Screening for posttraumatic stress disorder among Somali ex-combatants: a validation study

Mapping the availability of translated versions of posttraumatic stress disorder screening questionnaires for adults: A scoping review

Background: The most used questionnaires for PTSD screening in adults were developed in English. Although many of these questionnaires were translated into other languages, the procedures used to translate them and to evaluate their reliability and validity have not been consistently documented. This comprehensive scoping review aimed to compile the currently available translated and evaluated questionnaires used for PTSD screening, and highlight important gaps in the literature.Objective: This review aimed to map the availability of translated and evaluated screening questionnaires for posttraumatic stress disorder (PTSD) for adults.Methods: All peer-reviewed studies in which a PTSD screening questionnaire for adults was translated, and which reported at least one result of a qualitative and /or quantitative evaluation procedure were included. The literature was searched using Embase, MEDLINE, and APA PsycInfo, citation searches and contributions from study team members. There were no restrictions regarding the target languages of the translations. Data on the translation procedure, the qualitative evaluation, the quantitative evaluation (dimensionality of the questionnaire, reliability, and performance), and open access were extracted.Results: A total of 866 studies were screened, of which 126 were included. Collectively, 128 translations of 12 different questionnaires were found. Out of these, 105 (83.3%) studies used a forward and backward translation procedure, 120 (95.2%) assessed the reliability of the translated questionnaire, 60 (47.6%) the dimensionality, 49 (38.9%) the performance, and 42 (33.3%) used qualitative evaluation procedures. Thirty-four questionnaires (27.0%) were either freely available or accessible on request.Conclusions: The analyses conducted and the description of the methods and results varied substantially, making a quality assessment impractical. Translations into languages spoken in middle- or low-income countries were underrepresented. In addition, only a small proportion of all translated questionnaires were available. Given the need for freely accessible translations, an online repository was developed.HIGHLIGHTS We mapped the availability of translated PTSD screening questionnaires.The quality of the translation and validation processes is very heterogenous.We created a repository for translated, validated PTSD screening questionnaires.

Mental health outcomes in communities exposed to Armed Conflict Experiences

Background

Populations exposed to Armed Conflict Experiences (ACE) show different levels of impact in their mental health (i.e. clinical and positive components); however, there is limited evidence related to mental health of general population (civilians not classified as victims) exposed to ACE. Government guided mental health assessments exclude this population. The use of a newly validated Extreme Experiences Scale (EX²) seems appropriate to classify victims, ex-combatants, and civilians for their mental health assessment.

Methods

Here, we propose a novel approach to identify relationships between individuals classified with different levels of ACE exposure—independent of their legal role in the armed conflict, and mental health outcomes. According to the cut-off points derived from the scores of EX², we classified the sample in low and high exposure to ACE.

Results

The high-level ACE group (scores > 2.5) included 119 subjects, and the low-level ACE was constituted by 66 subjects. Our results evidence that people with high exposure to ACE experiment higher odds to present anxiety disorders, risk of suicide, or post-traumatic stress disorder, as well as increased cognitive empathy (i.e., fantasy dimension).

Conclusion

These findings allowed us to identify the influence of ACE on mental health outcomes beyond the conventional frame (victim or ex-combatant), and to discuss effective interventions and implementation of mental health strategies in these communities. We expect to help the health system to focus on key vulnerable subjects by including civilians not recognized as victims, which are neglected from most of the public health screening, assessment, and interventions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40359-021-00626-2.

Khat and neurobehavioral functions: A systematic review

Background

Khat is a plant that is used for its amphetamine-like stimulant properties. However, although khat is very popular in Eastern Africa, Arabian Peninsula, and the Middle East, there is still a lack of studies researching the possible neurobehavioral impairment derived from khat use.

Methods

A systematic review was conducted to identify studies that assessed the effects of khat use on neurobehavioral functions. MedLine, Scopus, Cochrane, Web of Science and Open Grey literature were searched for relevant publications from inception to December 2020. Search terms included (a) khat and (b) several cognitive domains. References from relevant publications and grey literature were also reviewed to identify additional citations for inclusion.

Results

A total of 142 articles were reviewed, 14 of which met the inclusion criteria (nine human and five rodent studies). Available human studies suggest that long term khat use is associated with significant deficits in several cognitive domains, including learning, motor speed/coordination, set-shifting/response inhibition functions, cognitive flexibility, short term/working memory, and conflict resolution. In addition, rodent studies indicated daily administration of khat extract resulted in dose-related impairments in behavior such as motor hyperactivity and decreased cognition, mainly learning and memory.

Conclusions

The findings presented in this review indicates that long-term khat use may be contributing to an impairment of neurobehavioral functions. However, gaps in literature were detected that future studies could potentially address to better understand the health consequences of khat use.

An updated review on synthetic cathinones

Cathinone, the main psychoactive compound found in the plant Catha edulis Forsk. (khat), is a β-keto analogue of amphetamine, sharing not only the phenethylamine structure, but also the amphetamine-like stimulant effects. Synthetic cathinones are derivatives of the naturally occurring cathinone that largely entered the recreational drug market at the end of 2000s. The former "legal status", impressive marketing strategies and their commercial availability, either in the so-called "smartshops" or via the Internet, prompted their large spread, contributing to their increasing popularity in the following years. As their popularity increased, the risks posed for public health became clear, with several reports of intoxications and deaths involving these substances appearing both in the social media and scientific literature. The regulatory measures introduced thereafter to halt these trending drugs of abuse have proved to be of low impact, as a continuous emergence of new non-controlled derivatives keep appearing to replace those prohibited. Users resort to synthetic cathinones due to their psychostimulant properties but are often unaware of the dangers they may incur when using these substances. Therefore, studies aimed at unveiling the pharmacological and toxicological properties of these substances are imperative, as they will provide increased expertise to the clinicians that face this problem on a daily basis. The present work provides a comprehensive review on history and legal status, chemistry, pharmacokinetics, pharmacodynamics, adverse effects and lethality in humans, as well as on the current knowledge of the neurotoxic mechanisms of synthetic cathinones.

