Long-term impact of war on healthcare costs: an eight-country study

Lived experience of healthcare providers amidst war and siege: a phenomenological study of Ayder Comprehensive Specialized Hospital of Tigray, Northern Ethiopia

BACKGROUND

Most wars are fought in poor countries and result in significant proportions of disabilities and mortalities. The consequences of wars and political instability on health workers and access to healthcare remain under-studied. This study aimed to explore the lived experience of healthcare providers amidst war and siege, in a teaching hospital in northern Ethiopia.

METHODS

The study was conducted between February 2022 to March 2022. A qualitative phenomenological study was conducted between February to March 2022 with 20 healthcare providers working in Ayder Comprehensive and Specialized Hospital (ACSH), Tigray, Ethiopia, during the Tigray War. The study employed in-depth interviews.

RESULTS

The main themes identified included the consequences of the siege on health service delivery at ACSH, personal survival threats posed by the siege, immediate health consequences of the siege among care providers, and consequences of the siege on the motivation and energy of health professionals.

CONCLUSIONS

Health workers are exposed to a range of direct and indirect impacts of war, emphasizing the need to amend the conditions in which they live and work.

Effects of stress on pain in females using a mobile health app in the Russia-Ukraine conflict

The chronic and acute effects of stress can have divergent effects on health; long-term effects are associated with detrimental physical and mental health sequelae, while acute effects may be advantageous in the short-term. Stress-induced analgesia, the attenuation of pain perception due to stress, is a well-known phenomenon that has yet to be systematically investigated under ecological conditions. Using Flo, a women's health and wellbeing app and menstrual cycle tracker, with a world-wide monthly active usership of more than 57 million, women in Ukraine were monitored for their reporting of stress, pain and affective symptoms before, and immediately after, the onset of the Russian-Ukrainian conflict. To avoid potential selection (attrition) or collider bias, we rely on a sample of 87,315 users who were actively logging multiple symptoms before and after the start of the war. We found an inverse relationship between stress and pain, whereby higher reports of stress predicted lower rates of pain. Stress did not influence any other physiological symptoms with a similar magnitude, nor did any other symptom have a similar effect on pain. This relationship generally decreased in magnitude in countries neighbouring and surrounding Ukraine, with Ukraine serving as the epicentre. These findings help characterise the relationship between stress and health in a real-world setting.

Making an economic argument for investment in global mental health: The case of conflict-affected refugees and displaced people

Mental health expenditure accounts for just 2.1% of total domestic governmental health expenditure per capita. There is an economic, as well as moral, imperative to invest more in mental health given the long-term adverse impacts of mental disorders. This paper focuses on how economic evidence can be used to support the case for action on global mental health, focusing on refugees and people displaced due to conflict. Refugees present almost unique challenges as some policy makers may be reluctant to divert scarce resources away from the domestic population to these population groups. A rapid systematic scoping review was also undertaken to identify economic evaluations of mental health-related interventions for refugees and displaced people and to look at how this evidence base can be strengthened. Only 11 economic evaluations focused on the mental health of refugees, asylum seekers and other displaced people were identified. All but two of these intervention studies potentially could be cost-effective, but only five studies reported cost per quality-adjusted life year gained, a metric allowing the economic case for investment in refugee mental health to be compared with any other health-focused intervention. There is a need for more consistent collection of data on quality of life and the longer-term impacts of intervention. The perspective adopted in economic evaluations may also need broadening to include intersectoral benefits beyond health, as well as identifying complementary benefits to host communities. More use can be also made of modelling, drawing on existing evidence on the effectiveness and resource requirements of interventions delivered in comparable settings to expand the current evidence base. The budgetary impact of any proposed strategy should be considered; modelling could also be used to look at how implementation might be adapted to contain costs and take account of local contextual factors.

"I Have No Capacities That Can Help Me": Young Asylum Seekers in Norway and Serbia - Flight as Disturbance of Developmental Processes

Most studies on refugee populations are organized around trauma-related issues and focus on explaining pathological factors. Few studies are anchored in general developmental psychology with the aim of exploring normal age-specific developmental tasks and how the special circumstances associated with forced migration can influence how developmental tasks are negotiated. This study is part of a larger mixed method study seeking to identify resilience-promoting and resilience-inhibiting factors, on individual and contextual levels, among asylum seekers and refugees on the move (passing through Serbia) and settled in reception centers in Norway. A strategic sample of 20 adolescent and young adult refugees/asylum seekers during flight in Serbia (10) and after arrival in Norway (10) was chosen from a sample of 178 refugees interviewed in depth in Serbia and at receptions centers in Norway. The sample reflects the focus of this paper, which is to explore adolescent and young adult refugees/asylum seekers' psychological and social needs and resources during flight to and after arrival in the host country, including how developmental tasks are negotiated. Through qualitative analysis, experiences associated with the developmental changes the participants experienced before, during, and after flight are contextualized. Their sense of self, their relationships with their families and their perceptions of their situation as adolescents or young adults in a highly unpredictable situation are presented in the light of relevant theory and findings from similar refugee studies. All the participants have fled from dangerous and intolerable situations in their home countries. They describe extreme dangers during flight in contexts that are unpredictable and where they feel lonely and unsupported. Most have unmet psychosocial needs and have received little support or help for their mental health issues during flight or after arrival in Norway. Suggestions for interventions and resilience-promoting actions are given based on the findings of the study.

