Towards a more comprehensive understanding of PTSD and parenting.

BACKGROUND: The impact of post-traumatic stress disorder (PTSD) on parenting and the parent-child relationship has been well-documented in the scientific literature. However, some conceptual and methodological challenges within this research field remain. PROCEDURE: We reflect on a number of challenges that we identified while examining the literature in preparation of an individual participant data meta-analysis on the relationships between PTSD and parenting. FINDINGS: We address 1) the presence of 'trauma-islands'; 2) the need for transdiagnostic theoretical frameworks for mechanisms between PTSD and parenting; 3) the lack of developmental perspectives; 4) the overuse of self-reported retrospective measures; 5) the need to study more diverse samples and cultural contexts; and 6) the lack of research on resilience and post-traumatic growth in parenting. Based on these reflections, we offer suggestions on strategies for responding to these challenges through: 1) welcoming open science; 2) working towards shared theoretical frameworks; 3) doing more longitudinal research 4) expanding the methodological palette; 5) centering lived experience; and 6) taking systemic inequality into account. CONCLUSION: With this commentary, we aim to open a discussion on next steps towards a more comprehensive understanding of the association between PTSD and parenting, and inspire collaborative research.

Health trajectories of international humanitarian aid workers: growth mixture modelling findings from a prospective cohort study.

BACKGROUND: Most staff stay healthy during humanitarian work, although some worsen. Mean scores on health indicators may be masking individual participants struggling with health issues. AIMS: To investigate different field assignment-related health trajectories among international humanitarian aid workers (iHAWs) and explore the mechanisms used to stay healthy. METHOD: Growth mixture modelling analyses for five health indicators using pre-/post-assignment and follow-up data. RESULTS: Among 609 iHAWs three trajectories (profiles) were found for emotional exhaustion, work engagement, anxiety and depression. For post-traumatic stress disorder (PTSD) symptoms, four trajectories were identified. The 'healthy/normative' trajectory had the largest sample size for all health indicators (73-86%). A stable (moderate) 'ill health' trajectory was identified for all health indicators (7-17%), except anxiety. An 'improving' trajectory was found for PTSD and anxiety symptoms (5-14%). A minority of staff (4-15%) worsened on all health indicators. Deterioration continued for PTSD, depressive symptoms and work engagement 2 months post-assignment. A strong sense of coherence was associated with higher odds of belonging to the 'healthy' trajectory. Female biological sex was associated with higher odds of belonging to the 'worsening' depression and anxiety trajectories. Extended duration of field assignment was related to higher odds of belonging to the 'worsening' depressive symptoms trajectory. CONCLUSIONS: Most iHAWs stayed healthy during their assignment; a stable 'ill health' trajectory was identified for most health indicators. Sense of coherence is an important mechanism for understanding the health of all iHAWs in the different health trajectories, including the 'healthy' profile. These findings give new possibilities to develop activities to prevent worsening health and help strengthen iHAWs' ability to remain healthy under stress.

Incidence and Severity of Sexual Harassment, and its Impact on Mental Health in a Cohort of International Humanitarian Field-Workers.

To date, there have been no cohort studies of sexual harassment incidence and its relation to mental health within humanitarian field-workers. Research among numerous occupations suggests an association between workplace sexual harassment and several health complaints. This study examined the incidence and severity of sexual harassment and its association with changes in mental health in a cohort of international humanitarian aid field-workers (iHAWs). Four hundred and seventy-eight iHAWs filled in questionnaires about sexual harassment, depression, anxiety, and Post-Traumatic Stress Disorder (PTSD) as part of a larger study on health and well-being. Six percent of male and 18% of female iHAWs reported experiencing sexual harassment during their latest field assignment, with most reporting low levels of nonphysical forms of sexual harassment. Sexual harassment was predictive of negative changes in both depression and anxiety symptom severity between before and after an assignment for females; for males, it predicted negative changes in PTSD symptom severity. Sexual harassment did not predict utilization of mental healthcare services within 2 months after the end of assignment. The current findings are the first figures derived from a representative sample of iHAWs on the incidence of sexual harassment during a field assignment and show sexual harassment to be a relatively common and present issue. The findings are mostly in line with the extant literature and underscore the importance of attending to the issue of sexual harassment in the humanitarian sector.

From Pathology to Intervention and Beyond. Reviewing Current Evidence for Treating Trauma-Related Disorders in Later Life.

Background: An emerging body of empirical research on trauma-focused interventions for older adults experiencing symptoms of posttraumatic stress disorder or PTSD has yielded encouraging results. Nevertheless, up to date, the evidence remains scattered and is developed within rather specific groups, while studies have focused mostly on individual psychopathology, overlooking the relevance of resilience and recovering in one's social environment. Objective: This study aims at summarizing the emerging evidence on treating trauma-related disorders in older adults, followed by implications for clinical practice and future research. Specifically, the following research questions are addressed: Which factors may optimize access to intervention, what treatment benefits can be realized, and how to improve resilience by using individual as well as community-oriented approaches? Methods: A systematic literature research of intervention studies on PTSD among older adults, published between 1980 and December 2021, was expanded by cross-referencing, summarized in a narrative synthesis and supplemented with a clinical vignette reflecting qualitative outcomes. Results: Five RCTs compared varying types of trauma-focused Cognitive Behavioral Therapy with non-trauma-focused control conditions. From one of them, qualitative results were reported as well. The most recent studies reported encouraging results, confirming the suggestion that evidence-based psychotherapy for PTSD can be safely and effectively used with older adults. Conclusions: Since evidence-based psychotherapy for PTSD can be safely and effectively used with older adults, new avenues for practice and research may be found in a resilience perspective and a public mental health framework.

