Psychiatry in Society - part 8 doc

scores were correlated with female gender, poverty, conflict with immigra- tion officials, loneliness and boredom. Adjustment Disorders Adjustment disorders have been defined in the ICD-10 as states of subjec- tive distress and emotional disturbance, usually interfering with social functioning and performance, and arising in the period of adaptation to a significant life change or to the consequences of a stressful life event (in- cluding the presence or possibility of serious physical illness). The stressor may have involved the individual or his community. The DSM-IV suggests that the essential feature of an adjustment disorder is the development of clinically significant emotional or behavioural symp- toms in response to an identifiable psychosocial stressor or stressors. The distress suffered by a person should be in excess of what is expected as a normal reaction to the stressor. It may be manifested as predominantly depressive or anxiety symptoms, a mixture of depressive and anxiety symptoms, or disturbances of conduct or emotion. As pointed out by the ICD-10 categorization under which adjustment disorder is incorporatedÐ ``reaction to severe stress, and adjustment disorders''Ðstress is the hallmark of this group of disorders. For the refugee population, stress may be experienced at every step, starting from the destruction of life and property as a result of war, the problems faced in shifting from one place to another and often to a new country, the pressures of coping with a new culture and language, the difficulties in relocation and ultimate absorption into another country, and the daily hardships faced in temporary refugee camps. As a result of this continuous series of stresses, refugees manifest many emotional problems, like frequent quarrels, frustration, despair, sadness, anxiety and bereavement. What may start as bereavement and sadness for the loss of life and property may eventually change to an adjustment disorder or a depressive disorder. Sometimes the initial trauma can be strong enough to lead to a transient disorder of significant severity called acute stress reaction, which gradually develops into a more prolonged adjustment disorder. During the course of the disorder, the person may have temporary diffi- culties in maintaining a relationship, have problems in rationalizing and reaching a decision, or have periods of depressive and anxiety symptoms. Depressive symptoms in the face of prolonged stress can be severe enough to lead to suicide. Generally, adjustment disorders last for a maximum of 6 months, but the disorder may be prolonged if the symptoms are predomin- antly depressive in nature of if the stressors continue. MENTAL HEALTH PROBLEMS IN REFUGEES 203 Schizophrenia and Other Psychotic Illnesses There have been a few studies that have looked at this issue. Kinzie et al. [5] found schizophrenia in 16% of the Indo-Chinese refugee population, similar figures were found among Cambodian refugees by Somasundaram et al. [19], and a slightly lower figure of 13% was found in refugees in Guinea- Bissau by de Jong [18]. Lavik et al. [6] opined that stress and traumatization connected with the refugee situation itself do not have a decisive impact on the development of psychotic symptoms, which may instead be related to other conditions or constitutional factors. However, certain traumatic experiences, like sensory deprivation, can cause psychotic symptoms. The stress±vulnerability model of schizophrenia also suggests a link between stress and schizophrenia in susceptible persons. So it is not unusual to find a higher prevalence of psychotic illnesses in refugee populations, though studies are lacking on the time of onset of the disorder, making it difficult to attribute to the refugee status the high prevalence of psychotic illnesses. Disorders in Child and Adolescent Population Children form one of the most vulnerable groups among refugees. Often they are the neglected lot. Psychiatric problems among refugee children are more prevalent than among the normal population of the same age. Al- though it has been argued that children are able to cope much better than adults, the fact remains that a large number of children among the refugee population suffer from mental disorders. Studies reveal that chil- dren, like adults, suffer an increasing number of psychiatric problems, among which PTSD, depression, anxiety and conduct disorders are the commonest ones. In Finland, Sourander [51] found that 48% of the surveyed refugee chil- dren had symptoms of PTSD, depression or anxiety. Fox et al. [52] found depression in 51% of the South East Asian refugee children surveyed by him in the USA. Sack et al. [53] conducted a long-term study using standardized instruments to assess the prevalence of PTSD and depression in a group of Cambodian children. They found that