Antifragility of healthcare systems in Croatia and Bosnia and Herzegovina: Learning from man-made and natural crises

Acute crises, such as a war or a pandemic, are the ultimate tests for health care systems' resilience (temporary response to stress with change and adaptation) and antifragility (permanent benefit from change in response to stress). In this Health Policy paper, we analyse and discuss how the healthcare systems of two European countries - Bosnia and Herzegovina and Croatia - adapted to war as a man-made disaster, and how they adapted to COVID-19 pandemic twenty-five years later. These countries experienced full scale wars in recent history, which significantly changed their political and healthcare systems. This experience prepared the countries for the response to the pandemic, which coincided with two earthquakes in Croatia. We argue that healthcare systems in Croatia and Bosnia and Herzegovina are not only resilient but antifragile, and that they benefited from stressors they were exposed to. The antifragility of the two systems were primarily based on human effort - the strength, adaptability and resilience of health care professionals. We will look at lessons from the wars that were applied to the pandemic and discuss newly recognized opportunities and improvements.

Pre-deployment risk factors for PTSD in active-duty personnel deployed to Afghanistan: a machine-learning approach for analyzing multivariate predictors

Active-duty Army personnel can be exposed to traumatic warzone events and are at increased risk for developing post-traumatic stress disorder (PTSD) compared with the general population. PTSD is associated with high individual and societal costs, but identification of predictive markers to determine deployment readiness and risk mitigation strategies is not well understood. This prospective longitudinal naturalistic cohort study-the Fort Campbell Cohort study-examined the value of using a large multidimensional dataset collected from soldiers prior to deployment to Afghanistan for predicting post-deployment PTSD status. The dataset consisted of polygenic, epigenetic, metabolomic, endocrine, inflammatory and routine clinical lab markers, computerized neurocognitive testing, and symptom self-reports. The analysis was computed on active-duty Army personnel (N = 473) of the 101st Airborne at Fort Campbell, Kentucky. Machine-learning models predicted provisional PTSD diagnosis 90-180 days post deployment (random forest: AUC = 0.78, 95% CI = 0.67-0.89, sensitivity = 0.78, specificity = 0.71; SVM: AUC = 0.88, 95% CI = 0.78-0.98, sensitivity = 0.89, specificity = 0.79) and longitudinal PTSD symptom trajectories identified with latent growth mixture modeling (random forest: AUC = 0.85, 95% CI = 0.75-0.96, sensitivity = 0.88, specificity = 0.69; SVM: AUC = 0.87, 95% CI = 0.79-0.96, sensitivity = 0.80, specificity = 0.85). Among the highest-ranked predictive features were pre-deployment sleep quality, anxiety, depression, sustained attention, and cognitive flexibility. Blood-based biomarkers including metabolites, epigenomic, immune, inflammatory, and liver function markers complemented the most important predictors. The clinical prediction of post-deployment symptom trajectories and provisional PTSD diagnosis based on pre-deployment data achieved high discriminatory power. The predictive models may be used to determine deployment readiness and to determine novel pre-deployment interventions to mitigate the risk for deployment-related PTSD.

Beneficial Treatment Outcomes of Severe COVID-19 Patients Treated Entirely in Primary Care Settings With Dexamethasone Including Regimen-Case Series Report

Even in 2021, coronavirus disease 2019 (COVID-19) remains a major global health concern, especially in developing countries. The burden of this disease, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which affects not only primary respiratory but also other organ systems, keeps rising as the pandemic continues. Primary health care centers are the first line where COVID-19 patients are managed and should be able to manage the vast majority of them successfully. In this paper, we present a case series and concept of beneficial management of even deteriorating and severe patients treated entirely in our primary health center. The management is based on well-timed and rational dexamethasone use, as well as on various other pharmacological and nonpharmacological treatments and interventions, and is supported by provided statistical data. According to the presented experience and positive outcomes achieved, it seems that even deteriorating and severe COVID-19 patients can be treated successfully to some extent or even completely in primary care settings. This kind of approach could be particularly beneficial in conditions of overload of higher-level health care institutions.

Unraveling specifics of mental health symptoms in war survivors who fled versus stayed in the area of conflict using network analysis

BACKGROUND

War survivors often report symptoms of post-traumatic stress disorder (PTSD), depression, anxiety, and somatization. Hence, understanding symptom constellations among different populations of war survivors is critical.

METHODS

Using the network approach to psychopathology, we examined symptom centrality for these conditions in war survivors from Balkan countries who had stayed in the area of former conflict compared to those individuals from Balkan countries who had fled to Western European countries (N = 4,167) with the Impact of Events Scale-Revised and the Brief Symptom Inventory. We further compared networks for war survivors who met criteria for PTSD-diagnosis (assessed with the MINI-International Neuropsychiatric Interview) to those without PTSD-diagnosis.

RESULTS

Globally, networks were similar across the groups, whereas specific differences emerged in symptom centrality. More consistencies were found between PTSD and Western country networks, which may be partially explained by a higher prevalence of PTSD in those who had fled to Western European than in those who had stayed in the Balkan countries.

LIMITATIONS

Given the cross-sectional nature of our data, the directionality of edges in our networks remains unclear. Further, higher levels of trauma exposure and symptom severity in Western country participants may have confounded results.

CONCLUSIONS

The PTSD findings are in line with previous research on PTSD symptoms. They further provide novel insights into depressive, anxiety, and somatization symptoms in survivors of war. These findings need to be substantiated and call for future intervention studies that test the effects of targeting central symptoms we identified in our study.

