Crime and victimization outcomes following civil rights limits to the use of compulsory treatment.

Community treatment orders (CTOs) have been associated with reduced crime/victimization-risk. Australia's ratification of the U.N. Convention on the Rights of Persons with Disabilities (CRPD) enabled patient-rights-advocacy to limit CTO-assignment to persons lacking decision-making-capacity. This effort was accompanied by a 15% reduction in CTO-utilization. Has this change affected crime/victimization-involvements of patients with schizophrenia-diagnoses? In Victoria Australia, the study considers crime/victimization-involvement among three patient-groups recruited with the same sampling-algorithm in the decade before (2000-2009, N = 14,711) and after (2010-2019, N = 10,702) CRPD-ratification. Each group is its own-control. Each group's positive-outcome across decades would be "no increase" in crime/victimization-involvement or in the ratio of the group's incident-rates to the State's. Following CRPD-ratification, first-hospitalized-patients with at least one CTO-assignment doubled their involvement in major crime-perpetrations (from 13% to 27%), non-CTO-hospitalized-patients almost doubled (from 10% to 18%), and 11% of outpatients were involved when none were before. Overall, a third (34%) were victimized-by-major-crime up from 28%, with 25% of outpatients experiencing victimization when none had before. Increases were most evident in major-crimes, led by assaults/abductions. Capacity-constraints on compulsory-treatment are associated with increases in crime/victimization-involvement, a transfer of responsibility for patients with schizophrenia-diagnoses from the mental-health-system to the criminal-justice-system, validation of dangerousness stereotypes, and growing negative family impact.

Mortality-Risk With "Capacity" Constraints On Community Treatment Order Utilization.

Background: Assignment to a community treatment order (CTO) has been associated with reduced mortality risk. In Victoria Australia civil-rights enhancements involving capacity to refuse involuntary treatment have contributed to a 15% reduction between 2010 and 2019 in CTO assignments among first hospitalized patients with Schizophrenia diagnoses. Has this change impacted patient mortality risk? Study Design: This study considered mortality-risk between 2010 and 2019 for 3 patient groups with schizophrenia diagnoses: All 4848 hospitalized patients who were assigned to a CTO for the first time in the period; 3988 matched and randomly selected patients, who were first hospitalized in the decade, without CTO assignment; and 1675 never hospitalized or CTO-assigned outpatients. Deaths of Schizophrenic patients in each group were evaluated against expected deaths given standardized mortality ratios for Victoria. Logistic regression was used to evaluate mortality risk for each treatment group while taking account of race, demographics, differential access to initial diagnoses of life-threatening physical illness, mental health service resources, and indicators of social disadvantage. Study Results: A total of 78% of the 777 deaths of schizophrenia patients in all 3 groups were premature. The 2 hospitalized groups did not differ in mortality risk. Among Victoria's 2010-2019 outpatients (inclusive of treatment refusers with a recorded service contact), 16.2% had a Schizophrenia diagnosis-up from 0.2% in 2000-2009, the prior decade. Outpatients with Schizophrenia were at 48% greater risk of death than individuals in the hospitalized groups, taking all the afore mentioned risk factors into account. Conclusions: Reductions in CTO utilization associated with potential treatment refusals of involuntary community-treatment supervision, seem to have increased mortality risk for this vulnerable population. The line between civil-rights protection and abandonment has been blurred.

Need for Treatment, A Less Restrictive Alternative to Hospitalization, and Treatment Provision: The Utility of Community Treatment Orders.