over a 12-year period the point prevalence for PTSD decreased from 50% to 35%, and that for depression dropped from 48% to 14%. Psychosocial problems were more prevalent than mental disorders in a group of refugee children studied in the UK [54]. Numerous children become innocent victims of war. Some lose their parents and relatives, some lose friends, schooling is disrupted and child- hood is lost. In many areas, children are inducted as soldiers. According to the Machel Report [55], nearly a quarter of a million child soldiers saw 204 PSYCHIATRY IN SOCIETY armed conflict in the late 1980s. Children are often forced to work as messengers, porters, and cooks or even to provide sexual gratification to older soldiers. They are often picked up from the streets or forcibly taken from their poor and frightened families by the leaders or chosen from the unaccompanied children. Unfortunately, all this leads to an increase in the prevalence rate of mental disorders among children caught in conflict areas. In this context, Schwarzwald et al. [56] conducted a survey among Israeli children from areas hit by missiles and compared them with children from areas not hit by missiles. The prevalence for PTSD was 24.9% in the former area and 12.9% in the latter. However, social functioning was found to be relatively preserved. Mollica et al. [57] surveyed 182 Khmer children settled in Thai refugee camps and found that 53.8% had psychiatric symptoms as per parent report on the Child Behaviour Checklist [58] and 26.4% on the Youth Self-Report [59]. PTSD was found in 945 of internally displaced Bosnian children in another survey [60]. In the Gaza Strip, Thabet and Vostanis [61, 62] found that out of the 959 children surveyed by them 44% showed ``caseness'' on the Rutter B2 scale [63], and 26.8% in the parent rating scale [64], with a cut-off score of 9. PTSD was again found to be an important disorder. Sack et al. [53] found almost half of the surveyed Khmer adolescents to be suffering from PTSD and depression in their initial assessment. The rates decreased to 35% for PTSD and 14% for depression after 12 years of follow- up. Servan-Schreiber et al. [65] found both PTSD and depression in 11.5% of the Tibetan children. Rates as high as 95% and 90% for PTSD and anxiety, respectively, have been found in displaced Bosnian children by Stein et al. [66]. However, all diagnoses of PTSD have to be judged carefully, keeping in mind the huge cultural difference across communities and the meaning and manifestations of trauma across different cultures. Children end up as refugees with or without their families. They are either willing or unwilling participants in a war and often have experienced death and destruction. At times they have been the cause of death, as soldiers, or have been tortured physically or sexually. Once in a foreign land, children express some coping behaviour that is culturally determined and some other that they gradually develop. Children are quicker to absorb the new culture, make friends and learn the new language. Often their ability to assimilate faster into a new community leads to a change of role in their home, and adults tend to depend on them more for help in resolving social issues. Although there are studies showing very high prevalence rates for mental disorders, especially PTSD, there are others [40] that have criti- cized the overdiagnosis of PTSD by Western assessors, including the inter- national organizations. Studies related to mental health problems among children and adolescents are summarized in Table 8.4. MENTAL HEALTH PROBLEMS IN REFUGEES 205 Tableable 8.4 Studies on children and adolescents Country Subjects and methods Prevalence (%) Reference Israel 492 schoolchildren whose areas were hit by missiles and controls Cross-sectional Stress Reaction Questionnaire, DSM-III-R, teacher's rating Affected/controls 24.9/12.9 (PTSD) Schwarzwald et al. [56] Thailand 182 Khmer children Cross-sectional Child Behaviour Checklist, Youth Self-Report 53.8 (psychiatric symptoms as per parent report) 26.4 (psychiatric symptoms as per youth report) Mollica et al. [57] Former Yugoslavia 364 internally displaced children Cross-sectional Bosnian War Questionnaire, Sead Picture Survey Tools 94 (PTSD) Goldstein et al. [60] Finland 46 unaccompanied refugee children Cross-sectional Child Behaviour Checklist 48 (symptoms of depression, anxiety or PTSD) Sourander [51] Former Yugoslavia 147 children in collective centres Follow-up over 8 months DSM-IV Initially: 95 (PTSD) 90 (anxiety) At 8 months: boys showed greater decrease of symptoms in relation to girls Stein et al. [66] India 61 randomly selected Tibetan children Cross-sectional DSM-IV 11.5 (PTSD) 11.5 (depression) Servan- Schreiber et al. [65] USA 47 South East Asian refugee children Cross-sectional Child Depression Inventory 51 (depression) Fox et al. [52] USA 46 