Publications by authors named "Derrick Silove"

224 Publications

A Naturalistic Evaluation of Group Integrative Adapt Therapy (IAT-G) with Rohingya Refugees During the Emergency Phase of a Mass Humanitarian Crisis in Cox's Bazar, Bangladesh.

EClinicalMedicine 2021 Aug 6;38:100999. Epub 2021 Jul 6.

National Institute of Mental Health, Dhaka, Bangladesh.

: Studies of scalable psychological interventions in humanitarian setting are usually carried out when the acute emergency has stabilized. We report the first evaluation of an evidence-based group psychological intervention, Group Integrative Adapt Therapy (IAT-G), during the emergency phase of a mass humanitarian crisis amongst Rohingya refugees in Cox's Bazar, Bangladesh. : We did a pragmatic naturalistic evaluation (2018-2020) of a seven-session group intervention with adult Rohingya refugees with elevated symptoms of depression (≥10 on the Patient Health Questionnaire) and/or posttraumatic stress disorder, PTSD, (≥3 on the Posttraumatic Stress Disorder-8), and functional impairment (≥17 on WHO Disability Assessment Schedule or WHODAS-brief). Screening was done across the most densely populated campsites. Blind assessments were completed at baseline, posttreatment, and at 3-month follow-up using culturally adapted measures of depression, anxiety, posttraumatic stress symptoms, complicated bereavement, adaptive stress associated with disrupted psychosocial support systems, functional impairment, and resilience. : 383 persons were screened and of the 144 persons who met inclusion criteria all participated in the group intervention. Compared to baseline scores, IAT-G participants recorded significantly lower mean scores on key outcome indices (mental health symptoms, adaptive stress, and functional impairment) at posttreatment and 3-month follow-up (all pairwise tests significant Ps<.05). From baseline to 3-month follow-up, score changes were greatest for functional impairment (d = 2.24), anxiety (d = 2.15) and depression (d = 1.9), followed by PTSD symptoms (d = 1.17). : A group-based intervention designed specifically to reflect the refugee experience and adapted to the language and culture, showed positive outcomes in the context of a pragmatic, naturalistic trial implemented in a mass humanitarian emergency. : United Nations High Commissioner for Refugees; National Health and Medical Research Council Australia.
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http://dx.doi.org/10.1016/j.eclinm.2021.100999DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8413262PMC
August 2021

Australian guidelines for the prevention and treatment of posttraumatic stress disorder: Updates in the third edition.

Aust N Z J Psychiatry 2021 Aug 27:48674211041917. Epub 2021 Aug 27.

Department of Psychiatry, University of New South Wales, Sydney, NSW, Australia.

Objective: This paper describes the development of the third edition of the National Health and Medical Research Australian Guidelines for the Prevention and Treatment of Acute Stress Disorder, posttraumatic stress disorder and Complex posttraumatic stress disorder, highlighting key changes in scope, methodology, format and treatment recommendations from the previous 2013 edition of the Guidelines.

Method: Systematic review of the international research was undertaken, with GRADE methodology used to assess the certainty of the evidence, and evidence to decision frameworks used to generate recommendations. The Guidelines are presented in an online format using MAGICApp.

Results: Key changes since the publication of the 2013 Guidelines include a new conditional recommendation for Child and Family Traumatic Stress Intervention for children and adolescents with symptoms within the first 3 months of trauma, and a strong recommendation for trauma-focused cognitive behaviour therapy for the child alone or with a caregiver, for those with diagnosed posttraumatic stress disorder. For adults with posttraumatic stress disorder, strong recommendations are made for specific types of trauma-focused cognitive behaviour therapy and conditional recommendations are made for five additional psychological interventions. Where medication is indicated for adults with posttraumatic stress disorder, venlafaxine is now conditionally recommended alongside sertraline, paroxetine or fluoxetine.

Conclusion: These Guidelines, based on systematic review of the international literature, are intended to guide decision making for practitioners, service planners, funders and those seeking treatment for trauma related mental health concerns. For an Australian Guideline, a critical limitation is the absence of research on the treatment of Australian Aboriginal and Torres Strait Islander peoples. The new online format of the Australian posttraumatic stress disorder Guidelines means that they can be updated as sufficient new evidence becomes available.
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http://dx.doi.org/10.1177/00048674211041917DOI Listing
August 2021

Attitudes towards gender roles and prevalence of intimate partner violence perpetrated against pregnant and postnatal women: Differences between women immigrants from conflict-affected countries and women born in Australia.

PLoS One 2021 30;16(7):e0255105. Epub 2021 Jul 30.

School of Psychiatry, Faculty of Medicine, University of New South Wales, Kensington, New South Wales, Australia.

Background: The aim was to compare, for the first time in a large systematic study, women born in conflict-affected countries who immigrated to Australia with women born in Australia for attitudes towards gender roles and men's use of IPV and the actual prevalence of IPV. The study also examined if any associations remained across the two timepoints of pregnancy and postpartum.

Methods: Women were interviewed during their first visit to one of three Australian public hospital antenatal clinics and re-interviewed at home six months after giving birth. A total of 1111 women completed both interviews, 583 were born in conflict-affected countries and 528 born in Australia. Associations between attitudes towards gender roles and men's use of IPV, socio-demographic characteristics and reported actual experiences of IPV were examined using bivariate and multiple logistic regression analyses.

Results: Attitudes toward inequitable gender roles including those that condone men's use of IPV, and prevalence of IPV, were significantly higher (p<0.001) among women born in conflict-affected countries compared to Australia-born women. Women born in conflict-affected countries with the strongest held attitudes towards gender roles and men's use of IPV had an adjusted odds ratio (aOR) of 3.18 for IPV at baseline (95% CI 1.85-5.47) and an aOR of 1.83 for IPV at follow-up (95% CI 1.11-3.01). Women born in Australia with the strongest held attitudes towards gender roles and IPV had an aOR of 7.12 for IPV at baseline (95% CI 2.12-23.92) and an aOR of 10.59 for IPV at follow-up (95% CI 2.21-50.75).

Conclusions: Our results underscore the need for IPV prevention strategies sensitively targeted to communities from conflict-affected countries, and for awareness among clinicians of gender role attitudes that may condone men's use of IPV, and the associated risk of IPV. The study supports the need for culturally informed national strategies to promote gender equality and to challenge practices and attitudes that condone men's violence in spousal relationships.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0255105PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8323950PMC
July 2021

Psychological distress, resettlement stress, and lower school engagement among Arabic-speaking refugee parents in Sydney, Australia: A cross-sectional cohort study.

PLoS Med 2021 Jul 12;18(7):e1003512. Epub 2021 Jul 12.

School of Psychiatry, University of New South Wales, Sydney, Australia.

Background: Schools play a key role in supporting the well-being and resettlement of refugee children, and parental engagement with the school may be a critical factor in the process. Many resettlement countries have policies in place to support refugee parents' engagement with their children's school. However, the impact of these programs lacks systematic evaluation. This study first aimed to validate self-report measures of parental school engagement developed specifically for the refugee context, and second, to identify parent characteristics associated with school engagement, so as to help tailor support to families most in need.

