Caring for carers: A virtual psychosocial supervision intervention to improve the quality and sustainability of mental health and psychosocial support in humanitarian contexts

Introduction

Mental health and psychosocial support (MHPSS) staff in humanitarian settings have limited access to clinical supervision and are at high risk of experiencing burnout. We previously piloted an online, peer-supervision program for MHPSS professionals working with displaced Rohingya (Bangladesh) and Syrian (Turkey and Northwest Syria) communities. Pilot evaluations demonstrated that online, peer-supervision is feasible, low-cost, and acceptable to MHPSS practitioners in humanitarian settings.

Objectives

This project will determine the impact of online supervision on i) the wellbeing and burnout levels of local MHPSS practitioners, and ii) practitioner technical skills to improve beneficiary perceived service satisfaction, acceptability, and appropriateness.

Methods

MHPSS practitioners in two contexts (Bangladesh and Turkey/Northwest Syria) will participate in 90-minute group-based online supervision, fortnightly for six months. Sessions will be run on zoom and will be co-facilitated by MHPSS practitioners and in-country research assistants. A quasi-experimental multiple-baseline design will enable a quantitative comparison of practitioner and beneficiary outcomes between control periods (12-months) and the intervention. Outcomes to be assessed include the Kessler-6, Harvard Trauma Questionnaire and Copenhagen Burnout Inventory and Client Satisfaction Questionnaire-8.

Results

A total of 80 MHPSS practitioners will complete 24 monthly online assessments from May 2022. Concurrently, 1920 people receiving MHPSS services will be randomly selected for post-session interviews (24 per practitioner).

Conclusions

This study will determine the impact of an online, peer-supervision program for MHPSS practitioners in humanitarian settings. Results from the baseline assessments, pilot evaluation, and theory of change model will be presented.

Disclosure

No significant relationships.

A prospective study of pre-employment psychological testing amongst police recruits

BACKGROUND

Pre-employment psychological screening to detect psychological vulnerability is common amongst emergency service organizations worldwide, yet the evidence for its ability to predict poor mental health outcomes is limited with published studies looking at post-recruitment research data rather than data collected by the organizations themselves.

AIMS

The present study sought to investigate the ability of pre-employment screening to predict later psychological injury-related absenteeism amongst police officers.

METHODS

A nested case-control study using prospective data was conducted. One hundred and fifty police officers with a liability-accepted psychological injury were matched to a control group of 150 psychologically healthy officers. Conditional logistic regression was used to examine associations between Minnesota Multiphasic Personality Inventory-2 (MMPI-2) scales measuring factors research has shown to predict psychological injury (Neuroticism, Psychoticism, Introversion, Disconstraint and Aggressiveness) and psychopathology (Depression, Anxiety and post-traumatic stress disorder [PTSD]) with subsequent psychological injury.

RESULTS

Contrary to expectations, we were unable to demonstrate any association between validated pre-employment measures of personality and psychopathology with mental health outcomes amongst newly recruited police officers over a 7-year follow-up.

CONCLUSIONS

Other measures may be better able to predict future mental health problems in police recruits.

Recently listed Stockholm convention POPs: Analytical methodology, occurrence in food and dietary exposure