Psychopathology and resilience in older adults with posttraumatic stress disorder: a randomized controlled trial comparing narrative exposure therapy and present-centered therapy.

Objective: Using data from a randomized controlled trial on psychotherapy for posttraumatic stress disorder (PTSD) in older adults (aged >55), this study aimed at analysing the efficacy of two psychological interventions in terms of self-reported symptoms, comorbid psychopathology and resilience outcomes. Method: Thirty-three outpatients (age 55-81) with PTSD were randomly assigned to eleven sessions of narrative exposure therapy or present-centered therapy. Self-reported symptom severity of PTSD, depression and general psychopathology, along with measures of resilience (self-efficacy, quality of life and posttraumatic growth cognitions), were target outcomes. Harvard Trauma Questionnaire, Beck Depression Inventory, Brief Symptom Inventory, General Efficacy Scale, World Health Organization Quality of Life Assessment and Meaning of War Scale (personal growth) were assessed pre-treatment, post-treatment and at four months follow-up. Because of variable inter-assessment intervals, a piecewise mixed effects growth model was used to investigate treatment effects. Results: Neither post-treatment, nor at mean follow-up, between-group effects were found. At follow-up, significant medium to large within-group effect sizes were found in the NET-group for psychopathology (self-reported PTSD: Cohen's d = 0.54, p < .01; depression: Cohen's d = 0.51, p = .03; general psychopathology: Cohen's d = 0.74, p = .001), but not so in the PCT-group. Resilience (self-efficacy, quality of life and personal growth cognitions) did not significantly change in either group. Conclusions: In older adults with PTSD, the efficacy of NET extended beyond PTSD, reducing not only self-reported symptoms of PTSD but also comorbid depression and general psychopathology.

Objetivo: Utilizando datos de un ensayo controlado aleatorizado sobre psicoterapia para pacientes con trastorno de estrés postraumático (TEPT) en adultos mayores (> 55 años), este estudio tuvo como objetivo analizar la eficacia de dos intervenciones psicológicas respecto a síntomas autoinformados, psicopatología comorbida, y resultados de resiliencia.Método: Treinta y tres pacientes ambulatorios (de 55 a 81 años) con TEPT fueron asignados al azar a once sesiones de terapia de exposición narrativa (NET en sus siglas en ingles) o terapia centrada en el presente (TCP). Los resultados que se midieron fueron, el autoreporte de la gravedad de síntomas de estrés postraumático, depresión y psicopatología general, junto con medidas de resiliencia (autoeficacia, calidad de vida y cogniciones de crecimiento postraumático). Se evaluaron antes del tratamiento, después del tratamiento y a los cuatro meses de seguimiento con los siguientes cuestionarios: Cuestionario de trauma de Harvard, el Inventario de depresión de Beck, el Inventario breve de síntomas, la Escala de eficacia general, Evaluación de la Calidad de Vida y de Significado de la Guerra de la Organización Mundial de la Salud (crecimiento personal). Debido a los intervalos variables entre evaluaciones, se utilizó un modelo de crecimiento de efectos mixtos por partes para investigar los efectos del tratamiento.Resultados: No se encontraron diferencias entre los grupos ni posteriores al tratamiento ni durante el seguimiento medio. En el seguimiento, se encontraron tamaños de efecto significativos medianos a grandes dentro del grupo NET. para psicopatología (TEPT autoinformado: d de Cohen = 0.54, p < .01; depresión: d de Cohen = 0,51, p = 0,03; psicopatología general: d de Cohen = 0,74, p = 0,001), pero no así en el grupo TCP. La resiliencia (autoeficacia, calidad de vida y cogniciones de crecimiento personal) no tuvieron cambios significativos en ninguno de los grupos.Conclusiones: En adultos mayores con TEPT, la eficacia de la NET se extendió más allá del TEPT, reduciendo no sólo síntomas autoinformados de TEPT, sino también depresión comórbida y psicopatología general.

Do initial mental health, somatic, and social problems predict postdisaster lack of social support in the medium term? A latent profile analysis.

