integration and optimism in prevention and treatment efforts may enhance clinical outcomes in this population.

Mental health issues among indigenous communities and the role of traditional medicine.

INTRODUCTION: Mental health in indigenous communities is a relevant issue for the World Health Organization (WHO). These communities are supposed to live in a pure, clean and intact environment. Their real condition is far different from the imaginary; they are vulnerable populations living in difficult areas, exposed to pollution, located far from the health services, exposed to several market operations conducted to extract natural resources, facing criminal groups or illegal exploitation of land resources. These factors may have an impact on mental health of indigenous population. METHODS: We reviewed all papers available on PubMed, EMBASE and The Cochrane Library until December 2018. We focused on those factors affecting the changes from a traditional to a post-modern society and reviewed data available on stress-related issues, mental distress affecting indigenous/aboriginal communities and the role of Traditional Medicine (TM). We reviewed articles from different countries hosting indigenous communities. RESULTS: The incidence of mental distress and related phenomena (e.g. collective suicide, alcoholism and violence) among indigenous populations is affected by political and socio-economic variables. The mental health of these populations is poorly studied and described even if mental illness indicators are somewhat alarming. TM still seems to have a role in supporting affected people and may reduce deficiencies due to poor access to medical insurance/coverage, psychiatry and psychotherapy. It would be helpful to combine TM and modern medicine in a healthcare model to face indigenous populations' health needs. CONCLUSION: This review confirms the impact of societal changes, environmental threats and exploitation of natural resources on the mental health of indigenous populations. Global Mental Health needs to deal with the health needs of indigenous populations as well as psychiatry needs to develop new categories to describe psychopathology related to social variance as recently proposed by the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5).

Symptoms of post-traumatic stress disorder and depression among Eritrean refugees in Ethiopia: identifying direct, meditating and moderating predictors from path analysis.

OBJECTIVE: This study aimed at testing the significance of mediating and moderating roles of sense of coherence, adaptive coping styles and social support in the relationship between exposure to trauma and psychological symptoms in a refugee population in sub-Saharan Africa. METHODS: A cross-sectional survey design was employed to collect data. The study was carried out in Mai Aini refugee camp in Ethiopia. A total of 562 adult Eritrean refugees aged 18-74 years were selected randomly to screen for depression and post-traumatic stress disorder (PTSD) symptoms and to examine associated factors. Data were collected using the premigration and postmigration living difficulties checklist, Center for Epidemiologic Studies Depression (CES-D) scale, Primary Care PTSD Screener, coping style scale, Sense of Coherence scale and Oslo Social Support scale. Path modelling was used to test the mediation and moderation effects of prespecified factors. RESULTS: Premigration living difficulties were associated directly with symptoms of PTSD (ß=0.09, p<0.05), and associated indirectly with PTSD symptoms in paths through duration of stay in the camp, sense of coherence, postmigration living difficulties, task-oriented coping style and depressive symptoms (ß=0.26, p<0.01). Premigration and postmigration living difficulties were associated directly with depressive symptoms with standardised estimate of ß=0.35(p<0.001) and ß=0.23(p<0.05), respectively. Postmigration living difficulties were associated indirectly with PTSD through paths of sense of coherence, task-oriented coping style and depressive symptoms (ß=0.13; p<0.01). Social support moderated the effect of postmigration living difficulties on depressive symptoms (p<0.05). Emotion-oriented coping style moderated the effect of premigration threat for abuse on PTSD (ß=-0.18, p<0.001) and depressive (ß=-0.12, p<0.01) symptoms, as well as moderating threat to life on PTSD symptoms (ß=-0.13, p<0.001). CONCLUSIONS: Sense of coherence and task-oriented coping style showed a partial mediating effect on the association between exposure to trauma and symptoms of PTSD. An emotion-oriented coping style and social support moderated the effect of premigration and postmigration living difficulties, respectively. Fostering social support, task-oriented and emotion-oriented coping styles may be beneficial for these refugees.

Psychological-Mindedness and American Indian Historical Trauma: Interviews with Service Providers from a Great Plains Reservation.

