Can peripheral psychophysiological markers predict response to exposure-based cognitive behavioral therapy in youth with severely impairing irritability? A study protocol.

BACKGROUND: Irritability, an increased proneness to anger, is a primary reason youth present for psychiatric care. While initial evidence supports the efficacy of exposure-based cognitive behavioral therapy (CBT) for youth with clinically impairing irritability, treatment mechanisms remain unclear. Here, we propose to measure peripheral psychophysiological indicators of arousal-heart rate (HR)/electrodermal activity (EDA)-and regulation-heart rate variability (HRV)-during exposures to anger-inducing stimuli as potential predictors of treatment efficacy. The objective of this study is to evaluate whether in-situ biosensing data provides peripheral physiological indicators of in-session response to exposures. METHODS: Blood volume pulse (BVP; from which HR and HRV canl be derived) and EDA will be collected ambulatorily using the Empatica EmbracePlus from 40 youth (all genders; ages 8-17) undergoing six in-person exposure treatment sessions, as part of a multiple-baseline trial of exposure-based CBT for clinically impairing irritability. Clinical ratings of irritability will be conducted at baseline, weekly throughout treatment, and at 3-month and 6-month follow-ups via the Clinical Global Impressions Scale (CGI) and the Affective Reactivity Index (ARI; clinician-, parent-, and child-report). Multilevel modeling will be used to assess within- and between-person changes in physiological arousal and regulation throughout exposure-based CBT and to determine whether individual differences are predictive of treatment response. DISCUSSION: This study protocol leverages a wearable biosensor (Empatica) to continuously record HR/HRV (derived from BVP) and EDA during in-person exposure sessions for youth with clinically impairing irritability. Here, the goal is to identify changes in physiological arousal (EDA, HR) and regulation (HRV) over the course of treatment in tandem with changes in clinical symptoms. TRIAL REGISTRATION: The participants in this study come from an overarching clinical trial (trial registration numbers: NCT02531893 first registered on 8/25/2015; last updated on 8/25/2023). The research project and all related materials were submitted and approved by the appropriate Institutional Review Board of the National Institute of Mental Health (NIMH).

The fear that remains: Associations between trauma, related psychopathology, and fear-potentiated startle in youth resettled as refugees.

Fear-potentiated startle (FPS) can be used to measure fear and safety learning-behaviors affected by trauma that may map onto posttraumatic stress disorder (PTSD). Therefore, FPS could be a candidate biomarker of trauma-related psychopathology and a potential identifier of trauma-exposed youth in need of focused treatment. We enrolled n = 71 (35 females, Mage  = 12.7 years) Syrian youth exposed to civilian war trauma. Eyeblink electromyogram (EMG) data from a differential conditioning FPS paradigm were obtained 2.5 years after resettlement. Youth provided self-report of trauma exposure (Harvard Trauma Questionnaire) and PTSD symptoms (UCLA PTSD Reaction Index). While FPS during conditioning was not associated with symptoms, associations with psychopathology emerged in fear extinction. Probable PTSD was associated with FPS in the last block of extinction, such that FPS to threat cue was significantly greater in the PTSD+ group compared to the PTSD- group at the end of extinction (F = 6.25, p = .015). As with adults, we observed a deficit in extinction learning but not fear conditioning in youth with PTSD. These results support the use of trauma-informed cognitive behavioral therapy based on the learning principles of extinction in youth with PTSD.

Neurocircuitry of Contingency Awareness in Pavlovian Fear Conditioning.