Methods And Findings: The report utilises 2016 baseline data of a cohort study of 233 Arabic-speaking parents (77% response rate) of 10- to 12-year-old schoolchildren from refugee backgrounds across 5 schools in Sydney, Australia. Most participants were born in Iraq (81%) or Syria (11%), and only 25% spoke English well to very well. Participants' mean age was 40 years old, and 83% were female. Confirmatory factor analyses were run on provisional item sets identified from a literature review and separate qualitative study. The findings informed the development of 4 self-report tools assessing parent engagement with the school and school community, school belonging, and quality of the relationship with the schools' bilingual cultural broker. Cronbach alpha and Pearson correlations with an established Teacher-Home Communication subscale demonstrated adequate reliability (α = 0.67 to 0.80) and construct and convergent validity of the measures (p < 0.01), respectively. Parent characteristics were entered into respective least absolute shrinkage and selection operator (LASSO) regression analyses. The degree of parents' psychological distress (as measured by the Kessler10 self-report instrument) and postmigration living difficulties (PLMDs) were each associated with lower school engagement and belonging, whereas less time lived in Australia, lower education levels, and an unemployed status were associated with higher ratings in relationship quality with the schools' cultural broker. Study limitations include the cross-sectional design and the modest amount of variance (8% to 22%) accounted for by the regression models.

Conclusions: The study offers preliminary refugee-specific measures of parental school engagement. It is expected they will provide a resource for evaluating efforts to support the integration of refugee families into schools. The findings support the need for initiatives that identify and support parents with school-attending children from refugee backgrounds who are experiencing psychological distress or resettlement stressors. At the school level, the findings suggest that cultural brokers may be effective in targeting newly arrived families.
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http://dx.doi.org/10.1371/journal.pmed.1003512DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8312975PMC
July 2021

Challenges to mental health services for refugees: a global perspective.

Authors:
Derrick Silove

World Psychiatry 2021 Feb;20(1):131-132

School of Psychiatry, University of New South Wales, Sydney, NSW, Australia.

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http://dx.doi.org/10.1002/wps.20818DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7801830PMC
February 2021

Predictors of treatment outcomes for trauma-affected refugees - results from two randomised trials.

J Affect Disord 2021 03 28;282:194-202. Epub 2020 Dec 28.

University of Copenhagen/Competence Centre for Transcultural Psychiatry, Mental Health Centre Ballerup, Denmark.

Introduction: Treatment effects in trials with trauma-affected refugees vary considerably between studies, but the variability in outcome between individual patients is often overlooked. Consequently, we know little about why some patients benefit more from treatment than others. The aim of the study was therefore to identify predictors of treatment outcome for refugees with Posttraumatic Stress Disorder (PTSD).

Methods: Data was derived from two randomised trials including 321 refugees, who had all participated in a 6-7 months bio-psycho-social treatment programme. Outcome measures were the Harvard Trauma Questionnaire (PTSD, self-rating), Hopkins Symptom Checklist-25 (depression and anxiety, self-rating) and Hamilton Depression and Anxiety rating scales (observer-ratings). Using hierarchical regressions models, associations were analysed between pre- to post treatment score changes (dependent variable) and a range of variables including sociodemographics, pre-migration trauma, post-migratory stressors, baseline symptom scores and level of functioning.

Results: A high baseline score (=more symptoms) and a high level of functioning were found to be associated with improvement on all ratings. Additionally, the following variables were associated with symptom improvement on at least one outcome measure: short time in host country, full time occupation, young age and status as family reunified (in contrast to refugee status). Being Muslim was inversely correlated with improvement.

Limitations: Translated self-ratings were used, which could impact reliability.

Conclusion: These results call for screening and early interventions for arriving refugees. For clinical populations, level of functioning should be included in assessments of refugees, to possibly begin stratifying samples to different interventions based on their likelihood of responding.
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http://dx.doi.org/10.1016/j.jad.2020.12.095DOI Listing
March 2021

Post-migration factors and mental health outcomes in asylum-seeking and refugee populations: a systematic review.

Eur J Psychotraumatol 2020 Dec 1;11(1):1793567. Epub 2020 Dec 1.

School of Psychiatry, University of New South Wales, Sydney, Australia.

The present systematic review examined post-migration variables impacting upon mental health outcomes among asylum-seeking and refugee populations in Europe. It focuses on the effects of post-settlement stressors (including length of asylum process and duration of stay, residency status and social integration) and their impact upon post-traumatic stress disorder, anxiety and depression. Twenty-two studies were reviewed in this study. Length of asylum process and duration of stay was found to be the most frequently cited factor for mental health difficulties in 9 out of 22 studies. Contrary to expectation, residency or legal status was posited as a marker for other explanatory variables, including loneliness, discrimination and communication or language problems, rather than being an explanatory variable itself. However, in line with previous findings and as hypothesised in this review, there were statistically significant correlations found between family life, family separation and mental health outcomes.
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http://dx.doi.org/10.1080/20008198.2020.1793567DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7717836PMC
December 2020

Prolonged grief in refugees, parenting behaviour and children's mental health.

Aust N Z J Psychiatry 2021 09 30;55(9):863-873. Epub 2020 Oct 30.

School of Psychiatry, University of New South Wales, Sydney, NSW, Australia.

Background: Many refugees experience bereavement, and as a result they suffer elevated rates of prolonged grief disorder. Evidence also indicates that elevated rates of psychological disturbance in refugee children can be associated with parental mental health. This study examined the extent to which prolonged grief disorder in refugees is associated with their parenting behaviour and in turn with their children's mental health.

Methods: This study recruited participants from the Building a New Life in Australia prospective cohort study of refugees admitted to Australia between October 2013 and February 2014. The current data were collected in 2015-2016 and comprised 1799 adults, as well as 411 children of the adult respondents. Adult refugees were assessed for trauma history, post-migration difficulties, harsh and warm parenting, probable prolonged grief disorder and posttraumatic stress disorder. Children were administered the Strengths and Difficulties Questionnaire. The current analyses on bereaved refugees comprise 110 caregivers and 178 children.

Results: In this cohort, 37% of bereaved refugees reported probable prolonged grief disorder. Path analysis indicated that caregivers' grief was directly associated with children's emotional difficulties. Caregiver warmth was associated with reduced emotional problems in children of refugees with minimal grief but associated with more emotional problems in caregivers with more severe grief. More harsh parenting was associated with children's conduct problems, and this was more evident in those with less severe grief.

Conclusion: Severity of prolonged grief disorder is directly linked to refugee children's mental health. The association between parenting style, grief severity and children's mental health highlights that managing grief reactions in refugees can benefit both refugees and their children.
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http://dx.doi.org/10.1177/0004867420967420DOI Listing
September 2021

Psychosocial mechanisms of change in symptoms of Persistent Complex Bereavement Disorder amongst refugees from Myanmar over the course of Integrative Adapt Therapy.

Eur J Psychotraumatol 2020 Sep 16;11(1):1807170. Epub 2020 Sep 16.