In recent years, the Stockholm Convention has listed an additional set of persistent organic pollutants (POPs) for elimination or restricted use/release. Data on the occurrence of these contaminants in food is scarce. Validated analytical methodology was developed to investigate the occurrence of hexachlorobutadiene (HCBD), pentachlorobenzene (PCBz), hexachlorobenzene (HCB) pentachlorophenol (PCP) and polychlorinated naphthalenes (PCNs) in 120 retail foods and 19 total diet study samples. The foods covered the range of commonly consumed dietary items including dairy products, eggs (hen and other species), poultry, meat, fish, vegetables, etc. HCBD showed a low frequency of detection, whereas PCBz, HCB and PCNs occurred in most samples (ranges: <0.01 to 0.19 μg/kg; <0.01 to 3.16 μg/kg and 0.1 to 166 ng ΣPCNs/kg respectively). PCP (<0.01 to 1.9 μg/kg) was detected more frequently in meat products, offal and eggs. Fish, shellfish, eggs from all species, animal fats, meat, offal and meat products showed higher contamination levels, which is normal when investigating lipophilic POPs. These levels of occurrence are similar to more recently reported literature levels but perhaps lower, relative to historic data. This is not unexpected, given the restrictions/limitations on these chemicals within the UK and Western Europe. The estimated human exposure to population groups through dietary intake is correspondingly low and based on current toxicological knowledge, the levels in the examined samples do not suggest a cause for health concern. The data also provide a current baseline for HCBD, PCBz and PCP, and update existing data for PCN and HCB occurrence in foods.

Key patterns and predictors of response to treatment for military veterans with post-traumatic stress disorder: a growth mixture modelling approach

BACKGROUND

To determine the patterns and predictors of treatment response trajectories for veterans with post-traumatic stress disorder (PTSD).

METHODS

Conditional latent growth mixture modelling was used to identify classes and predictors of class membership. In total, 2686 veterans treated for PTSD between 2002 and 2015 across 14 hospitals in Australia completed the PTSD Checklist at intake, discharge, and 3 and 9 months follow-up. Predictor variables included co-morbid mental health problems, relationship functioning, employment and compensation status.

RESULTS

Five distinct classes were found: those with the most severe PTSD at intake separated into a relatively large class (32.5%) with small change, and a small class (3%) with a large change. Those with slightly less severe PTSD separated into one class comprising 49.9% of the total sample with large change effects, and a second class comprising 7.9% with extremely large treatment effects. The final class (6.7%) with least severe PTSD at intake also showed a large treatment effect. Of the multiple predictor variables, depression and guilt were the only two found to predict differences in response trajectories.

CONCLUSIONS

These findings highlight the importance of assessing guilt and depression prior to treatment for PTSD, and for severe cases with co-morbid guilt and depression, considering an approach to trauma-focused therapy that specifically targets guilt and depression-related cognitions.

The longitudinal relationship between post-traumatic stress disorder and perceived social support in survivors of traumatic injury

BACKGROUND

Although perceived social support is thought to be a strong predictor of psychological outcomes following trauma exposure, the temporal relationship between perceived positive and negative social support and post-traumatic stress disorder (PTSD) symptoms has not been empirically established. This study investigated the temporal sequencing of perceived positive social support, perceived negative social support, and PTSD symptoms in the 6 years following trauma exposure among survivors of traumatic injury.

METHOD

Participants were 1132 trauma survivors initially assessed upon admission to one of four Level 1 trauma hospitals in Australia after experiencing a traumatic injury. Participants were followed up at 3 months, 12 months, 24 months, and 6 years after the traumatic event.

RESULTS

Latent difference score analyses revealed that greater severity of PTSD symptoms predicted subsequent increases in perceived negative social support at each time-point. Greater severity of PTSD symptoms predicted subsequent decreases in perceived positive social support between 3 and 12 months. High levels of perceived positive or negative social support did not predict subsequent changes in PTSD symptoms at any time-point.

CONCLUSIONS

Results highlight the impact of PTSD symptoms on subsequent perceived social support, regardless of the type of support provided. The finding that perceived social support does not influence subsequent PTSD symptoms is novel, and indicates that the relationship between PTSD and perceived social support may be unidirectional.

Symptoms of post-traumatic stress disorder, severe psychological distress, explosive anger and grief amongst partners of survivors of high levels of trauma in post-conflict Timor-Leste

BACKGROUND

Little is known about the mental health of partners of survivors of high levels of trauma in post-conflict countries.

METHOD

We studied 677 spouse dyads (n = 1354) drawn from a community survey (response 82.4%) in post-conflict Timor-Leste. We used culturally adapted measures of post-traumatic stress disorder (PTSD), psychological distress, explosive anger and grief.