Background: Provision of involuntary care is an abridgment of civil rights and a source of controversy. Its circumstances require continued monitoring. This study asks 4 questions: Whether, in an era, focused on allowing patients with capacity to refuse community-treatment-order (CTO)-assignments, CTO use decreased. And whether CTOs fulfilled 3 statute mandates: Were CTO-assigned patients in greater need of treatment than other psychiatric inpatients? Was CTO assignment a less-restrictive alternative to psychiatric hospitalization? and Did CTO assignment provide needed treatment at internationally recommended levels with consequences for patient outcomes? Method: All 214 388 Victoria, Australia mental health admissions between 2000- 2017 were reviewed. Two cohort samples were drawn and followed through 2019-ie, all 7826 hospitalized patients who were first placed on CTOs from 2010 to 2017 and 13 896 hospitalized patients without CTO placement. Logistic Regression was used to specify determinants of CTO assignment from the psychiatric inpatient population. OLS Regression with propensity score control to evaluate study questions. Results: In the 2010-2017 decade, initial CTO assignments decreased by 3.5%, and initial hospitalizations increased by 5.9% compared to the 2000-2009 period. At hospital admission and discharge, based on Health of the Nations Score ratings, the CTO-cohort's need for treatment exceeded that of non-CTO patients. CTO patients had 3.75 fewer days in average inpatient episode duration than other inpatients, when adjusted for CTO-assignment determinants, the ratio of patients to community case managers, and patient housing status. CTO patients needing rehospitalization spent 112.68 more days in the community than re-hospitalized non-CTO patients. Patient to case-manager ratios falling above recommended levels and the patient marginal housing status contributed to longer hospital stays and reduced community tenure. Conclusions: Victoria relied less on CTOs as an LRA, consequently, experiencing increased initial hospitalizations. CTO patients were in greater need of treatment than non-CTO patients, yet, with required oversite had shorter hospitalizations and more time out of hospital prior to rehospitalization than the less severely ill non-CTO group. Patient LRA outcomes were adversely affected by higher than recommended community patient to case-manager ratios limiting needed treatment provision to hospital.

The Syrian regime's apparatus for systemic torture: A qualitative narrative study of testimonies from survivors.

BACKGROUND: Despite broad interest of the Syrian refugee plight in the academic and media circles, there are still limited studies analyzing the lived experiences of torture survivors under the Syrian regime. This qualitative study interviewed torture survivors to examine the form and function of the Syrian regime's security apparatus, and the personal aftermath of survivors. METHODS: Thirteen in-depth interviews were conducted in Arabic with Syrian refugees who endured torture. Study participants were at least 19 years of age, resided as refugees in Jordan, and voluntarily agreed to participate in the study. Participation was anonymous and no incentives were provided. Only oral consent was required. Audio-recorded interviews were transcribed and translated to English, and then analyzed for repetitive themes utilizing the narrative approach. RESULTS: Major themes were observed across three experience-phases: pre-captivity, during captivity, and post-captivity. The pre-captivity phase included two sub-themes: the Syrian regime's initial detection and arrest system, and the intelligence system. The captivity phase was also divided into two sub-themes: environmental conditions in detention facilities, and torture methods including physical and psychological torture. Some of the environmental conditions in detention facilities included lack of sanitation, crowding, starvation, and withholding of medical care. Torture methods encompassed beatings, electric shocks, nail-pulling, hanging, drowning, suffocation, rape, and the witnessing of killing, sexual assault, or torture of others. The post-captivity phase included their release from captivity, escaping Syria, and post-displacement conditions and activism. CONCLUSIONS: The Syrian regime employs a vast security apparatus to track, detain, interrogate, torture, and subjugate its civilian population. A systematic mechanism commences even before captivity and continues for years after release, with negative implications on the well-being of survivors, their families, and the Syrian people as a collective community. The Syrian war saw a shift toward mass detention, torture as a form of social punishment, subjugation, and indeterminate imprisonment. Intervention agencies, host countries, and policymakers must be informed of survivors' experiences to better address their needs. Moreover, the international community must advocate for a firm stance against torture, demand justice, and prosecute all parties engaged in perpetuating such extreme forms of suffering and trauma.

Accessing acute medical care to protect health: the utility of community treatment orders.

Background: The conclusion that people with severe mental illness require involuntary care to protect their health (including threats due to physical-non-psychiatric-illness) is challenged by findings indicating that they often lack access to general healthcare and the assertion that they would access such care voluntarily if available and effective. Victoria, Australia's single-payer healthcare system provides accessible medical treatment; therefore, it is an excellent context in which to test these challenges. Aims: This study replicates a previous investigation in considering whether, in Australia's easy-access single-payer healthcare system, patients placed on community treatment orders, specifically involuntary community treatment, are more likely to access acute medical care addressing potentially life-threatening physical illnesses than voluntary patients with and without severe mental illness. Methods: Replicating methods used in 2000-2010, for the years 2010-2017, this study compared the acute medical care access of three new cohorts: 7826 hospitalised patients with severe mental illness who received a post-hospitalisation, community treatment order; 13 896 patients with severe mental illness released from the hospital without a community treatment order and 12 101 outpatients who were never psychiatrically hospitalised (individuals with less morbidity risk who were not considered to have severe mental illness) during periods when they were under versus outside community mental health supervision. Logistic regression was used to determine the influence of community-based community mental health supervision and the type of community mental health supervision (community treatment order vs non-community treatment order) on the likelihood of receiving an initial diagnosis of a life-threatening physical illness requiring acute care. Results: Validating their shared elevated morbidity risk, 43.7% and 46.7%, respectively, of each hospitalised cohort (community treatment order and non-community treatment order patients) accessed an initial acute-care diagnosis for a life-threatening condition vs 26.3% of outpatients. Outside community mental health supervision, the likelihood that a community treatment order patient would receive a diagnosis of physical illness was 36% lower than non-community treatment order patients-1.30 times that of outpatients. Under community mental health supervision, their likelihood was two times greater than that of non-community treatment order patients and 6.6 times that of outpatients. Each community treatment order episode was associated with a 14.6% increase in the likelihood of a community treatment order patient receiving a diagnosis. The results replicate those found in an independent 2000-2010 cohort comparison. Conclusions: Community mental health supervision, notably community treatment order supervision, in two independent investigations over two decades appeared to facilitate access to physical healthcare in acute care settings for patients with severe mental illness who were refusing treatment-a group that has been subject to excess morbidity and mortality.

