The role of site and severity of injury as predictors of mental health outcomes following traumatic injury

The aim of this study was to investigate the influence of injury site and severity as predictors of mental health outcomes in the initial 12 months following traumatic injury. Using a multisite, longitudinal study, articipants with a traumatic physical injury (N = 1,098) were assessed during hospital admission and followed up at 3 months (N = 932, 86%) and at 12 months (N = 715, 71%). Injury site was measured using the abbreviated Injury Scale 90, and objective injury severity was measured using the Injury Severity Score. Participants also completed the Hospital Anxiety and Depression Scale and the Clinician Administered Post-traumatic Stress Disorder (PTSD) Scale. A random intercept mixed modelling analysis was conducted to evaluate the effects of site and severity of injury in relation to anxiety, PTSD, and depressive symptoms. Injury severity, as well as head and facial injuries, was predictive of elevated PTSD symptoms, and external injuries were associated with both PTSD and depression severity. In contrast, lower extremity injuries were associated with depresssive and anxiety symptoms. The findings suggest that visible injuries are predictive of reduced mental health, particularly PTSD following traumatic injury. This has clinical implications for further advancing the screening for vulnerable injured trauma survivors at risk of chronic psychopathology.Katharine Baecher, Maria Kangas, Alan Taylor, Meaghan L. O'Donnell, Richard A. Bryant, Derrick Silove, Alexander C. McFarlane, Darryl Wad

The expectancy of threat and peritraumatic dissociation

Background: Peritraumatic dissociation is one of the most critical acute responses to a traumatic experience, partly because it predicts subsequent posttraumatic stress disorder. Despite this, there is little understanding about the factors that influence peritraumatic dissociation. This study investigated the extent to which peritraumatic dissociation is predicted by the amount of perceived warning that participants had of the impact of the trauma. Method: Randomized eligible admissions to four major trauma hospitals (N=243) were assessed during hospital admission with the Peritraumatic Dissociation Experiences Questionnaire (PDEQ) and the perceived warning that participants had before the trauma impact occurred. Results: Whereas female gender predicted both Awareness and Derealization subscale scores on the PDEQ, perceived warning also predicted scores on the Derealization subscale. Conclusions: This finding suggests that the degree of anticipated threat may contribute to peritraumatic dissociation.Pamela McDonald, Richard A. Bryant, Derrick Silove, Mark Creamer, Meaghan O'Donnell, Alexander C. McFarlan

Heart rate variability and the relationship between trauma exposure age, and psychopathology in a post-conflict setting

BACKGROUND: Cumulative exposure to potentially traumatic events (PTEs) increases risk for mental distress in conflict-affected settings, but the psychophysiological mechanisms that mediate this dose-response relationship are unknown. We investigated diminished heart rate variability (HRV) - an index of vagus nerve function and a robust predictor of emotion regulation capacity - as a vulnerability marker that potentially mediates the association between PTE exposure, age and symptoms of posttraumatic stress disorder (PTSD), psychological distress and aggressive behavior, in a community sample from Timor-Leste - a post-conflict country with a history of mass violence. METHOD: Resting state heart rate data was recorded from 45 cases of PTSD, depression and intermittent explosive disorder (IED); and 29 non-case controls. RESULTS: Resting HRV was significantly reduced in the combined case group compared with non-cases (p = .021; Cohen's d = 0.5). A significant mediation effect was also observed, whereby a sequence of increased age, reduced HRV and elevated PTSD symptoms mediated the association between PTE exposure and distress (B = .06, SE = .05, 95% CI = [.00-.217]) and aggression (B = .02, SE = .02, 95% CI = [.0003-.069])). CONCLUSION: The findings demonstrate an association between diminished resting HRV and psychopathology. Moreover, age-related HRV reductions emerged as a potential psychophysiological mechanism that underlies enhanced vulnerability to distress and aggression following cumulative PTE exposure

Effect of maternal panic disorder on mother-child interaction and relation to child anxiety and child self-efficacy

To determine whether mothers with panic disorder with or without agoraphobia interacted differently with their children than normal control mothers, 86 mothers and their adolescents (aged between 13 and 23 years) were observed during a structured play situation. Maternal as well as adolescent anxiety status was assessed according to a structured diagnostic interview. Results showed that mothers with panic disorder/agoraphobia showed more verbal control, were more criticizing and less sensitive during mother-child interaction than mothers without current mental disorders. Moreover, more conflicts were observed between mother and child dyadic interactions when the mother suffered from panic disorder. The comparison of parenting behaviors among anxious and non-anxious children did not reveal any significant differences. These findings support an association between parental over-control and rejection and maternal but not child anxiety and suggest that particularly mother anxiety status is an important determinant of parenting behavior. Finally, an association was found between children’s perceived self-efficacy, parental control and child anxiety symptoms

"They think we're OK and we know we're not". A qualitative study of asylum seekers' access, knowledge and views to health care in the UK