Incidence Rates of Posttraumatic Stress Disorder Over a 17-Year Period in Active Duty Military Service Members

Posttraumatic stress disorder (PTSD) affects approximately 8% of the general population. The prevalence of PTSD is twice as high in active duty service members and military veterans. Few studies have investigated the incidence rates of PTSD in active duty military personnel. The present study evaluated the incidence of PTSD diagnoses and the differences between demographic factors for service members between 2001 and 2017. Data on 182,400 active duty service members between 2001 and 2017 were drawn from the Defense Medical Epidemiological Database and examined by sex, age, service branch, military pay grade, marital status, and race. From 2001 to 2017, the incidence rates of PTSD in the active force (per 1,000 service members) steadily climbed, with a low of 1.24 in 2002 to a high of 12.94 in 2016. Service members most often diagnosed with PTSD were in the U.S. Army, with the enlisted pay grades of E-5-E-9, White, married, male, and between 20 and 24 years old. Statistically significant differences, ps < .001, were found between observed and expected counts across all examined demographic variables. The present study is the first to our knowledge to provide a comprehensive examination of PTSD incidence rates in an active duty military population.

Economic evaluations and cost analyses in posttraumatic stress disorder: a systematic review

BACKGROUND

Posttraumatic stress disorder is associated with a high economic burden. Costs of treatment are known to be high, and cost-effectiveness has been analysed for several treatment options.

OBJECTIVE

As no review on economic aspects of posttraumatic stress disorder exists, the aim of this study was to systematically review costs-of-illness studies and economic evaluations of therapeutic treatment for posttraumatic stress disorder, and to assess their quality.

METHOD

A systematic literature search was performed in March 2017 and was last updated in February 2020 in the databases PubMed, PsychInfo and NHS Economic Evaluation Database. Cost-of-illness studies and economic evaluations of treatment for posttraumatic stress disorder were selected. Extracted cost data were categorized as direct costs and indirect costs and inflated to 2015 US-$ purchasing power parities (PPP). Quality was assessed using an adapted cost-of-illness studies quality checklist, the Consensus on Health Economic Criteria list, and the questionnaire to assess relevance and credibility of modelling studies by the International Society for Pharmacoeconomics and Outcome Research.

RESULTS

In total, 13 cost-of-illness studies and 18 economic evaluations were included in the review. Annual direct excess costs ranged from 512 US-$ PPP to 19,435 US-$ PPP and annual indirect excess costs were 5,021 US-$ PPP per person. Trauma-focused cognitive-behavioural therapy (+selective serotonin re-uptake inhibitor) was found to be cost-effective compared with treatment as usual and no treatment. Overall, included studies were of low and moderate quality. Studies used inappropriate economic study designs and lacked information on the economic perspective used.

CONCLUSIONS

Posttraumatic stress disorder is a major public health problem that causes high healthcare costs. While trauma-focused cognitive-behavioural therapy was found to be cost-effective, further investigations regarding pharmacotherapy and other treatments are necessary.

Equity in Health Care: A Qualitative Study with Refugees, Health Care Professionals, and Administrators in One Region in Germany

Introduction. Equity in health is an essential issue and it would appear that it is not guaranteed for all human beings, especially refugee groups. The aim of this qualitative descriptive study was to explore the experiences of refugees, health care professionals, and administrators of refugee health care in a host country.

Methods

The study used qualitative methods which consisted of a convenience sample of stakeholders directly and indirectly involved in care for refugees and refugees themselves. The study participants were located in a rural area in the federal state of Schleswig-Holstein, Germany. Focus groups and interviews were conducted with 25 participants. A semistructured interview guideline was used for the focus groups and interviews. The data were evaluated using qualitative content analysis.

Results

Four main categories were identified which are important for equity in health care: legal aspects, sociocultural aspects, environmental aspects, and communication aspects. Legal frameworks and language barriers were perceived as strong barriers for accessing health care.

Conclusions

The findings suggest that the host countries should address the specific needs of this population group at a systemic and individual level. Based on the views of the participants interviewed it can be concluded that the refugee population group is particularly affected by limited access to health care services. Bureaucratic barriers, unfamiliarity with a new health system, and language issues all contribute to limiting access to health care services.

Mental health care utilisation among internally displaced persons in Ukraine: results from a nation-wide survey

AimsThere are an estimated 1.5 million internally displaced persons (IDPs) in Ukraine because of the armed conflict in the east of the country. The aim of this paper is to examine utilisation patterns of mental health and psychosocial support (MHPSS) care among IDPs in Ukraine.

METHODS

A cross-sectional survey design was used. Data were collected from 2203 adult IDPs throughout Ukraine between March and May 2016. Data on mental health care utilisation were collected, along with outcomes including post-traumatic stress disorder (PTSD), depression and anxiety. Descriptive and multivariate regression analyses were used.