School of Psychiatry, Faculty of Medicine, University of New South Wales, Sydney, Australia.

: The ability to adapt to the psychosocial disruptions associated with the refugee experience may influence the course of complicated grief reactions. : We examine these relationships amongst Myanmar refugees relocated to Malaysia who participated in a six-week course of Integrative Adapt Therapy (IAT). : Participants (n = 170) included Rohingya, Chin, and Kachin refugees relocated to Malaysia. At baseline and six-week post-treatment, we applied culturally adapted measures to assess symptoms of Prolonged Complex Bereavement Disorder (PCBD) and adaptive capacity to psychosocial disruptions, based on the Adaptive Stress Index (ASI). The ASI comprises five sub-scales of safety/security (ASI-1); bonds and networks (ASI-2); injustice (ASI-3); roles and identity (ASI-4); and existential meaning (ASI-5). : Multilevel linear models indicated that the relationship between baseline and posttreatment PCBD symptoms was mediated by the ASI scale scores. Further, ASI scale scores assessed posttreatment mediated the relationship between baseline and posttreatment PCBD symptoms. Mediation of PCBD change was greatest for the ASI II scale representing disrupted bonds and networks. : Our findings are consistent with the informing model of IAT in demonstrating that changes in adaptive capacity, and especially in dealing with disrupted bonds and networks, may mediate the process of symptom improvement over the course of therapy.
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http://dx.doi.org/10.1080/20008198.2020.1807170DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7534324PMC
September 2020

Variations in prevalence and risk profiles for Common Mental Disorders amongst Rohingya, Chin and Kachin refugees from Myanmar.

Psychol Med 2020 Sep 11:1-15. Epub 2020 Sep 11.

Faculty of Medicine, School of Psychiatry, University of New South Wales, Australia.

Background: Large variations in prevalence rates of common mental disorder (CMD) amongst refugees and forcibly displaced populations have raised questions about the accuracy and value of epidemiological surveys in these cross-cultural settings. We examined the associations of sociodemographic indices, premigration traumatic events (TEs), postmigration living difficulties (PMLDs), and psychosocial disruptions based on the Adaptive Stress Index (ASI) in relation to CMD prevalence amongst the Rohingya, Chin and Kachin refugees originating from Myanmar and relocated to Malaysia.

Methods: Parallel epidemiological studies were conducted in areas where the three groups were concentrated in and around Malaysia (response rates: 80-83%).

Results: TE exposure, PMLDs and ASI were significantly associated with CMD prevalence in each group but the Rohingya recorded the highest exposure to all three of these former indices relative to Chin and Kachin (TE: mean = 11.1 v. 8.2 v. 11; PMLD: mean = 13.5 v. 7.4 v. 8.7; ASI: mean = 128.9 v. 32.1 v. 35.5). Multiple logistic regression analyses based on the pooled sample (n = 2058) controlling for gender and age, found that ethnic group membership, premigration TEs (16 or more TEs: OR, 2.00; 95% CI, 1.39-2.88; p < 0.001), PMLDs (10-15 PMLDs: OR, 4.19; 95% CI, 3.17-5.54; 16 or more PMLDs: OR, 7.23; 95% CI, 5.24-9.98; p < 0.001) and ASI score (ASI score 100 or greater: OR, 2.19; 95% CI, 1.46-3.30; p < 0.001) contributed to CMD.

Conclusions: Factors specific to each ethnic group and differences in the quantum of exposure to TEs, PMLDs and psychosocial disruptions appeared to account in large part for differences in prevalence rates of CMDs observed across these three groups.
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http://dx.doi.org/10.1017/S0033291720003104DOI Listing
September 2020

Associations between family-level adversity and society-level trauma with emotional and behavioural problems amongst children of West Papuan refugees.

Eur Child Adolesc Psychiatry 2021 Jun 4;30(6):909-920. Epub 2020 Jun 4.

School of Psychiatry, Faculty of Medicine, The University of New South Wales, Sydney, NSW, Australia.

Few studies have examined associations between family-level parental factors, society-level violence, and the emotional and behavioral status of children of refugee populations. Our study used cross-sectional epidemiological data to test a theoretical model of these key associations amongst a community sample of children (n = 162) of West Papuan refugees living in remote town in Papua New Guinea (PNG), a setting of endemic violence and poverty. Culturally adapted instruments were used to assess three types of intra-familial factors (adverse parenting, physical and/or sexual abuse and emotional abuse) and three types of society-level violence and stressors (exposure to systematic violence, peer violence, living difficulties). Emotional and behavioural problems were assessed using the Youth Self-Report Checklist. Path analysis was used to test theoretical associations. Key findings include direct associations between both family-level physical and/or sexual abuse (β = .43; p < .001) and adverse parenting (β = .40; p < .001) with emotional and behavioural problems amongst children. In the broader social domain, peer violence (β = .29; p < .001) had a direct association with children's emotional and behavioural problems. Several indirect paths demonstrated a chain of relationships involving family- and society-level factors and emotional and behavioural problems in children. Only longitudinal data can provide further support for veridical causal pathways linking family and social factors with adverse emotional and behavioural outcomes in offspring of refugees, thereby supporting mechanisms leading to a transgenerational transmission of adverse mental health outcomes in refugee populations. Such data would give further support for a multisectoral approach to dealing with at risk families in refugee populations, in which attention should focus on supporting parents, and promoting the protection of children from abuse in the family and in the wider society.
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http://dx.doi.org/10.1007/s00787-020-01569-6DOI Listing
June 2021

Longitudinal path analysis of depressive symptoms and functioning among women of child-rearing age in postconflict Timor-Leste.

BMJ Glob Health 2020 30;5(3):e002039. Epub 2020 Mar 30.

Psychiatry, University of New South Wales, Sydney, New South Wales, Australia.

This longitudinal study indicates that exposure to the traumas of mass conflict and subsequent depressive symptoms play an important role in pathways leading to functional impairment in the postconflict period among women of child-rearing age. Our study, conducted in Timor-Leste, involved an analytic sample of 1292 women recruited at antenatal clinics in the capital and its surrounding districts. Women were re-interviewed at home 2 years later (77.3% retention). We applied the Edinburgh Postnatal Depression Scale, the Harvard Trauma Questionnaire for conflict-related traumatic events, the WHO Violence Against Women Instrument covering the past year for intimate partner violence and the WHO Disability Assessment Schedule (WHODAS V.2.0) to assess functional impairment. A longitudinal path analysis tested direct and indirect relationships involving past conflict-related trauma exposure, depressive symptoms measured over the two time points and functional impairment at follow-up. The prevalence of predefined clinically significant depressive symptoms diminished from 19.3% to 12.8%. Nevertheless, there was a tendency for depressive symptoms to persist over time (β=0.20; p<0.001). Follow-up depressive symptoms were associated with functional impairment (β=0.35; p<0.001). Reported conflict-related trauma occurring a minimum of 6 years earlier (β=0.23; p<0.001) and past-year physical intimate partner violence (β=0.26; p<0.001) were each associated with depressive symptoms at baseline and at follow-up. A measure of poverty specific to the context and reported health problems in the mother and infant also contributed to depressive symptoms. The findings highlight the association between ongoing trauma-related depressive symptoms and the capacity of women in the childbearing age to function in multiple areas of their lives in a postconflict country. Recognition of these relationships is important in the formulation and implementation of contemporary international recovery and development policies applied to postconflict countries.
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http://dx.doi.org/10.1136/bmjgh-2019-002039DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7170425PMC
June 2021

An Integrative Adapt Therapy for common mental health symptoms and adaptive stress amongst Rohingya, Chin, and Kachin refugees living in Malaysia: A randomized controlled trial.