In Pavlovian fear conditioning, contingency awareness provides an indicator of explicit fear learning. A less studied aspect of fear-based psychopathologies and their treatment, awareness of learned fear is a common cause of distress in persons with such conditions and is a focus of their treatment. The present work is a substudy of a broader fear-conditioning fMRI study. Following fear conditioning, we identified a subset of individuals who did not exhibit explicit awareness of the CS-US contingency. This prompted an exploratory analysis of differences in "aware" versus "unaware" individuals after fear conditioning. Self-reported expectancies of the CS-US contingency obtained immediately following fear conditioning were used to differentiate the two groups. Results corrected for multiple comparisons indicated significantly greater BOLD signal in the bilateral dlPFC, right vmPFC, bilateral vlPFC, left insula, left hippocampus, and bilateral amygdala for the CS+>CS- contrast in the aware group compared with the unaware group (all p values ≤ 0.004). PPI analysis with a left hippocampal seed indicated stronger coupling with the dlPFC and vmPFC in the aware group compared with the unaware group (all p values ≤ 0.002). Our findings add to our current knowledge of the networks involved in explicit learning and awareness of conditioned fear, with important clinical implications.

Real-life contextualization of exposure therapy using augmented reality: A pilot clinical trial of a novel treatment method.

BACKGROUND: Phobias, including arachnophobia, are common and can be treated with exposure therapy, a method that is limited by a lack of feared objects/situations in clinical settings. METHODS: In a pilot parallel randomized controlled trial (RCT) to test the feasibility and efficacy of augmented reality exposure therapy (ARET), 25 men and women ages 18 to 45 with arachnophobia were designated (ABAB block allocation) to ARET for arachnophobia (n = 13) or waitlist control (n = 12). Data were collected at baseline, 1-week, and 1-month follow-up, and single-session ARET occurred immediately following baseline collection for the intervention group. RESULTS: All ARET participants were able to touch a live tarantula or the tank containing it after single-session exposure; the control group remained >1 meter away from the tank. Effects persisted or improved at 1-month followup. The Fear of Spiders Questionnaire (FSQ) and Behavioral Approach Test (BAT) showed large, significant beneficial effects of ARET compared with a waitlist control group (BAT: P < .001, partial eta squared = .542; FSQ: P < .001, partial eta squared = .720). CONCLUSIONS: We found ARET can feasibly be delivered using a wearable device running novel software with rapid responses and sustained effects. Replication and expansion of this pilot RCT will further support use of ARET for this and other specific phobias.

Treatments of Posttraumatic Stress Disorder in Civilian Populations.

PURPOSE OF REVIEW: Posttraumatic stress disorder is a chronic, heterogeneous disorder for which a multitude of psychotherapies, pharmaceuticals, and immerging treatment programs are available. Majority of efficacy studies focus on Caucasian male military populations, which may be a reason why not all patients respond to treatment with long-term positive outcomes. Additionally, effects of treatment on symptom clusters have been neglected. This work reviews treatment of PTSD and its symptom clusters exclusively in civilian populations, which have been historically under-examined in the literature. RECENT FINDINGS: Exposure therapy stands at the forefront of successful PTSD treatment and offers a more cost-effective solution to pharmacotherapy; however, refugees and patients with comorbid depression may not experience such strong benefits. For exposure therapy and other forms of psychotherapy, non-inferiority studies point to promise of internet-delivered and telemedicine-based methods for reaching populations that may not have access to in-person care. SSRIs are the most widely used pharmaceutical treatment for PTSD; moderate initial benefits are observed yet long-term retention and outcomes may be enhanced by adjunct treatment. Again, refugees are a group that experiences lesser benefit. Research has begun to explore efficacy of treatments for individual symptom clusters, with hyperarousal benefiting most from currently available modalities. Avoidance, intrusion, negative thoughts and beliefs, and dissociation are symptoms requiring more research for focused interventions. Treatment of PTSD has evolved to (1) include equivalent proportions of men and women, along with focused female-exclusive cohorts; (2) explore novel methods of treatment online and in various cultural contexts; and (3) less focus on medication as evidenced by current clinical trials. In addition to further efficacy and safety studies in more diverse ethnic populations, work is needed to examine what therapies are best for targeting specific symptom clusters of PTSD. This research will drive precision treatment, and such research is beginning to point towards underlying mechanisms of pathology and change.

