Improving access to evidence-based interventions for trauma-exposed adults in low- and middle-income countries.

In low- and middle-income countries (LMICs), the mental health consequences of trauma exposure pose a substantial personal, societal, and economic burden. Yet, the significant need for evidence-based mental health treatment remains largely unmet. To unlock the potential for mental health care for trauma survivors in lower-resource contexts, it is critical to map treatment barriers and identify strategies to improve access to evidence-based, culturally appropriate, and scalable interventions. This review, based on an International Society for Traumatic Stress (ISTSS) briefing paper, describes the treatment gap facing adults with traumatic stress in LMICs and identifies the barriers that contribute to this gap. We then highlight strategies for enhancing access to effective treatments for these populations, including task-sharing, the use of culturally adapted and multiproblem interventions, and digital tools to scale access to appropriate care. Finally, we offer recommendations for policymakers, researchers, and service providers to guide an agenda for action to close the treatment gap for trauma survivors in LMICs.

Mixed-Method Investigations Uncovering Tension, PTSD Symptoms, and Trauma-Related Difficulties Among Indian Women from Slums Reporting Gender-Based Violence.

Indian women exposed to gender-based violence (GBV) report experiencing cultural concepts of distress, such as tension, and trauma-related difficulties. However, tension and trauma-related sequalae have not been explicitly explored. The present study examined the symptoms, causes, and coping strategies associated with tension among slum-residing Indian women reporting GBV (N = 100). This study also explored linkages between tension and posttraumatic stress disorder (PTSD) symptom severity. Qualitative results among a subsample of women (n = 38) indicated tension was commonly reported. Tension was characterized by varied affective, behavioral, cognitive, and somatic components and was most commonly caused by interpersonal stressors. Participants described various coping strategies to manage tension, including avoiding, cognitively reframing, considering consequences, distracting themselves, seeking medical, religious and/or spiritual assistance, finding social support, and tolerating tension. Barriers to coping were stigma, hopelessness about present circumstances, and negative reactions from others. One-way analysis of covariance with Bonferroni-adjusted post hoc results (N = 100) indicated that participants with higher tension exhibited significantly higher PTSD symptom severity as compared to participants reporting no tension. Altogether, the polyvalence of tension suggested that it requires idiographic assessment. Tension appears responsive to skills consistent with evidence-based psychological treatments for Indian women from slums reporting GBV.

A pilot study adapting and validating the Harvard Trauma Questionnaire (HTQ) and PTSD checklist-5 (PCL-5) with Indian women from slums reporting gender-based violence.

BACKGROUND: Despite high rates of gender-based violence (GBV) in India, culturally sensitive measures that examine universal and culturally relevant trauma reactions are lacking. Although the Harvard Trauma Questionnaire (HTQ) has been used in India, no study has adapted the measure in full for use with this population. Similarly, the  PTSD checklist-5 (PCL-5) has not yet been validated in India. This study describes the adaptation, validation, and results from the adapted HTQ, and embedded PCL-5, for Indian women from slums reporting GBV. METHOD: This study used the adaptation framework proposed by the HTQ measure developers. The adapted HTQ contained a (1) trauma screen relevant for stressors faced by Indian women from slums, (2) description of the index trauma, (3) description of any ongoing stressors, (4) universal trauma reactions (i.e., PTSD measured by the PCL-5), and culturally relevant trauma reactions (i.e., idioms of distress measured by a scale developed for the study). This measure was piloted on 111 women from Indian slums in face-to-face interviews. Trauma characteristics, types of ongoing stressors, and psychometric properties of the PCL-5 and idioms of distress scale were explored. These scales were validated against measures of depression (PHQ-9), anxiety (GAD-7), and somatic complaints (PHQ-15). RESULTS: The majority of participants (77%) reported physical beatings, 18% reported unwanted sexual touch, and 28.8% reported infidelity as the primary emotional abuse. Further, 96.7% of GBV was perpetrated by partner or family member and over half reported ongoing stressors (e.g., poverty-related strain). The PCL-5 embedded in the HTQ yielded good internal consistency (Cronbach's alpha = .88) as did the idioms of distress scale with deletion of one item (Cronbach's alpha = .80). Both scales were externally valid, yielding large correlations with depression, anxiety, and somatic complaints (rs between .54 and .80, ps < .05). DISCUSSION: This is the first study to develop a comprehensive measure of trauma exposure with universal and culturally relevant trauma reactions in India. This study also enhances HTQ usage in India by delineating all the steps in the adaptation process. Results can inform the development of trauma-focused interventions for Indian women from slums.