PLoS Med 2020 03 31;17(3):e1003073. Epub 2020 Mar 31.

School of Psychiatry, Faculty of Medicine, University of New South Wales, Australia.

Background: This randomised controlled trial (RCT) aims to compare 6-week posttreatment outcomes of an Integrative Adapt Therapy (IAT) to a Cognitive Behavioural Therapy (CBT) on common mental health symptoms and adaptive capacity amongst refugees from Myanmar. IAT is grounded on psychotherapeutic elements specific to the refugee experience.

Methods And Findings: We conducted a single-blind RCT (October 2017 -May 2019) with Chin (39.3%), Kachin (15.7%), and Rohingya (45%) refugees living in Kuala Lumpur, Malaysia. The trial included 170 participants receiving six 45-minute weekly sessions of IAT (97.6% retention, 4 lost to follow-up) and 161 receiving a multicomponent CBT also involving six 45-minute weekly sessions (96.8% retention, 5 lost to follow-up). Participants (mean age: 30.8 years, SD = 9.6) had experienced and/or witnessed an average 10.1 types (SD = 5.9, range = 1-27) of traumatic events. We applied a single-blind design in which independent assessors of pre- and posttreatment indices were masked in relation to participants' treatment allocation status. Primary outcomes were symptom scores of Post Traumatic Stress Disorder (PTSD), Complex PTSD (CPTSD), Major Depressive Disorder (MDD), the 5 scales of the Adaptive Stress Index (ASI), and a measure of resilience (the Connor-Davidson Resilience Scale [CDRS]). Compared to CBT, an intention-to-treat analysis (n = 331) at 6-week posttreatment follow-up demonstrated greater reductions in the IAT arm for all common mental disorder (CMD) symptoms and ASI domains except for ASI-3 (injustice), as well as increases in the resilience scores. Adjusted average treatment effects assessing the differences in posttreatment scores between IAT and CBT (with baseline scores as covariates) were -0.08 (95% CI: -0.14 to -0.02, p = 0.012) for PTSD, -0.07 (95% CI: -0.14 to -0.01) for CPTSD, -0.07 for MDD (95% CI: -0.13 to -0.01, p = 0.025), 0.16 for CDRS (95% CI: 0.06-0.026, p ≤ 0.001), -0.12 (95% CI: -0.20 to -0.03, p ≤ 0.001) for ASI-1 (safety/security), -0.10 for ASI-2 (traumatic losses; 95% CI: -0.18 to -0.02, p = 0.02), -0.03 for ASI-3 (injustice; (95% CI: -0.11 to 0.06, p = 0.513), -0.12 for ASI-4 (role/identity disruptions; 95% CI: -0.21 to -0.04, p ≤ 0.001), and -0.18 for ASI-5 (existential meaning; 95% CI: -0.19 to -0.05, p ≤ 0.001). Compared to CBT, the IAT group had larger effect sizes for all indices (except for resilience) including PTSD (IAT, d = 0.93 versus CBT, d = 0.87), CPTSD (d = 1.27 versus d = 1.02), MDD (d = 1.4 versus d = 1.11), ASI-1 (d = 1.1 versus d = 0.85), ASI-2 (d = 0.81 versus d = 0.66), ASI-3 (d = 0.49 versus d = 0.42), ASI-4 (d = 0.86 versus d = 0.67), and ASI-5 (d = 0.72 versus d = 0.53). No adverse events were recorded for either therapy. Limitations include a possible allegiance effect (the authors inadvertently conveying disproportionate enthusiasm for IAT in training and supervision), cross-over effects (counsellors applying elements of one therapy in delivering the other), and the brief period of follow-up.

Conclusions: Compared to CBT, IAT showed superiority in improving mental health symptoms and adaptative stress from baseline to 6-week posttreatment. The differences in scores between IAT and CBT were modest and future studies conducted by independent research teams need to confirm the findings.

Trial Registration: The study is registered under Australian New Zealand Clinical Trials Registry (ANZCTR) (http://www.anzctr.org.au/). The trial registration number is: ACTRN12617001452381.
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http://dx.doi.org/10.1371/journal.pmed.1003073DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7108685PMC
March 2020

Genomic influences on self-reported childhood maltreatment.

Transl Psychiatry 2020 01 27;10(1):38. Epub 2020 Jan 27.

US Army Medical Research and Materiel Command, Fort Detrick, MD, USA.

Childhood maltreatment is highly prevalent and serves as a risk factor for mental and physical disorders. Self-reported childhood maltreatment appears heritable, but the specific genetic influences on this phenotype are largely unknown. The aims of this study were to (1) identify genetic variation associated with self-reported childhood maltreatment, (2) estimate SNP-based heritability (h), (3) assess predictive value of polygenic risk scores (PRS) for childhood maltreatment, and (4) quantify genetic overlap of childhood maltreatment with mental and physical health-related phenotypes, and condition the top hits from our analyses when such overlap is present. Genome-wide association analysis for childhood maltreatment was undertaken, using a discovery sample from the UK Biobank (UKBB) (n = 124,000) and a replication sample from the Psychiatric Genomics Consortium-posttraumatic stress disorder group (PGC-PTSD) (n = 26,290). h for childhood maltreatment and genetic correlations with mental/physical health traits were calculated using linkage disequilibrium score regression. PRS was calculated using PRSice and mtCOJO was used to perform conditional analysis. Two genome-wide significant loci associated with childhood maltreatment (rs142346759, p = 4.35 × 10, FOXP1; rs10262462, p = 3.24 × 10, FOXP2) were identified in the discovery dataset but were not replicated in PGC-PTSD. h for childhood maltreatment was ~6% and the PRS derived from the UKBB was significantly predictive of childhood maltreatment in PGC-PTSD (r = 0.0025; p = 1.8 × 10). The most significant genetic correlation of childhood maltreatment was with depressive symptoms (r = 0.70, p = 4.65 × 10), although we show evidence that our top hits may be specific to childhood maltreatment. This is the first large-scale genetic study to identify specific variants associated with self-reported childhood maltreatment. Speculatively, FOXP genes might influence externalizing traits and so be relevant to childhood maltreatment. Alternatively, these variants may be associated with a greater likelihood of reporting maltreatment. A clearer understanding of the genetic relationships of childhood maltreatment, including particular abuse subtypes, with a range of phenotypes, may ultimately be useful in in developing targeted treatment and prevention strategies.
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http://dx.doi.org/10.1038/s41398-020-0706-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7026037PMC
January 2020

International meta-analysis of PTSD genome-wide association studies identifies sex- and ancestry-specific genetic risk loci.