Protecting Health and Safety with Needed-Treatment: the Effectiveness of Outpatient Commitment.

Outpatient civil commitment (OCC) requires the provision of needed-treatment, as a less restrictive alternative (LRA) to psychiatric-hospitalization in order to protect against imminent-threats to health and safety associated with severe mental illness (SMI). OCC-reviews aggregating all studies report inconsistent outcomes and interpret such as intervention failure. This review, considering those studies whose outcome criteria are consistent with the provisions of OCC-law, seeks to determine OCC-effectiveness in meeting its legislated objectives. This review incorporated studies from previous systematic-reviews, used their search methodology, and added investigations through August 2020. Selected OCC-studies evaluated samples of all eligible patients in a jurisdiction. Their outcome-measures were threats to health or safety or the receipt of needed-treatment exclusive of post-OCC-assignment- hospitalization, the latter being the OCC-default for providing needed-treatment in the absence of an LRA and dependent on bed-availability. A study's evidence-quality was evaluated with the Berkeley Evidence Ranking and the New Castle Ottawa systems. Thirty-nine OCC-outcome-studies in six-outcome-areas directly addressed OCC-statute objectives: 21 considered imminent threats to health and safety, 10 compliance with providing needed-treatment, and 8 conformity to the LRA-standard. With the top evidence-rank equal to one, the studies M = 2.55. OCC-assignment was associated with reducing mortality-risk, increasing access to acute-medical-care, and reducing risks of violence and victimization. It enabled reaching these objectives as a LRA to hospitalization and facilitated the use of community-services by individuals refusing such assistance when outside of OCC-supervision. OCC's appears to enable recovery by reducing potentially life-altering health and safety risks associated with SMI.

Hospital Utilization Outcomes Following Assignment to Outpatient Commitment.

Outpatient civil commitment (OCC) requires people with severe mental illness (SMI) to receive needed-treatment addressing imminent-threats to health and safety. When available, such treatment is required to be provided in the community as a less restrictive alternative (LRA) to psychiatric-hospitalization. Variance in hospital-utilization outcomes following OCC-assignment has been interpreted as OCC-failure. This review seeks to specify factors accounting for this outcome-variation and to determine whether OCC is used effectively. Twenty-five studies, sited in seven meta-analyses and subsequently published investigations, assessing post-OCC-assignment hospital utilization outcomes were reviewed. Studies were grouped by structural pre-determinants of hospital-utilization and OCC-implementation-i.e. deinstitutionalization (bed-availability), availability of a less restrictive alternative to hospitalization, and illness severity. Design quality at study completion was ranked on causal-certainty. In OCC-follow-up-studies, deinstitutionalization associated hospital-bed-cuts, when not taken into account, ensured lower hospital-bed-day utilization. OCC-assignment coupled with aggressive case-management was associated with reduced-hospitalization. With limited community-service, hospitalizations increased as the default option for providing needed-treatment. Follow-up studies showed less hospitalization while on OCC-assignment and more outside of it. Studies using fixed-follow-up periods usually found increased-utilization as patients spent less time under OCC-supervision than outside it. Comparison-group-studies reporting no between-group differences bring more severely ill OCC-patients to equivalent use as less disturbed patients, a success. Mean evidence-rank for causal-certainty 2.96, range 2-4, of 5 with no study ranked 1, the highest rank. Diverse mental health systems yield diverse OCC hospital-utilization outcomes, each fulfilling the law's legal mandate to provide needed-treatment protecting health and safety.