Unpacking the 'black box' of suicide: A latent class analysis predicting profiles of suicidal ideation in a longitudinal cohort of adolescent girls from India.

INTRODUCTION: Indian women account for 37% of global suicide-related deaths. As suicide is a growing concern among adolescent girls, identifying the social determinants of suicide with this group targeted prevention. We selected social determinants that include intersectional identities and broader syndemics; we then used longitudinal data from a prospective cohort of adolescent girls from Northern India to classify them into unique profiles across multiple socioecological levels. METHODS: Girls aged 10-19 (N = 11,864) completed self-report questionnaires measuring socio-demographic and trauma exposure variables. At three-year follow-up, they were asked to indicate current suicidal ideation (SI). We conducted latent class analysis (LCA) to classify profiles and then predicted risk of current SI at three-year follow-up. RESULTS: LCA supported a four-class solution: a 'privileged' class (Class 1; n = 1,470), a 'modal' class (Class 2; n = 7,449), an 'intergenerational violence' class (Class 3; n = 2,113), and a 'psychological distress' class (Class 4; n = 732). Classes significantly predicted odds ratios (OR) for SI at follow up; women in Class 4 were associated with the greatest likelihood of SI (OR 1.84, 95% CI 1.38, 2.47), suggesting that psychological distress factors confer greatest risk. CONCLUSION: Results of the distinct classes of risk and protective factors indicate targets for policy-level interventions. Disrupting cycles of psychological distress and substance use, increasing access to behavioral interventions, and intervening to mitigate intergenerational violence may be particularly impactful with this population.

Psychotherapies for Generalized Anxiety Disorder in Adults: A Systematic Review and Network Meta-Analysis of Randomized Clinical Trials.

Importance: Generalized anxiety disorder (GAD) is one of the most common mental disorders in adults. Psychotherapies are among the most recommended treatments for GAD, but which should be considered as first-line treatment needs to be clarified. Objective: To use a network meta-analysis to examine the short- and long-term associations of different psychotherapies with outcomes of effectiveness and acceptability in adults with GAD. Data Sources: MEDLINE, Embase, PsycINFO, and the Cochrane Register of Controlled Trials were searched from database inception to January 1, 2023, to identify randomized clinical trials (RCTs) of psychotherapies for adults with GAD. Study Selection: RCTs comparing any type of psychotherapy against another or with a control condition for the treatment of adults (≥18 years, both sexes) with a primary diagnosis of GAD were eligible for inclusion. Data Extraction and Synthesis: This study followed Cochrane standards for extracting data and assessing data quality and used the PRISMA guideline for reporting. Risk of bias of individual studies was assessed using the second version of the Cochrane risk of bias tool, and the Confidence in Network Meta-Analysis was used to rate the certainty of evidence for meta-analytical results. Main Outcomes and Measures: Eight psychotherapies were compared against one another and with 2 control conditions. Primary outcomes were severity of GAD symptoms and acceptability of the psychotherapies. Random-effects model pairwise and network meta-analyses were conducted. For effectiveness, standardized mean differences (SMDs) were pooled, and for acceptability, relative risks with 95% CIs were calculated. Results: Data from 65 RCTs were included. Effect size estimates on data from 5048 participants (mean [SD], 70.9% [11.9%] women; mean [SD] age, 42.2 [12.5] years) suggested that third-wave cognitive behavior therapies (CBTs) (SMD, -0.76 [95% CI, -1.15 to -0.36]; certainty, moderate), CBT (SMD, -0.74 [95% CI, -1.09 to -0.38]; certainty, moderate), and relaxation therapy (SMD, -0.59 [95% CI, -1.07 to -0.11]; certainty, low) were associated with reduced GAD symptoms vs treatment as usual. Relative risks for all-cause discontinuation (indication of acceptability) signaled no differences compared with treatment as usual for all psychotherapies (eg, relative risk, 1.04 [95% CI, 0.64-1.67] for CBT vs treatment as usual). When excluding studies at high risk of bias, relaxation therapy lost its superiority over treatment as usual (SMD, -0.47; 95% CI, -1.18 to 0.23). When considering anxiety severity at 3 to 12 months after completion of the intervention, only CBT remained significantly associated with greater effectiveness than treatment as usual (SMD, -0.60; 95% CI, -0.99 to -0.21). Conclusions and Relevance: Given the evidence in this systematic review and network meta-analysis for its associations with both acute and long-term effectiveness, CBT may represent the first-line therapy of GAD. Third-wave CBTs and relaxation therapy were associated with short-term effectiveness and may also be offered.