Nat Commun 2019 10 8;10(1):4558. Epub 2019 Oct 8.

Durham VA Medical Center, Research, Durham, NC, USA.

The risk of posttraumatic stress disorder (PTSD) following trauma is heritable, but robust common variants have yet to be identified. In a multi-ethnic cohort including over 30,000 PTSD cases and 170,000 controls we conduct a genome-wide association study of PTSD. We demonstrate SNP-based heritability estimates of 5-20%, varying by sex. Three genome-wide significant loci are identified, 2 in European and 1 in African-ancestry analyses. Analyses stratified by sex implicate 3 additional loci in men. Along with other novel genes and non-coding RNAs, a Parkinson's disease gene involved in dopamine regulation, PARK2, is associated with PTSD. Finally, we demonstrate that polygenic risk for PTSD is significantly predictive of re-experiencing symptoms in the Million Veteran Program dataset, although specific loci did not replicate. These results demonstrate the role of genetic variation in the biology of risk for PTSD and highlight the necessity of conducting sex-stratified analyses and expanding GWAS beyond European ancestry populations.
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http://dx.doi.org/10.1038/s41467-019-12576-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6783435PMC
October 2019

Functional impairment as a proxy measure indicating high rates of trauma exposure, post-migration living difficulties, common mental disorders, and poor health amongst Rohingya refugees in Malaysia.

Transl Psychiatry 2019 09 2;9(1):213. Epub 2019 Sep 2.

Faculty of Medicine, School of Psychiatry, University of New South Wales, Sydney, NSW, 2052, Australia.

A major challenge in the refugee field is to ensure that scarce mental health resources are directed to those in greatest need. Based on data from an epidemiological survey of 959 adult Rohingya refugees in Malaysia (response rate: 83%), we examine whether a brief screening instrument of functional impairment, the WHO Disability Assessment Schedule (WHODAS), prove useful as a proxy measure to identify refugees who typically attend community mental health services. Based on estimates of mental disorder requiring interventions from analyses of epidemiological studies conducted worldwide, we selected a WHODAS cutoff that identified the top one-fifth of refugees according to severity of functional impairment, the remainder being distributed to moderate and lower impairment groupings, respectively. Compared to the lower impairment grouping, the severe impairment category comprised more boat arrivals (AOR: 5.96 [95% CI 1.34-26.43); stateless persons (A20·11 [95% CI 7.14-10); those with high exposure to pre-migration traumas (AOR: 4.76 [95% CI 1.64-13.73), peri-migration stressors (AOR: 1.26 [95% CI 1.14-1.39]) and postmigration living difficulties (AOR: 1.43 [95% CI 1.32-1.55); persons with single (AOR: 7.48 [95% CI 4.25-13.17]) and comorbid (AOR: 13.54 [95% CI 6.22-29.45]) common mental disorders; and those reporting poorer general health (AOR: 2.23 [95% CI 1-5.02]). In addition, half of the severe impairment grouping (50.6%) expressed suicidal ideas compared to one in six (16.2 percent) of the lower impairment grouping (OR: 2.39 [95% CI 1.94-2.93]). Differences between the severe and moderate impairment groups were similar but less extreme. In settings where large-scale epidemiological studies are not feasible, the WHODAS may serve as readily administered and brief public health screening tool that assists in stratifying the population according to urgency of mental health needs.
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http://dx.doi.org/10.1038/s41398-019-0537-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6718407PMC
September 2019

The mental health of asylum seekers in Australia and the role of psychiatrists.

BJPsych Int 2018 Aug;15(3):65-68

Conjoint Senior Lecturer, School of Psychiatry, University of New South Wales, Sydney, Australia. Email

There are more displaced people around the world than ever before, and over half are children. Australia and other wealthy nations have implemented increasingly harsh policies, justified as 'humane deterrence', and aimed at preventing asylum seekers (persons without preestablished resettlement visas) from entering their borders and gaining protection. Australian psychiatrists and other health professionals have documented the impact of these harsh policies since their inception. Their experience in identifying and challenging the effects of these policies on the mental health of asylum seekers may prove instructive to others facing similar issues. In outlining the Australian experience, we draw selectively on personal experience, research, witness account issues, reports by human rights organisations, clinical observations and commentaries. Australia's harsh response to asylum seekers, including indefinite mandatory detention and denial of permanent protection for those found to be refugees, starkly demonstrates the ineluctable intersection of mental health, human rights, ethics and social policy, a complexity that the profession is uniquely positioned to understand and hence reflect back to government and the wider society.
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http://dx.doi.org/10.1192/bji.2018.11DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6690255PMC
August 2018

Prevalence and Risk Factors of Major Depressive Disorder Among Women at Public Antenatal Clinics From Refugee, Conflict-Affected, and Australian-Born Backgrounds.

JAMA Netw Open 2019 05 3;2(5):e193442. Epub 2019 May 3.

Psychiatry Research and Teaching Unit, School of Psychiatry, Faculty of Medicine, University of New South Wales, Kensington, Australia.

Importance: Pregnancy may increase the risk of depression among women who self-identify as refugees and have resettled in high-income countries. To our knowledge, no large systematic studies among women with refugee backgrounds in the antenatal period have been conducted.

Objectives: To compare the prevalence of major depressive disorder (MDD), trauma exposure, and other psychosocial risk factors among women who identify as refugees, women from the same conflict-affected countries, and women from the host nation and to test whether self-identification as a refugee indicates greater likelihood of prevalence and risk.

Design, Setting, And Participants: This cross-sectional study was undertaken in 3 public antenatal clinics in Sydney and Melbourne, Australia, between January 2015 and December 2016. Overall, 1335 women (685 consecutively enrolled from conflict-affected backgrounds and 650 randomly selected from the host nation) participated. Data analysis was undertaken between June and September 2018.

Exposures: One-hour interviews covering mental health, intimate partner violence, and other social measures.

Main Outcome And Measures: World Health Organization measure for intimate partner violence and the Mini-International Neuropsychiatric Interview from the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) for MDD. To make a diagnosis, 1 of 2 items relating to being consistently depressed for 2 weeks and 3 further symptoms that cause personal distress or psychosocial dysfunction were endorsed.