Healthcare access barriers for FARC ex-combatants in Colombia: qualitative perspectives from healthcare providers and FARC health promoters

Background

Following the 2016 Peace Agreement with the Fuerzas Armadas Revolucionarias de Colombia (FARC), Colombia promised to reincorporate more than 13,000 guerrilla fighters into its healthcare system. Despite a subsidized healthcare insurance program and the establishment of 24 Espacios Territoriales de Capacitación y Reincorporación (ETCRs—Territorial Spaces for Training and Reintegration) to facilitate this transition, data has shown that FARC ex-combatants access care at disproportionately lower rates, and face barriers to healthcare services.

Methods

Semi-structured interviews were conducted with FARC health promoters and healthcare providers working in ETCRs to determine healthcare access barriers for FARC ex-combatants. Analysis was completed with a qualitative team-based coding method and barriers were categorized according to Julio Frenk’s Domains of Healthcare Access framework.

Results

Among 32 participants, 25 were healthcare providers and 7 self-identified as FARC health promoters. The sample was majority female (71.9%) and worked with the FARC for an average of 12 months in hospital, health center, medical brigade, and ETCR settings. Our sample had experiences with FARC across 16 ETCRs in 13 Departments of Colombia. Participants identified a total of 141 healthcare access barriers affecting FARC ex-combatants, which affected healthcare needs, desires, seeking, initiation and continuation. Significant barriers were related to a lack of resources in rural areas, limited knowledge of the Colombian health system, the health insurance program, perceived stigma, and transition process from the FARC health system.

Conclusions

FARC ex-combatants face significant healthcare access barriers, some of which are unique from other low-resource populations in Colombia. Potential solutions to these barriers included health insurance provider partnerships with health centers close to ETCRs, and training and contracting FARC health promoters to be primary healthcare providers in ETCRs. Future studies are needed to quantify the healthcare barriers affecting FARC ex-combatants, in order to implement targeted interventions to improve healthcare access.

The Relationship Between Khat Use Disorder and Post-Traumatic Stress Disorder Among Prisoners with Life Time Trauma Exposure in Ethiopia: A Cross-Sectional Study

BACKGROUND

Problematic khat use is an emerging health problem worldwide. Trauma experience, crime, and substance misuse is closely related. However, there is lack of evidence whether post-traumatic stress disorder (PTSD) and life time trauma exposure has a relationship with problematic khat use among prisoners in our country Ethiopia, or elsewhere. Therefore, this study assessed the relationship between PTSD and life time trauma exposure with khat use disorder among newly admitted prisoners in Bench Shako and West Omo zone correctional institution, Mizan Aman, Ethiopia.

METHODS

A cross-sectional study was conducted among 411 (N=422) prisoners from April 20 to July 19, 2019, by using a consecutive sampling technique. Trauma exposure and post-traumatic stress disorder were assessed with a life event check list and Post-traumatic stress disorder - civilian version (PCL-C), respectively. The WHO ASSIST tool was used to assess khat, alcohol, and tobacco use disorder. Antisocial personality disorder, criminal, and clinical history were also assessed. The data were entered into Epi-data version 3.1 and then exported to Statistical Package for Social Science version 21. A logistic regression model was used and variables with a p-value less than 0.05 in the final fitting model were stated as independent predictors of PTSD.

RESULTS

Nearly one out of four prisoners exposed to life time trauma exposure developed PTSD, and the prevalence of khat use disorder among prisoners with life time trauma exposure and PTSD was 45% and 85%, respectively. Prisoners with khat use disorder had more than 5 times higher odds of association with PTSD than their counterparts (AOR=5.3, 95% CI=2.4-11.8). In addition, antisocial personality disorder (AOR=2.8, 95% CI=1.6-5.5), criminal recidivism (AOR=2.5, 95% CI=1.5-4.3), and being a driver (AOR=2, 95% CI=1.2-3.3) were positively associated with PTSD.

CONCLUSION

Khat use disorder was higher among prisoners with life time trauma exposure and PTSD, and khat use disorder was positively associated with PTSD.

Evaluating emergency physicians' knowledge, attitudes, and experiences of FARC ex-combatants: A pilot study of Colombia's emergency medicine teaching hospitals

OBJECTIVES

In the 2016 Peace Accord with the Fuerzas Armadas Revolucionarias de Colombia (FARC), Colombia promised to reincorporate 14,000 ex-combatants into the healthcare system. However, FARC ex-combatants have faced significant challenges in receiving healthcare, and little is known about physicians' abilities to address this population's healthcare needs.

METHODS

An electronic questionnaire sent to the Colombian Emergency Medicine professional society and teaching hospitals assessed physicians' knowledge, attitudes, and experiences with the FARC ex-combatant reincorporation process.

RESULTS

Among 53 participants, most were male (60.4%), and ∼25% were affected by the FARC conflict (22.6%). Overall knowledge of FARC reincorporation was low, with nearly two-thirds of participants (61.6%) scoring in the lowest category. Attitudes around ex-combatants showed low bias. Few physicians received training about reincorporation (7.5%), but 83% indicated they would like such training. Twenty-two participants (41.5%) had identified a patient as an ex-combatant in the healthcare setting. Higher knowledge scores were significantly correlated with training about reincorporation (r = 0.354, n = 53, P = 0.015), and experience identifying patients as ex-combatants (r = 0.356, n = 47, P = 0.014).