RESULTS

PTSD prevalence was 32%, depression prevalence was 22%, and anxiety prevalence was 17%. Among those that likely required care (screened positive with one of the three disorders, and also self-reporting a problem) there was a large treatment gap, with 74% of respondents who likely required MHPSS care over the past 12 months not receiving it. For the 26% (N = 180) that had sought care, the most common sources of services/support were pharmacies, family or district doctor/paramedic (feldsher), neurologist at a polyclinic, internist/neurologist at a general hospital, psychologists visiting communities, and non-governmental organisations/volunteer mental health/psychosocial centres. Of the 180 respondents who did seek care, 163 could recall whether they had to pay for their care. Of these 163 respondents, 72 (44%) recalled paying for the care they received despite government care officially being free in Ukraine. The average costs they paid for care was US$107 over the previous 12 months. All 180 respondents reported having to pay for medicines and the average costs for medicines was US$109 over the previous 12 months. Among the 74% had not sought care despite likely needing it; the principal reasons for not seeking care were: thought that they would get better by using their own medications, could not afford to pay for health services or medications, no awareness of where to receive help, poor understanding by health care providers, poor quality of services, and stigma/embarrassment. The findings from multivariate regression analysis show the significant influence of a poor household economic situation on not accessing care.

CONCLUSIONS

The study highlights a high burden of mental disorders and large MHPSS treatment gap among IDPs in Ukraine. The findings support the need for a scaled-up, comprehensive and trauma-informed response to provision of MHPSS care of IDPs in Ukraine alongside broader health system strengthening.

Prevalence of depression and posttraumatic stress disorder in adult civilian survivors of war who stay in war-afflicted regions. A systematic review and meta-analysis of epidemiological studies

BACKGROUND

Epidemiological surveys on depression and posttraumatic stress disorder (PTSD) among civilian war survivors in war-afflicted regions have produced heterogeneous prevalence estimates of these conditions.

METHODS

To determine the prevalence of both depression and PTSD in civilian war survivors in the area of conflict, we conducted a systematic search of Medline, PsycInfo, and Pilots databases. We included epidemiological studies that had used structured clinical interviews. We conducted random effects meta-analyses on prevalence proportions as well as univariate mixed model meta-regressions.

RESULTS

We included 33 studies that assessed prevalences of depression (k = 18) and/or PTSD (k = 30). Across all studies, pooled point prevalences of 0.27 and 0.26 were found for depression and PTSD, respectively. Ten percent of participants fulfilled criteria for both disorders. Surveys with a higher mean age of participants reported higher prevalence of depression. Furthermore, samples with higher rates of unemployment and higher percentages of women reported higher prevalence of PTSD, whereas samples with a higher number of participants living with a partner reported lower prevalence of PTSD.

LIMITATIONS

The findings are limited by poor psychometric reporting practices.

CONCLUSIONS

Our findings suggest that both depression and PTSD are highly prevalent in war survivors who stayed in the area of conflict. Yet, future research on this topic need to focus on psychometric properties of instruments used to assess psychopathology among war survivors. Notwithstanding this limitation, there is an urgent need for large-scale mental health programs that are appropriate for war-affected countries with limited resources and address depression as much as PTSD.

Barriers to mental health care utilization among internally displaced persons in the republic of Georgia: a rapid appraisal study

BACKGROUND

There is a paucity of evidence on access to services for mental health and psychosocial support for conflict-affected populations in low- and middle-income countries. In the Republic of Georgia, rates of utilization of mental health services among internally displaced people with mental disorders are low. We set out to identify the health system barriers leading to this treatment gap.

METHODS

We used rapid appraisal methods (collection and triangulation of multiple data sources) to investigate barriers to accessing mental health care services among adult IDPs in Georgia. Data collection included review of existing policy documents and other published data, as well as semi-structured interviews with 29 key informants including policy makers, NGO staff, health professionals and patients.

RESULTS

The following factors emerged as important barriers affecting access to mental health care services among IDPs in Georgia: inadequate insurance coverage of mental disorders and poor identification and referral systems, underfunding, shortage of human resources, poor information systems, patient out-of-pocket payments and stigmatization.

CONCLUSION

While rapid appraisal methods cannot control for potential biases or achieve representativeness, triangulation supports internal validity and reliability of the data collected, allowing data to be used to inform health care interventions. The appropriateness and potential effectiveness of policy interventions such as insurance coverage of a wider range of mental disorders, integration of services for these at the primary health care level, and community-based approaches in this context should be explored.

[Health status of asylum seekers and their access to medical care: Design and pilot testing of a questionnaire]

BACKGROUND

Scientific evidence on the health status of asylum seekers in Germany and their access to health care is fragmentary. There is a lack of appropriate questionnaires collecting indicators of health status and health care, which enable a meaningful comparison with a reference population. This article presents experiences in designing a questionnaire and findings available from a pilot testing to pave the way to improve design and methods in future studies.

MATERIALS AND METHODS

The questionnaire comprises 28 mainly closed questions on self-reported health status, access to medical care and sociodemographic indicators. In order to guarantee comparability with the general population in Germany, most questions are derived from national health surveys. The questionnaire was translated into seven languages. Pilot testing was conducted between October 2014 and February 2015 in the course of the monthly welfare payments to asylum seekers in three districts of the German federal state of Baden-Wuerttemberg.

RESULTS

A total of 156 out of 614 contacted asylum seekers participated in the pilot study (response rate: 25.4 %). The completion rate for items concerning health status and health care was satisfactory (> 75 %). Several items regarding sociodemographic data and linguistically complex questions showed the lowest item response rates (< 50 %). We recommend streamlining the questionnaire and using precise, closed and culturally adapted items.

CONCLUSIONS

The questionnaire proved to be expedient and practicable to assess relevant indicators of health status and health care provision. It appears that there is scope for improvement regarding the shortening and cultural adaptation of the questionnaire and the range of available translations. After addressing the mentioned limitations and further development, our approach could contribute to measuring regional disparities, differences between asylum seekers and the general population and temporal changes. In order to obtain representative data, the sampling strategy should be optimised.