"I put a stone on my heart and kept going": An explanatory model of how distress is generated and regulated among Indian women from slums reporting gender-based violence.

Clinical variation in the expression of panic disorder, depression and anxiety, and posttraumatic stress disorder (PTSD) has have been documented across cultures. However, local (emic) cultural models that explain how people make sense of their illness experiences remain relatively understudied in India among trauma-exposed populations. Further, the integration of emic findings into clinical care is limited, underscoring the need for emic perspectives following trauma to improve the development or adaptation of trauma-focused treatments in India. This study describes an emic explanatory model of distress, which includes idioms of distress, perceived causes of distress, and coping/help-seeking behaviors among Indian women from slums reporting gender-based violence. This explanatory model can be used as a culturally grounded way to develop clinical case conceptualizations to adapt and deliver psychological treatments for this under-served population.

Drug-facilitated sexual assault, impaired trauma memory, and implications for mental health treatment.

Background: Sexual assault (SA) is a highly prevalent global public health problem and a robust predictor of posttraumatic stress disorder (PTSD), substance use disorder (SUD), and suicidality. A large percentage are drug or alcohol facilitated (DFSA), impairing trauma memory and affecting the application of evidence-based treatments. Despite these problems, few have investigated DFSA-specific mental health (MH) needs. Objective: Goals of this study were (1) to identify psychological sequelae characterizing DFSA towards explaining why symptoms have been treatment-refractory, comparing survivors with involuntary substance ingestion (forced, covert: DFSA-I), voluntary ingestion (DFSA-V), and non-DFSA; and (2) to determine how impaired trauma memory relates to the development of PTSD and depression symptoms. Method: Data from a retrospective chart review of 74 adults receiving SA MH services at an outpatient trauma center are presented. The sample includes a 2-year cohort seen acutely at an urban rape treatment center. The study is one of the first to examine therapy records beyond case studies for DFSA. Logistic, Poisson, and negative binomial regression analyses of quantitative data and qualitative thematic analysis of trauma cognitions and treatment foci were conducted. Results: DFSA-V had five times greater odds of SUD, and notable substance-related self-blame compared to DFSA-I. DFSA-I had prominent relationship distress and self-blame for missing danger of perpetrator drugging. Survivors with impaired trauma memory had significantly fewer hyper-arousal and overall PTSD symptoms, and specifically less hypervigilance. No differences were found in re-experiencing symptoms. Conclusion: Impaired trauma memory is common in DFSA and is associated with fewer baseline hyper-arousal and overall PTS. Despite this, DFSA issues including re-experiencing symptoms that are particularly distressing without the ability to cognitively connect the intrusions contribute to increased treatment needs. Impaired memory limits the application of evidence-based treatments, and collectively these findings call for the development of trauma-specific treatment protocols to enhance recovery for DFSA survivors. HIGHLIGHTS: Survivors of drug-facilitated sexual assault have prominent PTSD including reexperiencing, though trauma memory may not be encoded. • Those absent trauma memory have less hyperarousal, but DFSA complications explain why it is treatment refractory and inform treatment development.