RESULTS

Latent class analysis identified three classes of couples: class 1, comprising women with higher trauma events (TEs), men with intermediate TEs (19%); class 2, including men with higher TEs, women with lower TEs (23%); and class 3, comprising couples in which men and women had lower TE exposure (58%) (the reference group). Men and women partners of survivors of higher TE exposure (classes 1 and 2) had increased symptoms of explosive anger and grief compared with the reference class (class 3). Women partners of survivors of higher TE exposure (class 2) had a 20-fold increased rate of PTSD symptoms compared with the reference class, a pattern that was not evident for men living with women exposed to higher levels of trauma (class 1).

CONCLUSIONS

Men and women living with survivors of higher levels of trauma showed an increase in symptoms of grief and explosive anger. The manifold higher rate of PTSD symptoms amongst women living with men exposed to high levels of trauma requires replication. It is important to assess the mental health of partners when treating survivors of high levels of trauma in post-conflict settings.

Six-year trajectories of post-traumatic stress and severe psychological distress symptoms and associations with timing of trauma exposure, ongoing adversity and sense of injustice: a latent transition analysis of a community cohort in conflict-affected Timor-Leste

OBJECTIVES

To identify the 6-year trajectories of post-traumatic stress symptoms (PTSS) and psychological distress symptoms, and examine for associations with timing of trauma exposure, ongoing adversity and with the sense of injustice in conflict-affected Timor-Leste.

SETTING

A whole-of-household survey was conducted in 2004 and 2010 in Dili, the capital of Timor-Leste.

PARTICIPANTS

1022 adults were followed up over 6 years (retention rate 84.5%). Interviews were conducted by field workers applying measures of traumatic events (TEs), ongoing adversity, a sense of injustice, PTS symptoms and psychological distress.

RESULTS

Latent transition analysis supported a 3-class longitudinal model (psychological distress, comorbid symptoms and low symptoms). We derived 4 composite trajectories comprising recovery (20.8%), a persisting morbidity trajectory (7.2%), an incident trajectory (37.2%) and a low-symptom trajectory (34.7%). Compared with the low-symptom trajectory, the persistent and incident trajectories reported greater stress arising from poverty and family conflict, higher TE exposure for 2 historical periods, and a sense of injustice for 2 historical periods. The persistent trajectory was unique in reporting greater TE exposure in the Indonesian occupation, whereas the incident trajectory reported greater TE exposure during the later internal conflict that occurred between baseline and follow-up. Compared with the low-symptom trajectory, the incident trajectory reported a greater sense of injustice relating to the periods of the Indonesian occupation and independence. The persistent trajectory was characterised by a sense of injustice relating to the internal conflict and contemporary times. The recovery trajectory was characterised by the absence of these risk factors, the only difference from the low-symptom trajectory being that the former reported a sense of injustice for the period surrounding independence.

CONCLUSIONS

Our findings suggest that the timing of both TE exposure and the focus of a sense of injustice may differentiate those with persisting and new-onset mental health morbidity in settings of recurrent conflict.

Social and trauma-related pathways leading to psychological distress and functional limitations four years after the humanitarian emergency in Timor-Leste

There is growing acknowledgment that research in the postconflict field needs to include a focus on social conditions. The authors applied structural equation modeling to epidemiologic data obtained from postconflict Timor-Leste, to examine for links involving potentially traumatic events and sociodemographic factors (age, gender, educational levels, and unemployment) with psychological symptoms and functioning. Exposure to trauma and lack of education emerged as most relevant with psychological distress impacting on education in the urban area. Age and gender exerted influences at different points in the model consistent with the known history of Timor. Although based on cross-sectional data, the model supports the relevance of past trauma, posttraumatic distress, and postconflict social conditions to functioning in societies such as Timor-Leste.