Meta-analysis of interventions for posttraumatic stress disorder and depression in adult survivors of mass violence in low- and middle-income countries

BACKGROUND

Most survivors of mass violence live in low- and middle-income countries (LMICs). We conducted a meta-analysis of randomized controlled psychotherapy trials for adult posttraumatic stress disorder (PTSD) and/or depression in LMICs.

METHODS

We included 18 clinical trials (3,058 participants), in which 25 and 18 treatment arms measured symptoms of PTSD and depression, respectively.

RESULTS

Active treatments for PTSD yielded a large aggregated pre-post effect size (g = 1.29; 95% CI = [0.99; 1.59]) and a small to medium effect size at posttreatment when compared to control conditions (g = 0.39; 95% CI = [0.24; 0.55]). Effect sizes were similar for pretreatment versus follow-up (g = 1.75; 95% CI = [1.17; 2.32]) and in comparison to waitlist at follow-up (g = 0.93; 95% CI = [0.56; 1.31]). Active treatments for depression produced large pre-post (g = 1.28; 95% CI = [0.96; 1.61]) and controlled effect sizes (posttreatment, comparison to control conditions, g = 0.86; 95% CI = [0.54; 1.18]).

CONCLUSIONS

Our findings suggest that psychological interventions can effectively reduce symptoms of PTSD and depression in LMICs. Future research needs to focus on cost-effective interventions that are likely to be disseminated to the large numbers of war survivors in LMICs.

[Systematic review and evidence mapping of empirical studies on health status and medical care among refugees and asylum seekers in Germany (1990-2014)]

BACKGROUND

Owing to a lack of routine statistics on the health status and medical care of asylum seekers, empirical studies play a major role in the mapping of these aspects.

OBJECTIVES

The aim of this review is to provide a comprehensive overview of the research landscape in this area, synthesizing knowledge from empirical studies and identifying evidence gaps.

METHODS

A three-tiered search strategy included searching for empirical studies in national/international databases and on the internet, screening reference lists, and contacting experts. Studies meeting predefined inclusion criteria were thematically organized and described in a narrative synthesis.

RESULTS

The searches generated 1,190 hits; 52 articles met the inclusion criteria. Of these, 41 were quantitative studies (78.9 %), 10 qualitative (19.2 %), and 1 was a review (1.9 %). A total of 30 primary articles (58.9 %) analyzed mental health aspects, followed by infectious diseases (n = 12, 23.5 %). Qualitative studies, mainly ethnographies and case studies, explored mental health and social determinants of health, providing evidence for the impact of living conditions on health and medical care. Few studies analyzed chronic diseases (n = 3) or childhood illnesses (n = 6). No studies analyzed the health needs or medical care of asylum-seeking women during pregnancy and child birth. In 62.7 % of the primary studies, a single sampling point was used to recruit asylum seekers. Nationwide external validity was given in two quantitative studies.

CONCLUSION

The priority research areas identified are chronic diseases and childhood and maternal health. The divergency and heterogeneity of the studies hamper a comprehensive and comparable acquisition of knowledgeand emphasize the  need for collaborative research to close the existing evidence gaps.

Virtual agent-mediated appraisal training: a single case series among Dutch firefighters

Background: First responders are a prime example of professionals that are at a high risk of being exposed to traumatic experiences. Reappraisal as a coping strategy might help first responders to better cope with their emotional responses to traumatic events. Objective: This study investigated the effects of repeated sessions of a digital reappraisal training among seven firefighters. The training consisted of four sessions supported by a virtual agent, conducted at home or at work, over a two-week period in a single case series. Method: Sixteen data points were collected from each participant in the eight days pre- and post-training. Results: Significantly more themes were used at post-training than at pre-training, implying more flexibility and confirming the main hypothesis of the study. Negative side effects were not reported during or in the week after the training. Conclusions: More controlled studies into the short- and long-term effects of a training of this nature are needed. Furthermore, it provides a reference for developers in this field.

The long-term burden of military deployment on the health care system

Health care providers need to be aware that stress complaints that result from deployment can emerge even after many years. This has important implications for health care policies. The main aim of this study is to investigate the relation between the development of posttraumatic stress and other mental health complaints and the burden on (mental) health care after a deployment. For this study we used data from a large prospective cohort study on stress-factors related to deployment in 1007 Dutch soldiers, who were deployed to Afghanistan. Participants were assessed at six follow up times up until five years after deployment. In a Generalized Estimated Equations model we estimated the relation between mental health complaints and the utilization of psychological treatment and a general practitioner, respectively. Moreover, we studied the relation between mental health complaints and health care costs using bootstrap techniques. The results showed that higher scores for PTSD, depression and fatigue relate to increased use of a psychologist. And lower PTSD scores and higher depression, anxiety and somatization scores relate to increased odds to visit a GP. Furthermore, mental health complaints relate to higher costs. In conclusion, monitoring soldiers is important in order to be informed on the current demand for (mental) health care to satisfy the health care need of veterans. Early treatment, which is enabled by lowering barriers to care, relates to positive results and therefore, lower health care costs.