The concept of historical trauma (HT) was developed to explain clinical distress among descendants of Jewish Holocaust survivors and has since been ascribed new meanings to account for suffering in diverse contexts. In American Indian (AI) communities, the concept of AI HT has been tailored and promoted as an expanded notion of trauma that combines psychological injury with historical oppression to causally connect experiences with Euro-American colonization to contemporary behavioral health disparities. However, rather than clinical formulations emphasizing psychological injury, a focused content analysis of interviews with 23 AI health and human service providers (SPs) on a Great Plains reservation demonstrated strong preferences for socio-cultural accounts of oppression. Reflective of a local worldview associated with minimal psychological-mindedness, this study illustrates how cultural assumptions embedded within health discourses like HT can conflict with diverse cultural forms and promote "psychologized" perspectives on suffering that may limit attention to social, economic, and political determinants of health.

Posttraumatic Stress among Victimized Latino Women: Evaluating the Role of Cultural Factors.

Research examining victimization and posttraumatic symptomatology among Latinos is lacking in the extant literature. This analysis used the victimized subsample (N = 752) of the Sexual Assault Among Latinas Study. The aim was to evaluate victimization prevalence and test the following hypotheses: (a) that victimization would be associated with higher levels of posttraumatic symptoms, (b) that cultural factors that move away from traditional Latino culture would be associated with higher levels of posttraumatic symptomatology, and (c) that cultural factors associated with traditional Latino culture would be related to lower posttraumatic symptomatology. Average age of the sample was 44.57 years, with three fourths having a high school education or higher, and two thirds having a household income below $30,000. Of exposure types, adulthood threats were most likely to result in Criterion A traumatic events (23.4%). Using the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; American Psychiatric Association, 2000) based PTSD Checklist, between 8.8% and 45.5% of individuals met presumed PTSD diagnosis based on various PCL cut scores or algorithm criteria. Regression analyses indicated that the combined different types of adult and childhood victimizations, masculine gender role, and negative religious coping were associated with increased symptoms (ßs ranging from .16 to .27). The results suggested a role of culture in posttraumatic symptoms for Latinas.

Cognitive behavioral psychotherapeutic treatment at a psychiatric trauma clinic for refugees: description and evaluation.

INTRODUCTION: Cognitive behavioural therapy (CBT) with trauma focus is the most evidence supported psychotherapeutic treatment of PTSD, but few CBT treatments for traumatized refugees have been described in detail. PURPOSE: To describe and evaluate a manualized cognitive behavioral therapy for traumatized refugees incorporating exposure therapy, mindfulness and acceptance and commitment therapy. MATERIAL AND METHODS: 85 patients received six months' treatment at a Copenhagen Trauma Clinic for Refugees and completed self-ratings before and after treatment. The treatment administered to each patient was monitored in detail. The changes in mental state and the treatment components associated with change in state were analyzed statistically. RESULTS: Despite the low level of functioning and high co-morbidity of patients, 42% received highly structured CBT, which was positively associated with all treatment outcomes. The more methods used and the more time each method was used, the better the outcome. The majority of patients were able to make homework assignments and this was associated with better treatment outcome. Correlation analysis showed no association between severity of symptoms at baseline and the observed change. CONCLUSION: The study suggests that CBT treatment incorporating mindfulness and acceptance and commitment therapy is promising for traumatized refugees and punctures the myth that this group of patients are unable to participate fully in structured CBT. However, treatment methods must be adapted to the special needs of refugees and trauma exposure should be further investigated.

A Socioecological Predication Model of Posttraumatic Stress Disorder in Low-Income, High-Risk Prenatal Native Hawaiian/Pacific Islander Women.