CONCLUSION

Findings suggested high interest in training and low knowledge of the reincorporation process. Most physicians had low bias, frequent experiences with ex-combatants, and cared for these patients when they self-identify. The emergency department (ED) serves as an entrance into healthcare for this population and a potential setting for interventions to improve care delivery, especially those related to mental healthcare. Future studies could evaluate effects of care delivery following training on ex-combatant healthcare reintegration.

A systematic review of validated screening tools for anxiety disorders and PTSD in low to middle income countries

BACKGROUND

Anxiety and post-traumatic stress disorder (PTSD) contribute significantly to disability adjusted life years in low- to middle-income countries (LMICs). Screening has been proposed to improve identification and management of these disorders, but little is known about the validity of screening tools for these disorders. We conducted a systematic review of validated screening tools for detecting anxiety and PTSD in LMICs.

METHODS

MEDLINE, EMBASE, Global Health and PsychINFO were searched (inception-April 22, 2020). Eligible studies (1) screened for anxiety disorders and/or PTSD; (2) reported sensitivity and specificity for a given cut-off value; (3) were conducted in LMICs; and (4) compared screening results to diagnostic classifications based on a reference standard. Screening tool, cut-off, disorder, region, country, and clinical population were extracted for each study, and we assessed study quality. Accuracy results were organized based on screening tool, cut-off, and specific disorder. Accuracy estimates for the same cut-off for the same screening tool and disorder were combined via meta-analysis.

RESULTS

Of 6322 unique citations identified, 58 articles including 77 screening tools were included. There were 46, 19 and 12 validations for anxiety, PTSD, and combined depression and anxiety, respectively. Continentally, Asia had the most validations (35). Regionally, South Asia (11) had the most validations, followed by South Africa (10) and West Asia (9). The Kessler-10 (7) and the Generalized Anxiety Disorder-7 item scale (GAD-7) (6) were the most commonly validated tools for anxiety disorders, while the Harvard Trauma Questionnaire (3) and Posttraumatic Diagnostic Scale (3) were the most commonly validated tools for PTSD. Most studies (29) had the lowest quality rating (unblinded). Due to incomplete reporting, we could meta-analyze results from only two studies, which involved the GAD-7 (cut-off ≥10, pooled sensitivity = 76%, pooled specificity = 64%).

CONCLUSION

Use of brief screening instruments can bring much needed attention and research opportunities to various at-risk LMIC populations. However, many have been validated in inadequately designed studies, precluding any general recommendation for specific tools in LMICs. Locally validated screening tools for anxiety and PTSD need further evaluation in well-designed studies to assess whether they can improve the detection and management of these common disorders.

TRIAL REGISTRATION

PROSPERO registry number CRD42019121794 .

Trauma, Aggression, and Post Conflict Perpetration of Community Violence in Female Former Child Soldiers-A Study in Eastern DR Congo

OBJECTIVE

Former combatants are exposed to multiple traumatic stressors during conflict situations and usually participate in perpetration of violence. Ongoing perpetration of violence in post conflict areas, linked to mental health problems and appetitive aggression, destabilises peace keeping efforts. The aim of this study is to investigate lifetime exposure to violence and the relationship between this exposure and mental health and current violent behaviour in a sample of female former child soldiers with a history of perpetration of violence in Eastern DR Congo.

METHODS

98 female former child soldiers who had been abducted and forcibly recruited during the M23 insurgency (2012-2014) were assessed for lifetime exposure to trauma including perpetration of violence, clinical outcomes (PTSD and appetitive aggression), and current violent behaviour.

RESULTS

Female former child soldiers had been exposed to extremely high levels of trauma including perpetration of violence and presented with high levels of mental health problems. Linear regression models showed that current violent behaviour was predicted by both PTSD and appetitive aggression.

CONCLUSIONS

Trauma exposure predicts ongoing perpetration of violence post conflict via the resulting mental health problems. The findings imply that if PTSD and appetitive aggression symptoms are successfully treated, ongoing violent behaviour in the community post conflict will also decrease.

Disarming Ex-Combatants' Minds: Toward Situated Reintegration Process in Post-conflict Colombia

Collective violence in the context of armed conflict impacts the economy, health systems, and social stability of affected countries. This is considered a complex phenomenon with interwoven biological, psychological, social, cultural, and political factors. However, most of the research on this topic still lacks suitable established integrative approaches to assess multilevel perspectives. Social, cognitive and affective mental processes (SCAMP) are critical factors that should be considered in multilevel approaches. In this article, we critically discuss some of the classically isolated approaches used in violence research, the absence of successful interventions for ex-combatants reintegration, and the specific neglect of SCAMP in these interventions. We present the case of post-conflict Colombia as a unique opportunity to study the different roots of collective violence, and we call for a more robust and situated approach to understanding of and intervention in this multifaceted phenomenon. In addition, we suggest a two-stage approach for addressing ex-combatants’ reintegration programs, which considers the situated nature of post-conflict scenarios and the urgent need for evidence-based interventions. This approach focuses on the comprehensive scientific assessment of specific factors involved in violence exposure and the subsequent design of successful interventions. The implementation of this approach will contribute to the effective reintegration of individuals who have been exposed to extreme violence for more than 50 years.

The Impact of PTSD on Functioning in Patients Seeking Treatment for Chronic Pain and Validation of the Posttraumatic Diagnostic Scale

Purpose

The purpose of this study was to assess the psychometric properties of a Swedish version of the Posttraumatic Diagnostic Scale (PDS); to investigate the prevalence of traumatic experiences, trauma types, and posttraumatic stress disorder (PTSD) in a sample of patients seeking treatment for chronic pain; and to examine how indices of pain-related functioning vary with a history of traumatic exposure and PTSD diagnostic status.

Method

Participants were 463 consecutive patients with chronic pain referred for assessment at the Pain Rehabilitation Unit at Skåne University Hospital.