Epidemiology of Substance Use among Forced Migrants: A Global Systematic Review

INTRODUCTION

Forced migration is occurring at unprecedented levels. Forced migrants may be at risk for substance use for reasons including coping with traumatic experiences, co-morbid mental health disorders, acculturation challenges and social and economic inequality. This paper aimed to systematically review the literature examining substance use among forced migrants, and identify priority areas for intervention and future research.

METHODS

Seven medical, allied health and social science databases were searched from inception to September 2015 in accordance with PRISMA guidelines to identify original peer-reviewed articles describing any findings relating to alcohol and/or illicit drug use among refugees, internally displaced people (IDPs), asylum seekers, people displaced by disasters and deportees. A descriptive synthesis of evidence from quantitative studies was conducted, focusing primarily on studies which used validated measures of substance use. Synthesis of evidence from qualitative studies focused on identifying prominent themes relating to the contexts and consequences of substance use. Critical Appraisal Skills Programme (CASP) checklists were used to assess methodological quality of included studies.

RESULTS

Forty-four quantitative (82% cross-sectional), 16 qualitative and three mixed-methods studies were included. Ten studies were rated as high methodological quality (16%), 39 as moderate quality (62%) and 14 as low quality (22%). The majority of research was conducted among refugees, IDPs and asylum seekers (n = 55, 87%), predominantly in high-income settings. The highest-quality prevalence estimates of hazardous/harmful alcohol use ranged from 17%-36% in camp settings and 4%-7% in community settings. Few studies collected validated measures of illicit drug use. Seven studies compared substance use among forced migrants to other migrant or native-born samples. Among eight studies which conducted multivariable analysis, male sex, trauma exposure and symptoms of mental illness were commonly identified correlates of substance use.

CONCLUSION

Our understanding of substance use among forced migrants remains limited, particularly regarding persons displaced due to disasters, development and deportation. Despite a growing body of work among refugee-background populations, few studies include refugees in low and middle-income countries, where over 80% of the global refugee population resides. Findings suggest a need to integrate substance use prevention and treatment into services offered to forced migrants, particularly in camp settings. Efforts to develop and evaluate interventions to reduce substance use and related harms are needed.

Socioeconomic Inequalities in Mental Health of Adult Population: Serbian National Health Survey

BACKGROUND

The global burden of mental disorders is rising. In Serbia, anxiety is the leading cause of disability-adjusted life years. Serbia has no mental health survey at the population level. The information on prevalence of mental disorders and related socioeconomic inequalities are valuable for mental care improvement.

AIMS

To explore the prevalence of mental health disorders and socioeconomic inequalities in mental health of adult Serbian population, and to explore whether age years and employment status interact with mental health in urban and rural settlements.

STUDY DESIGN

Cross-sectional study.

METHODS

This study is an additional analysis of Serbian Health Survey 2006 that was carried out with standardized household questionnaires at the representative sample of 7673 randomly selected households - 15563 adults. The response rate was 93%. A multivariate logistic regression modeling highlighted the predictors of the 5 item Mental Health Inventory (MHI-5), and of chronic anxiety or depression within eight independent variables (age, gender, type of settlement, marital status and self-perceived health, education, employment status and Wealth Index). The significance level in descriptive statistics, chi square analysis and bivariate and multivariate logistic regressions was set at p<0.05.

RESULTS

Chronic anxiety or depression was seen in 4.9% of the respondents, and poor MHI-5 in 47% of respondents. Low education (Odds Ratios 1.32; 95% confidence intervals=1.16-1.51), unemployment (1.36; 1.18-1.56), single status (1.34; 1.23-1.45), and Wealth Index middle class (1.20; 1.08-1.32) or poor (1.33; 1.21-1.47) were significantly related with poor MHI-5. Unemployed persons in urban settlements had higher odds for poormMHI-5 than unemployed in rural areas (0.73; 0.59-0.89). Single (1.50; 1.26-1.78), unemployed (1.39; 1.07-1.80) and inactive respondents (1.42; 1.10-1.83) had a higher odds of chronic anxiety or depression than married individuals, or those with partner, and employed persons. Those with perceived good health status had lower odds for poor MHI-5, chronic anxiety or depression than those whose general health was average and poor.

CONCLUSION

Almost half of the population assessed their mental health as poor and 5% had diagnosed chronic anxiety or depression. Multi-sectoral socioeconomic and female-sensitive policies should be wisely tailored to reduce mental health inequalities contributed by differences in age, education, employment, marriage and the wealth status of the adult population.

Mental Health Disorders Among Women Victims of Conflict-Related Sexual Violence in the Democratic Republic of Congo

To assess the effects of sexual violence (SV) in armed conflicts on women's mental health, on its own and in conjunction with reproductive health issues such as fistula or chronic pelvic pain (CPP). A cross-sectional population-based study of 320 women living in Goma, the Democratic Republic of Congo, aged 15 to 45 years, was conducted. Women who experienced conflict-related sexual violence (CRSV) were compared with those who experienced non-conflict-related sexual violence (NCRSV) and those who never experienced such acts. Data were gathered through individual interviews by local staff using standardized questionnaires. The outcomes investigated were post-traumatic stress disorder (PTSD) symptoms severity and psychological distress symptoms (PDS) severity. Experience of SV in either context was associated with more severe PDS (p < .0001). Only CRSV was associated with more severe PTSD symptoms (p < .0001). Women who suffered from fistula or CPP also had a higher PDS score mean (p < .0001 and p = .007) and a higher PTSD symptoms score mean (p < .0001, for both reproductive health issues). Multivariate analyses showed that compared with women who never experienced SV and never suffered from fistula or CPP, those who experienced CRSV and suffered from fistula or CPP had the most severe PDS and PTSD symptoms after adjustment for potential confounders. The differences in PDS and PTSD symptoms severity were all significant (p < .0001). Psychological and physical health care are urgently needed for women who experienced CRSV, particularly those with additional issues of fistula or CPP. Current interventions should simultaneously seek to improve both reproductive and mental health.