Manzuaat wa Musharadat, Uprooted and Scattered: Refugee Women Escape Journey and the Longing to Return to Syria.

OBJECTIVE: Violent conflict forced millions of Syrians to flee their homes to host countries. This study examines Syrian refugee women's experiences from the war's outset through their journey to Jordan. It addresses the toll this journey had on their lives. METHODS: Twenty-four in-depth interviews were completed with Syrian refugee women who currently reside in urban areas of Jordan. Researchers translated, transcribed, and analyzed the interviews using group narrative methodology. RESULTS: The Syrian women had unique nostalgic memories of times before the war. They experienced atrocities during the war that forced their decision to escape Syria. Their journey narratives testify of internal displacement, personal and collective traumatic journeys via legal and illegal routes. Almost all the women were placed in refugee camps during their transitions to host country residency. In Jordan, they faced diverse hurdles of displacement and extremely different realities compared to the ones they had in Syria. Despite how very different but difficult each of their journeys were, every single woman longed to return home to Syria. CONCLUSIONS: This study presents a new understanding of the role and process of the journeys undertaken and highlights the concept of "return" as the defining element for Syrian refugee women. Regardless of the hardships women endured to escape their homeland to find safety, "return" marks an ending to their horror journey and the beginning of a new journey of hope for a better future.

Rape Crisis Counseling: Trauma Contagion and Supervision.

This study of rape crisis counselors considers whether increased exposure to victims' trauma is associated with increased supervision-believed necessary to combat trauma contagion-and whether such supervision will reduce the negative impact of such exposure. One hundred six women counselors in seven of nine rape crisis centers in Israel completed anonymous questionnaires documenting their work and trauma exposure. Trauma exposure was defined by counselors' number of victim-contact hours per week and their assessment of the trauma severity they experienced. Supervision was measured by the number of hours received. Counselors trauma outcome indicators included sexual intimacy, secondary traumatization (evidenced in posttraumatic stress disorder [PTSD]-type symptomology), and vicarious traumatization (expressed as a disturbance in cognitive schemes that undermine the self and others). Hypotheses were evaluated in fully recursive path analyses via ordinary least squares (OLS) regression. Participants' mean age was 43.4 years; 58% were married, 26% single, 13% divorced, and 3% widowed; 81% had a college degree or more; 18.9% reported being exposed to victims-trauma at a minimal level, 54.7% moderate and 26.4% extreme; and 43.4% were abused at some time in their lives. Job exposure to victims' trauma was significantly associated with increases in supervision time (ß = .33, p = .002). Supervision time fully mediated the relationship between duration of exposure to victims' trauma and counselors' secondary traumatization reports such that increased supervision was associated with degrading sexual intimacy (ß = .22; p = .032) and increased Secondary Trauma Scale scores (ß = .44; p = .004) after taking into account counselors' education level, history of abuse, anger management in intimate relationship, and posttraumatic growth scores. The study results raise concern about counselors' mental health in that the supervision effect exacerbated the trauma contagion impacts. The study suggests a need for documenting the nature of the supervision and considering different types of supervision methods.

"Children Are Not Children Anymore; They Are a Lost Generation": Adverse Physical and Mental Health Consequences on Syrian Refugee Children.

This research examines Syrian refugee mothers' accounts of the physical and mental health of their children being affected by war traumas and displacement challenges. Open-ended audio-recorded interviews were conducted in Arabic with 23 mothers residing in Jordan. Using a narrative approach in the data collection and analysis, five major themes were identified: (1) children were exposed to diverse war traumatic experiences in Syria; (2) the escape journey and refugee camps threatened children's lives; (3) displacement and family stressors exposed children to poverty, hostility from local peers, educational and recreational challenges, child labor, and domestic violence (these three major themes were considered as trauma related variables); (4) children were not only directly affected physically and mentally by their own traumatic experiences and displacement stressors, but these experiences were mediated and magnified by familial interrelated processes, evidenced in intergenerational transmission of trauma, harsh parenting style, parental control, and parentification; and (5) adverse consequences of both trauma related variables and family processes directly and indirectly traumatized children and adversely impacted their physical and mental health. We examined the themes that emerged from the data in view of three theoretical frameworks and the impact of trauma in the family system on child development. To conclude, humanitarian organizations that provide services and interventions to refugees need to take into account familial processes and not only individual factors affecting refugee children's physical and mental health. Further implications on policies and trauma research are discussed.