Understanding community psychosocial needs after disasters: implications for mental health services

The psychosocial impact of disasters has attracted increasing attention. There is little consensus, however, about what priorities should be pursued in relation to mental health interventions, with most controversy surrounding the relevance of traumatic stress to mental health. The present overview suggests that acute traumatic stress may be a normative response to life threat which tends to subside once conditions of safety are established. At the same time, there is a residual minority of survivors who will continue to experience chronic posttraumatic stress disorder (PTSD) and their needs can be easily overlooked. The ADAPT model offers an expanded perspective on the psychosocial systems undermined by disasters, encompassing threats to safety and security; interpersonal bonds; systems of justice; roles and identities; and institutions that promote meaning and coherence. Social reconstruction programs that are effective in repairing these systems maximize the capacity of communities and individuals to recover spontaneously from various forms of stress. Within that broad recovery context, clinical mental health services can focus specifically on those psychologically disturbed persons who are at greatest survival risk. Only a minority of persons with acute traumatic stress fall into that category, the remainder comprising those with severe behavioural disturbances arising from psychosis, organic brain disorders, severe mood disorders and epilepsy. Establishing mental health services that are community-based, family-focused and culturally sensitive in the post-emergency phase can create a model that helps shape future mental health policy for countries recovering from disaster.

Mental disorders, disability and health service use amongst Vietnamese refugees and the host Australian population

OBJECTIVE

To compare the prevalence of common mental disorders, disability and health service utilization amongst Vietnamese refugees resettled in Australia for 11 years, with data obtained from a national survey of the host population.

METHOD

A stratified multistage probability household survey of 1611 Vietnamese undertaken in the state of New South Wales was compared with data from 7961 Australian-born respondents. Measures included the CIDI 2.1 and the MOS SF-12.

RESULTS

The 12-month prevalence of anxiety, depression and drug and alcohol dependence amongst Vietnamese was 6.1% compared with 16.7% amongst Australians. Vietnamese with a mental illness reported higher disability but exhibited similar levels of mental health consultation. The overall service burden of mental disorders was lower for the Vietnamese.

CONCLUSION

The findings suggest that refugee groups resettled for some time in Western countries may show sound mental health adaptation and do not necessarily impose a burden on general or mental health services.

Comprehensive health assessment for newly arrived refugee children in Australia

Providing appropriate and responsive care to refugees from diverse backgrounds and with unique health needs is challenging. Refugee children may present with a wide range of conditions, which may be unfamiliar to health professionals in developed countries. Additionally, refugees may experience unfamiliarity with the Australian health system and distrust of authority figures and/or medical practitioners. This article provides an overview of the priority areas in health and health management for paediatric refugee patients for paediatricians as well as other relevant health care providers caring for this group. Specific issues covered include general health assessment, infectious diseases, immunization, growth and nutrition, oral health, development and disability, mental health and child protection. Comprehensive health assessment can assist in identifying children at risk of poor health and to provide them with timely and effective care, advocacy and appropriate referral.

An issue of access: delivering equitable health care for newly arrived refugee children in Australia

Newly arrived refugees and asylum seekers are faced with many difficulties in accessing effective health care when settling in Australia. Cultural, language and financial constraints, lack of awareness of available services, and lack of health provider understanding of the complex health concerns of refugees can all contribute to limiting access to health care. Understanding the complexities of a new health care system under these circumstances and finding a regular health provider may be difficult. In some cases there may be a fundamental distrust of government services. The different levels of health entitlements by visa category and (for some) detention on arrival in Australia may further complicate the provision and use of health services for providers and patients. Children are particularly at risk of suboptimal health care due to the impact of these factors combined with the effect of resettlement stresses on parents' ability to care for their children. Unaccompanied and separated children, and those in detention experience additional challenges in accessing care. This article aims to increase awareness among health professionals caring for refugee children of the challenges faced by this group in accessing and receiving effective health care in Australia. Particular consideration is given to the issues of equity, rights of asylum seekers, communication and cultural sensitivities in health care provision, and addressing barriers to health care. The aim of the paper is to alert practitioners to the complex issues surrounding the delivery of health care to refugee children and provide realistic recommendations to guide practice.