Results

The translated version of the PDS demonstrated high levels of internal consistency and a factor structure similar to that reported in previous validation studies using samples identified because of trauma exposure (not chronic pain), both of which provide preliminary support for the validity of this translated version. Based on their responses to the PDS, most patients (71.8%) reported one or more traumatic events with 28.9% fulfilling criteria for a current PTSD diagnosis. The patients with PTSD also reported significantly higher levels of pain interference, kinesiophobia, anxiety, and depression and significantly lower levels of life control, compared to patients exposed to trauma and not fulfilling criteria for PTSD and patients with no history of traumatic exposure.

Conclusion

Consistent with previous research, a significant proportion of patients seeking treatment for chronic pain reported a history of traumatic exposure and nearly one third of these met current criteria for PTSD according to a standardized self-report measure. The presence of PTSD was associated with multiple indictors of poorer functioning and greater treatment need and provides further evidence that routine screening of chronic pain patients for PTSD is warranted. Self-report measures like the PDS appear to be valid for use in chronic pain samples and offer a relative low-cost method for screening for PTSD.

Comorbid psychopathology and everyday functioning in a brief intervention study to reduce khat use among Somalis living in Kenya: description of baseline multimorbidity, its effects of intervention and its moderation effects on substance use

BACKGROUND AND AIMS

Migration and khat use were found to correlate with high rates of psychopathology. In this paper we aimed for assessing baseline multimorbidity and its interactions with a Brief Intervention.

METHODS

In the RCT, 330 male Somali khat users were assigned to treatment conditions (khat use is a predominantly male habit). The ASSIST-linked BI for khat users was administered. Using the TLFB Calendar, the PHQ-9, a Somali short version of the PDS and parts from the CIDI, khat use and comorbidity was assessed. With a regression analysis we tested for the influence of comorbidity and with mixed effect models group differences over time in sleep duration, khat use-time and everyday functioning.

RESULTS

We found high rates of baseline multimorbidity: 51% (N = 168) for depression, 22% (N = 74) for PTSD and 23% (N = 73) for khat-psychotic symptoms. Depression and khat-psychotic symptoms, but not PTSD symptoms decreased without group differences. Khat use-time decreased and functional time increased with significant time × group interactions (p ≤ 0.046). Depression and PTSD did not influence therapy success but in participants without comorbid psychopathology, more khat use reduction after the intervention was found (p = 0.024).

CONCLUSION

Somali khat users in Kenya are highly burdened by multimorbidity of depression, PTSD and khat-psychotic symptoms. The main effects for time and differences in healthy vs. mentally ill khat users indicate potential of unspecific support and the specific need for mental health care in combination with substance abuse treatment. The increase of everyday functioning promises more options for alternative activities, preventing excessive use and addiction.

Psychotherapeutic Intervention in the Demobilization Process: Addressing Combat-related Mental Injuries with Narrative Exposure in a First and Second Dissemination Stage

BACKGROUND

Depending on the exposure to traumatic stressors and combat, 20% to 50% of ex-combatants present with trauma-related disorders, and more than half of the members of armed groups have a proclivity to violence. Therefore, psychotherapeutic assistance should address both, trauma-related suffering and the lowered threshold for aggressive behaviour.

OBJECTIVE

Supporting the demobilization process of ex-combatants in the eastern DR-Congo, we implemented a version of Narrative Exposure Therapy adapted for Forensic Offender Rehabilitation (FORNET).

METHOD

In two successive dissemination stages (DS), local counsellors conducted FORNET. In DS1, they were trained by clinical experts, and in DS2, the by then experienced counsellors trained and supervised a second group of local counsellors (DS2). The training consisted of a 3-week workshop covering theoretical concepts and practical therapeutic skills. In DS1 and DS2, a total of 98 demobilizing combatants received an intervention; treatment-as-usual served as the control condition. Posttraumatic stress disorder, appetitive aggression, depression severity and drug dependence were assessed prior to the intervention and 6 and 12 months later; additionally, we assessed reintegration success.

RESULTS

Six months post-intervention, FORNET significantly reduced Posttraumatic stress disorder symptoms but had less effect on the trait of appetitive aggression; moreover, beneficial effects were found for depression severity and drug dependence as well as for reintegration indices. Treatment gains were retained at 12 months.

CONCLUSIONS

Individuals without previous training in psychotherapy can learn to effectively apply the brief intervention FORNET and support the demobilization process in ongoing conflicts. The study suggests that it is possible to pass down psychotherapeutic techniques over generations of counsellors. © 2015 The Authors. Clinical Psychology & Psychotherapy published by John Wiley & Sons Ltd.

KEY PRACTITIONER MESSAGE

Posttraumatic stress symptoms, depression and clinically relevant levels of drug dependence can effectively be reduced with a version of Narrative Exposure Therapy (NET) adapted for Forensic Offender Rehabilitation (FORNET). The intervention is effective in the context of ongoing conflict. Individuals without previous training in psychotherapy can learn to effectively apply the brief intervention FORNET. It is possible to pass down psychotherapeutic techniques like FORNET over generations of counsellors. Psychotherapeutic interventions like FORNET may facilitate the transition to peace in war-torn regions.

Khat (Catha edulis F.) and cannabinoids: Parallel and contrasting behavioral effects in preclinical and clinical studies

After a brief outline of Catha edulis F. (khat) and the cannabinoid systems, the interactions between the pharmacological effects of khat and cannabinoids will be reviewed. Khat chewing is a widespread habit that has a deep-rooted sociocultural tradition in Africa and the Middle East. Experimental studies conducted to investigate khat's central and peripheral effects have revealed an amphetamine-like mechanism of action mediated through the dopaminergic system. The endocannabinoid system comprises the receptors, the endogenous agonists and the related biochemical machinery responsible for synthesizing these substances and terminating their actions. Endocannabinoids are synthesized "on demand" from membrane phospholipids and then rapidly cleared by cellular uptake and enzymatic degradation. Khat and cannabinoids produce a body of parallel and contrasting behavioral effects. Concurrent consumption of khat and cannabinoids may increase the risk of getting or precipitating psychosis, has rewarding and motivational effect, increases the threshold of pain perception and impairs learning and memory. On the other hand, the action of cannabis to enhance food intake is likely to reduce khat's appetite suppressant effects.