Refugee trauma work: Effects on intimate relationships and vicarious posttraumatic growth.

BACKGROUND: Bearing witness to Syrian refugee atrocities may result in aid-workers' vicarious traumatization (VT). This study examined work stressors and organizational support and their associations with vicarious posttraumatic growth (VPTG) and intimate relationships. It also examined the potential mediating effects of differentiation of the self and finding meaning in trauma-work. METHODS: Aid-workers (N = 317) from organizations in Jordan were surveyed. Univariate statistics and structural equation modeling (SEM) were utilized to test hypothesized relationships. RESULTS: Increased VT was associated with increased VPTG, decreased intimacy and decreased differentiation. Increased needs addressed by NGOs was associated with increased VPTG, differentiation, and finding meaning. Increased trauma-exposure was associated with increased finding meaning. Increased co-workers support was associated with increased intimacy and finding meaning. Higher differentiation was associated with decreased VPTG, and increased intimacy. Whereas, increased finding meaning was associated with increased VPTG and intimacy. Differentiation partially mediated the associations between VT, and both VPTG and intimacy, and between needs at work and VPTG. Differentiation fully mediated the association between needs at work and intimacy. Finding meaning fully mediated the associations between extent of trauma-exposure, and both VPTG and intimacy, and between co-workers support and VPTG; needs at work and intimacy. It partially mediated the associations between needs at work and VPTG; co-workers support and intimacy. LIMITATIONS: The study is cross-sectional and generalization is limited to aid-workers who provide services to Syrian refugees in Jordan. CONCLUSIONS: Organizational support is crucial in mitigating the negative impacts of trauma-work, and in enabling a nurturing space for potential growth.

The utility of outpatient civil commitment: Investigating the evidence.

BACKGROUND: Outpatient civil commitment (OCC), community treatment orders (CTOs) in European and Commonwealth nations, require the provision of needed-treatment to protect against imminent threats to health and safety. OCC-reviews aggregating all studies report inconsistent outcomes. This review, searches for consistency in OCC-outcomes by evaluating studies based on mental health system characteristics, measurement, and design principles. METHODS: All previously reviewed OCC-studies and more recent investigations were grouped by their outcome-measures' relationship to OCC statute objectives. A study's evidence-quality ranking was assessed. Hospital and service-utilization outcomes were grouped by whether they represented treatment provision, patient outcome, or the conflation of both. RESULTS: OCC-studies including direct health and safety outcomes found OCC associated with reduced mortality-risk, increased access to acute medical care, and reduced violence and victimization risks. Studies considering treatment-provision, found OCC associated with improved medication and service compliance. If coupled with assertive community treatment (ACT) or aggressive case management OCC was associated with enhanced ACT success in reducing hospitalization need. When outpatient-services were limited, OCC facilitated rapid return to hospital for needed-treatment and increased hospital utilization in the absence of a less restrictive alternative. OCC-studies measuring "total hospital days", "prevention of hospitalization", and "readmissions" report negative and/or no difference findings because they erroneously conflate their intervention (provision of needed treatment) and outcome. CONCLUSIONS: This investigation finds replicated beneficial associations between OCC and direct measures of imminent harm indicating reductions in threats to health and safety. It also finds support for OCC as a less restrictive alternative to inpatient care.

Trauma during humanitarian work: the effects on intimacy, wellbeing and PTSD-symptoms.

Background: Organizations assisting refugees are over burdened with the Syrian humanitarian catastrophe and encounter diverse difficulties facing the consequences of this massive displacement. Aid-workers experience the horrors of war through their efforts to alleviate suffering of Syrian refugees. Objective: This study of Syrian refugee aid-workers in Jordan examined work-stressors identified as secondary traumatic stress (STS), number of refugees assisted, worker feelings towards the organization, and their associations to PTSD-symptoms, wellbeing and intimacy. It also examined whether self-differentiation, physical health, and physical pain were associated with these variables. Method: Syrian refugee aid-workers (N = 317) in Jordan's NGOs were surveyed. Univariate statistics and structural equation modeling (SEM) were utilized to test study hypotheses. Results: Increased STS was associated with lower self-differentiation, decreased physical health and increased physical pain, as well as elevated PTSD-symptoms and decreased intimacy. Decreased connection to the NGO was associated with lower self-differentiation, decreased physical health, increased physical pain, and with decreased intimacy and wellbeing. Lower self-differentiation was associated with increased PTSD-symptoms, decreased wellbeing and intimacy. Elevated physical pain was associated with increased PTSD-symptoms, and decreased wellbeing. Diverse mediation effects of physical health, physical pain and self-differentiation were found among the study's variables. Conclusions: Aid-workers who assist refugees were at risk of physical and mental sequelae as well as suffering from degraded self-differentiation, intimacy and wellbeing. Organizations need to develop prevention policies and tailor interventions to better support their aid-workers while operating in such stressful fieldwork.