INTRODUCTION: Only recently has perinatal posttraumatic stress disorder (PTSD) been researched in any depth; however, the causes and consequences of this serious illness remain unclear. Most commonly, childbirth trauma and interpersonal violence have been reported as contributing factors. However, not all Native Hawaiian/Pacific Islander (NHPI) women who experience these events experience PTSD. The factors affecting PTSD are many and complex, intertwining individual, family, and community contexts. Using a socioecological framework, 3 levels of contextual variables were incorporated in this study (individual, family, and social/community). The purpose of this study was to determine the socioecological predictors associated with prenatal PTSD among NHPI. METHODS: A case-control design was used to collect retrospective data about socioecological variables from medical record data. The sample was low-income, high-risk NHPI women receiving perinatal health care at a rural community health center in Hawaii who screened positive (n = 55) or negative (n = 91) for PTSD. RESULTS: Hierarchical logistic regression was conducted to determine socioecological predictors of positive PTSD screening. Although the majority of women (66.4%) experienced some form of interpersonal violence, a constellation of significant predictor variables from all 3 levels of the model were identified: depression (individual level), lack of family support and family stress (family level), and violence (social/community level). DISCUSSION: Each of the predictor variables has been identified by other researchers as significantly affecting perinatal PTSD. However, it is because these variables occur together that a more complex picture emerges, suggesting the importance of considering multiple variables in context when identifying and caring for these women. Although additional research is needed, it is possible that the significant predictor variables could be useful in identifying women who are at higher risk for PTSD in other similar populations.

Collective trauma processing: dissociation as a way of processing postwar traumatic stress in Guinea Bissau.

Guidelines on psychosocial interventions in postconflict areas commonly mention that interventions should be based on local needs and be built on culture-specific expertise. This paper is based on a dissociative cult, the Kiyang-yang (KYY), in Guinea Bissau. In a previous article, we used a refined definition of the concept of idiom of distress to analyze the dissociative behavior displayed in KYY as a symbolic language addressing politically dangerous truths. This paper uses the concept of "collective trauma processing" to analyze how the idiom offered the local population a pathway to mitigate the consequences of protracted and widespread political violence. The paper first argues that the field of psychotraumatology lacks a comprehensive ecological theory on trauma. Moreover, within clinical psychology and psychiatry, little attention is paid to local cultural healing mechanisms addressing traumatic stress. This paper is an effort to study such mechanisms in their own right. To compare trauma processing mechanisms across the globe, we propose to analyze trauma processing mechanisms with the help of a comprehensive model discerning five ontological dimensions that are considered to be involved in suffering and are addressed in healing approaches. Our paper describes similarities and differences between psychological healing traditions and collective trauma processing within the West African context of Guinea Bissau. We will illustrate how the KYY movement uses the idiom of dissociation as both a collective expression of distress and as a vehicle to process social suffering and traumatic stress as a circular phenomenon.

Loving-kindness in the treatment of traumatized refugees and minority groups: a typology of mindfulness and the nodal network model of affect and affect regulation.

This article discusses how loving-kindness can be used to treat traumatized refugees and minority groups, focusing on examples from our treatment, culturally adapted cognitive-behavioral therapy (CA-CBT). To show how we integrate loving-kindness with other mindfulness interventions and why loving-kindness should be an effective therapeutic technique, we present a typology of mindfulness states and the Nodal Network Model (NNM) of Affect and Affect Regulation. We argue that mindfulness techniques such as loving-kindness are therapeutic for refugees and minority populations because of their potential for increasing emotional flexibility, decreasing rumination, serving as emotional regulation techniques, and forming part of a new adaptive processing mode centered on psychological flexibility. We present a case to illustrate the clinical use of loving-kindness within the context of CA-CBT.

Redressing First Nations historical trauma: theorizing mechanisms for indigenous culture as mental health treatment.

Indigenous "First Nations" communities have consistently associated their disproportionate rates of psychiatric distress with historical experiences of European colonization. This emphasis on the socio-psychological legacy of colonization within tribal communities has occasioned increasingly widespread consideration of what has been termed historical trauma within First Nations contexts. In contrast to personal experiences of a traumatic nature, the concept of historical trauma calls attention to the complex, collective, cumulative, and intergenerational psychosocial impacts that resulted from the depredations of past colonial subjugation. One oft-cited exemplar of this subjugation--particularly in Canada--is the Indian residential school. Such schools were overtly designed to "kill the Indian and save the man." This was institutionally achieved by sequestering First Nations children from family and community while forbidding participation in Native cultural practices in order to assimilate them into the lower strata of mainstream society. The case of a residential school "survivor" from an indigenous community treatment program on a Manitoba First Nations reserve is presented to illustrate the significance of participation in traditional cultural practices for therapeutic recovery from historical trauma. An indigenous rationale for the postulated efficacy of "culture as treatment" is explored with attention to plausible therapeutic mechanisms that might account for such recovery. To the degree that a return to indigenous tradition might benefit distressed First Nations clients, redressing the socio-psychological ravages of colonization in this manner seems a promising approach worthy of further research investigation.