"Natural Amphetamine" Khat: A Cultural Tradition or a Drug of Abuse?

Khat, Catha edulis Forsk, is among the most widely used plant-based psychoactive substance in the world. Grown in Eastern Africa, Horn of Africa, and southwestern part of the Arabian Peninsula, its fresh young leaves and twigs are used daily by over 20 million people for the psychostimulatory effects it produces in the user, a practice deeply rooted in the history, tradition, and culture of the indigenous population. Once hardly known outside the regions where it is grown and used, khat use has now spread to other countries. This review will cover the, phytochemistry, pharmacokinetics of the active ingredients-cathinone, cathine, norephedrine, neurochemistry, effects on cognitive and executive functions as well as its ability to produce dependency in the user. Whether it is an innocuous cultural practice or a drug of abuse is debatable as the preclinical and clinical data needed to arrive at an authoritative conclusion is lacking.

From War to Classroom: PTSD and Depression in Formerly Abducted Youth in Uganda

BACKGROUND

Trained local screeners assessed the mental-health status of male and female students in Northern Ugandan schools. The study aimed to disclose potential differences in mental health-related impairment in two groups, former child soldiers (n = 354) and other war-affected youth (n = 489), as well as to separate factors predicting mental suffering in learners.

METHODS

Participants were randomly selected. We used the Post-Traumatic Diagnostic Scale to assess symptoms of post-traumatic stress disorder (PTSD) and for potential depression the respective section of the Hopkins Symptom Checklist with a locally validated cut-off.

RESULTS

Almost all respondents had been displaced at least once in their life. 30% of girls and 50% of the boys in the study reported past abduction history. Trauma exposure was notably higher in the group of abductees. In former child soldiers, a PTSD rate of 32% was remarkably higher than that for non-abductees (12%). Especially in girls rates of potential depression were double those in the group of former abductees (17%) than in the group of non-abductees (8%). In all groups, trauma exposure increased the risk of developing PTSD. A path-analytic model for developing PTSD and potential depression revealed both previous trauma exposure as well as duration of abduction to have significant influences on trauma-related mental suffering. Findings also suggest that in Northern Ugandan schools trauma spectrum disorders are common among war-affected learners.

CONCLUSIONS

Therefore, it is suggested the school context should be used to provide mental-health support structures within the education system for war-affected youth at likely risk of developing war-related mental distress.

Socio-Cultural Context and Feelings of Hatred and Revenge in War Veterans with Post-Traumatic Stress Disorder 15 Years after War in Kosovo

We aimed to assess, in socio-cultural context, the level of hatred and revenge in war veterans with post-traumatic stress disorder (PTSD). The sampling frame consisted of 215 Kosova War veterans, randomly selected. The Harvard Trauma Questionnaire was used to assess the prevalence of PTSD and Manchester Short Assessment of Life was used to assess social satisfactions. The participants were asked to declare the strength of feelings of hatred and revenge in the four preceding weeks by using four items scale: not at all, a little bit/sometimes, a lot and extremely. Willingness for action of veterans was assessed using three item scale: yes, no or maybe. A probability level of 0.05 was adopted to be considered as statistically significant for differences among groups. DSM-IV-TR criteria for PTSD (very similar to DSM-V) were met by 52.6% of veterans; the data have confirmed existence of thoughts and fantasies of revenge against opposing forces by 42.8% veterans; at the same level 42.8% manifested feelings of hatred. Fantasies of taking revenge a lot was recorded by 19.5% and extremely by 1.4% of veterans, while hateful thoughts at level a lot were likely expressed by 22.3% and extreme by 2.8% of veterans. It is important to note that 84.7% were confident to act based on their beliefs. Social-economic and cultural factors have played major role in the understanding of psychological problems of traumatized individuals with a direct impact on their ability to function socially. This study has confirmed the urgent need for the establishment of psychological rehabilitation programs as well as programs for the social and economic rehabilitation of War Veterans.

Khat Use, PTSD and Psychotic Symptoms among Somali Refugees in Nairobi - A Pilot Study

In East-African and Arab countries, khat leaves are traditionally chewed in social settings. They contain the amphetamine-like alkaloid cathinone. Especially among Somali refugees, khat use has been associated with psychiatric symptoms. We assessed khat-use patterns and psychiatric symptoms among male Somali refugees living in a disadvantaged urban settlement area in Kenya, a large group that has not yet received scientific attention. We wanted to explore consume patterns and study the associations between khat use, traumatic experiences, and psychotic symptoms. Using privileged access sampling, we recruited 33 healthy male khat chewers and 15 comparable non-chewers. Based on extensive preparatory work, we assessed khat use, khat dependence according to DSM-IV, traumatic experiences, posttraumatic stress disorder (PTSD), and psychotic symptoms using standardized diagnostic instruments that had been adapted to the Somali language and culture. Hazardous use patterns like chewing for more than 24 h without interruption were frequently reported. All khat users fulfilled the DSM-IV-criteria for dependence and 85% reported functional khat use, i.e., that khat helps them to forget painful experiences. We found that the studied group was heavily burdened by traumatic events and posttraumatic symptoms. Khat users had experienced more traumatic events and had more often PTSD than non-users. Most khat users experience khat-related psychotic symptoms and in a quarter of them we found true psychotic symptoms. In contrast, among control group members no psychotic symptoms could be detected. We found first evidence for the existence and high prevalence of severely hazardous use patterns, comorbid psychiatric symptoms, and khat use as a self-medication of trauma-consequences among male Somali refugees in urban Kenyan refugee settlements. There is a high burden by psychopathology and adequate community-based interventions urgently need to be developed.