Results: Overall, 1335 women (84.8% overall response rate), comprising 685 (51.3%) from conflict-affected countries (women self-identifying as refugees: 289 [42.2%]) and 650 (48.7%) from the host nation, participated. The mean (SD) age was 29.7 (5.4) years among women from conflict-affected backgrounds and 29.0 (5.5) years among women born in the host nation. Conflict-affected countries included Iraq (260 [38.0%]), Lebanon (125 [18.2%]), Sri Lanka (71 [10.4%]), and Sudan (66 [9.6%]). Women who identified as refugees reported higher exposure to 2 to 3 (67 [23.2%]) and 4 or more (19 [6.6%]) general traumatic events compared with women from the host nation (103 [15.8%] and 21 [3.2%], respectively). Women who identified as refugees also reported higher exposure to 1 (147 [50.9%]) and 2 or more (97 [33.6%]) refugee-related traumatic events compared with women from the host nation (86 [13.2%] and 20 [3.1%], respectively). Women who identified as refugees reported higher rates of psychological intimate partner violence than women born in the host nation (124 [42.9%] vs 133 [20.5%]; P < .001). Women who identified as refugees were less likely to identify 5 or more supportive family or friends compared with women born in the host nation (36 [12.5%] vs 297 [45.7%]; P < .001). A greater proportion of women who identified as refugees reported experiencing 3 or more financial stressors compared with women born in the host nation (65 [22.5%] vs 41 [6.3%]; P < .001). Women who identified as refugees had the highest prevalence of MDD (94 [32.5%]), followed by women from other conflict-affected backgrounds (78 [19.7%]), and women born in the host nation (94 [14.5%]).

Conclusion And Relevance: Women identifying as refugees reported a higher prevalence of MDD and all the indicators of adversity related to that disorder. Even after risk factors were accounted for, refugee status was associated with risk of MDD. Assessing whether women attending an antenatal clinic self-identify as refugees may offer an important indicator of risk of MDD and a range of associated psychosocial adversities.
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http://dx.doi.org/10.1001/jamanetworkopen.2019.3442DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6503483PMC
May 2019

School factors related to the emotional wellbeing and resettlement outcomes of students from refugee backgrounds: protocol for a systematic review.

Syst Rev 2019 04 30;8(1):107. Epub 2019 Apr 30.

University of New South Wales, Kensington, New South Wales, Australia.

Background: Schools can play a vital role in the resettlement of refugee children and their families. Yet, the body of research examining school environmental factors that support the mental health and acculturation of refugee children is methodologically heterogeneous, investigates numerous and disparate school factors, and is often "hidden" in broader qualitative studies. This limits the capacity to apply the findings in a practical manner.

Methods: Based on PRISMA statement principles, we review the relevant literature to investigate the relationship between school climate and the emotional wellbeing and resettlement outcomes of refugee students. Six electronic databases will be systematically searched: MEDLINE, PsycINFO, Embase, CINAL, Web of Science, and ERIC, supplemented by a systematic review of the grey literature, relevant international websites, and sequential, site-specific internet searches. Finally, subject area experts will be consulted and backward and forward citation searches of included articles will be completed. Two independent reviewers will screen identified articles against eligibility criteria and extract data for included studies. Quality of included studies will be assessed using the Mixed Methods Appraisal Tool (MMAT) for mixed studies reviews. Data will be synthesised using a convergent qualitative narrative approach.

Discussion: Given the centrality of school in the daily lives of resettled refugee children, it is vital to assess the impact of school climate on the psychosocial wellbeing and resettlement trajectories of this population. This review will identify evidence-based school factors which support good mental health and resettlement outcomes for refugee students and make recommendations for translation of this knowledge into the school environment.

Systematic Review Registration: PROSPERO CRD42017077570.
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http://dx.doi.org/10.1186/s13643-019-1016-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6492402PMC
April 2019

Identifying distinctive psychological symptom profiles among a nationally representative sample of refugees resettled in Australia.

Aust N Z J Psychiatry 2019 09 28;53(9):908-919. Epub 2019 Apr 28.

1 School of Psychology, University of New South Wales, Sydney, NSW, Australia.

Objective: The number of refugees worldwide is unprecedented in recent history. Little is known, however, about profiles of psychological symptoms following persecution and displacement.

Methods: This study reports on a latent class analysis that identified profiles of posttraumatic stress disorder (PTSD), depression and anxiety symptoms in a nationally representative sample of 1625 refugees in Australia. The association between specific symptom profiles, exposure to potentially traumatic events and post-migration stressors, and overall health and help-seeking was examined.

Results: Latent class analysis yielded an optimal five-class solution. These classes comprised the Pervasive Symptom class (19.2%), the High PTSD Symptom class (17.1%), the High Depression/Anxiety Symptom class (16.4%), the Moderate PTSD Symptom class (16.2%) and the Low Symptom class (31.1%). Participants in the symptomatic classes were more likely to be female, older and report greater post-migration stressors than those in the Low Symptom class. In addition, individuals in classes characterized by PTSD symptoms had been exposed to more types of potentially traumatic events. Membership in symptomatic classes was associated with poorer overall heath and greater help-seeking.

Conclusion: Qualitatively distinct symptom profiles were observed in a nationally representative sample of refugees. In addition to a group of people who reported high symptoms across psychological disorders and may warrant clinical intervention, we identified two subclinical classes who may be missed by existing diagnostic classification systems. Post-migration stressors play an important role in influencing refugee symptom profiles over and above exposure to potentially traumatic events. Clinicians should consider specific symptom profiles and contextual factors when planning interventions with refugees.
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http://dx.doi.org/10.1177/0004867419846403DOI Listing
September 2019

The structure and psychosocial correlates of complicated bereavement amongst refugees from West Papua.

Soc Psychiatry Psychiatr Epidemiol 2019 Jun 18;54(6):771-780. Epub 2019 Feb 18.

Centre for Population Mental Health Research, Liverpool Hospital and Psychiatry Research and Teaching Unit, School of Psychiatry, Cnr Forbes and Campbell Streets, University of New South Wales, Liverpool NSW 2170, Sydney, NSW, 2052, Australia.

Purpose: Refugees may be at risk of experiencing a complicated form of bereavement. As yet, however, the nosological status of this putative category across cultures remains in question. We apply qualitative and quantitative methods to investigate the manifestations, prevalence, factorial structure and psychosocial correlates of complicated bereavement amongst refugees from West Papua, a population with no past exposure to western concepts of grief or to formal mental health services.

Methods: Qualitative methods (focus groups and informant interviews) were used to identify cultural expressions of complicated bereavement derived from international classification systems, that is, DSM 5 persistent complex bereavement disorder (PCBD) and ICD-11 prolonged grief disorder (PGD) in developing a structured interview applied by trained field workers. Participants were adult West Papuan refugees and their offspring recruited from households (n = 486, response 85.8%) across nine villages in a remote town in Papua New Guinea.

Results: The qualitative data obtained from focus groups (n = 20) and informant interviews (n = 4) with local psychiatrists supported the cultural validity of complicated bereavement. 16% (n = 78) of the sample met criteria for PCBD based on DSM-5 criteria and 103 (21%) met criteria for PGD based on ICD-11 criteria. Confirmatory factor analysis yielded a six-factor model of complicated bereavement with a moderately good fit to the data. The model included dimensions of anger/negative appraisal (AN), avoidance/giving up, estrangement from others, and confusion and diminished identity. In contrast, the DSM-5 three-factor model and the ICD-11 two-factor model each yielded a poor fit. Cumulative traumatic losses (β = 0.16, P = 0.03), duration since displacement [(β = 0.10, P = 0.02)] and postmigration living difficulties (β = 0.20, P = 0.01) were associated with an aggregated index of complicated bereavement, supporting the concurrent validity of the structure identified.