Khmer adolescents from high school Follow-up study over 12 years DICA, SADS, KSADS PTSD/depression 50/48 (time 0) 35/14 (time 12 years) Sack et al. [53] 206 PSYCHIATRY IN SOCIETY Tableable 8.4 (Continued) Country Subjects and methods Prevalence (%) Reference Gaza Strip 959 randomly selected school children Follow-up over 1 year Rutter Scale A2/B2 with PTSD cut-off score 9 PTSD (initial/1 year later) 26.8/20.9 (parent rating) 44/- (teacher rating) Thabet and Vostanis [61, 62] UK 30 refugee children and families Retrospective, case- controlled DSM-IV, Children's Global Assessment Scale Psychosocial problems more than psychiatric problems Howard and Hodes [54] Though the prevalence rates vary widely across studies, the message that comes through clearly is that PTSD, depression and anxiety disorders form the bulk ofpsychiatric problems among refugees. Theincreased rates could be due to the multiple stresses that a refugee faces both at home and in refugee camps. Some critics have attributed this supposed higher rate of PTSD to application of culturally untested Western diagnostic systems and schedules. While this may be a valid criticism, it cannot be denied that a large number of refugees do manifest some symptoms akin to PTSD, although whether full- blown PTSD is present can be debated. Depression, anxiety disorders and somatic complaints are definitely more common among the refugee popula- tion. In spite of all these sufferings, studies have reported relatively well preserved social functioning among the refugee populations [30, 42, 43]. MANAGEMENT The number of refugees has increased considerably in the last decades as millions of people have been forcibly displaced. To address the mental health needs of such large populations, specific management ability and approaches are required. The task becomes even more complex as the health and mental health infrastructure, if it ever existed, is destroyed and health professionals are eliminated [3]. The accumulation of traumatic experiences brings psychosocial dysfunc- tioning due to feelings of fear of mental illness, loss of trust, coping capacities and hope. However, it would still be incorrect to label an entire refugee group as suffering from mental disorders and requiring psychiatric help. As dem- onstrated by Mollica [67] (Figure 8.1), the percentage of the population actu- ally suffering from any serious mental illness is very low. MENTAL HEALTH PROBLEMS IN REFUGEES 207 Basic income generating activities Physical and mental exhaustion Lack of trust in local and national institutions Social justice/revenge Despair and hopelessness Vocational problems Family problems Severe functional impairment Physical handicaps 100% of the general population Serious mental illness Figureigure 8.1 Trauma pyramid. Functional outcomes. Reproduced from Mollica [67] by permission of Richard F. Mollica It is often seen that a number of international, governmental and non- governmental organizations come forward with their expertise in any refu- gee condition. But not all the help rendered is coordinated, focused or useful under the circumstances. Therefore, it becomes pertinent to develop a systematic course of management. Some guidelines are provided by the World Health Organization (WHO)/UNHCR manual Mental Health of Refu- gees [68] and the WHO's Declaration of Cooperation. Mental Health of Refugees, Displaced and Other Populations Affected by Conflict and Post-Conflict Situations [69]. Other instruments for assessment of mental health problems are being developed by the WHO. Some basic tenets that should be followed in meeting the mental health needs of refugees are that interventions should be integrated with overall health care; they should be responsive to all severity and kinds of problems; they should be part of the redevelopment of mental health services; and they should be sustainable, culturally sensi- tive, evidence-based and cost-effective. The following sections briefly de- scribe some of the broad public health principles and strategies in mental 208 PSYCHIATRY IN SOCIETY health care in complex emergencies. No attempt has been made to cover all the strategies that have been suggested or implemented. Emergency Phase In this phase, initial health needs and available resources should be rapidly assessed with the help and knowledge of local authorities. The aim should be to assess psychological problems, and the availability of economic re- sources and human resources. Assessments should be made keeping the culture of local community in mind. Since most of the health requirements during the emergency phase are related to non-mental issues, the endeavour during this stage should be to make correct assessment of the situation and intervene immediately in cases of acute stress disorder due to physical or sexual trauma. Some of the common problems that require immediate