Strong Mind, Strong Body: The Promise of Mind-Body Interventions to Address Growing Mental Health Needs Among Youth.

As the prevalence of childhood and adolescent anxiety, depression, and other mental health concerns continues to rise, there has been an unprecedented increase in support of mind-body practices like yoga, dance, meditation, mindfulness, aerobic exercise, and more-in part driven by the mental health burden imposed by the COVID-19 pandemic. While a growing body of evidence supports the safety and effectiveness of mind-body approaches, gaps in funding for and empirical research on mechanistic underpinnings, methodology development to assess multi-component therapeutic practices, dissemination and implementation, and diversity in researchers, practitioners, and recipients remain. As a consequence, the neurobiological impacts of mind-body techniques are not well understood nor broadly accepted as standard forms of care by clinicians and insurers-often being considered as 'alternative' rather than 'complementary' or 'integrative'. In this commentary, we summarize work from our labs and others highlighting the promise of mind-body approaches for improving mental health in youth, in line with the National Institute of Mental Health's strategic plan to address health disparities. We offer a potential framework for implementation and research-the Expressive Therapies Continuum. We also propose solutions to key research and policy gaps, that by could have positive public health impacts for those who are struggling and to prevent emergence of psychiatric illness, especially in developing youth.

Photovoice techniques and art therapy approaches with refugee and immigrant adolescents.

This paper describes a program informed by art therapy and Photovoice approaches and techniques aimed at helping new immigrant and refugee teens to navigate personal and cultural identities by reflecting on their experiences as new residents in the US. Photovoice is a photography and social action method that encourages participants to photograph aspects of their daily lives, reflect on their meaning and significance and galvanize necessary changes. The program began in February 2020 at the Arab-American National Museum (AANM), but was adapted for an online format and re-framed towards a reflection on the COVID-19 pandemic. Broad questions teens explored included: What is good? What is challenging? What is sustaining during challenging times? What needs to change? and What about your culture and background are you proud of and wish to share with other US residents? Highlights of the sessions demonstrate how art therapy interventions paralleled photography-assigned themes of self, home, and community and encouraged group interaction and mutual support. A virtual museum exhibition culminated the program and reached community leaders. Self-reports from select participants highlight changes in posttraumatic stress, anxiety, and somatic symptoms over the course of programming.

The Predictive Utility of Trauma Subtypes in the Assessment of Mental Health Outcomes for Persons Resettled as Refugees.

Pre-migration trauma, a psychological risk factor for refugees, is often measured using cumulative indices. However, recent research suggests that trauma subtypes, rather than cumulative trauma, may better predict psychological outcomes. This study investigated the predictive utility of trauma subtypes in the assessment of refugee mental health. Multiple regression was used to determine whether cumulative trauma or trauma subtypes explained more variance in depression, anxiety, and post-traumatic stress disorder (PTSD) symptom scores in 70 Syrian and Iraqi refugees. Subtype models performed better than cumulative trauma models for PTSD (cumulative R2 = 0.138; subtype R2 = 0.32), anxiety (cumulative R2 = 0.061; subtype R2 = 0.246), and depression (cumulative R2 = 0.041; subtype R2 = 0.184). Victimization was the only subtype significantly associated with PTSD (p < 0.001; r2 = 0.210), anxiety (p < 0.001; r2 = 0.162), and depression (p = 0.002; r2 = 0.140). Cumulative trauma was predictive of PTSD symptoms only (p = 0.003; r2 = 0.125). Trauma subtypes were more informative than cumulative trauma, indicating their utility for improving predictive efforts in research and clinical contexts.

Addressing Mental Health Concerns in Refugees and Displaced Populations: Is Enough Being Done?