Dimensions of trauma associated with posttraumatic stress disorder (PTSD) caseness, severity and functional impairment: a study of Bosnian refugees resettled in Australia

Refugee survivors of inter-ethnic warfare vary greatly in the extent and range of their trauma experiences. Discerning which experiences are most salient to generating and perpetuating disorders such as posttraumatic stress disorder (PTSD) is critical to the mounting rational strategies for targeted psychosocial interventions. In a sample of Bosnian Muslim refugees (n=126) drawn from a community centre and supplemented by a snowball sampling method, PTSD status and associated disability were measured using the clinician-administered PTSD Scale (CAPS) for DSM-IV. A principal components analysis (PCA) based on a pool of trauma items yielded four coherent trauma dimensions: Human Rights Violations, Threat to Life, Traumatic Loss and Dispossession and Eviction. A cluster analysis identified three subgroupings according to extent of trauma exposure. There were no differences in PTSD risk for the group most exposed to human rights violations (internment in concentration camps, torture) compared to the general war-exposed group. Logistic regression analysis using the dimensions derived from the PCA indicated that Threat to Life alone of the four trauma factors predicted PTSD status, a finding that supports the DSM-IV definition of a trauma. Both Threat to Life and Traumatic Loss contributed to symptom severity and disability associated with PTSD. It may be that human rights violations pose a more general threat to the survivor's future psychosocial adaptation in areas of functioning that extend beyond the confines of PTSD.

The mental health implications of detaining asylum seekers

The possible mental health impact on asylum seekers of Australia's policy of mandatory detention is an issue of special relevance to health professionals and the public. Independent commissions of inquiry in Australia have found varying degrees of mental distress to be common in detained asylum seekers. Research studies in Australia and elsewhere suggest that detained asylum seekers may have suffered greater levels of past trauma than other refugees, and this may contribute to their mental health problems, with their detention providing a retraumatising environment. Studies are urgently required to examine the mental health consequences of detention, and to determine the effect of detention on acculturation and adaptation for asylum seekers subsequently released into the community.

Cultural aspects of cancer genetics: setting a research agenda

BACKGROUND

Anecdotal evidence suggests that people from non-Anglo-Celtic backgrounds are under-represented at familial cancer clinics in the UK, the USA, and Australia. This article discusses cultural beliefs as a potential key barrier to access, reviews previous empirical research on cultural aspects of cancer genetics, draws implications from findings, and sets a research agenda on the inter-relationships between culture, cancer genetics, and kinship.

METHODS

The CD-ROM databases MEDLINE, PsychLIT, CINAHL, and Sociological Abstracts were searched from 1980 onwards.

RESULTS

Cultural aspects of cancer genetics is the focus of an emerging body of publications. Almost all studies assessed African-American women with a family history of breast cancer and few studies included more diverse samples, such as Americans of Ashkenazi Jewish background or Hawaiian- and Japanese-Americans. Our analysis of published reports suggests several directions for future research. First, an increased focus on various Asian societies appears warranted. Research outside North America could explore the extent to which findings can be replicated in other multicultural settings. In addition, control group designs are likely to benefit from systematically assessing culture based beliefs and cultural identity in the "majority culture" group used for comparative purposes.

CONCLUSION

More data on which to base the provision of culturally appropriate familial cancer clinic services to ethnically diverse societies are needed. Empirical data will assist with culturally appropriate categorisation of people from other cultures into risk groups based on their family histories and provide the basis for the development of culturally appropriate patient education strategies and materials.

Why the high rate of dropout from individualized cognitive-behavior therapy for bulimia nervosa?

OBJECT

To investigate predictors of dropout from cognitive-behavior therapy for bulimia nervosa.