Antecedentes: Las organizaciones que ayudan a los refugiados están sobrecargadas con la ayuda humanitaria siria catástrofe y encontrar diversas dificultades que enfrentan las consecuencias de esta masiva. Los trabajadores de ayuda al desplazamiento experimentan los horrores de la guerra a través de sus esfuerzos para alivian el sufrimiento de los refugiados sirios.Objetivo: Este estudio de trabajadores humanitarios de refugiados sirios en Jordania examinó los estresores laborales identificados como el estrés traumático secundario (STS en sus siglas en inglés), el número de refugiados asistidos, los sentimientos del trabajador con respecto a la organización, y sus asociaciones con los síntomas del TEPT, bienestar e intimidad. Se examinó también si la auto-diferenciación, la salud física, y el dolor físico se asociaban con estas variables.Método: Se encuestaron los trabajadores humanitarios de refugiados sirios (N=317) de organizaciones no gubernamentales (ONGs) en Jordania. Se utilizaron las estadísticas univariadas y el modelamiento de ecuaciones estructurales (SEM en sus siglas en inglés) para probar las hipótesis del estudio.Resultados: El aumento en el STS se asoció con una más baja auto-diferenciación, una disminuida salud física y un aumento del dolor físico, como también con síntomas elevados de TEPT y una intimidad disminuida. Una conexión disminuida con la ONG se asoció con una más baja auto-diferenciación, una disminuida salud física, un aumento de dolor físico, y con una disminuida intimidad y bienestar. Una más baja auto-diferenciación se asoció con un aumento en los síntomas del TEPT, y un disminuido bienestar e intimidad. El dolor físico elevado fue asociado con un aumento en los síntomas del TEPT, y un disminuido bienestar. Se encontraron diversos efectos mediadores de la salud física, dolor físico y la auto-diferenciación entre las variables del estudio.Conclusiones: Los trabajadores humanitarios que asisten a los refugiados se encuentran en riesgo de secuelas físicas y mentales como también de sufrir un deterioro en su auto-diferenciación, intimidad y bienestar. Las organizaciones necesitan desarrollar políticas de prevención y adaptar intervenciones para apoyar mejor a sus trabajadores humanitarios mientras operan en tan estresante campo laboral.

War can harm intimacy: consequences for refugees who escaped Syria.

BACKGROUND: Syrians seeking refuge have been exposed to atrocities and trauma beyond comprehension. This study examines how personal, interpersonal, displacement and war-related factors have impacted married refugees' intimate lives. METHODS: Data included 158 married Syrian refugee individuals who live in the host communities of Jordan. Refugees reported on their personal, interpersonal, current-displacement and past-war related experiences. Traumatic impacts were assessed using the Harvard Trauma Questionnaire (HTQ), K6 screening scale for serious mental illness (SMI), The War Events Questionnaire (WEQ), and Personal Assessment of Intimacy in Relationships (PAIR). Stepwise multiple regressions were used to determine the factors associated with refugees' intimacy-total score and its six dimensions. RESULTS: Most refugees (94.2%) experienced war events, and 34% screened positive on the PTSD-HTQ scale. Overall intimacy scores were low, scoring M (±standard deviation) = 2.4 (±1.1) of a possible five on average. Intimacy scores were lower for refugees who screened positive on the PTSD-HTQ (M = 1.95 ± 65) compared to the ones screening negative, respectively (M = 2.23 ± 66). Furthermore, the higher the PTSD symptoms reported, the lower the couples' intimacy. PTSD and forced marriage were the strongest factors to predict decreased total-intimacy scores (ß = -0.23, P = 0.002; ß = -0.32, P < 0.001), and decreased scores on four dimensions of intimacy (emotional, sexual, intellectual and recreational). Whereas gender was the second strongest factor associated with decreased total-intimacy scores (ß = -0.29, P < 0.001), and decreased scores on three dimensions of intimacy (emotional, social and anger), meaning that women reported suffering more than men from deteriorated intimacy in their marital relationships. Other displacement and war-related factors associated with intimacy were: decreased sexual intimacy associated with having been raped; increased intellectual intimacy associated with escaped from Syria with one's spouse; decreased recreational intimacy associated with the number of family members lived with; decreased sexual, emotional and total-intimacy scores associated with number of children; and years of education as a seemingly personal protective factor associated with increased intellectual and recreational intimacy. CONCLUSIONS: Addressing Syrian refugees' intimacy issues in interventions is essential, as well as raising the awareness of stakeholders and community leaders to the negative impacts of PTSD, forced marriage, rape, and displacement difficulties endured by the already challenged and distressed married refugees.