Conclusions: Culture and exposure to persecution and displacement may contribute to the content and configuration of the complicated bereavement reaction, an issue that requires recognition in international classification systems and clinical practice.
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http://dx.doi.org/10.1007/s00127-019-01666-1DOI Listing
June 2019

Developing a measure of adaptive stress arising from the psychosocial disruptions experienced by refugees based on a sample of displaced persons from West Papua.

Int J Methods Psychiatr Res 2019 03 11;28(1):e1770. Epub 2019 Feb 11.

The Academic Mental Health Unit, Psychiatry Research and Teaching Unit, School of Psychiatry, University of New South Wales, Sydney, New South Wales, Australia.

Objectives: We report the testing and refinement of the Adaptive Stress Index (ASI), a psychosocial assessment tool designed to measure the longer terms stressors of adapting to the psychosocial disruptions experienced by refugees.

Methods: The ASI is based on a theoretical model, the Adaptation and Development After Persecution and Trauma (ADAPT), which postulates that five psychosocial domains are disrupted by conflict and displacement, namely, safety and security, attachment, access to justice, roles and identities, and existential meaning. We used confirmatory factor analysis (CFA) and item response theory (IRT) to shorten and refine the measure based on data obtained from 487 refugees participating in a household survey in Papua New Guinea (response rate: 85.8%).

Results: CFA allowed the exclusion of low loading items (<0.5) and locally dependent items. A good fit was found for single models representing each of the five ASI domains. A graded response IRT model identified items with the highest discrimination and information content in each of the five derived scales.

Conclusions: The analysis produced a shortened and refined ASI for use amongst refugee populations. The study offers a guide to adapting measures of stress for application to diverse populations exposed to mass conflict and refugee displacement.
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http://dx.doi.org/10.1002/mpr.1770DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6877204PMC
March 2019

The HTQ-5: revision of the Harvard Trauma Questionnaire for measuring torture, trauma and DSM-5 PTSD symptoms in refugee populations.

Eur J Public Health 2019 06;29(3):468-474

Department of Health and Social Work, University of Applied Sciences Emden, Emden, Germany; Women's Research Center, Brandeis University, Waltham, MA, United States.

Background: The Harvard Trauma Questionnaire (HTQ) was developed 25 years ago as a cross-cultural screening instrument to document trauma exposure, head trauma and trauma-related symptoms in refugees. This article aims to: (i) outline the process of revision of Part IV of the HTQ to (a) include the new DSM-5 diagnostic criteria for PTSD, and (b) separate out and more fully develop the refugee-specific functioning items; and (ii) promote a consistent approach to the validation of the HTQ-5 when adapted for use in other cultures and language groups.

Methods: Our process involved item mapping; expert consultations; generating items according to the new DSM-5 criteria; and drafting, refinement and finalization of the revised measure focusing closely on issues of meaning, future translation into multiple languages and comprehension amongst groups with low literacy and little or no exposure to Western trauma concepts. Validity and reliability testing of the new HTQ-5 is underway.

Results: The HTQ symptom checklist was modified consistent with current DSM-5 diagnostic criteria to identify those refugees at risk for mental health and other symptoms associated with traumatic life events, disability and dysfunction.

Conclusions: Accurate screening of post-traumatic distress and dysfunction enables those working with refugees to triage them more effectively to scarce health and mental health resources. When developing screening measures to inform public health policy and practice, it is vital that these measures can bridge the gap between western (etic) nosologies and indigenous (emic) understandings of traumatic stress.
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http://dx.doi.org/10.1093/eurpub/cky256DOI Listing
June 2019

Adjustment of refugee children and adolescents in Australia: outcomes from wave three of the Building a New Life in Australia study.

BMC Med 2018 09 4;16(1):157. Epub 2018 Sep 4.

Phoenix Australia, Melbourne, Victoria, Australia.

Background: High-income countries like Australia play a vital role in resettling refugees from around the world, half of whom are children and adolescents. Informed by an ecological framework, this study examined the post-migration adjustment of refugee children and adolescents 2-3 years after arrival to Australia. We aimed to estimate the overall rate of adjustment among young refugees and explore associations with adjustment and factors across individual, family, school, and community domains, using a large and broadly representative sample.

Methods: Data were drawn from Wave 3 of the Building a New Life in Australia (BNLA) study, a nationally representative, longitudinal study of settlement among humanitarian migrants in Australia. Caregivers of refugee children aged 5-17 (N = 694 children and adolescents) were interviewed about their children's physical health and activity, school absenteeism and achievement, family structure and parenting style, and community and neighbourhood environment. Parent and child forms of the Strengths and Difficulties Questionnaire (SDQ) were completed by caregivers and older children to assess social and emotional adjustment.

Results: Sound adjustment according to the SDQ was observed regularly among young refugees, with 76-94% (across gender and age) falling within normative ranges. Comparison with community data for young people showed that young refugees had comparable or higher adjustment levels than generally seen in the community. However, young refugees as a group did report greater peer difficulties. Bivariate and multivariate linear regression analyses showed that better reported physical health and school achievement were associated with higher adjustment. Furthermore, higher school absenteeism and endorsement of a hostile parenting style were associated with lower adjustment.

Conclusions: This is the first study to report on child psychosocial outcomes from the large, representative longitudinal BNLA study. Our findings indicate sound adjustment for the majority of young refugees resettled in Australia. Further research should examine the nature of associations between variables identified in this study. Overall, treating mental health problems early remains a priority in resettlement. Initiatives to enhance parental capability, physical health, school achievement and participation could assist to improve settlement outcomes for young refugees.
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http://dx.doi.org/10.1186/s12916-018-1124-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6122776PMC
September 2018

Longitudinal association between trust, psychological symptoms and community engagement in resettled refugees.

Psychol Med 2019 07 30;49(10):1661-1669. Epub 2018 Aug 30.

School of Psychology,University of New South Wales,Sydney,Australia.

Background: The mental health and social functioning of millions of forcibly displaced individuals worldwide represents a key public health priority for host governments. This is the first longitudinal study with a representative sample to examine the impact of interpersonal trust and psychological symptoms on community engagement in refugees.

Methods: Participants were 1894 resettled refugees, assessed within 6 months of receiving a permanent visa in Australia, and again 2-3 years later. Variables measured included post-traumatic stress disorder symptoms, depression/anxiety symptoms, interpersonal trust and engagement with refugees' own and other communities.

Results: A multilevel path analysis was conducted, with the final model evidencing good fit (Comparative Fit Index = 0.97, Tucker-Lewis Index = 0.89, Root Mean Square Error of Approximation = 0.05, Standardized Root-Mean-Square-Residual = 0.05). Findings revealed that high levels of depression symptoms were associated with lower subsequent engagement with refugees' own communities. In contrast, low levels of interpersonal trust were associated with lower engagement with the host community over the same timeframe.

Conclusions: Findings point to differential pathways to social engagement in the medium-term post-resettlement. Results indicate that depression symptoms are linked to reduced engagement with one's own community, while interpersonal trust is implicated in engagement with the broader community in the host country. These findings have potentially important implications for policy and clinical practice, suggesting that clinical and support services should target psychological symptoms and interpersonal processes when fostering positive adaptation in resettled refugees.
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http://dx.doi.org/10.1017/S0033291718002246DOI Listing
July 2019

Defining a combined constellation of complicated bereavement and PTSD and the psychosocial correlates associated with the pattern amongst refugees from West Papua.