Ethnic syndromes as disguise for protest against colonialism: three ethnographic examples.

Historical connections are suggested between the domination of 1 culture by another and dissociative spiritual and religious responses to that oppression. Connections are drawn between colonial oppression, trauma, and 3 examples of dissociation and spirit possession: the Zar cult of Southern Sudan, "Puerto Rican syndrome" or ataque, and the Balinese trance dance. Discussed by means of these examples are the role and functions of spirit possession as a means of escape from unbearable reality, where it becomes a form of the expression of needs and desires forbidden by authorities, a way of entering an identity not subject to traditional authorities, and reenactment of traumatic experience.

Dissociation and symptoms of culture-bound syndromes in North America: a preliminary study.

The aim of this study was to determine whether classical culture-bound syndromes occur among psychiatric inpatients with dissociative disorders in North America. The Dissociative Trance Disorder Interview Schedule, the Dissociative Experiences Scale, and the Dissociative Disorders Interview Schedule were administered to 100 predominantly Caucasian, American, English-speaking trauma program inpatients at a hospital in the United States. The participants reported high rates of childhood physical and/or sexual abuse (87%), dissociative disorders (73%), and membership in the dissociative taxon (78%). They also reported a wide range of possession experiences and exorcism rituals, as well as the classical culture-bound syndromes of latah, bebainan, amok, and pibloktoq. Our data are consistent with the view that possession and classical culture-bound syndromes are predominantly dissociative in nature and not really culture-bound from the perspective of Caucasian, English-speaking America.

Dreams of the dead among Cambodian refugees: frequency, phenomenology, and relationship to complicated grief and posttraumatic stress disorder.

The authors investigated the importance of dreams of the deceased in the experiencing of prolonged grief (PG) and posttraumatic stress disorder (PTSD) among Cambodian refugees who survived the Pol Pot genocide (1975-1979). Such dreams were frequent in the last month (52% of those surveyed), and most often involved a relative who died in the Pol Pot period. Past month frequency was correlated with PG severity (r = .59) and PTSD severity (r = .52). The dreams were almost always deeply upsetting because the dreams indicated the deceased to be in a difficult spiritual state. Dreams of the deceased as a central component of PG and PTSD among Cambodian refugees is discussed.

Measures of psychophysiological arousal among resettled traumatized Iraqi refugees seeking psychological treatment.

Resettled refugees living in Western countries frequently report high levels of posttraumatic stress disorder (PTSD) and depression. This study sought to measure levels of physiological arousal in a group of resettled Iraqi refugees in Australia receiving psychological treatment. A continuous recording of electrocardiogram (ECG) data was used to examine baseline heart rate (HR) and heart rate variability (HRV) in refugees (n = 25) and healthy age- and sex-matched controls (n = 23). Descriptively, PTSD (48%) was the most commonly noted disorder followed equally by major depressive episode (36%) and dysthymia (36%) in the refugees. Examination of the physiological data indicated that the refugee group had increased resting HR compared with healthy controls (78.84 vs. 60.08 beats per minute, p < .001). No significant differences were noted in the HRV data with age, gender, and years of education included in the model. This finding highlights the importance of examining levels of arousal in refugees presenting with mental health complaints to provide appropriate treatment strategies.

"Our culture is medicine": perspectives of Native healers on posttrauma recovery among American Indian and Alaska Native patients.

American Indian and Alaska Native (Native) people experience more traumatic events and are at higher risk for developing posttraumatic stress disorder compared with the general population. We conducted in-depth interviews with six Native healers about their perspectives on traumatic injury and healing. We analyzed the interviews using an inductive approach to identify common themes. We categorized these themes into four categories: causes and consequences of traumatic injury, risk factors, protective factors, and barriers to care. The implications of our study include a need for improving cultural competence among health care and social services personnel working with Native trauma patients. Additional cumulative analyses of Native healers and trauma patients would contribute to a much-needed body of knowledge on improving recovery and promoting healing among Native trauma patients.