Antecedentes: La agresión sexual (AS) es un problema de salud pública mundial de alta prevalencia y es un sólido predictor del trastorno de estrés postraumático (TEPT), del trastorno por uso de sustancias (TUS) y de suicidalidad. Un gran porcentaje de AS son facilitadas por drogas o alcohol (ASFDA), deteriorando la memoria del trauma y afectando la aplicación de tratamientos basados en la evidencia. A pesar de estos problemas, pocos han investigado las necesidades de salud mental (SM) específicas de los ASFDA.Objetivo: Los objetivos de este estudio fueron; primero, identificar las secuelas psicológicas que caracterizan a las ASFDA para explicar por qué los síntomas han sido refractarios al tratamiento. Para ello, se comparó a sobrevivientes a una ingestión involuntaria de sustancias (forzada, encubierta: ASFDA-I), a una ingestión voluntaria (ASFDA-V), y a una AS no-ASFDA; y, segundo; determinar cómo el deterioro de la memoria del trauma se relaciona con el desarrollo de síntomas del TEPT y depresión.Método: Se presentan los datos de una revisión retrospectiva de las historias clínicas de 74 adultos que recibieron servicios de SM por AS en un centro de trauma para pacientes ambulatorios. La muestra incluye a una cohorte de 2 años en donde los casos de AS fueron vistos de forma aguda en un centro urbano de tratamiento para violación. El estudio es uno de los primeros, más allá de los estudios de casos, en examinar los registros de terapia por ASFDA. Se realizaron análisis de regresión logística, Poisson y binomial negativa de datos cuantitativos y un análisis temático cualitativo de las cogniciones del trauma y los puntos clave del tratamiento.Resultados: Los ASFDA-V tuvieron cinco veces más probabilidades de TUS y de un notable sentimiento de culpa relacionado con las sustancias comparado con los ASFDA-I. Las ASFDA tenían problemas de relación importantes y sentimientos de culpa por haber pasado por alto el peligro de que el agresor se drogara. Los sobrevivientes con deterioro de la memoria traumática tuvieron significativamente menos síntomas de hiperactivación y del TEPT en general y, específicamente, menos hipervigilancia. No se encontraron diferencias en los síntomas de reexperimentación.Conclusión: El deterioro de la memoria traumática es común en las ASFDA y se asocia con menos hiperactivación de base y síntomas postraumáticos en general. A pesar de esto, los problemas de los ASFDA incluyen a los síntomas de reexperimentación que son particularmente angustiantes y que restan la capacidad de conectar cognitivamente las intrusiones, por lo que contribuyen a aumentar las necesidades de tratamiento. El deterioro de la memoria limita la aplicación de tratamientos basados en la evidencia y, en conjunto, estos hallazgos exigen el desarrollo de protocolos de tratamiento específicos para trauma para mejorar la recuperación de los sobrevivientes a las ASFDA.

Beyond the DSM-5 Diagnoses: A Cross-Cultural Approach to Assessing Trauma Reactions.

Although trauma exposure is a global phenomenon, trauma reactions vary considerably across cultures. Western psychiatric diagnoses, such as posttraumatic stress disorder (PTSD), may be limited in capturing the breadth of trauma reactions in cross-cultural contexts. Instead, cross-cultural instruments should examine locally relevant reactions, such as idioms of distress and explanatory models of illness, and account for ongoing stress and adversity. This article explains the need for complementing traditional trauma assessment approaches, how to create culturally sensitive instruments, the style and stance of practicing cultural humility when administering instruments, how to account for ongoing trauma and adversity, and ways to incorporate findings into treatment. These steps can improve culturally sensitive and comprehensive trauma assessment to capture universal and culturally relevant trauma reactions.