OBJECTIVE: Findings on the relationship between social support and mental health problems after potentially traumatic events vary across studies. Aim of our longitudinal study is to assess to what extent initial postdisaster mental health, somatic, and social functioning problems affect social support 1.5 years later. This is relevant for the discussion about social causation versus social selection processes. METHOD: Data from Time 1 (T1; 2 to 3 weeks postevent) and Time 2 (T2; 1.5 years postevent) from the Dutch longitudinal Enschede Fireworks Disaster Study were extracted (N = 781). Latent profile analysis (LPA) was used to identify classes of (mental) health and social problems at T1 among disaster affected adult residents, using anxiety, depressive and PTSD symptoms, and somatic and social functioning problems as indicators. Relationships between classes at T1 and lack of social support at T2 were assessed using analyses of covariance (ANCOVAs). RESULTS: LPA identified the following seven classes: very resilient (10.6%), resilient (7.2%), minor problems (16.1%), elevated problems (28.8%), subclinical problems (20.5%), clinical problems (13.9%), and severe clinical problems (2.9%). In general, classes with subclinical to severe clinical levels at T1 showed higher lack of everyday, emotional, esteem, instrumental, companionship, and informative support at T2 while controlling for demographics and disaster experiences. CONCLUSIONS: Affected adults who belong to the subclinical to severe clinical classes in the first weeks suffered more often from a lack of social support 1.5 years postevent than did others. Mental health policies should target the risk of lack of social support among these groups. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Prolonged grief disorder, posttraumatic stress disorder, and depression following traffic accidents among bereaved Balinese family members: Prevalence, latent classes and cultural correlates.

INTRODUCTION: Qualitative studies have described the rather unique styles of Balinese people to adjust to adversity. No quantitative research assessing psychopathology among bereaved individuals has been performed yet. This study estimated the prevalence of prolonged grief disorder (PGD), posttraumatic stress disorder (PTSD) and depression among bereaved individuals after traffic deaths in Bali and the relations between subgroups sharing the same symptoms and cultural, socio-demographic characteristics and posttraumatic growth (PTG). METHODS: In this cross-sectional study, 301 participants participated in questionnaire-interviews assessing PGD, PTSD, depression, PTG and cultural and socio-demographic characteristics. On average, the time since loss was 16 months. The purpose of the rituals was examined by a thematic qualitative analysis. We performed latent class analyses and subsequently calculated the odds ratios between membership of classes and characteristics with a multivariate 3step analysis. RESULTS: Prevalence rates of PGD (0%), PTSD (1%) and moderate depression (2%) were low. Most participants followed the bereavement rituals characteristic for Balinese culture. The purpose of these rituals was mainly the expression of caring for the deceased. We found a large resilient class (76%) and two smaller classes, one characterized by elevated PGD symptoms (11%) and one by elevated PTSD symptoms (13%). Loss of close kin was associated with membership of the PTSD class. CONCLUSIONS: Prevalence rates of PGD, PTSD and depression in the Balinese community were remarkably low. Participants appeared to be quite homogeneous in following religious and cultural habits. Aspects of the Balinese culture might protect bereaved individuals for developing mental health issues and could be used for an informed refinement of bereavement rituals in other cultures.

Post-Migration Stressors and Their Association With Symptom Reduction and Non-Completion During Treatment for Traumatic Grief in Refugees.

BACKGROUND: Resettled refugees exposed to trauma and loss are at risk to develop mental disorders such as posttraumatic stress disorder (PTSD) and persistent complex bereavement disorder (PCBD). Post-migration stressors have been linked to poor mental health and smaller treatment effects. AIM: Our aim was to evaluate reductions in PTSD and PCBD symptoms and to explore the presence of post-migration stressors and their associations with symptom change and non-completion in a traumatic grief focused treatment in a cohort of refugees. METHODS: Paired sample t-tests were used to test the significance of the symptom reductions in PTSD and PCBD symptoms during treatment. The presence of post-migration stressors was derived from a qualitative analysis of the patient files. Associations between post-migration stressors and symptom reductions as well as non-completion were calculated. RESULTS: In this uncontrolled study, 81 files of consecutive patients were included. Significant reductions in both PCBD and PTSD symptomatology with medium effect sizes were found. Patients experienced a mean of three different post-migration stressors during the treatment. Undocumented asylum seekers were more likely to be non-completers. Ongoing conflict in the country of origin was associated with smaller PTSD symptom reductions and the total number of post-migration stressors was associated with smaller PCBD symptom reductions. CONCLUSIONS: Treatment for resettled refugees for traumatic grief coincides with alleviations in both PCBD and PTSD symptomatology. Specific post-migration stressors were associated with reduced treatment effects and increased non-completion. This is a first step towards well-informed improvements of mental health interventions for resettled refugees.

Which groups affected by Potentially Traumatic Events (PTEs) are most at risk for a lack of social support? A prospective population-based study on the 12-month prevalence of PTEs and risk factors for a lack of post-event social support.