There are over 82.4 million forcibly displaced people worldwide, about a quarter of whom are resettling as refugees. In the wake of the global refugee crisis spurred by conflict, religious and political persecution, human rights violations, and climate disasters, a mental health has crisis followed. Not only does trauma experienced in home countries and as part of forced migration affect mental health, so too do post-migration traumatic events, discrimination, lack of access to quality and affordable healthcare and housing, and acculturation. To address mental health concerns in refugees and displaced populations, collective action is needed not only from health care providers but also from mental health researchers, funders, journals, resettlement agencies, government entities, and humanitarian organizations. The present review highlights the work of numerous scholars and organizations with the goal of understanding the mental health concerns of forcibly displaced persons within and across ecological systems. The present review seeks to bring attention to the experiences of forcibly displaced persons, summarize the growing body of research understanding the acute and chronic effects of forced displacement and possible interventions, and give a call to action for all members of the global community at every level to engage in joint efforts to improve mental health in refugees and displaced persons. Notably, there is a need for more interventions at the familial and community level that serve not only as treatment but also as prevention. Smartphone-based interventions, mind-body modalities, and interventions delivered by lay and non-clinician community members hold promise. Numerous strides could be made in refugee mental health and treatment when funding agencies include these goals in their research priorities. Despite the challenges they have faced, persons who resettle as refugees are incredibly resilient and deserve to be afforded every right, opportunity, dignity, and respect.

Biological Psychiatry in Displaced Populations: What We Know, and What We Need to Begin to Learn.

Conflict and climate change continue to displace millions of people, who experience unique trauma and stressors as they resettle in host countries. Both children and adults who are forcibly displaced, or choose to migrate, experience posttraumatic stress disorder, anxiety, depression, and other mental health conditions at higher rates than the general population. This may be attributed to severe, cumulative stress and trauma (largely interpersonal traumas); discrimination and harassment in host countries; and structural barriers to accessing and addressing mental health concerns, including clinician availability, language barriers, cultural differences, geographic accessibility, health care access, and stigma. Despite high exposure to and clinical impact of such experiences, and despite representing 1% of the world population, forcibly displaced people are underrepresented in neuroscientific research. The availability of such literature and research findings is significant in understanding the unique genetic and cultural aspects of trauma- and stress-related mental health, advocacy, reducing stigma, informing prevention, and treatment. The present work aimed to explore how the field of neuroscience can address mental health equity for individuals who have been uprooted in relation to land, with a focus on refugee populations. We offer practical suggestions on how to improve research in this area and narrow the gap in knowledge.

The integration of the heart-centered paradigm of Sufi psychology in contemporary psychotherapy practice.

Maktab Tarighat Oveyssi (M.T.O) Sufi Psychology provides a psychological method based on the teachings of the M.T.O Shahmaghsoudi School of Islamic Sufism. Sufi Psychology aims to address physical and spiritual aspects of patients in order to foster a sense of identity that is not limited to a diagnostic status or an emotional state. The present work provides an overview of what Sufi Psychology is and how it builds on current gold-standard psychotherapeutic practices. We also present data from a bottom-up, practice-based observational study in which male and female patients from various cultural and religious backgrounds received Sufi Psychotherapy and provided self-report measures of distress, perceived stress, hope, and resilience. Results from multilevel models fit to examine within- and between-person variance and change over time indicated significant reductions in therapeutic, relationship, psychological, spiritual, and critical distress. Hope and resilience were already high at baseline, and no significant changes in these measures were found. This work serves as a foundational model for future research and writings on Sufi Psychology, as the evidence base is extremely limited, with directives for research models to further demonstrate the efficacy of this treatment approach. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Neural Impacts of Stigma, Racism, and Discrimination.