Testing for Differences in the Reporting of Somatic Symptoms of Depression in Racial/Ethnic Minorities.

We tested if Latinx and Black individuals are more likely to somaticize depression compared with their White counterparts. We analyzed 14,745 depression ratings from 4,101 people living with HIV from 2007 to 2014. We calculated the percentage of each depression score accounted for by somatic symptom items (e.g., feeling tired). We analyzed depression scores using generalized estimation equations, which accounts for repeated measures within each person. Somatic symptoms accounted for 70% of depression scores for White patients, 66% for Latinx patients, and 68% for Black patients. Across the 14,745 assessments, adjusting for age and sex, and within-person correlation, the percentage of the depression scores made up of somatic items was lower for Latinx (b = -.03, p < .0001) and Black patients (b = -.02, p < .001), compared with White patients. The idea that Latinx and Black individuals are likely to somaticize depression may lead to underdiagnoses and perpetuate stereotypes and inequities that are not supported by empirical data.

Gender-based violence and suicidal ideation among Indian women from slums: An examination of direct and indirect effects of depression, anxiety, and PTSD symptoms.

OBJECTIVE: India accounts for 36.6% of suicide-related deaths among women worldwide. One social determinant of suicide in India is gender-based violence (GBV), and it disproportionately affects women from poorer socioeconomic classes. Although Indian women from slums are at high risk of GBV, the direct and indirect relationships between types of GBV and suicidal ideation (SI) for Indian women remain unexplored. This study examined: (a) the direct associations between types of GBV and SI and (b) indirect associations between GBV and risk for SI through depression, anxiety, and posttraumatic stress disorder (PTSD) symptoms. METHOD: Trauma-exposed Indian women were recruited (N = 112); 98 completed a trauma screen, PHQ-9, GAD-7, and PCL-5 in Hindi. Traumatic events were categorized as GBV overlapping with Criterion A trauma (CA-GBV), emotional/economic GBV without Criterion A (E-GBV), and Criterion A without GBV (CA). The relation between trauma types and SI was examined through the indirect role of depression, anxiety, and PTSD symptoms. RESULTS: Logistic regression analyses revealed that CA-GBV was associated with higher odds of SI than other trauma types. This relationship was explained through the indirect role of depression symptom severity after accounting for other trauma types, anxiety, and PTSD symptoms. CONCLUSION: Results align with research showing that CA-GBV is particularly pernicious and affects SI. While anxiety and PTSD symptoms are related to CA-GBV, results suggest the relative importance of depression severity in the relation between CA-GBV and SI. Screening for SI among GBV survivors and treating depression symptoms may reduce the risk of suicide. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Gestalt principle use in college students, children with autism, toddlers (Homo sapiens), and cotton top tamarins (Saguinus oedipus).

The use of Gestalt principles of proximity, similarity, and closure to recognize objects by configural superiority was examined in college students, low- and high-functioning children with autism, toddlers, and adult cotton top tamarin monkeys. At issue was whether the monkeys showed differences from humans in perceptual processing and whether they showed any similarities with clinical or developmental groups. The method required a pointing response to discriminate an odd item in a 4-item visual display. All subjects were trained to a high accuracy to point to the odd item before being tested with graphic stimuli that differentiated feature changes based on configural superiority. The results were that college students and high-functioning children with autism responded faster and more accurately to trials in which the odd item was easily noticed by the use of Gestalt principles and configural superiority. Toddlers also responded more accurately to the Gestalt trials, but without being faster at making the response. Low-functioning children with autism and tamarins showed no advantage to Gestalt trials but exhibited different processing styles. The implications of these findings to track the evolution of human perception and to develop a primate model for the perceptual deficits of autism are discussed.