OBJECTIVES: Little is known about the 12-month prevalence of potentially traumatic events (PTEs) and to what extent the type of PTE is a risk factor for post-event lack of social support. In addition, it is largely unknown if pre-event mental health problems and loneliness, and demographics are risk factors for a lack of support. Aim of the present prospective study is to fill these gaps in evidence-based knowledge. METHODS: A survey was conducted among a large random sample of the Dutch adult population (i.e. the longitudinal LISS panel) in March-April 2018, and linked with pre-event mental health and loneliness data from surveys conducted in 2016 (n = 5,879). We distinguished four forms of perceived social support: emotional and esteem support, and social recognition and general disapproval. RESULTS: Loss of a significant other and/or colleague (28%) was the most prevalent 12-month PTE. The 12-month prevalence of violence, accidents and/or, and theft-related events was 13%. Multivariate logistic regression analyses revealed no differences in lack of emotional and esteem support, or in lack of recognition across non-death PTEs and death-related PTEs. However, victims of threat and physical (sexual) violence more often faced disapproval than those affected by burglary and accidents. Results furthermore showed that pre-event mental health problems, pre-event loneliness and stress during the PTE were important independent predictors of forms of support and acknowledgment. Affected individuals with a non-Western background more often lacked support and acknowledgment. CONCLUSIONS: Many adults are confronted with a PTE during a year. In general, pre-event factors and stress during the event are better predictors of a perceived lack of support and acknowledgment than type of event. Early screening programs should especially assess pre-event mental health and loneliness, besides levels of stress during the event, to identify affected people who are at risk for a lack of social support and acknowledgment.

Intrusions related to indirectly experienced events in clinical offspring of World War Two survivors.

Negative events may not only linger on in the form of intrusive memories in the minds of those directly exposed but also in those who are only indirectly confronted with these events. The aim of the present study was to investigate if intrusions referring to indirectly experienced traumatic events do indeed occur, and to compare their frequency and characteristics to intrusions about directly experienced negative events. Participants (N = 98) were adult postwar offspring of World War Two survivors currently in treatment in one of two clinics specialized in the treatment of war victims. We examined the frequency and characteristics of intrusions about indirectly experienced (i.e., parent war-related) events and two types of directly (self-) experienced events: Self-experienced traumatic events and negative events related to participants' upbringing. Intrusions referring to indirectly experienced traumatic events did indeed occur. The frequency as well as other characteristics of these intrusions did not differ from those of both types of intrusions about directly experienced events. The similarities between intrusions related to different types of events emphasize the (re)constructive nature of memory. Our findings indicate that traumatic events not only affect those directly involved but may also continue to plague the next generation.

The prevalence of prolonged grief disorder in bereaved individuals following unnatural losses: Systematic review and meta regression analysis.

BACKGROUND: Previous research has indicated that one out of ten naturally bereaved individuals develops prolonged grief disorder (PGD). Less is known about the prevalence of PGD following unnatural deaths, such as accidents, disasters, suicides, or homicides. The aim of this study was to compute the pooled prevalence of PGD and to determine possible causes of its varied estimates. METHODS: A literature search was conducted in PsycINFO, Ovid Medline, PILOTS, Embase, Web of Science, and CINAHL. A meta-analysis using random effects models was performed to calculate the pooled prevalence rate of PGD. Multivariate meta-regression was used to explore heterogeneity among the studies. RESULTS: Twenty-five articles met eligibility criteria. The random-effects pooled prevalence was 49%, 95% CI [33.6, 65.4]. Death of only child, violent killings and non-western study location were associated with a higher PGD prevalence. A longer time since loss and a loss in a natural disaster were associated with a lower PGD prevalence. LIMITATIONS: These findings should be interpreted with caution, because of the heterogeneity in study methodology. CONCLUSIONS: This first meta-analysis of PGD following unnatural losses indicated that nearly half of the bereaved adults experienced PGD. This illustrates the importance of assessing PGD in individuals affected by loss and trauma.

Severity profiles of posttraumatic stress, depression, anxiety, and somatization symptoms in treatment seeking traumatized refugees.

BACKGROUND: Western countries are facing many challenges hosting refugees from several regions in the world. Many of them are severely traumatized and suffer from a variety of mental health symptoms, which complicates the identification and treatment of refugees at risk. This study examined subgroups based on a broad range of psychopathology, and several predictors, including trauma characteristics and gender. METHODS: Participants were 1147 treatment-seeking, traumatized refugees. Latent profile analysis was conducted to identify different subgroups based on levels of posttraumatic stress disorder (PTSD), depression, anxiety, and somatic symptoms. Multinomial logistic regression was used to identify predictors of subgroup membership. RESULTS: Three distinct subgroups were identified, reflecting Moderate (10.2%), Severe (43.0%), and Highly Severe (45.9%) symptom severity levels, respectively. Symptom severity of all psychopathology dimensions was distributed equally between the subgroups. Participants in the Severe and Highly Severe Symptoms subgroups reported more types of traumatic events compared to the Moderate subgroup. In particular, traumatic events associated with human right abuses, lack of human needs and separation from others predicted subgroup membership, as did gender. LIMITATIONS: The results are confined to treatment-seeking, traumatized refugee populations. CONCLUSIONS: Distinguishable symptom severity profiles of PTSD, depression, anxiety and somatic complaints could be identified in this large treatment-seeking refugee population, without qualitative differences in symptom distribution. Instead of focusing on specific mental disorders, classification based on overall symptom severity is of interest in severely traumatized patients. This knowledge will help to identify individuals at risk and to enhance existing treatment programs for specific patient groups.

Symptomatology following loss and trauma: Latent class and network analyses of prolonged grief disorder, posttraumatic stress disorder, and depression in a treatment-seeking trauma-exposed sample.