METHOD

Pretreatment assessment measures were examined including the Eating Disorder Inventory-2, Body Satisfaction Questionnaire, Beck Depression Inventory, Beck Hopelessness Scale, the Locus of Control of Behavior Scale, and demographic and behavioral measures.

RESULTS

Forty-three percent (n = 14) of clients with a DSM-IV diagnosis of bulimia nervosa dropped out of treatment prematurely. No differences were found between treatment completers and dropouts with respect to the initial severity of bulimia-related symptoms. Noncompleters were, however, found to have significantly higher depression and hopelessness scores as well as elevated levels of external locus of control. Discriminate analysis showed that these variables resulted in a 90% prediction accuracy of individuals who prematurely dropped out of treatment.

DISCUSSION

Results suggest a need to focus treatment directly on factors such as hopelessness and depression in addition to standard bulimia procedures to ensure clients are able to engage in therapy.

Policies of deterrence and the mental health of asylum seekers

In the past, most refugees who permanently resettled in the traditional recipient countries of North America, Europe, and Australasia were screened prior to arrival in a host country. In the last decade, increasing numbers of unauthorized refugees or asylum seekers, those who formally lodge application for refugee status in the country in which they are residing, have applied for protection after crossing the borders of these countries. Concerns about uncontrolled migration have encouraged host countries to adopt policies of deterrence in which increasingly restrictive measures are being imposed on persons seeking asylum. These measures include, variously, confinement in detention centers, enforced dispersal within the community, the implementation of more stringent refugee determination procedures, and temporary forms of asylum. In several countries, asylum seekers living in the community face restricted access to work, education, housing, welfare, and, in some situations, to basic health care services. Allegations of abuse, untreated medical and psychiatric illnesses, suicidal behavior, hunger strikes, and outbreaks of violence among asylum seekers in detention centers have been reported. Although systematic research into the mental health of asylum seekers is in its infancy, and methods are limited by sampling difficulties, there is growing evidence that salient postmigration stress facing asylum seekers adds to the effect of previous trauma in creating risk of ongoing posttraumatic stress disorder and other psychiatric symptoms. The medical profession has a role in educating governments and the public about the potential risks of imposing excessively harsh policies of deterrence on the mental health of asylum seekers. JAMA. 2000;284:604-611

Problems Tamil asylum seekers encounter in accessing health and welfare services in Australia

Over the last decade, western countries have reduced their intake of refugees, even though a substantial number of persons continue to be displaced by war and persecution. At the same time, there has been a substantial increase in the number of asylum seekers who apply for refugee status after entering western countries without resettlement documents. Evidence is accruing that asylum seekers are at high risk to trauma-related psychiatric and physical disorders. Increasing concerns have been raised, therefore, about the difficulties that asylum seekers face in accessing health and welfare services. The present Australian-based volunteer study compared Tamil asylum seekers (n = 62) from Sri Lanka with compatriots (30 refugees; 62 immigrants) on a number of indices relating to difficulties accessing medical, counselling and welfare services. The majority of asylum seekers (>60%) reported serious difficulties accessing medical and dental services and a sizeable minority reported problems obtaining assistance with welfare (40%), counselling (34%), and charity (23%). Difficulties accessing medical and dental services consistently exceeded those reported by refugees and immigrants. In spite of the inevitable sampling limitations, the data support past research as well as clinical impressions in suggesting that asylum seekers are particularly disadvantaged in accessing health care services.

Pathways from war trauma to posttraumatic stress symptoms among Tamil asylum seekers, refugees, and immigrants

Path analysis was used to examine the antecedents of posttraumatic stress (PTS) symptoms in Tamil asylum-seekers, refugees, and immigrants in Australia. The Harvard Trauma Questionnaire and a postmigration living difficulties questionnaire were completed by 62 asylum-seekers, 30 refugees, and 104 immigrants who responded to a mail-out. Demographic characteristics, residency status, and measures of trauma and postmigration stress were fitted to a structural model in PTS symptoms. Premigration trauma exposure accounted for 20% of the variance of PTS symptoms. Postmigration stress contributed 14% of the variance. Although limited by sampling constraints and retrospective measurement, the study supports the notion that both traumatic and posttraumatic events contribute to the expression of PTS symptoms.