Racism is a chronic stressor fueled by stigma that can result in significant distress and dysfunction as well as negatively affect emotions, behavior, quality of life, and brain health. The effects of stigma and discrimination emerge early in life and have long-term consequences. In this review, we sought to use neuroscience research to describe how stigma, racism, and discrimination can impact brain and mental health. Societal stigmas may be encoded by associative fear learning and pattern completion networks, and experiences of racial discrimination may similarly affect threat-responsive regions and circuits. Race-related differences in brain function and structure supporting threat circuitry are largely attenuated when negative life experiences and discrimination are taken into account. Downstream, chronic activation of the hypothalamic-pituitary-adrenal axis and the sympathetic-adrenal-medullary axis in the context of discrimination and stigma can contribute to physical health disparities in minoritized and marginalized groups. Finally, we discuss models that provide a framework for interventions and societal-level strategies across ecologic systems to build resilience and foster posttraumatic growth.

Perceived health, adversity, and posttraumatic stress disorder in Syrian and Iraqi refugees.

BACKGROUND: Exposure to armed conflict and fleeing country of origin for refugees has been associated with poorer psychological health. METHODS: Within the first month following their arrival in the United States, 152 Syrian and Iraqi refugees were screened in a primary care setting for posttraumatic stress disorder (PTSD), anxiety, and depression and rated their perceived health, and perceived level of adversity of violence, armed conflict/flight. The moderating effects of psychiatric symptoms on the relation between perceived adversity and perceived health were assessed. RESULTS: Three models based on diagnosis (PTSD, anxiety, and depression) were tested. While significant effects were found on perceived adversity negatively influencing perceived health across diagnoses, slightly different patterns emerged based on diagnosis. DISCUSSION: Findings suggest that refugees' perception regarding adversity of violence, armed conflict, and flight may contribute to perceived health, with a moderating role of clinically significant symptoms of PTSD, anxiety, and depression.

Skin conductance response to trauma interview as a candidate biomarker of trauma and related psychopathology in youth resettled as refugees.

Background: Posttraumatic stress symptoms (PTSS) include a constellation of physical and emotional profiles that youth exposed to trauma may experience. An estimated 20% of youth are exposed to trauma, and in refugee populations, up to 54% experience posttraumatic stress. Given the physical and mental health consequences associated with trauma exposure and subsequent psychopathology, identifying biomarkers of symptom severity is a top research priority.Objective: Previous research in adults found that skin conductance responses to trauma interview predicted current and future PTSS. We extended this method to refugee youth exposed to civilian war trauma and forced migration, to examine associations between PTSS and skin conductance in this uniquely vulnerable child and adolescent population.Methods: 86 refugee youth ages 7-17 years completed a trauma interview and assessment of self-reported PTSS. The mobile eSense app on a iPad was used to obtain continuous recordings of skin conductance level (SCL) during a trauma interview (trauma SCL). Skin conductance response (SCR) was calculated by subtracting the baseline SCL from the maximum amplitude of the trauma SCL.Results: SCL during trauma was significantly greater than baseline SCL, Trauma exposure was significantly associated with SCR to trauma interview, R2 = .084, p = .042. SCR to trauma interview was positively correlated with reexperiencing (R2 = .127, p = .028), and hyperarousal symptoms (R 2 = .123, p = .048).Conclusions: The present study provides evidence for feasibility of SCR to trauma interview as a candidate biomarker of PTSS in youth. This is the first study to look at SCR to trauma interview in youth resettled as refugees and is part of the limited but growing body of research to look at biomarkers in refugee cohorts more broadly. As the number of forcibly displaced persons surges, early detection and prevention of trauma-related psychology is becoming more important than ever. HIGHLIGHTS: Using the mobile eSense app, we demonstrate that skin conductance is measurable in a variety of research settings and that skin conductance response may be a biological indicator of trauma and related psychopathology - namely re-experiencing symptoms - in youth resettled as refugees.

Safety learning during development: Implications for development of psychopathology.