BACKGROUND: Although bereavement is likely a common stressor among patients referred to a psychotrauma clinic, no study has yet examined the co-occurrence and relationships between symptoms of prolonged grief disorder (PGD), posttraumatic stress disorder (PTSD), and major depressive disorder symptoms in this population. METHOD: In a sample of patients seeking treatment following psychological trauma (n = 458), we used latent class analysis to identify classes of patients sharing the same profile of PGD, PTSD, and depression symptoms. We then used network analysis to investigate the relationships among these symptoms and with loss-related variables. RESULTS: Most participants (65%) were members of a class that exhibited elevated endorsement of PGD symptoms. PGD, PTSD, and depression symptoms hung together as highly overlapping but distinguishable communities of symptoms. Symptoms related to social isolation and diminished sense of self bridged these communities. Violent loss was associated with more difficulty accepting the loss. The loss of close kin was most strongly associated with difficulty moving on in life. CONCLUSIONS: PGD symptoms are common in trauma-exposed bereaved adults and closely associated with symptoms of PTSD and depression, illustrating the importance of assessing bereavement and PGD symptoms in those seeking treatment following trauma.

Intergenerational consequences of the Holocaust on offspring mental health: a systematic review of associated factors and mechanisms.

Exposure to war and violence has major consequences for society at large, detrimental impact on people's individual lives, and may also have intergenerational consequences. To gain more insight into these intergenerational consequences, research addressing the impact of the Holocaust on offspring is an important source of information. The aim of the current study was to systematically review the mechanisms of intergenerational consequences by summarizing characteristics in Holocaust survivors and their offspring suggested to impact the offspring's mental health. We focused on: 1) parental mental health problems, 2) (perceived) parenting and attachment quality, 3) family structure, especially parental Holocaust history, 4) additional stress and life events, and 5) psychophysiological processes of transmission. We identified 23 eligible studies published between 2000 and 2018. Only Holocaust survivor studies met the inclusion criteria. Various parent and child characteristics and their interaction were found to contribute to the development of psychological symptoms and biological and epigenetic variations. Parental mental health problems, perceived parenting, attachment quality, and parental gender appeared to be influential for the mental well-being of their offspring. In addition, having two survivor parents resulted in higher mental health problems compared to having one survivor parent. Also, there was evidence suggesting that Holocaust survivor offspring show a heightened vulnerability for stress, although this was only evident in the face of actual danger. Finally, the results also indicate intergenerational effects on offspring cortisol levels. Clinical and treatment implications are discussed.

La exposición a la guerra y la violencia tiene consecuencias importantes para la sociedad en general, un impacto perjudicial en la vida individual de las personas, y también puede tener consecuencias intergeneracionales. Para obtener más información sobre estas consecuencias intergeneracionales, la investigación que aborda el impacto del Holocausto en la descendencia es una fuente importante de información. El objetivo del presente estudio fue revisar sistemáticamente los mecanismos de las consecuencias intergeneracionales resumiendo las características de los sobrevivientes del Holocausto y sus descendientes, que podrían impactar la salud mental de la descendencia. Nos centramos en: 1) los problemas de salud mental de los padres, 2) la calidad (percibida) de la crianza y el apego, 3) la estructura familiar, especialmente antecedentes del Holocausto de los padres, 4) el estrés y los eventos de la vida adicionales, y 5) los procesos psicofisiológicos de la transmisión. Identificamos 23 estudios elegibles publicados entre 2000 y 2018. Solo los estudios de sobrevivientes del Holocausto cumplieron con los criterios de inclusión. Se descubrió que diversas características de los padres y de los hijos y su interacción contribuyen al desarrollo de los síntomas psicológicos y las variaciones biológicas y epigenéticas. Los problemas de salud mental de los padres, la crianza percibida, la calidad del apego, y el género parental parecieron influir en el bienestar mental de sus hijos. Además, tener dos padres sobrevivientes resultó en mayores problemas de salud mental en comparación con tener uno de los padres sobrevivientes. Además, hubo evidencia que sugiere que los descendientes de los sobrevivientes del Holocausto muestran una mayor vulnerabilidad al estrés, aunque esto fue solo evidente ante el peligro real. Finalmente, los resultados también indican los efectos intergeneracionales en los niveles de cortisol de la descendencia. Se discuten las implicaciones clínicas y de tratamiento.

Trauma and Public Mental Health: A Focused Review.

Psychological trauma has developed into a very common concept in the scientific community, in mental health care, as well as in popular language and mass media. The purpose of this article is to show the relevance of the discipline of traumatic stress studies to the field of public mental health by examining central concepts and findings concerning trauma and its aftermath and examining implications for public mental health. Attention is paid to the diagnosis of posttraumatic stress disorder (PTSD) and the construct of resilience as well as to specific areas of public mental health activities. A public mental health perspective will help to develop preventive approaches to trauma and extend the impact of various forms of interventions. It will also make clear that trauma care will have to consider the community and the society at large.

Undocumented asylum seekers with posttraumatic stress disorder in the Netherlands.