Health service utilization for mental, behavioural and emotional problems among conflict-affected population in Georgia: a cross-sectional study

Background

There is large gap in mental illness treatment globally and potentially especially so in war-affected populations. The study aim was to examine health care utilization patterns for mental, behavioural and emotional problems among the war-affected adult population in the Republic of Georgia.

Methods

A cross-sectional household survey was conducted among 3600 adults affected by 1990s and 2008 armed conflicts in Georgia. Service use was measured for the last 12 months for any mental, emotional or behavioural problems. TSQ, PHQ-9 and GAD-7 were used to measure current symptoms of PTSD, depression and anxiety. Descriptive and regression analyses were used.

Results

Respondents were predominantly female (65.0%), 35.8% were unemployed, and 56.0% covered by the government insurance scheme. From the total sample, 30.5% had symptoms of at least one current mental disorder. Among them, 39.0% sought care for mental problems, while 33.1% expressed facing barriers to accessing care and so did not seek care. General practitioners (29%) and neurologists (26%) were consulted by the majority of those with a current mental disorder who accessed services, while use of psychiatric services was far more limited. Pharmacotherapy was the predominant type of care (90%). Female gender (OR 1.50, 95% CI: 1.25, 1.80), middle-age (OR 1.83, 95% CI: 1.48, 2.26) and older-age (OR 1.62, 95% CI: 1.19, 2.21), possession of the state insurance coverage (OR 1.55, 95% CI: 1.30, 1.86), current PTSD symptoms (OR 1.56, 95% CI: 1.29, 1.90) and depression (OR 2.12, 95% CI: 1.70, 2.65) were associated with higher rates of health service utilization, while employed were less likely to use services (OR 0.71, 95% CI: 0.55, 0.89).

Conclusions

Reducing financial access barriers and increasing awareness and access to local care required to help reduce the burden of mental disorders among conflict-affected persons in Georgia.

Circulating levels of hormones, lipids, and immune mediators in post-traumatic stress disorder - a 3-month follow-up study

A number of peripheral blood analytes have been proposed as potential biomarkers of post-traumatic stress disorder (PTSD). Few studies have investigated whether observed changes in biomarkers persist over time. The aim of this study was to investigate the association of combat-related chronic PTSD with a wide array of putative PTSD biomarkers and to determine reliability of the measurements, i.e., correlations over time. Croatian combat veterans with chronic PTSD (n = 69) and age-matched healthy controls (n = 32), all men, were assessed at two time points separated by 3 months. Serum levels of lipids, cortisol, dehydroepiandrosterone-sulfate (DHEA-S), prolactin, and C-reactive protein were determined. Multiplex assay was used for the simultaneous assessment of 13 analytes in sera: cytokines [interferon-γ, interleukin (IL)-1β, IL-2, IL-4, IL-6, TNF-α], adhesion molecules (sPECAM-1, sICAM-1), chemokines (IL-8 and MIP-1α), sCD40L, nerve growth factor, and leptin. Group differences and changes over time were tested by parametric or non-parametric tests, including repeated measures analysis of covariance. Reliability estimates [intraclass correlation coefficient (ICC) and kappa] were also calculated. Robust associations of PTSD with higher levels of DHEA-S [F(1,75) = 8.14, p = 0.006)] and lower levels of prolactin [F(1,75) = 5.40, p = 0.023] were found. Measurements showed good to excellent reproducibility (DHEA-S, ICC = 0.50; prolactin, ICC = 0.79). Serum lipids did not differ between groups but significant increase of LDL-C after 3 months was observed in the PTSD group (t = 6.87, p < 0.001). IL-8 was lower in the PTSD group (t = 4.37, p < 0.001) but assessments showed poor reproducibility (ICC = -0.08). Stable DHEA-S and prolactin changes highlight their potential to be reliable markers of PTSD. Change in lipid profiles after 3 months suggests that PTSD patients may be more prone to hyperlipidemia. High intra-individual variability in some variables emphasizes the importance of longitudinal studies in investigations of PTSD biomarkers.

Frequency of trauma exposure and Post-Traumatic Stress Disorder in Italy: analysis from the World Mental Health Survey Initiative

Epidemiological studies have examined the relative importance of Traumatic Events (TEs) in accounting for the societal burden of post-traumatic stress disorder (PTSD). However, most studies used the worst trauma experienced, which can lead to an overestimation of the conditional risk of PTSD. Although a number of epidemiological surveys on PTSD have been carried out in the United States, only a few studies in limited sample have been conducted in Italy. This study, carried out in the framework of the World Mental Health Survey Initiative, is a cross-sectional household survey of a representative sample of the Italian adult population. Lifetime prevalence of TEs and 12-month prevalence of PTSD were evaluated using the Composite International Diagnostic Interview (CIDI). Reports of PTSD associated with randomly selected TEs were weighted by the individual-level probabilities of TE selection to generate estimates of population-level PTSD risk associated with each TE. Network events was the most commonly reported class of TEs (29.4%). War events had the highest conditional risk of PTSD (12.2%). The TEs that contributed most to societal PTSD burden were unexpected death of a loved one (24.1%) and having seen atrocities (18.2%). Being female was related to high risk of PTSD after experiencing a TE. Exposure to network events is commonly reported among Italian adults, but two TEs are responsible for the highest burden associated with PTSD: the unexpected death of someone close and sexual assault. These results can help designing public health interventions to reduce the societal PTSD burden.