The utility of outpatient commitment: Reduced-risks of victimization and crime perpetration.

BACKGROUND: Outpatient civil commitment (OCC) provisions, community treatment orders (CTOs) in Australia and Commonwealth nations, are part of mental health law worldwide. This study considers whether and by what means OCC provides statutorily required "needed-treatment" addressing two aspects of its legal mandate to protect the safety of self (exclusive of deliberate-self-harm) and others. METHOD: Over a 12.4-year period, records of hospitalized-psychiatric-patients, 11,424 with CTO-assignment and 16,161 without CTO-assignment were linked to police-records. Imminent-safety-threats included perpetrations and victimizations by homicides, rapes, assaults/abductions, and robberies. "Need for treatment" determinations were validated independently by Health of the Nations Scale (HoNOS) severity-score-profiles. Logistic regressions, with propensity-score- adjustment and control for 46 potential confounding-factors, were used to evaluate the association of CTO-assignment with occurrence-risk of perpetrations and victimizations. RESULTS: CTO-assignment was associated with reduced safety-risk: 17% in initial-perpetrations, 11% in initial-victimizations, and 22% for repeat-perpetrations. Each ten-community-treatment-days in interaction with CTO-assignment was associated with a 3.4% reduced-perpetration-risk. CTO-initiated-re-hospitalization was associated with a 13% reduced-initial-perpetration-risk, a 17% reduced-initial-victimization-risk, and a 22% reduced-repeat-victimization-risk. All risk-estimates appear to be the unique contributions of the CTO, CTO-initiated-re-hospitalization, or the provision of ten-community-treatment-days-i.e. after accounting for the influence of prior crimes and victimizations, ethnic-bias, neighborhood disadvantage and other between-group differences in the analysis. CONCLUSIONS: CTO assignment's association with reduced criminal-victimization and perpetration-risk, in conjunction with requiring participation in needed-treatment via re-hospitalization and community-service, adds support to the conclusion that OCC is to some extent fulfilling its legal objectives related to protecting safety of self (exclusive of deliberate-self-harm), and others.

The utility of outpatient commitment: acute medical care access and protecting health.

OBJECTIVES: This study considers whether, in an easy access single-payer health care system, patients placed on outpatient commitment-community treatment orders (CTOs) in Victoria Australia-are more likely to access acute medical care addressing physical illness than voluntary patients with and without severe mental illness. METHOD: For years 2000 to 2010, the study compared acute medical care access of 27,585  severely mentally ill psychiatrically hospitalized patients (11,424 with and 16,161 without CTO exposure) and 12,229 never psychiatrically hospitalized outpatients (individuals with less morbidity risk as they were not considered to have severe mental illness). Logistic regression was used to determine the influence of the CTO on the likelihood of receiving a diagnosis of physical illness requiring acute care. RESULTS: Validating their shared and elevated morbidity risk, 53% of each hospitalized cohort accessed acute care compared to 32% of outpatients during the decade. While not under mental health system supervision, however, the likelihood that a CTO patient would receive a physical illness diagnosis was 31% lower than for non-CTO patients, and no different from lower morbidity-risk outpatients without severe mental illness. While, under mental health system supervision, the likelihood that CTO patients would receive a physical illness diagnosis was 40% greater than non-CTO patients and 5.02 times more likely than outpatients were. Each CTO episode was associated with a 4.6% increase in the likelihood of a member of the CTO group receiving a diagnosis. CONCLUSION: Mental health system involvement and CTO supervision appeared to facilitate access to physical health care in acute care settings for patients with severe mental illness, a group that has, in the past, been subject to excess morbidity and mortality.

Well-Being and Posttraumatic Growth Among Syrian Refugees in Jordan.