Background: To date, most studies on the mental health of refugees in Europe have focused on the prevalence and treatment of psychopathology. Little is known about those who illegally reside in the host country, referred to, in the Netherlands, as undocumented asylum seekers. There are indications that mental health and psychosocial problems are more prevalent in this group than among refugees in general, with unsatisfactory treatment outcomes. Objective: To describe characteristics and mental health and psychosocial problems of undocumented asylum seekers, and to establish the need for, and feasibility of, a tailored treatment approach. Method: Based on a literature review and extensive clinical experience, common mental health and psychosocial problems and accessibility of care for undocumented asylum seekers are established, as well as the common treatment approach in the Netherlands. A tailored treatment programme and experiences with its implementation are described. Results: Mental health and psychosocial problems are highly prevalent among undocumented asylum seekers, and access to care is limited. In addition, treatment in the Netherlands, if provided, is mostly insufficient yet prolonged. Given the specific psychosocial problems and living conditions of undocumented asylum seekers, a necessary criterion to enable adequate and evidence-based treatment provision is acknowledgement of their distinct needs. A tailored treatment programme as currently implemented in the Netherlands appears to meet this criterion and be feasible under certain conditions. Collaboration between mental health care providers and involved social service and governmental parties by regular meetings, though complicated, is a relevant element. Conclusions: Even though undocumented asylum seekers are illegally residing in a country, medical ethics and the human rights perspective necessitate for adequate and evidence-based treatment for those among them with mental health problems. The tailored treatment approach presented here suggests that, notwithstanding factors complicating care provision which require specific attention, this is feasible.

Antecedentes: Hasta la fecha, la mayoría de los estudios sobre la salud mental de los refugiados en Europa se han centrado en la prevalencia y el tratamiento de la psicopatología. Sin embargo, poco se sabe acerca de aquellos que residen ilegalmente en el país que le acoge, en los Países Bajos, en su mayoría referidos como solicitantes de asilo indocumentados. Hay indicios de que la salud mental y los problemas psicosociales son más frecuentes en este grupo, que entre los refugiados en general, con resultados de tratamiento insatisfactorios.Objetivo: Describir las características y los problemas psicosociales y de salud mental de los solicitantes de asilo indocumentados, y establecer la necesidad y la viabilidad de un enfoque de tratamiento personalizado.Método: Basado en una revisión de la literatura y una amplia experiencia clínica, se establecen problemas comunes de salud mental y psicosociales y acceso a la atención para solicitantes de asilo indocumentados, así como el enfoque de tratamiento común en los Países Bajos. Se describe un programa de tratamiento a medida y experiencias con su implementación.Resultados: La salud mental y los problemas psicosociales son muy frecuentes entre los solicitantes de asilo indocumentados, y el acceso a la atención es limitado. Además, el tratamiento en los Países Bajos, si se proporciona, es en su mayoría insuficiente y prolongado. Dados los problemas psicosociales específicos y las condiciones de vida de los solicitantes de asilo indocumentados, un criterio necesario para permitir una provisión de tratamiento adecuada y basada en la evidencia es el reconocimiento de sus necesidades específicas. Un programa de tratamiento a medida como se implementa actualmente en los Países Bajos parece cumplir con este criterio y ser factible bajo ciertas condiciones. La colaboración entre los proveedores de atención de salud mental y el servicio social involucrado y las partes gubernamentales mediante reuniones periódicas, aunque complicadas, es un elemento relevante.Conclusiones: A pesar de que los solicitantes de asilo indocumentados residen ilegalmente en un país, por ética médica y perspectiva de los derechos humanos, aquellos con problemas de salud mental, requieren un tratamiento adecuado y basado en la evidencia. El enfoque de tratamiento personalizado presentado aquí sugiere que, a pesar de los factores que complican la provisión de atención que requieren atención específica, esto es factible.

The moderating role of individual resilience in refugee and Dutch adolescents after trauma.

OBJECTIVE: Exposure to potentially traumatic events (PTEs) has been identified as a risk factor for various psychological problems in adolescents generally and in young refugees. The aim of this study was to examine whether individual resilience (assessed as a personality characteristic) can protect adolescents in diverse contexts from negative effects of trauma exposure. METHOD: A path model was used to assess whether individual resilience buffered the negative effects of exposure to PTEs in a cross-sectional study of adolescent refugees (aged 12-17 years; n = 117) and their Dutch peers (n = 148). Measurements included the Children's Revised Impact of Event Scale, Strengths and Difficulties Questionnaire, Satisfaction with Life Scale and the Resilience Scale. RESULTS: The moderating effects of individual resilience on the relationship between PTEs and mental health problems and life satisfaction were mixed: In the nonrefugee group, but not in the refugee group most moderation effects reached significance. CONCLUSION: Findings suggest that not all groups benefit similarly from individual-level resilience. Consequently, adolescents, who differ with regard to the risks to which they are exposed, may need different forms of support. This study points to the interplay of factors that contributes to demonstration of individual resilience. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

The effectiveness of narrative exposure therapy: a review, meta-analysis and meta-regression analysis.