Psychol Med 2019 07 28;49(9):1481-1489. Epub 2018 Aug 28.

Centre for Population Mental Health Research, Liverpool Hospital, Psychiatry, Research and Teaching Unit, School of Psychiatry, University of New South Wales,Cnr Forbes and Campbell Streets, Liverpool NSW 2170, Sydney,Australia.

Background: Refugees are at risk of experiencing a combined constellation of complicated bereavement and posttraumatic stress disorder (PTSD) symptoms following exposure to complex traumas associated with personal threat and loss. Features of identity confusion are central to both complicated bereavement and PTSD and these characteristics may be particularly prominent amongst refugees from traditional cultures displaced from their homelands, families, and kinship groups. We investigate whether a combined pattern of complicated bereavement and PTSD can be identified amongst West Papuan refugees participating in an epidemiological survey (n = 486, response rate: 85.8%) in a remote town in Papua New Guinea.

Methods: Latent class analysis was applied to derive subpopulations of refugees based on symptoms of complicated bereavement and PTSD. Associations were examined between classes and traumatic loss events, post-migration living difficulties (PMLDs), and psychosocial support systems.

Results: The four classes identified comprised a complicated bereavement class (11%), a combined posttraumatic bereavement class (10%), a PTSD class (11%), and a low symptom class (67%). Symptoms of identity confusion were prominent in the posttraumatic bereavement class. Compared with the low symptom class, the combined posttraumatic bereavement class reported greater exposure to traumatic loss events (OR 2.43, 95% CI 1.11-5.34), PMLDs (OR 2.24, 95% CI 1.01-4.6), disruptions to interpersonal bonds and networks (OR 3.3, 95% CI 1.47-7.38), and erosion of roles and identities (OR 2.18, 95% CI 1.11-4.27).

Conclusions: Refugees appear to manifest a combined pattern of complicated bereavement and PTSD symptoms in which identity confusion is a prominent feature. This response appears to reflect the combined impact of high levels of exposure to traumatic losses, PMLDs, and disruption of relevant psychosocial systems.
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http://dx.doi.org/10.1017/S0033291718002027DOI Listing
July 2019

Risk of perpetrating intimate partner violence amongst men exposed to torture in conflict-affected Timor-Leste.

Glob Ment Health (Camb) 2018 3;5:e23. Epub 2018 Jul 3.

Psychiatry Research and Teaching Unit, School of Psychiatry, University of New South Wales, Sydney, New South Wales, Australia.

Background: A key issue in need of empirical exploration in the post-conflict and refugee mental health field is whether exposure to torture plays a role in generating risk of intimate partner violence (IPV), and whether this pathway is mediated by the mental health effects of torture-related trauma. In examining this question, it is important to assess the impact of socio-economic hardship which may be greater amongst survivors of torture in low-income countries.

Methods: The study data were obtained from a cohort of 870 women (recruited from antenatal clinics) and their male partners in Dili district, Timor-Leste. We conducted bivariate and path analysis to test for associations of men's age, socioeconomic status, torture exposure, and mental disturbance, with IPV (the latter reported by women).

Results: The path analysis indicated positive paths from a younger age, torture exposure, and lower socio-economic status amongst men leading to mental disturbance. Mental disturbance, in turn, led to IPV. In addition, younger age, lower socio-economic status, torture exposure, and mental disturbance were directly associated with IPV.

Conclusions: Our data provide the first systematic evidence of an association between torture and IPV in a low-income, post-conflict country, confirming that low socio-economic status, partly related to being a torture survivor, adds to the risk. The high prevalence of IPV in this context suggests that other structural factors, such as persisting patriarchal attitudes, contribute to the risk of IPV. Early detection and prevention programs may assist in reducing the risk of IPV in families in which men have experienced torture.
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http://dx.doi.org/10.1017/gmh.2018.16DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6036651PMC
July 2018

Factor structures of Complex Posttraumatic Stress Disorder and PTSD in a community sample of refugees from West Papua.

Compr Psychiatry 2018 08 26;85:15-22. Epub 2018 May 26.

Psychiatry Research and Teaching Unit, School of Psychiatry, University of New South Wales, NSW, Australia.

Objectives: The intention to include a category of Complex Posttraumatic Stress Disorder (CPTSD) in ICD-11 has renewed interest in this construct. Although growing evidence from high income countries supports the construct validity of CPTSD, little parallel research has been undertaken across cultures. We tested theoretically supported CPTSD structures (a one-factor, six-factor, one-factor higher-order, and two-factor higher order structure) in a community sample of West Papuan refugees living in a remote town, Kiunga, in Papua New Guinea (PNG).

Procedures: A community-wide survey was conducted (2016-2017; response rate 85.5%) amongst 486 West Papuans. Culturally adapted measures were applied to assess cumulative traumatic exposure, postmigration living difficulties (PMLDs), CPTSD symptoms, and functional impairment.

Findings: A six factor structure for CPTSD provided the best fit to the data, consistent with our past study amongst West Papuans.

Conclusions: The cross-cultural validity of our findings is supported by the isolation of West Papuan participants from services treating traumatic stress. To further support the universal applicability of CPTSD, our findings need to be confirmed amongst other refugee groups from diverse cultural backgrounds.
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http://dx.doi.org/10.1016/j.comppsych.2018.05.001DOI Listing
August 2018

The role of site and severity of injury as predictors of mental health outcomes following traumatic injury.

Stress Health 2018 Oct 1;34(4):545-551. Epub 2018 Jun 1.

Phoenix Australia: Centre for Posttraumatic Mental Health, Carlton, VIC, Australia.

The aim of this study was to investigate the influence of injury site and severity as predictors of mental health outcomes in the initial 12 months following traumatic injury. Using a multisite, longitudinal study, participants with a traumatic physical injury (N = 1,098) were assessed during hospital admission and followed up at 3 months (N = 932, 86%) and at 12 months (N = 715, 71%). Injury site was measured using the Abbreviated Injury Scale 90, and objective injury severity was measured using the Injury Severity Score. Participants also completed the Hospital Anxiety and Depression Scale and the Clinician Administered Post-traumatic Stress Disorder (PTSD) Scale. A random intercept mixed modelling analysis was conducted to evaluate the effects of site and severity of injury in relation to anxiety, PTSD, and depressive symptoms. Injury severity, as well as head and facial injuries, was predictive of elevated PTSD symptoms, and external injuries were associated with both PTSD and depression severity. In contrast, lower extremity injuries were associated with depressive and anxiety symptoms. The findings suggest that visible injuries are predictive of reduced mental health, particularly PTSD following traumatic injury. This has clinical implications for further advancing the screening for vulnerable injured trauma survivors at risk of chronic psychopathology.
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http://dx.doi.org/10.1002/smi.2815DOI Listing
October 2018
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