Do truth commissions heal? The East Timor experience.
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Female↗
Biomedical subjects
Derrick Silove
Publications and source records attributed to Derrick Silove.
Delays in referral of patients with social phobia, panic disorder and generalized anxiety disorder attending a specialist anxiety clinic.
Individuals with anxiety disorders experience substantial delays in obtaining treatment, but little is known about whether people with specific anxiety subcategories are differentially affected. The present study used a modified Encounter Form to examine the cause and length of delays in reaching primary care and specialist services amongst patients with panic disorder (PD/PD-Ag), social phobia (SP), and generalized anxiety disorder (GAD). Participants were 142 consecutive patients attending a specialist anxiety clinic in South Western Sydney. On average, participants with SP took much longer to consult a primary health care provider. Primary care assessments of those with SP often failed to detect anxiety as the key problem, and subsequently, those with SP reported longer delays in reaching specialist care (>9 years). It is not possible to extrapolate the findings to all individuals with SP, as the study was based on specialist service attenders. Nevertheless, the data supports previous findings in suggesting that SP may not be well-recognized as a disorder needing treatment, either by the patient or the primary health care provider. Appropriate educational programs seem warranted to ensure appropriate treatment for this condition.
Adult↗
Pathways to the first contact with specialist mental health care.
OBJECTIVE: To examine the pathways to mental health care followed by patients presenting for the first time to community- and hospital-based services and the degree to which individual characteristics, cultural background, illness type, severity and service-related variables influence the time and pathways taken to reach care. METHOD: One hundred and forty-six consecutive Australian-born, Asian and Arabic-speaking patients making their first lifetime contact with mental health services in two area health regions were included. Symptom severity was assessed using the Health of the Nations Outcome Scales. Illness explanatory models, social support, English-language proficiency and acculturation were also assessed. RESULTS: An average of three professional consultations were made prior to first contact with public mental health services. Family physicians occupied a pivotal role in the help-seeking pathway with 53% of patients consulting a general practitioner. The median time taken to reach specialist mental health services was 6 months, with significantly shorter time for patients with psychotic disorders. Individual variables such as gender, social support, ethnicity and English fluency were not associated with delays in receiving public mental health care. Ethnicity was associated with lower utilization of allied health professionals. CONCLUSIONS: The data suggest that social and cultural factors influence the range of professionals consulted by those with a mental illness but do not delay their presentation to public mental health services.
Acculturation↗
Impact of immigration detention and temporary protection on the mental health of refugees.
BACKGROUND: Over the past decade, developed Western countries have supplied increasingly stringent measures to discourage those seeking asylum. AIMS: To investigate the longer-term mental health effects of mandatory detention and subsequent temporary protection on refugees. METHOD: Lists of names provided by community leaders were supplemented by snowball sampling to recruit 241 Arabic-speaking Mandaean refugees in Sydney (60% of the total adult Mandaean population). Interviews assessed post-traumatic stress disorder (PTSD), major depressive episodes, and indices of stress related to past trauma, detention and temporary protection. RESULTS: A multilevel model which included age, gender, family clustering, pre-migration trauma and length of residency revealed that past immigration detention and ongoing temporary protection each contributed independently to risk of ongoing PTSD, depression and mental health-related disability. Longer detention was associated with more severe mental disturbance, an effect that persisted for an average of 3 years after release. CONCLUSIONS: Policies of detention and temporary protection appear to be detrimental to the longer-term mental health of refugees.
Adult↗
Disability and health service utilization associated with psychological distress: the influence of ethnicity.
This study examined levels of disability and use of health services, as a result of psychological distress, across various ethnic groups after taking into account selected sociodemographic factors such as age, gender, education, and employment. We have analyzed data from the 1997-1998 New South Wales Health Survey, Australia. A telephone interview of 35,025 adults aged 16 years and over selected from each of the 17 Health Service Areas in the state. While people from non-English speaking backgrounds were more likely to suffer high levels of disability as a result of psychological distress, they were less likely to utilize health services compared to those from English speaking backgrounds. This was particularly true for those born in Southern and South-East Asia as well as the Middle East and Africa. Further research into the reasons underlying these findings for each ethnic group is warranted.
Adolescent↗
Science and the common good: indefinite, non-reviewable mandatory detention of asylum seekers and the research imperative.
Despite a strong historical record of resettling and providing care for refugee populations, the Australian Federal Government has increasingly implemented harsh and restrictive policies regarding the treatment and management of asylum seekers. Most controversial of these has been the mandatory detention of asylum seekers, a policy applied indiscriminately and without discretion where individual cases have not been subject to judicial review or time constraints. From the outset health professionals have raised concerns about the possible adverse mental health impacts of prolonged detention. In contrast, government representatives have characterized conditions in detention as benign and comfortable, and have consistently contested criticism of detention, often citing a lack of scientific evidence as tacit support for the continuation of the policy. Nevertheless, requests for access to the detention centres to undertake rigorous scientific investigations have gone unheeded. In this context we argue that the Australian Government has failed to uphold its commitment to good governance by allowing transparency, openness and a willingness to have the impact of its policies scrutinized by scientists. The manifest conflict of interest in the government position leads to a breach in the normal social contract between mental health researchers and those responsible for the policy of detention. There is, we argue, a legitimate moral imperative in such situations for clinical researchers to breach the walls of enforced silence and give a voice to those who are afflicted. This imperative, however, must be carefully balanced against the risks that may face detainees agreeing to participate in such research.