Fear and safety learning are necessary adaptive behaviors that develop over the course of maturation. While there is a large body of literature regarding the neurobiology of fear and safety learning in adults, less is known regarding safety learning during development. Given developmental changes in the brain, there are corresponding changes in safety learning that are quantifiable; these may serve to predict risk and point to treatment targets for fear and anxiety-related disorders in children and adolescents. For healthy, typically developing youth, the main developmental variation observed is reduced discrimination between threat and safety cues in children compared to adolescents and adults, while lower expression of extinction learning is exhibited in adolescents compared to adults. Such distinctions may be related to faster maturation of the amygdala relative to the prefrontal cortex, as well as incompletely developed functional circuits between the two. Fear and anxiety-related disorders, childhood maltreatment, and behavioral problems are all associated with alterations in safety learning for youth, and this dysfunction may proceed into adulthood with corresponding abnormalities in brain structure and function-including amygdala hypertrophy and hyperreactivity. As impaired inhibition of fear to safety may reflect abnormalities in the developing brain and subsequent psychopathology, impaired safety learning may be considered as both a predictor of risk and a treatment target. Longitudinal neuroimaging studies over the course of development, and studies that query change with interventions are needed in order to improve outcomes for individuals and reduce long-term impact of developmental psychopathology.

Virtual Arts and Movement Therapies for Youth in the Era of COVID-19.

The COVID-19 pandemic has had a significant impact on youth, including through increased isolation, the transition to online schooling, decreased access to arts and sports programming, exposure to illness, and anxiety. The pandemic has also affected the delivery of therapeutic services at a time when youth have needed more help building coping skills and reducing stress. Creative arts and movement therapies promote creativity and adaptability to better develop cognitive flexibility1 while enhancing self-regulation and self-direction, adaptive skills that are protective in the face of stress.2 Creative arts and movement-based group therapies delivered through community settings-such as resettlement agencies, schools, and community recreation centers-are feasible, cost-effective, and increase accessibility, especially for populations often underrepresented in the therapeutic space.3 Offering such interventions at the group level benefits both those who are experiencing significant stress and anxiety4,5 and those who are not experiencing such symptoms, as they still reap the long-term benefits of building stress-relaxation and emotion regulation skills. Having previously demonstrated the efficacy of art therapy (AT) and dance/movement therapy (DMT) in improving posttraumatic stress and anxiety symptoms for youth,4,5 our laboratory-the Stress, Trauma, and Anxiety Research Clinic-shifted programming to virtual formats, in partnerships with local resettlement agencies and schools.

Trauma-Related Psychopathology in Iraqi Refugee Youth Resettled in the United States, and Comparison With an Ethnically Similar Refugee Sample: A Cross-Sectional Study.

BACKGROUND: Conflict in Iraq has displaced millions of refugee youth. Warzone exposure and forced migration have unique acute and chronic impacts on youth, yet effects of exposure may not be universal across diverse refugee groups. Understanding how youth from various refugee groups are differentially affected by stress and trauma is critical to allocate resources and implement screening measures with the goal of providing early intervention. METHOD: To identify the effects of warzone exposure and forced migration, a convenience sample of 48 Iraqi refugee youth ages 6-17 was assessed within the first month of arrival to the United States. Youth provided self-reported severity of posttraumatic stress and anxiety symptoms; symptom severity was then compared with an existing sample of 135 Syrian refugee youth to explore whether refugee youth of different nationalities experience the same effects of warzone exposure and forced migration. These data are the baseline for a longitudinal developmental study of refugee health, which also includes parental data. RESULTS: Severity of separation anxiety and negative alterations in cognition and mood were the greatest symptomatic concerns in Iraqi refugee youth. Thirty-eight percent of responding Iraqi youth showed possible indication of an anxiety disorder. Severity of posttraumatic stress symptoms was lower in Iraqi youth compared to Syrian youth. For both Iraqi and Syrian refugee youth, separation anxiety was the most significant concern, with more than 80% of both samples showing a possible indication of clinically significant separation anxiety. CONCLUSION: The present observational study indicated that Iraqi refugee youth experience a range of anxiety and posttraumatic stress symptoms following warzone exposure and forced migration; posttraumatic stress symptoms were less severe in Iraqi versus Syrian youth. Comparing refugee youth of different nationalities is of particular importance, as our results demonstrate that findings from one refugee population cannot easily be generalized to another. Clinical and research efforts should prioritize interventions to address separation anxiety in refugee youth, which was of concern in both samples.