Background: Narrative exposure therapy (NET) is a short-term psychological treatment for post-traumatic stress disorder (PTSD) that has been investigated in various contexts among traumatized refugees and other trauma survivors. Sustained treatment results have been reported, but the methodological quality of the trials needs a more thorough examination. Objective: To evaluate the effectiveness of NET for survivors of trauma, using a quality assessment, an updated meta-analysis, and a meta-regression analysis. Method: Following a systematic literature selection, the methodological quality of the included studies was assessed; Non-controlled and controlled effect sizes (Hedges' g) were estimated using a random effects model. Predictor analyses were performed. Non-controlled effect sizes for PTSD and depression included symptom change at post-treatment and follow-up time-points. Controlled effect sizes included post-treatment comparisons of NET with non-active and active comparators: both trauma-focused (TF) and non-trauma-focused (non-TF) interventions. Results: The selected studies showed high external validity; methodological quality was equivalent to other guideline-supported TF interventions. In 16 randomized controlled trials, involving 947 participants, large non-controlled effect sizes were found for PTSD symptoms, at post-treatment (g = 1.18, 95% confidence interval [0.87; 1.50]) and follow-up (g = 1.37 [0.96; 1.77]). For depression symptoms, medium non-controlled effect sizes were found, at post-treatment (g = 0.47 [0.23; 0.71]) and follow-up (g = 0.60 [0.26; 0.94]). Post-treatment, NET outperformed non-active comparators and non-TF active comparators for PTSD, but not the combined active comparators. For depression, NET only outperformed non-active comparators. Advancing age predicted better treatment results for PTSD and depression symptoms; a history of migration predicted smaller treatment results for depression symptoms. Conclusions:The findings of this meta-analysis suggest that patients and providers may expect sustained treatment results from NET. Controlled comparisons with other guideline-supported TF interventions are not yet available.

Antecedentes: la terapia de exposición narrativa (NET en sus siglas en inglés) es un tratamiento psicológico a corto plazo para el trastorno de estrés postraumático (TEPT) que ha sido investigado en diversos contextos entre refugiados traumatizados y otros sobrevivientes de traumas. Se han informado resultados sostenidos del tratamiento, pero la calidad metodológica de los ensayos requiere un examen más exhaustivo.Objetivo: evaluar la efectividad de la NET para sobrevivientes de trauma, mediante una evaluación de la calidad, un metanálisis actualizado y un análisis de metarregresión.Método: después de una selección sistemática de la literatura, se evaluó la calidad metodológica de los estudios incluidos; se estimaron los tamaños del efecto no controlados y controlados (g de Hedges), utilizando un modelo de efectos aleatorios. Se realizaron análisis predictivos. Los tamaños del efecto no controlados para el TEPT y la depresión incluyeron el cambio de los síntomas en los puntos de tiempo del postratamiento y del seguimiento. Los tamaños de los efectos controlados incluyeron las comparaciones postratamiento de la NET con comparadores no activos y activos: ambas intervenciones centradas en el trauma (TF en su sigla en inglés) y no enfocadas en el trauma (no TF).Resultados: la calidad metodológica de los estudios incluidos varió de incierto a alto riesgo de sesgo. En los 16 ensayos controlados aleatorios (ECA), con 947 participantes, se encontraron tamaños grandes de efectos no controlados para los síntomas del TEPT, en el postratamiento (g = 1.18, intervalo de confianza del 95% [0.87; 1.50]), y el seguimiento (g = 1.37, [0.96; 1.77]). Para los síntomas de depresión, se encontraron tamaños medios de efectos no controlados: en el postratamiento (g = 0.47, [0.23; 0.71]) y el seguimiento (g = 0.60, [0.26; 0.94]). En los postratamientos, la NET superó a los comparadores no activos y los comparadores no TF activos para el TEPT, pero no a los comparadores activos combinados. Para la depresión, la NET solo superó a los comparadores no activos. La edad avanzada predijo mejores resultados de tratamiento para el TEPT y los síntomas de depresión; un historial de migración predijo resultados de tratamiento más pequeños para los síntomas de depresión.Conclusiones: los hallazgos de este metanálisis sugieren que los pacientes y los proveedores pueden esperar resultados sostenidos del tratamiento de la NET. Hasta ahora, no se dispone de comparaciones controladas con otras intervenciones apoyadas por la guía de intervenciones de TF.

A longitudinal evaluation of active outreach after an aeroplane crash: screening for post-traumatic stress disorder and depression and assessment of self-reported treatment needs.