Australia↗
Comorbidity of PTSD and depression: associations with trauma exposure, symptom severity and functional impairment in Bosnian refugees resettled in Australia.
BACKGROUND: Posttraumatic stress disorder (PTSD) is common in refugees but its association with longer-term psychosocial dysfunction remains unclear. We examined whether a subgroup of refugees with comorbid PTSD and depression were at particularly high risk of disability. We also investigated whether specific trauma experiences were linked to this comorbid pattern. METHODS: Consecutive Bosnians (and one or two compatriots nominated by them) were recruited from a community centre, yielding a total sample of 126 participants (response rate 86%). Measures included a trauma inventory, the Clinician Administered PTSD Scale (CAPS) (Blake et al., 1995) and the depression module of the Structured Clinical Interview (SCID) (First et al., 1997). RESULTS: Three diagnostic groupings emerged: normals (n=39), pure PTSD (n=29), and comorbid PTSD and depression (n=58). Of four trauma dimensions derived from principle components analysis (human rights violations, dispossession and eviction, life threat and traumatic loss), life threat alone was associated with pure PTSD, with life threat and traumatic loss both being associated with comorbidity. Compared to normals and those with pure PTSD, the comorbid group manifested more severe PTSD symptoms as well as higher levels of disability on all indices (global dysfunction: odds ratio=5.0, P<0.001, distress: odds ratio=6.0, P<0.001, social impairment: odds ratio 5.9, P<0.001, and occupational disability: odds ratio 5.0, P<0.001). LIMITATIONS: Recruitment was not random, the sample size was modest, and trauma event endorsement was based on retrospective accounts. CONCLUSIONS: The combination of life threat and traumatic loss may be particularly undermining to the psychological well-being of refugees and consequent comorbidity of PTSD and depression may be associated with longer-term psychosocial dysfunction. The findings raise the question whether the comorbid pattern identified should be given more recognition as a core posttraumatic affective disorder.
Adolescent↗
The use of international videoconferencing as a strategy for teaching medical students about transcultural psychiatry.
Videoconferencing is an innovative method that potentially allows medical students exposure to international teachers in refugee mental health who would otherwise be inaccessible. This article reports a pilot study using videoconferencing with international teachers from Australia, Sweden and the USA participating in the training of ten senior Swedish medical students. Interviews with an actual and a simulated patient were conducted at the U.S. and Australian sites respectively, followed by discussions involving those two sites with students and their supervisors in Sweden. Students evaluated the method favourably, as did the teachers, although the brevity of the program was seen as a limitation. Teachers noted the importance of preparing students and patients and ensuring that the technology operates smoothly to ensure success. Although cost-effective in teaching medical students in developed countries, videoconferencing may still be out of the reach of training programs in many developing countries where it is most needed.
Adult↗
An ethnographically derived measure of anxiety, depression and somatization: the Phan Vietnamese Psychiatric Scale.
This article describes the development and validation of the Phan Vietnamese Psychiatric Scale (PVPS). The PVPS was derived from Vietnamese idioms and cultural understandings of psychiatric and emotional distress identified from the Vietnamese literature and using ethnographic methods. The PVPS consists of a 26-item depression subscale, a 13-item anxiety subscale and a 14-item somatization subscale. Estimates of internal consistency for the three subscales ranged from .87 to .95, with 4-day interval test-retest reliability ranging from .81 to .89. Confirmatory factor analysis supported the subscale structure, with the depression subscale comprising two components 'general mood disturbance' and 'psychovegetative symptoms.' Multitrait-multimeasure analysis supported the construct validity of the scale. The PVPS demonstrated good criterion validity against case assignments by psychiatrists, naturalist healers, and structured diagnostic measures. The PVPS was rated as superior in clinical sensitivity and acceptability in comparison to other related measures.
Adolescent↗
Overcoming obstacles in confronting torture.
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Attitude of Health Personnel↗
Capacity of screening questionnaires to predict psychiatric morbidity 18 months after motor vehicle accidents.
Motor vehicle accidents are one of the most common causes of trauma-related psychiatric morbidity. Previous studies have suggested that symptom screening instruments may be useful in predicting risk of longer-term psychiatric morbidity, but results have varied. The present study is based on 83 of an eligible 102 consecutive hospital-admitted survivors of road trauma who completed a structured clinical interview at baseline and 18-month follow-up. A subsample returned symptom questionnaires within 2 weeks of the accident, with between 60 and 66 completing the questionnaire. Receiver Operator Characteristic curve analyses were applied to obtain optimal predictive scores on each screening measure. Combining the derived cutoff scores on the Impact of Event Scale (measuring posttraumatic stress disorder symptoms) and the Beck Depression Inventory yielded an odds ratio of 82.9 in predicting any psychiatric morbidity at 18 months, with a specificity of 95%, and high positive (89%) and negative (91%) predictive indices. If these exploratory findings are confirmed by future studies, the case will be strengthened for routine screening of motor vehicle accident survivors to allow ongoing monitoring and selective early interventions for the high-risk subgroup. Compliance with completing and returning questionnaires remains a major challenge in this population, however, as indicated by the level of attrition in our study.