Impulsivity, personality disorders and pathological gambling severity

AIMS

The present study seeks to replicate and expand findings from earlier studies that pathological gamblers manifest elevated traits of impulsivity. Secondly, the study aims to elucidate the relationship between impulsivity, indices reflecting severity of pathological gambling and other measures of psychopathology and personality dysfunction.

DESIGN

Case series.

PARTICIPANTS

Eighty-two consecutive gamblers, seeking treatment for problem gambling.

SETTING

Impulse Disorders Research Unit, School of Psychiatry, University of New South Wales, Australia.

MEASUREMENTS

Semi-structured interview designed to obtain demographic information and gambling history, the South Oaks gambling Screen, the Eysenck Impulsivity Scale, the Personality Disorder Questionnaire-Revised, the Beck Depression Inventory and the Beck Anxiety Inventory.

FINDINGS

Results show elevated traits of impulsivity among clinic samples of pathological gamblers compared to normative data and show that impulsivity is related to the severity of gambling behaviour as measured by the South Oaks Gambling Questionnaire. A principal component analysis of the Eysenck Impulsivity Scale and the personality Disorder Questionnaire-Revised, demonstrated that the concept of the "antisocial-impulivist" identified to Blaszczynski, Steel & McConaghy (1997) is not only characterized by impulsivity and antisocial personality disorder but also by high loadings from other cluster B and cluster C personality disorders. CONCLUSION. This research supports the role of the construct of impulsivity in mediating the severity of gambling behaviour and associated behavioural and psychological disturbance among pathological gamblers presenting for treatment. Impulsivity is best understood as part of a general personality disorder structure characterized primarily by DSM-III-R Axis II cluster B and some cluster C personality disorder.

Trauma exposure, postmigration stressors, and symptoms of anxiety, depression and post-traumatic stress in Tamil asylum-seekers: comparison with refugees and immigrants

Compared to research on displaced persons whose refugee status has been endorsed prior to arriving in Western countries, there is little systematic information available about levels of past trauma, postmigration living difficulties and psychiatric symptoms amongst asylum-seekers who claim refugee status only after arrival. Asylum-seekers, authorized refugees and immigrants of Tamil background were recruited by personal contact and mail-out in Sydney, Australia. A total of 62 subjects, constituting approximately 60% of the estimated pool of Tamil asylum-seekers, agreed to participate in the study. They returned statistically significantly higher scores than immigrants (n = 104) on measures of past trauma, symptoms of anxiety, depression and post-traumatic stress, and on all dimensions of postmigration difficulties. Asylum-seekers did not differ from refugees (n = 30) on measures of past trauma or psychiatric symptoms, but they scored higher on selective components of postmigration stress relating to difficulties associated with their insecure residency status. Although limited by sampling and diagnostic constraints, the present study suggests that asylum-seekers may be a high-risk group in relation to ongoing stress in the postmigration period.

Compounding of premigration trauma and postmigration stress in asylum seekers

Unauthorized immigrants arriving in Western countries increasingly are being subjected to stringent restrictions while their residency claims are assessed. The present study was a investigation of premigration exposure to organized violence and postmigration stressors in 40 individuals seeking asylum who were attending a community welfare center in Sydney, Australia. Almost 80% reported exposure to premigration trauma such as witnessing murders, having their lives threatened, being separated from family members, and brainwashing; 25% had been tortured. Asylum seekers reported a marked decline in socioeconomic status. Common ongoing sources of severe stress included fears of being repatriated, barriers to work and social services, separation from family, and issues related to the process of pursuing refugee claims. More than one third had problems obtaining health services in Australia--the same number who reported similar difficulties in their home countries. Although based on a selective and culturally heterogeneous sample, the results suggest that salient aspects of the asylum-seeking process may compound the stressors suffered by an already traumatized group.