Background: In 2009, an aeroplane crashed near Amsterdam. To remedy unmet mental health needs, active outreach was used to identify victims at risk for post-traumatic stress disorder (PTSD) and depression. Objective: The active outreach strategy was evaluated by examining the accuracy of screening methods in predicting PTSD and depression, self-reported treatment needs, and the extent to which perceived treatment needs predict trajectories of PTSD. Method: In 112 adult survivors, semi-structured telephone interviews were held at 2 (T1, n = 76), 9 (T2, n = 77) and 44 months (T3, n = 55) after the crash. The Trauma Screening Questionnaire (TSQ) and the Patient Health Questionnaire-2 (PHQ-2) measured symptoms of PTSD and depression, respectively. At T3, a clinical interview assessed PTSD and depression diagnoses. Based on the TSQ scores at the three time-points, participants were grouped into five 'trajectories': resilient (n = 38), chronic (n = 30), recovery (n = 9), delayed onset (n = 9) and relapse (n = 3). Results: The TSQ accurately predicted PTSD at T3 (sensitivity: .75-1.00; specificity: .79-.90). The PHQ-2 showed modest accuracy (sensitivity: .38-.89; specificity: .67-.90). Both measures provided low positive predictive values (TSQ: 0.57; PHQ-2: .50 at T3). A number of participants reported unmet treatment needs (T1: 32.9%; T2: 19.5%; T3: 10.9%). Reporting unmet needs at T2 was more often assigned to a chronic PTSD trajectory compared to reporting no needs (p < .01). Conclusions: The prevalence of unmet needs at 44 months after the crash within a chronic PTSD trajectory indicated that active outreach may be warranted. Nevertheless, although the TSQ was accurate, many participants screening positive did not develop PTSD. This implies that, although active outreach may benefit those with unmet needs, it also has its costs in terms of possible unnecessary clinical assessments.

Antecedentes: En 2009 ocurrió un accidente aéreo cerca de Amsterdam. Para subsanar las necesidades de salud mental insatisfechas, se usó contacto activo para identificar víctimas en riesgo de trastorno de estrés postraumático (TEPT) y depresión. Objetivo: Evaluar esta estrategia examinando: 1) la precisión de los métodos de tamizaje para predecir TEPT Y depresión, 2) necesidades de tratamiento auto-reportadas, y 3) el grado en que las necesidades de tratamiento percibidas predicen las trayectorias de TEPT. Métodos: En 112 adultos sobrevivientes, se realizaron entrevistas telefónicas semi-estructuradas a los 2 (T1, n=76), 9 (T2, n=77) y 44 meses (T3, n=55) posteriores al accidente. El Cuestionario de Tamizaje de Trauma (TSQ por sus siglas en inglés) y el Cuestionario de Salud de los Pacientes-2 (PHQ-2 por sus siglas en inglés) midieron síntomas de TEPT y depresión, respectivamente. En T3, se evaluó con una entrevista clínica los diagnósticos de TEPT y depresión. En base a los puntajes de TSQ en los 3 puntos de tiempo, los participantes fueron agrupados en 5 'trayectorias': resiliente (n=38), crónico (n=30), recuperación (n=9), inicio demorado (n=9) y recaída (n=3). Resultados: la TSQ predijo TEPT en forma precisa al T3 (sensibilidad: .75 a 1.00, especificidad: .79 a .90). El PHQ-2 mostró modesta precisión (sensibilidad: .38 a .89, especificidad: .67 a .90). Ambas medidas entregaron bajos valores predictivos positivos (TSQ: .57, PHQ-2: .50 en T3). Un número de participantes reportaron necesidades de tratamiento insatisfechas (T1: 32.9%, T2: 19.5%, T3: 10.9%). El reportar necesidades insatisfechas en T2 fue más frecuentemente asignado a una trayectoria crónica de TEPT comparado a no reportar necesidades (p<.01). Conclusiones: La prevalencia de necesidades insatisfechas 44 meses después del accidente dentro de una trayectoria crónica de TEPT indicó que el contacto activo puede estar justificado. Sin embargo, aunque la TSQ fue precisa, muchos participantes detectados como positivos no desarrollaron TEPT. Esto implica que, aunque el contacto activo puede beneficiar a aquellos con necesidades insatisfechas, tiene también sus costos en términos de posibles evaluaciones clínicas innecesarias.

Trauma-Focused Art Therapy in the Treatment of Posttraumatic Stress Disorder: A Pilot Study.

Research showed that more than 30% of patients with Posttraumatic Stress Disorder (PTSD) do not benefit from evidence-based treatments: Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) or Eye Movement Desensitization and Reprocessing (EMDR). These are patients with prolonged and multiple traumatization, with poor verbal memory, and patients with emotional over-modulation. Retelling traumatic experiences in detail is poorly tolerated by these patients and might be a reason for not starting or not completing the recommended treatments. Due to lack of evidence, no alternative treatments are recommended yet. Art therapy may offer an alternative and suitable treatment, because the nonverbal and experiential character of art therapy appears to be an appropriate approach to the often wordless and visual nature of traumatic memories. The objective of this pilot study was to test the acceptability, feasibility, and applicability of trauma-focused art therapy for adults with PTSD due to multiple and prolonged traumatization (patients with early childhood traumatization and refugees from different cultures). Another objective was to identify the preliminary effectiveness of art therapy. Results showed willingness to participate and adherence to treatment of patients. Therapists considered trauma-focused art therapy feasible and applicable and patients reported beneficial effects, such as more relaxation, externalization of memories and emotions into artwork, less intrusive thoughts of traumatic experiences and more confidence in the future. The preliminary findings on PTSD symptom severity showed a decrease of symptoms in some participants, and an increase of symptoms in other participants. Further research into the effectiveness of art therapy and PTSD is needed.