Accidents, Traffic↗
Long-term effect of psychological trauma on the mental health of Vietnamese refugees resettled in Australia: a population-based study.
BACKGROUND: What are the deleterious effects of mass trauma on the psychological wellbeing of refugees and other war-affected populations? Most epidemiological data are for short-to-medium term effects, leaving the possibility that early psychological reactions could reduce naturally over time. We aimed to assess the long-term effects of trauma on mental health and disability in Vietnamese refugees resettled in Australia. METHODS: In a population-based study, we identified a community sample of 1413 adult Vietnamese from census collection areas in Sydney, Australia. Participants were interviewed by trained bilingual workers who administered questionnaires to assess the frequency of international classification of disease, version 10 (ICD-10) mental disorders in the 12 months before interview; psychiatric symptoms, by use of a culturally-sensitive symptom measure; exposure to psychologically traumatic events; disability and use of health services; and social, economic, and cultural factors since migration. We did multivariate analyses with adjustment for stressors since migration to establish the risk factors for mental illness. FINDINGS: 1161 (82%) adults completed the interview. Mean length of residence in Australia was 11.2 years (SD 14.4) and mean time since the most severe traumatic event was 14.8 years (SD 10.8). 95 (8%) and 75 (7%) of participants had mental disorders defined by ICD-10 and the culturally-sensitive measure, respectively. Trauma exposure was the most important predictor of mental health status. Risk of mental illness fell consistently across time. However, people who had been exposed to more than three trauma events (199) had heightened risk of mental illness (23, [12%]) after 10 years compared with people with no trauma exposure (13, [3%]) (odds ratio 4.7, p<0.0001, 95% CI 2.3-9.5). INTERPRETATION: Most Vietnamese refugees were free from overt mental ill health. Trauma-related mental illness seemed to reduce steadily over time, but a subgroup of people with a high degree of exposure to trauma had long-term psychiatric morbidity. Our findings support the need to develop specialised mental health services to reduce disability in refugees whose exposure to extreme trauma puts them at risk of chronic psychiatric disability.
Adult↗
Hearing the voices: mental health services in East Timor.
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Humans↗
How well do refugees adapt after resettlement in Western countries?
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Acculturation↗
The asylum debacle in Australia: a challenge for psychiatry.
OBJECTIVE: To examine the mental health consequences of contemporary Australian policies pertaining to asylum seekers and to consider the possible roles of psychiatrists in responding to this issue. METHODS: Historical and political factors driving policy are considered. The results of Australian studies examining the mental health of asylum seekers are reviewed. RESULTS: Available research shows high rates of trauma, posttraumatic stress disorder (PTSD) and depression in asylum seekers. The conditions of the postmigration environment influence outcomes. Psychiatrists working with other agencies continue to advocate for this group. Important roles include the provision of clinical services, undertaking and disseminating research, acting as expert witnesses and consultants, and writing reports for refugee applicants. CONCLUSIONS: Complex political motivations steer asylum policy. Psychiatric formulations are important in considering the impact of contemporary policy, but a wider ecological model is needed to understand acts of desperation displayed by asylum seekers,particularly those in long-term detention. Sustained effort will be needed to alter a policy of exclusion that has become entrenched.
Australia↗
Associations between juvenile and adult forms of separation anxiety disorder: a study of adult volunteers with histories of school refusal.
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Adult↗
Complicated grief in Bosnian refugees: associations with posttraumatic stress disorder and depression.
Complicated grief is likely to be common among refugee populations exposed to war trauma. However, there have been few studies investigating the traumatic antecedents and correlates of complicated grief in refugees, and the relationship of that symptom pattern with other common disorders such as posttraumatic stress disorder (PTSD) and depression. We studied Bosnian refugees recruited from a community center in Sydney, Australia, with the sample being supplemented by a snowball method (N = 126; response rate, 86%). Measures included a trauma inventory, the Clinician Administered PTSD Scale (CAPS), the depression module of the Structured Clinical Interview (SCID), and the Core Bereavement Items (CBI). A dimension of traumatic loss derived from the trauma inventory was a specific predictor of complicated grief, with exposure to human rights violations being associated with images of the traumatic events surrounding the lost person. There was no link between PTSD and grief other than for a low-order association with the PTSD intrusion dimension. In contrast, depression was strongly associated with grief and its subscales. Only the subgroup with comorbid grief and depression reported higher levels of traumatic loss. The results suggest that complicated grief in refugees can become persistent and associated with depression. While PTSD and grief share common symptoms of intrusion, the two symptom domains are sufficiently distinct to warrant independent assessment of grief in refugee populations.
Adolescent↗