Anxiety, depression and PTSD in asylum-seekers: assocations with pre-migration trauma and post-migration stressors

BACKGROUND

Research into the mental health of refugees has burgeoned in recent times, but there is a dearth of studies focusing specifically on the factors associated with psychiatric distress in asylum-seekers who have not been accorded residency status.

METHOD

Forty consecutive asylum-seekers attending a community resource centre in Sydney, Australia, were interviewed using structured instruments and questionnaires.

RESULTS

Anxiety scores were associated with female gender, poverty, and conflict with immigration officials, while loneliness and boredom were linked with both anxiety and depression. Thirty subjects (79%) had experienced a traumatic event such as witnessing killings, being assaulted, or suffering torture and captivity, and 14 subjects (37%) met full criteria for PTSD. A diagnosis of PTSD was associated with greater exposure to pre-migration trauma, delays in processing refugee applications, difficulties in dealing with immigration officials, obstacles to employment, racial discrimination, and loneliness and boredom.

CONCLUSIONS

Although based on correlational data derived from'a convenient' sample, our findings raise the possibility that current procedures for dealing with asylum-seekers may contribute to high levels of stress and psychiatric symptoms in those who have been previously traumatised.

Impulsivity in pathological gambling: the antisocial impulsivist

The construct of impulsivity has to date remained relatively unexplored in the pathological gambling literature. This is in spite of recent claims suggesting that impulsivity may be an important feature characterizing a subgroup of pathological gamblers who are claimed to suffer from a Multi-Impulse Personality Disorder. The present study examined the potential role of impulsivity using the Eysenck Impulsivity Scale among 115 pathological gamblers. Results indicate that heightened impulsivity is associated with the degree of severity of psychological and behavioural change in pathological gamblers. However, the findings also indicate that impulsivity closely mirrors components contained in Eysenck Personality Questionnaire Psychoticism Scale, the California Personality Inventory Socialization Scale and DSM-III Antisocial Personality Disorder. This is manifest both in terms of high intercorrelations between the measures of psychopathy and impulsivity and in their predictive relationship to the level of psychological distress suggesting a uniform impulsivity/psychopathy construct. Thus, the research supports a model of pathological gambling in which the severity of associated behavioural and psychological disturbance is mediated by a impulsivity/ psychopathy construct.

Asylum seekers: general health status and problems with access to health care

OBJECTIVE

To investigate the general health status of asylum seekers and their access to health services.

DESIGN

Prospective questionnaire survey.

SETTING

A community-based asylum seeker centre in Sydney from March to September 1994, before the Limited Health Care Assistance Scheme had taken effect.

PARTICIPANTS

Forty of 57 eligible asylum seekers from 21 different countries attending English language classes.

MAIN OUTCOME MEASURES

Results on the traumatic events section of the Harvard Trauma Questionnaire, a postmigratory problem checklist, the COOP Functional Health Assessment charts, the Duke-University of Northern Carolina Health Profile, and a structured interview to assess difficulties in accessing health care in Australia.

RESULTS

More than 30 of the 40 participants reported exposure to past trauma. Asylum seekers were more impaired in their emotional health than a normative group of patients with minor (P < 0.001) and serious (P < 0.001) medical illnesses, and more impaired in role functioning than those with minor medical illnesses (P < 0.001). Twenty or more reported symptoms of nervousness, headache, and/or depression; 28 reported having pain in the previous four weeks. Twenty-seven reported major difficulties in accessing dental services. The same number reported problems in obtaining general medical care; the most important reason cited was not having a Medicare card.

CONCLUSIONS

Although a selective sample, the asylum seekers in our study appeared to be suffering substantial levels of emotional and somatic symptoms, yet, for most, access to health care was a major problem. The effectiveness of recent sequential changes to the provisions covering welfare and health care for asylum seekers needs to be closely monitored.