Transgenerational consequences of PTSD: risk factors for the mental health of children whose mothers have been exposed to the Rwandan genocide

Background

Understanding how parental Posttraumatic Stress Disorder (PTSD) may or may not affect the development and mental health in the offspring is particularly important in conflict regions, where trauma-related illness is endemic. In Rwanda, organised atrocities and the genocide against the Tutsi of 1994 have left a significant fraction of the population with chronic PTSD. The aim of the present investigation was to establish whether PTSD in mothers is associated with symptoms of depression, anxiety, and aggressive and antisocial behaviour in their children.

Methods

A community sample of 125 Rwandan mothers who experienced the genocide of 1994 and their 12-year-old children were interviewed. Using a structured interview, symptoms of maternal PTSD and children’s depression, anxiety, and aggressive and antisocial behaviour were assessed by trained and on-site supervised local B.A. psychologists. The interview also included a detailed checklist of event types related to family violence.

Results

In showing that a maternal PTSD was not associated with child’s psychopathology, the results contradict the assumption of straight “trans-generational trauma transmission”. Instead, a child’s exposure to maternal family violence posed a significant risk factor for a negative mental health outcome. Furthermore, it was not maternal PTSD-symptoms but mother’s exposure to family violence during her own childhood that was associated with the magnitude of adversities that a child experiences at home.

Conclusions

Contrary to a simple model of a trans-generational transmission of trauma, neither maternal PTSD nor maternal traumatic experiences were directly associated with symptoms of anxiety, depression, or antisocial and aggressive behaviour in the children. Instead, the present results suggest a relationship between parental child rearing practices and children’s mental health. Furthermore, the study details the “cycle of violence”, showing a significant link between maternal violence against a child and its mother’s experience of childhood maltreatment.

Validation of the Kirundi versions of brief self-rating scales for common mental disorders among children in Burundi

BACKGROUND

In Sub Saharan Africa, there has been limited research on instruments to identify specific mental disorders in children in conflict-affected settings. This study evaluates the psychometric properties of three self-report scales for child mental disorder in order to inform an emerging child mental health programme in post-conflict Burundi.

METHODS

Trained lay interviewers administered local language versions of three self-report scales, the Depression Self-Rating Scale (DSRS), the Child PSTD Symptom Scale (CPSS) and the Screen for Child Anxiety Related Emotional Disorders (SCARED-41), to a sample of 65 primary school children in Burundi. The test scores were compared with an external 'gold standard' criterion: the outcomes of a comprehensive semistructured clinical psychiatric interview for children according the DSM-IV criteria (the Schedule for Affective Disorders and Schizophrenia for School-Age Children - K-SADS-PL).

RESULTS

The DSRS has an area under the curve (AUC) of 0.85 with a confidence interval (c.i.) of 0.73-0.97. With a cut-off point of 19, the sensitivity was 0.64, and the specificity was 0.88. For the CPSS, with a cut-off point of 26, the AUC was 0.78 (c.i.: 0.62-0.95) with a sensitivity of 0.71 and a specificity of 0.83. The AUC for the SCARED-41, with a cut-off point of 44, was 0.69 (c.i.: 0.54-0.84) with a sensitivity of 0.55 and a specificity of 0.90.

CONCLUSIONS

The DSRS and CPSS showed good utility in detecting depressive disorder and posttraumatic stress disorder in Burundian children, but cut-off points had to be put considerably higher than in western norm populations. The psychometric properties of the SCARED-41 to identify anxiety disorders were less strong. The DSRS and CPSS have acceptable properties, and they could be used in clinical practice as part of a two-stage screening procedure in public mental health programmes in Burundi and in similar cultural and linguistic settings in the African Great Lakes region.

Health in fragile and post-conflict states: a review of current understanding and challenges ahead

Health systems face enormous challenges in fragile and post-conflict states. This paper will review recent literature to better understand how, within a context of economic volatility, political instability, infrastructural collapse and human resource scarcity, population health deteriorates and requires significant attention and resources to rebuild. Classifications of fragile and post-conflict states differ among organizations and reviewing the basic consensus as well as differences will assist in clarifying how organizations use these terms and how statistics on these nations come about. Of particular interest is the increase in local conflicts within states that may not affect national mortality and morbidity but pose heavy burdens on regional populations. Recent research on sexual and reproductive health, children's health and mental health within fragile and post-conflict states highlights the effects of healthcare systems and their breakdown on communities. We propose a research agenda to further explore knowledge gaps concerning health in fragile and post-conflict states.

Cross-cultural and factorial validity of PTSD check list-military version (PCL-M) in Sinhalese language

BACKGROUND

There are currently no validated instruments to assess the burden of combat-related Posttraumatic Stress Disorder (PTSD) in Sinhalese-the main spoken language in Sri Lanka.

OBJECTIVE

The purpose of this research was to establish the cross-cultural and structural validity of the PTSD Check List-Military Version (PCL-M) translated into Sinhalese.

METHODS

Expert committee consensus generation as well as translation-back translation approaches were used to establish the semantic, conceptual, and content equivalence of the Sinhalese and English versions of the PCL-M. Four translations of each item were made. In the absence of any "gold standard" psychometric instrument in Sinhalese to establish the criterion validity for the PCL-M (SIN), the study utilized more informal checks for assessment of validity and Sri Lankan cutoffs for caseness for PTSD to establish the psychometric strength of the translated instrument along with standard reliability analysis. Confirmatory factor analysis was performed on PCL-M scoring of a random sample of 1,586 soldiers to examine construct validity.