intervention are fear and anxiety, sleep problems, reduced interest in work and self, and feelings of guilt, bereavement, anger. Many of these issues can be managed easily through community-based discussions of these issues and enumerating means to tackle them. Proper venting of emotions helps and a psychiatrist can help in catharsis, though it should be borne in mind that catharsis is not mandatory for all cases. The individuals should be taught to look for experi- ences of solidarity in their new environment. New coping skills should be taught. Mental health workers can also help by educating the community on issues of stigmatization, so that an already traumatized person is not overburdened with the problem of stigma. Towards this end, training of local mental health workers is required. Training should involve knowledge of psychosocial issues and mental disorders and basic management skills. On-the-job training could supplement existing knowledge. Important community leaders or focal persons or institutions can be introduced to simple ways of addressing the problems of refugees in an effective way. To overcome the traumatic experiences, some individuals may require individual or group interventions or occasionally administration of anxio- lytics. Mid-Phase This phase starts after the initial few days or weeks of shock have passed and people have started the process of rebuilding. It is during this phase that the subject is likely to experience the frustrations and troubles of the life of a refugee in greater proportion. In addition, past memories may add to the problem, causing symptoms of PTSD and depression. Adjustment MENTAL HEALTH PROBLEMS IN REFUGEES 209 problems, depression, anxiety, psychotic breakthroughs, behavioural prob- lems and PTSD are common. After a detailed assessment of the problem, a decision will have to be taken about the mode of management. Among refugees, community-based psychosocial interventions have been advocated. Interventions may include increasing community awareness; encouraging self-help groups and com- munity care among the group; promoting human rights issues; giving individual, family and group psychotherapy; and provision of counselling sessions and activities for youth and children. A model multilevel approach to counselling and psychotherapy has been formulated by Bemak et al. [70], integrating traditional Western psychotherapy with indigenous healing methods, cultural empowerment and psychosocial education in a four- level intervention approach. However, wherever necessary, pharmacother- apy should be used. Inexpensive and locally available psychotropics should be used as far as possible, keeping in mind that some individuals may require medication for long periods. Those persons with pre-existing mental disorders should be prescribed psychotropics that had been effective previ- ously, although the dosage may need to be adjusted. While many psychosocial interventions have been suggested in the litera- ture, it should be clearly recognized that there is no evidence of the effective- ness for most of them. Hence, counselling and psychotherapy for prevention or management of stress-induced disorders and associated disability should be advocated after careful consideration of the cost and any likely benefits. Children may have some additional problems due to the loss of parents or other changes within home and family. Separation anxiety, reversal of roles, bed-wetting, phobic disorders, substance abuse and behavioural problems may be present in addition to depression, anxiety, PTSD and psychotic illnesses. The family should be properly educated and informed about the symp- toms of their children, the prognosis and the means of response. Commu- nity resources like mass media, schools or religious groups can be used to impart information. Library facilities and radio talk shows can be used to discuss the problems of children. Children should be reintegrated into a family appropriately. Recreational and leisure activities in addition to basic amenities should be provided. Severe cases should be referred to specialized centres. An outreaching, discreet and non-stigmatizing approach is essential for care and assistance to ex-detainees and victims of torture and sexual vio- lence. Particularly in instances of rape, maintenance of absolute confidenti- ality is essential to protect against damaging cultural stigmas and to provide a trusting atmosphere in which adaptive change can be advocated. The aim of proper management should follow the basic tenets of respect, confidenti- ality, justice, and doing no harm [71]. 