The Neurocircuitry Underlying Additive Effects of Safety Instruction on Extinction Learning.

Extinction learning is the dominant laboratory model for exposure therapy, a treatment involving both experience of safety near the feared object, and safety instructions relayed by a therapist. While the experiential aspect of extinction learning is well researched, less is known about instructed extinction learning and its neurocircuitry. Here, in 14 healthy participants we examined the neural correlates of, and the network interactions evoked by instructed extinction learning. Following fear conditioning to two CS+ stimuli, participants were instructed about the absence of the aversive unconditioned stimulus (US) for one of the CS+s (instructed CS; CS+I) but not the second CS+ (uninstructed CS+; CS+U). Early during extinction learning, greater activation was observed for the CS+I > CS+U contrast in regions including the vmPFC, dmPFC, vlPFC, and right parahippocampus. Subsequently, psychophysiological interaction (PPI) was applied to investigate functional connectivity of a seed in the vmPFC. This analyses revealed significant modulation of the dmPFC, parahippocampus, amygdala, and insula. Our findings suggest that the addition of cognitive instruction yields greater activation of emotion regulation and reappraisal networks during extinction learning. This work is a step in advancing laboratory paradigms that more accurately model exposure therapy and identifies regions which may be potential targets for neuromodulation to enhance psychotherapy effects.

Inflammation and Trauma-Related Psychopathology in Syrian and Iraqi Refugees.

Refugees experience high rates of post-traumatic stress disorder (PTSD), anxiety, and depression due to exposure to civilian war trauma and forced migration. Inflammatory products may offer viable biological indicators of trauma-related psychopathology in this cohort, promoting rapid and objective assessment of psychopathology. Incoming Syrian and Iraqi refugees (n = 36) ages 18-65 completed self-report measures of PTSD, anxiety, and depression and provided saliva samples during an assessment at a primary care clinic within the first month of resettlement in the United States. Interleukin 1ß (IL-1ß) and C-reactive protein (CRP) differentially correlated with symptom severity by domain, and there was a non-significant trend for sex moderating the relation between inflammation and PTSD symptoms. Our findings show unique relations between trauma-related psychopathology and inflammation. There is a need for further research in diverse ethnic cohorts with differential trauma exposures for inflammation to be considered a biological indicator of psychopathology.

Mental Health of Refugees and Torture Survivors: A Critical Review of Prevalence, Predictors, and Integrated Care.

Civilian war trauma and torture rank among the most traumatic life experiences; exposure to such experiences is pervasive in nations experiencing both internal and external conflict. This has led to a high volume of refugees resettling throughout the world with mental health needs that primary care physicians may not be screening for and prepared to effectively address. In this article, we review the literature on demographics, predictors, mental health outcomes of torture, and integrated care for the mental health needs of refugees. We searched PubMed and PSYCINFO databases for original research articles on refugees and mental health published in the English language between 2010 and present. Nine percent of 720 adults in conflict areas in Nepal, with predominance of literate married males, met the threshold for Post-Traumatic Stress Disorder (PTSD), 27.5% for depression, and 22.9% for anxiety. While, PTSD rate has been documented as high as 88.3% among torture survivors from Middle East (ME), Central Africa (CA), South Asia (SA), Southeast Europe (SE). Depression was recorded as high as 94.7% among 131 African torture survivors and anxiety as high as 91% among 55 South African torture survivors. Torture severity, post-migration difficulties, and wait time to receive clinical services were significantly associated with higher rate of mental health symptoms. Mental health screening is not a standard component of initial physical exams for refugees, yet these individuals have had high trauma exposure that should inform clinical care. Integrated care models are lacking but would greatly benefit this community to prevent progression to greater severity of mental health symptoms.