RESULTS

Thirteen of the 17 items were selected by popular vote, and the remaining 4 through discussion and consensus. Reliability measured by Cronbach's-α was 0.944 for the total scale and 0.812, 0.869, and 0.895 for the three DSM-IV sub-scales (re-experiencing, avoidance/numbing, and hyperarousal), respectively. The desired cutoff point for the translated instrument was determined to be 44. The five-factor model by Elhai et al. and the four-factor model by King et al. fitted best, demonstrating good fit to all three fit indices, while the four-factor model and the DSM-IV three-factor model by Simms et al. only had acceptable levels of fit for root mean squared error of approximation. χ(2) difference test comparing the two better-fitting models suggests that the five-factor model by Elhai et al. has the better fit.

CONCLUSION

The PCL-M (SIN) version is suitable for use in the study of PTSD in the Sri Lankan military forces, as judged by cross-cultural and construct validity as well as reliability.

The validation of the Polish version of the Posttraumatic Diagnostic Scale and its factor structure

BACKGROUND

Posttraumatic Diagnostic Scale (PDS) is a self-descriptive measure developed to provide information regarding posttraumatic stress disorder (PTSD) diagnosis and symptom severity.

OBJECTIVES

THE AIM OF THIS ARTICLE IS TO REPORT ON THE VALIDATION OF THE POLISH VERSION OF PDS AND TO TEST ITS FACTOR STRUCTURE WITH REFERENCE TO TWO MODELS: an original three-factor model (Reexperiencing, Avoidance, and Arousal) and alternative five-factor model (Reexperiencing, Avoidance, Numbing, Dysphoric Arousal, and Anxious Arousal).

METHOD

THE VALIDATION PROCEDURE INCLUDED THREE STUDIES CONDUCTED ON SAMPLES OF SEPARATE POPULATIONS: university-level students (n=507), individuals who had experienced various traumas (n=320), and treatment-seeking survivors of motor vehicle accidents (MVA) (n=302). Various other measures of trauma-related psychopathology were administered to participants, as well as the PTSD module of the Structured Clinical Interview (SCID) in the case of MVA patients.

RESULTS

PDS showed high internal consistency and test-retest reliability, good diagnostic agreement with SCID, good sensitivity but relatively low specificity. The satisfactory convergent validity was supported by a large number of significant correlations with other measures of trauma-related psychopathology. Confirmatory factor analysis (CFA) generally confirmed both the three-factor structure and the alternative five-factor structure of the questionnaire.

CONCLUSIONS

The results show generally good psychometric properties of the Polish version of PDS.

Exposure to violence and PTSD symptoms among Somali women

Posttraumatic stress disorder (PTSD) symptoms, exposure to traumatic stressors, and health care utilization were examined in 84 women attending a primary health care clinic in Mogadishu, Somalia. The Somalia-Posttraumatic Diagnostic Scale was used in this active warzone to measure symptoms. Nearly all women reported high levels of confrontations with violence; half described being exposed to a potentially traumatizing event. Nearly one third had significant PTSD symptoms. Compared to those who did not, women who reported exposure to a traumatic stressor reported more confrontations with violence (7.1 vs. 3.3; p < . 001), health complaints (3.8 vs. 2.9; p = .03), and nearly 3 times as much (p = .03) health service utilization. A potentially traumatizing event was found to be a simplified proxy for assessing mental health distress in women attending a primary health care facility in highly insecure, unpredictable, resource-limited settings.

The stimulant khat--another door in the wall? A call for overcoming the barriers

AIM

In this article, we comment on the current international discourse on khat, we highlight pitfalls and and suggest balanced national international regulatory actions.

METHOD

A brief an focussed review of the available literature on khat and health and examples from our own research are provided.

RESULTS

The use patterns of catha edulis (khat) have changed throughout the last decades. During this period khat has had a remarkable economic boom and developed from a niche crop to the backbone of the regional economy. Now it contributes to the livelihoods of millions of people. Today, khat use is often the proverbial "Door in the wall" for large parts of the populations in African and Arab countries beyond the traditional user groups. Its use is often excessive and not restricted by social regulation mechanisms. Under such conditions, problematic khat use patterns develop rapidly, exemplified by the growing group of binge users, and it gets even prevalent among especially vulnerable groups such as children, people with mental disorders or pregnant women. The currently existing scientific evidence suggests that problematic use patterns not the use per se can be linked to numerous health consequences.

CONCLUSION

This paper argues that changed patterns of khat use are a burden for some of the most underdeveloped countries in the world. But the debate around khat is stuck between extreme poles arguing for prohibition or for de-regulation. Here, we call for a balanced action of governments and international organizations leaving behind the decades of debilitating debate pro vs. contra scheduling and banning khat leaves. Instead, regulation and harm-reduction measures are urgently needed. We suggest a number of steps that should be taken immediately to better understand current khat use patterns, to address noxious excesses and to relieve suffering.

Khat - a controversial plant

Khat (Catha edulis) is a shrub or tree whose leaves have been chewed for centuries by people who live in the Eastern part of Africa and the Arabian Peninsula. It has recently turned up in North America and Europe, particularly among emigrants and refugees from countries such as Somalia, Ethiopia and Yemen. Khat contains a number of chemicals, among which are two controlled substances, cathinone (Schedule I) and cathine (Schedule IV). Both chemicals are stimulant drugs with effects similar to amphetamine. Chewing the leaves makes people feel more alert and talkative, and suppresses appetite. Chewing khat leaves releases cathinone, a stimulant that produces the feeling of euphoria. When cathinone is broken down in the body, it produces chemicals including cathine and norephedrine, which have a similar structure to amphetamine and adrenaline (epinephrine). Regular khat use is associated with a rise in arterial blood pressure and pulse rate, corresponding with levels of cathinone in the plasma. Moreover, regular khat chewers have gingivitis and loose teeth, but there appears to be no convincing unusual incidence of oral cancer. Among khat users in Yemen there is, however, a higher incidence of esophageal cancer compared with gastric cancer. Long term use or abuse can cause insomnia, anorexia, gastric disorders, depression, liver damage and cardiac complications, including myocardial infarction. Manic and delusional behavior, violence, suicidal depression, hallucinations, paranoia and khat-induced psychosis have also been reported. On the basis of the scientific data it seems clear that khat use has negative consequences on the economic development of a country and on the health of the society.