Integrative testimonial therapy: an Internet-based, therapist-assisted therapy for German elderly survivors of the World War II with posttraumatic stress symptoms

Trauma-focused cognitive behavioral treatments are known to be effective for posttraumatic stress disorder (PTSD) in adults. However, evidence for effective treatments for older persons with PTSD, particularly elderly war trauma survivors, is scarce. In an open trial, 30 survivors of World War II aged 65 to 85 years (mean, 71.73 years; SD, 4.8; n = 17 women) with PTSD symptoms were treated with a Web-based, therapist-assisted cognitive-behavioral/narrative therapy for 6 weeks. Intent-to-treat analyses revealed a significant decrease in PTSD severity scores (Cohen's d = 0.43) and significant improvements on secondary clinical outcomes of quality of life, self-efficacy, and posttraumatic growth from pretreatment to posttreatment. All improvements were maintained at a 3-month follow-up. The attrition rate was low (13.3%), with participants who completed the trial reporting high working alliance and treatment satisfaction. Results of this study suggest that integrative testimonial therapy is a well accepted and potentially effective treatment for older war trauma survivors experiencing PTSD symptoms.

Characteristics of successful technological interventions in mental resilience training

In the last two decades, several effective virtual reality-based interventions for anxiety disorders have been developed. Virtual reality interventions can also be used to build resilience to psychopathology for populations at risk of exposure to traumatic experiences and developing mental disorders as a result, such as for people working in vulnerable professions. Despite the interest among mental health professionals and researchers in applying new technology-supported interventions for pre-trauma mental resilience training, there is a lack of recommendations about what constitutes potentially effective technology-supported resilience training. This article analyses the role of technology in the field of stress-resilience training. It presents lessons learned from technology developers currently working in the area, and it identifies some key clinical requirements for the supported resilience interventions. Two processes made up this research: 1) developers of technology-assisted resilience programs were interviewed regarding human-computer interaction and system development; 2) discussions with clinicians were prompted using technology-centered concept storyboards to elicit feedback, and to refine, validate and extend the initial concepts. A qualitative analysis of the interviews produced a set of development guidelines that engineers should follow and a list of intervention requirements that the technology should fulfill. These recommendations can help bridge the gap between engineers and clinicians when generating novel resilience interventions for people in vulnerable professions.

PTSD in the military: special considerations for understanding prevalence, pathophysiology and treatment following deployment

Given the unique context of warzone engagement, which may include chronic threat, multiple and lengthy deployments, and loss, there is a need to understand whether and to what extent knowledge about PTSD derived from studies of civilian trauma exposure is generalizeable to the military. This special issue on PTSD in the military addresses a range of issues and debates related to mental health in military personnel and combat veterans. This article provides an overview of the issues covered in selected contributions that have been assembled for a special volume to consider issues unique to the military. Several leading scholars and military experts have contributed papers regarding: 1) prevalence rates of PTSD and other post-deployment mental health problems in different NATO countries, 2) the search for biomarkers of PTSD and the potential applications of such findings, and 3) prevention and intervention approaches for service members and veterans. The volume includes studies that highlight the divergence in prevalence rates of PTSD and other post-deployment mental health problems across nations and that discuss potential causes and implications. Included studies also provide an overview of research conducted in military or Veteran's Affairs settings, and overarching reviews of military-wide approaches to research, promotion of resilience, and mental health interventions in the Unites States and across NATO and allied ISAF partners.

Symptoms and subjective quality of life in post-traumatic stress disorder: a longitudinal study

BACKGROUND

Evidence suggests that post-traumatic stress disorder (PTSD) is associated with substantially reduced subjective quality of life (SQOL). This study aimed to explore whether and how changes in the levels of PTSD symptom clusters of intrusion, avoidance and hyperarousal are associated with changes in SQOL.

METHODS

Two samples with PTSD following the war in former Yugoslavia were studied, i.e. a representative sample of 530 people in five Balkan countries and a non-representative sample of 215 refugees in three Western European countries. They were assessed on average eight years after the war and re-interviewed one year later. PTSD symptoms were assessed on the Impact of Event Scale - Revised and SQOL on the Manchester Short Assessment of Quality of Life. Linear regression and a two-wave cross lagged panel analysis were used to explore the association between PTSD symptom clusters and SQOL.

RESULTS

The findings in the two samples were consistent. Symptom reduction over time was associated with improved SQOL. In multivariable analyses adjusted for the influence of all three clusters, gender and time since war exposure, only changes in hyperarousal symptoms were significantly associated with changes in SQOL. The two-wave cross-lagged panel analysis suggested that the link between hyperarousal symptoms and SQOL is bidirectional.

CONCLUSIONS

Low SQOL of patients with war-related PTSD is particularly associated with hyperarousal symptoms. The findings suggest a bidirectional influence: a reduction in hyperarousal symptoms may result in improved SQOL, and improvements in SQOL may lead to reduced hyperarousal symptoms.