210 PSYCHIATRY IN SOCIETY Long-Term Management Phase The long-term management should have two objectives: consolidation of the care provided initially and building of new resources. In the consolidation stage, the focus should be on community-based approaches, and existing staff should be properly mobilized and trained, starting from local level to the national level. Ongoing training and super- vision of the staff should be carried out. It is important to coordinate and supervise these activities, with one department of the local government or an international agency taking the lead. All the key governmental and non- governmental organizations should be involved and proper directions given according to the needs, keeping in mind the socio-cultural/political viewpoint. Family counselling; community dramas to relive previous trau- matic experience and to discuss means of coping; cultural activities; sports; discussions on stigma, the problems of women and children, and human rights; and coping strategies are some of the activities that should be con- sidered at this stage. Since the eventual aim is to build up the morale of the people and help them to rebuild their lives, all agencies, community leaders, traditional healers and religious organizations should be involved in the healing process. Self-help groups should be organized to look into the problems of specific subpopulations like widows, orphans, victims of rape and torture, ex-combatants, the elderly and victims of substance abuse. For special groups, psychotherapy in the form of family or group therapy should be carried out over a prolonged period. Local psychiatrists, general physicians, and psychiatric nurses should be trained in effective manage- ment of mental disorders and if necessary provided with basic kits of psychotropic drugs as advised by the WHO. If needed, camps should be organized to reach a greater population. Last, but not least, the mental health issues of health workers should be taken care of. Issues of frustration, burnout, and hopelessness should be handled with empathy. Some of the important issues relating to man- agement of mental health problems in complex emergencies are briefly described here. Training. This should include training of primary health care personnel, supervision and on-the-job training whenever required, and monitoring and evaluation of trained personnel. Training should be a continuing process and should involve as many personnel as possible like doctors, nurses, primary health care personnel, teachers, religious leaders, community leaders, etc. However, a selection of training programmes is needed to opti- mize the benefits from the given resources. Training should cover the sub- jects' mental health problems, the social issues that precipitate psychiatric symptoms, stigmatization, human rights issues, management, and means of MENTAL HEALTH PROBLEMS IN REFUGEES 211 developing new set-ups to tackle the current problem and also future problems. Mental health education. Knowledge about mental health problems should be incorporated at all levels of schooling. Discussions of relevant issues at school should be encouraged, so that children and adolescents have a platform to discuss issues related specifically to their lives. Younger chil- dren could be taught through plays or stories. Older children could be taught through special discussions, films, and reading material. A school counsellor may be of a great help in some cases. Emergency services. Emergency services should be established with the sup- port of available organizations and staff adequately trained to handle future problems. Mobile teams should be formed. Initial technical assistance, in- cluding material and financial support, will have to be provided. Self-help groups. Self-help groups from among the local populations should be encouraged and their activities supported initially to ensure that they work effectively. These groups can be extremely effective in providing mutual support, which is a crucial ingredient for better mental health. Supply of psychotropics. For countries that lack basic psychotropics, inter- national organizations and other governments can assist in providing sup- plies, until the national government is able to. Financial institutions may have to step in at times to provide assistance in the development of proper infrastructure. Community care facilities. Mental health workers should ensure that mental health facilities are integrated into community care and that different psychosocial interventions at a community-based level are available. Outreach facilities should be developed. The staff should be properly trained to tackle the specific needs, not only of refugees, but also of the general population. Increasing awareness. Often the awareness of mental health issues, per se, is so poor in some regions that it becomes difficult to organize resources directed towards mental health at times of crises. Steps should be taken to increase the awareness of mental health issues through mass education campaigns using newspapers, television, newsreels, brochures, group dis- cussions, etc. Technical support. In countries lacking an initial set-up, technical support needs to be provided until minimum facilities are created. It is imperative 212 PSYCHIATRY IN SOCIETY [...]