No PTSD-related differences in diurnal cortisol profiles of genocide survivors

Posttraumatic stress disorder (PTSD) has been associated with reduced cortisol levels. Opposing results have been interpreted as resulting from methodological differences between studies. We investigated the diurnal profile of salivary cortisol in a population of highly traumatized adult males from Rwanda with and without PTSD, who spent the whole day of examination together under a maximally standardized schedule. Besides the detection of PTSD-related alterations in cortisol release we aimed at determining physiologically relevant effects of cumulative trauma exposure on HPA functioning in interaction with or independent of diagnosis. There were no differences in the diurnal pattern of cortisol release between subjects with and without PTSD. We observed an increasing prevalence of PTSD with increasing number of different traumatic event types experienced, replicating earlier results on a "building-block effect" of multiple traumatization. However, size of cumulative exposure was not related to any of the cortisol measures. The results suggest that besides methodological constraints also confounding factors not previously controlled for, e.g., sex differences or current life stress, might contribute to the diverging results of lowered, unchanged or enhanced cortisol secretion in PTSD. Future research should therefore closely monitor these possible confounds to optimize models for cortisol in research on stress-dependent illnesses.

A review of the neuropharmacological properties of khat

BACKGROUND

The psychostimulant khat (Catha edulis Forsk), is a herbal drug cultivated and chewed as a recreational and socializing drug in East Africa and the Arabian Peninsula for centuries. Due to increasing air transportation and the loosening of customs restrictions, it is now readily available in the Western Countries mainly used by immigrants from khat growing areas causing a concern to policy-makers.

OBJECTIVE

We conducted this review to further gain an insight to the neuropharmacological effects of khat.

METHODOLOGY

PubMed search engine with key terms 'khat' or 'qat' or 'mirra' or'qaad/jaad' or 'cathinone' was used to obtain articles relevant to khat chewing. In total 284 English written articles published from 1959 to 2007 were screened.

RESULTS

Most of the studies focused on cathinone, the postulated active psychostimulant alkaloid in khat. There were few studies which investigated the entire plant extract in either in vitro or animal studies. In the majority of the studies it was reported that both cathinone and cathine, another psychoactive constituent, have actions that are similar to those of amphetamine.

CONCLUSIONS

It seems that the well investigated khat alkaloids have many features similar to amphetamines; however there is a need for a more thorough examination of khat itself in well designed in vitro, animal and human studies with a range of comparator drugs before confirming the claim that khat is a "natural amphetamine".

The consumption of khat and other drugs in Somali combatants: a cross-sectional study

BACKGROUND

For more than a decade, most parts of Somalia have not been under the control of any type of government. This "failure of state" is complete in the central and southern regions and most apparent in Mogadishu, which had been for a long period in the hands of warlords deploying their private militias in a battle for resources. In contrast, the northern part of Somalia has had relatively stable control under regional administrations, which are, however, not internationally recognized. The present study provides information about drug abuse among active security personnel and militia with an emphasis on regional differences in relation to the lack of central governmental control-to our knowledge the first account on this topic.

METHODS AND FINDINGS

Trained local interviewers conducted a total of 8,723 interviews of armed personnel in seven convenience samples in different regions of Somalia; 587 (6.3%) respondents discontinued the interview and 12 (0.001%) were excluded for other reasons. We assessed basic sociodemographic information, self-reported khat use, and how respondents perceived the use of khat, cannabis (which includes both hashish and marijuana), psychoactive tablets (e.g., benzodiazepines), alcohol, solvents, and hemp seeds in their units. The cautious interpretation of our data suggest that sociodemographic characteristics and drug use among military personnel differ substantially between northern and southern/central Somalia. In total, 36.4% (99% confidence interval [CI] 19.3%-57.7%) of respondents reported khat use in the week before the interview, whereas in some regions of southern/central Somalia khat use, especially excessive use, was reported more frequently. Self-reported khat use differed substantially from the perceived use in units. According to the perception of respondents, the most frequent form of drug use is khat chewing (on average, 70.1% in previous week, 99% CI 63.6%-76.5%), followed by smoking cannabis (10.7%, 99% CI 0%-30.4%), ingesting psychoactive tablets (8.5%, 99% CI 0%-24.4%), drinking alcohol (5.3%, 99% CI 0%-13.8%), inhaling solvents (1.8%, 99% CI 0%-5.1%), and eating hemp seeds (0.6%, 99% CI 0%-2.0%). Perceived use of khat differs little between northern and southern Somalia, but perceived use of other drugs reaches alarmingly high levels in some regions of the south, especially related to smoking cannabis and using psychoactive tablets.

CONCLUSIONS

Our data suggest that drug use has quantitatively and qualitatively changed over the course of conflicts in southern Somalia, as current patterns are in contrast to traditional use. Although future studies using random sampling methods need to confirm our results, we hypothesize that drug-related problems of armed staff and other vulnerable groups in southern Somalia has reached proportions formerly unknown to the country, especially as we believe that any biases in our data would lead to an underestimation of actual drug use. We recommend that future disarmament, demobilization, and reintegration (DDR) programs need to be prepared to deal with significant drug-related problems in Somalia.