The cross-cultural validity of posttraumatic stress disorder: implications for DSM-5.

BACKGROUND: There is considerable debate about the cross-cultural applicability of the posttraumatic stress disorder (PTSD) category as currently specified. Concerns include the possible status of PTSD as a Western culture-bound disorder and the validity of individual items and criteria thresholds. This review examines various types of cross-cultural validity of the PTSD criteria as defined in DSM-IV-TR, and presents options and preliminary recommendations to be considered for DSM-5. METHODS: Searches were conducted of the mental health literature, particularly since 1994, regarding cultural-, race-, or ethnicity-related factors that might limit the universal applicability of the diagnostic criteria of PTSD in DSM-IV-TR and the possible criteria for DSM-5. RESULTS: Substantial evidence of the cross-cultural validity of PTSD was found. However, evidence of cross-cultural variability in certain areas suggests the need for further research: the relative salience of avoidance/numbing symptoms, the role of the interpretation of trauma-caused symptoms in shaping symptomatology, and the prevalence of somatic symptoms. This review also indicates the need to modify certain criteria, such as the items on distressing dreams and on foreshortened future, to increase their cross-cultural applicability. Text additions are suggested to increase the applicability of the manual across cultural contexts: specifying that cultural syndromes-such as those indicated in the DSM-IV-TR Glossary-may be a prominent part of the trauma response in certain cultures, and that those syndromes may influence PTSD symptom salience and comorbidity. CONCLUSIONS: The DSM-IV-TR PTSD category demonstrates various types of validity. Criteria modification and textual clarifications are suggested to further improve its cross-cultural applicability.

Factors related to posttraumatic stress symptoms in women experiencing police-involved intimate partner violence.

Relationships among intimate partner violence (IPV), Post Traumatic Stress Disorder (PTSD) symptoms, health, and danger, using M.A. Dutton's Empowerment framework, were examined among 423 ethnically diverse women in contact with police due to IPV. Significant predictors of PTSD symptoms in multivariate analysis included Danger Assessment score, poor overall health, abuse leading to pain, victim expectations of future injury victimization, feeling unsafe, and shame. Results provide further evidence supporting routine assessment for violent trauma and PTSD as well as the need for research testing holistic interventions for women traumatized by violence.

The land of milk and honey: a picture of refugee torture survivors presenting for treatment in a South African trauma centre.

Intake data obtained from 55 refugee torture survivors accessing trauma treatment services at a centre in Johannesburg, South Africa, paints a picture of suffering beyond the torture experience. The intake forms part of a more comprehensive monitoring and evaluation system developed for the work done with torture survivors accessing psychosocial services. The diverse sample with different nationalities highlights that torture occurs in many countries on the African continent. It also highlights South Africa's role as a major destination for refugee and asylum seekers. However, "the land of milk and honey" and the process of arriving here, often poses additional challenges for survivors of torture. This is reflected in the high levels of Post Traumatic Stress Disorder (69%), anxiety (91%), and depression (74%) for our sample, all of which were significantly correlated. The loss of employment status from before the torture experience until the time of intake was great for this sample, impacting on their recovery. In addition the presence of medical conditions (44%), disabilities (19%), and pain (74%) raise serious questions regarding interventions that focus mainly on psychosocial needs. No significant gender differences were found. The paper begins to paint a clearer picture of the bio-psycho-social state of torture survivors accessing services in South Africa, as well as highlighting many of the contextual challenges which impact on recovery.

Honoring children, mending the circle: cultural adaptation of trauma-focused cognitive-behavioral therapy for American Indian and Alaska native children.

American Indians and Alaska Natives are vulnerable populations with significant levels of trauma exposure. The Indian Country Child Trauma Center developed an American Indian and Alaska Native (AI/AN) adaptation of the evidence-based child trauma treatment, trauma-focused cognitive-behavioral therapy. Honoring Children, Mending the Circle (HC-MC) guides the therapeutic process through a blending of AI/AN traditional teachings with cognitive-behavioral methods. The authors introduced the HC-MC treatment and illustrated its therapeutic tools by way of a case illustration.