The Syrian War has created a mass exodus of Syrian citizens to neighboring countries and exposed them to many atrocities. We explored factors affecting well-being and posttraumatic growth (PTG) of refugees residing in Jordan. Participants (N = 250) were surveyed via nongovernmental organizations (NGOs). Outcome criteria included a global well-being rating and the Posttraumatic Growth Inventory. Trauma exposure assessment included The Harvard Trauma Questionnaire (HTQ) and The War Events Questionnaire. Ordinary least squares regression examined associations between potential contributors to refugee well-being and PTG, including work, age, sex, income, education, posttraumatic stress disorder (PTSD) severity, physical pain, health, NGO assistance, psychotic/affective mental disorder, and length of residence in Jordan. Mean participant score on the PTSD-HTQ scale was 2.37 (SD = 0.63; range: 1 [no symptoms] to 3.88 [extremely severe symptoms]). Additionally, 74.6% of participants received NGO assistance and 92.7% experienced war events. Univariate and multivariate results indicated enhancement of well-being was associated with income, r = .34, ß = .26, p < .001; health, r = .35, ß = .26, p = .001; and absence of affective disorder, r = -.31, ß = -.18, p = .012; and that PTG increased in association with income, r = .28, ß = .20, p = .007; NGO assistance, r = .07, ß = .14, p = .045; and absence of psychosis, r = -.12, ß = -.17, p = .013, and affective disorder, r = -.26; ß = -.16, p = .033. Findings suggest sufficient income and humanitarian assistance can contribute to Syrian refugees' mental health.

Contributors to Screening Positive for Mental Illness in Lebanon's Shatila Palestinian Refugee Camp.

This study evaluates contributors to the mental health status of Palestinians, Syrians, and nonrefugee residents of Lebanon's Shatila Refugee Camp. Primary health care clinic patients in Shatila were screened for mental illness between 2012 and 2013 using the K6, the Primary Care Posttraumatic Stress Disorder (PTSD), and the Modified Mini International Neuropsychiatric Interview. Logistic regressions enabled the consideration of potential contributors to participants' positive mental illness screens. The sample (n = 254) included 63.4% Palestinians, 18.5% Syrians, and 18.1% nonrefugees. People lived in the camp for 21.1 years (±17), 63% had stable housing and 78% had war event exposure. Mental illness prevalence was 51.6% in total (34.8% serious mental illness [SMI] alone, 5.1% PTSD alone, 11.4% comorbid SMI/PTSD, and 0.08% comorbid psychotic spectrum disorder SMI/PTSD). For Palestinians and nonrefugees, respectively, stable housing accounted for a 79% and a 98% reduction in positive SMI screen risk. For Syrians, access to paid employment accounted for a 66% risk reduction. Stable living situations and economically productive employment for those trapped in a refugee situation, even in the face of war trauma, seem most important for ensuring reduced mental disorder risk.

The Utility of Outpatient Commitment: II. Mortality Risk and Protecting Health, Safety, and Quality of Life.

OBJECTIVE: This study assessed the contribution of a form of outpatient commitment-community treatment orders (CTOs)-to mortality risk and quality of life of patients with severe mental illness. METHODS: Data (2000--2012) were obtained from the Australian National Death Index, Victoria Department of Health, Victoria police records, and National Outcomes and CaseMix Collection quality-of-life records for patients in the Victorian Psychiatric Case Register/RAPID with a history of psychiatric hospitalization: CTO cohort, N=11,424; non-CTO cohort, N=16,161. The contribution of CTOs to mortality risk associated with CTO facilitation of access to general medical care and prevention of criminal involvement was assessed with logistic regression models. Cohort differences in quality of life were also examined. RESULTS: A total of 2,727 patients (10%) in the overall sample died, and the sample had a higher mortality risk than the general population. Probability of death by any cause was 9% lower in the CTO cohort than in the non-CTO cohort. Facilitation of access to medical care accounted for a 20% reduction in risk of non-injury-related deaths in the CTO cohort, compared with the non-CTO cohort. Risk of death by self-harm was 32% higher, compared with the non-CTO cohort. CTO placement appeared to lead to a gain of 3.8 years of life among men and 2.4 years among women, compared with the non-CTO cohort. Quality-of-life scores were modestly less favorable for the non-CTO cohort. CONCLUSIONS: CTO placement was associated with lower mortality risk via facilitated access to medical care and with modest enhancement of quality of life.