... health intervention integrating emergency care into development of sustainable health systems and services MENTAL HEALTH PROBLEMS IN REFUGEES 215 monitoring and evaluation of programmes compiling an evidence base for effectiveness of interventions providing high-level advocacy of the mental health needs of the affected populations integrating the responses of non-governmental organizations working in. .. within developing world: symptomatology among Bhutanese refugees in Nepal JAMA, 280 : 443±4 48 Rasekh Z., Bauer H.M., Manos M., Lacopino V (19 98) Women's health and human rights in Afghanistan JAMA, 280 : 449±455 Peltzer K (1999) Trauma and mental health problems of Sudanese refugees in Uganda Cent Afr J Med., 45: 110±113 2 18 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 PSYCHIATRY IN SOCIETY. .. both alcohol- and drug-related problems, it was only the latter that persisted in their multivariate model Substance abuse acts in a variety of ways to increase the risk of becoming homeless, diverting money from housing and other daily living expenses, as well as leading to a loss of social support and contributing to criminal behaviour [39] The latter in turn may jeopardize housing by causing conflict... comparing data, since morbidity is very much linked to these; homeless populations are generally mostly male and young According to Burt [21], sampling methods can be classified into three generations The first generation relied on experts' opinions, as in the case of data from the Community for Creative Non-Violence (1 983 ) or the US Department of Housing and Urban Development (1 984 ) (quoted in Burt... disability Interface and integration of mental health care with overall health care INTERNATIONAL ORGANIZATIONS A number of international agencies operate during crises involving refugees or IDPs Each performs separate or at times overlapping functions Within the UN system, the Inter-Agency Standing Committee, chaired by the Emergency Relief Coordinator, is responsible for the smooth functioning of relief... Adolesc Psychiatry, 36: 49±54 Frye B.A., D'Avanzo C (1994) Themes in managing culturally defined illness in Cambodian refugee family J Comm Health Nurs., 11: 89 ± 98 Chung R.C., Singer M.K (1995) Interpretation of symptom presentation and distress A Southeast Asian refugee example J Nerv Ment Dis., 183 : 639±6 48 D'Avanzo C.E., Barab S.A (19 98) Depression and anxiety among Cambodian refugee women in France... Vermont, Department of Psychiatry, Burlington Achenbach T.M (1991) Manual for Youth Self-Report and 1991 Profile University of Vermont, Department of Psychiatry, Burlington Goldstein R.D., Wampler N.S., Wise P.H (1997) War experiences and distress symptoms of Bosnian children Paediatrics, 100: 87 3 87 8 Thabet A.A.M., Vostanis P (2000) Post traumatic stress disorder in children of war: a longitudinal study... disorder and major disorder in Tibetan refugee children J Am Acad Child Adolesc Psychiatry, 37: 87 4 87 9 Stein B., Comer D., Gardner W., Kelleher K (1999) Prospective study of displaced children's symptoms in wartime Bosnia Soc Psychiatry Psychiatr Epidemiol., 34: 464±469 220 67 68 69 70 71 72 PSYCHIATRY IN SOCIETY Mollica R.F (19 98) Trauma and Human Development, Harvard Programme in Refugee Trauma Harvard... non-governmental 214 PSYCHIATRY IN SOCIETY organizations, UN agencies and individualsÐseek to respond simultaneously It becomes essential that all efforts are well coordinated and the Office for the Coordination of Humanitarian Affairs (OCHA) plays a major role in coordination There are three major ways in which OCHA fulfils its role First, it coordinates the international humanitarian response, including... and is done in the daytime [21±23] It requires accurate canvassing of a given facility and a system able to assess diverse levels of utilisation In addition, this method assumes that 224 PSYCHIATRY IN SOCIETY homeless service users represent homeless people as a whole; in fact, 85 % of homeless people interviewed at night in the streets of Los Angeles admitted to having slept in a shelter during the past . on-the-job training whenever required, and monitoring and evaluation of trained personnel. Training should be a continuing process and should involve as many personnel as possible like doctors,. care . integrating mental health with other health intervention . integrating emergency care into development of sustainable health systems and services 214 PSYCHIATRY IN SOCIETY . monitoring and. refugees and immigrants as a cultur- ally-shaped illness behaviour. Ann. Acad. Med. Singapore, 28: 84 1 84 5. 2 18 PSYCHIATRY IN SOCIETY 46. Handelman L., Yeo G. (1996) Using explanatory models to understand