<i>Background</i>: The provision of healthcare for asylum seekers is a global issue. Providing appropriate and culturally sensitive services requires us to understand the barriers facing asylum seekers and the facilitators that help them access health care. Here, we report on two linked studies exploring these issues, along with the health care needs and beliefs of asylum seekers living in the UK. <i>Methods</i>: Two qualitative methods were employed: focus groups facilitated by members of the asylum seeking community and interviews, either one-to-one or in a group, conducted through an interpreter. Analysis was facilitated using the Framework method. <i>Results</i>: Most asylum seekers were registered with a GP, facilitated for some by an Asylum Support nurse. Many experienced difficulty getting timely appointments with their doctor, especially for self-limiting symptoms that they felt could become more serious, especially in children. Most were positive about the health care they received, although some commented on the lack of continuity. However, there was surprise and disappointment at the length of waiting times both for hospital appointments and when attending accident and emergency departments. Most had attended a dentist, but usually only when there was a clinical need. The provision of interpreters in primary care was generally good, although there was a tension between interpreters translating verbatim and acting as patient advocates. Access to interpreters in other settings, e.g. in-patient hospital stays, was problematic. Barriers included the cost of over-the-counter medication, e.g. children's paracetamol; knowledge of out-of-hours medical care; and access to specialists in secondary care. Most respondents came from countries with no system of primary medical care, which impacted on their expectations of the UK system. <i>Conclusion</i>: Most asylum seekers were positive about their experiences of health care. However, we have identified issues regarding their understanding of how the UK system works, in particular the role of general practitioners and referral to hospital specialists. The provision of an Asylum Support nurse was clearly a facilitator to accessing primary medical care. Initiatives to increase their awareness and understanding of the UK system would be beneficial. Interpreting services also need to be developed, in particular their role in secondary care and the development of the role of interpreter as patient advocate

Onset of common mental disorders and suicidal behavior following women's first exposure to gender based violence: a retrospective, population-based study

Published: 18 November 2014BACKGROUND: Women exposed to gender-based violence (GBV) experience a high rate of common mental disorders and suicidal behaviour ("mental disturbance"). Little is known however about the timing of onset of mental disturbance following first exposure to GBV amongst women with no prior mental disorder. METHODS: The analysis was undertaken on the Australian National Mental Health and Wellbeing Survey dataset (N = 8841). We assessed lifetime prevalence and first onset of common mental disorder and suicidal behaviour (mental disturbance) and exposure to GBV and its first occurrence based on the Composite International Diagnostic Interview Version 3 (WMH-CIDI 3.0). We used the Kaplan-Meier method to derive cumulative incident curves for first onset mental disturbance. The two derived subgroups were women who experienced GBV without prior mental disturbance; and women never exposed to GBV stratified to match the former group on age and socio-economic status. RESULTS: For women with no prior mental disorder, the cumulative incidence curves showed a high incidence of all mental disturbances following first GBV, compared to women without exposure to GBV (all log rank tests <0.0001). Nearly two fifths (37%) of any lifetime mental disturbance had onset in the year following first GBV in women exposed to abuse. For these women, over half (57%) of cases of lifetime PTSD had onset in the same time interval. For GBV exposed women, half of all cases of mental disturbance (54%) and two thirds of cases of PTSD (66.9%) had onset in the five years following first abuse. In contrast, there was a low prevalence of onset of mental disturbance in the comparable imputed time to event period for women never exposed to GBV (for any mental disturbance, 1% in the first year, 12% in five years; for PTSD 3% in the first year, 7% in five years). CONCLUSIONS: Amongst women without prior mental disturbance, common mental disorders and suicidal behaviour have a high rate of onset in the one and five year intervals following exposure to GBV. There is a particularly high incidence of PTSD in the first year following GBV.Susan Rees, Zachary Steel, Mark Creamer, Maree Teesson, Richard Bryant, Alexander C McFarlane, Katherine L Mills, Tim Slade, Natacha Carragher, Meaghan O, Donnell, David Forbes and Derrick Silov

The effect of post-traumatic stress disorder on refugees' parenting and their children's mental health: a cohort study

BackgroundChildren and adolescents, who account for most of the world's refugees, have an increased prevalence of psychological disorders. The mental health of refugee children is often associated with the severity of post-traumatic stress disorder (PTSD) in their caregivers. Despite the potential for refugee caregivers' PTSD to affect child mental health, little evidence exists concerning the underlying mechanisms of this association. This study tested the effect of refugee caregivers' previous trauma and levels of ongoing stressors on current PTSD, and in turn how this influences parenting behaviour and consequent child psychological health.MethodsThis cohort study recruited participants from the Building a New Life in Australia study, a population-based prospective cohort study of refugees admitted to 11 sites in Australia between October, 2013, and February, 2014. Eligible participants were aged 18 years or older and the principal or secondary applicant (ie, the refugee applicant within a migrating family unit) for a humanitarian visa awarded between May, 2013, and December, 2013. Primary caregiver PTSD and postmigration difficulties were assessed at Wave 1 (in 2013), and caregiver PTSD was reassessed at Wave 2 (in 2014). At Wave 3, between October, 2015, and February, 2016, primary caregivers repeated measures of trauma history, postmigration difficulties, probable PTSD, and harsh and warm parenting style, and completed the Strengths and Difficulties Questionnaire for their child. We used path analysis to investigate temporal patterns in PTSD, trauma history, postmigration stressors, parenting style, and children's psychological difficulties.FindingsThe current data comprised 411 primary caregivers who provided responses in relation to at least one child (660 children). 394 primary caregivers with 639 children had data on independent variables and were included in the final model. Path analyses revealed that caregivers' trauma history and postmigration difficulties were associated with greater subsequent PTSD, which in turn was associated with greater harsh parenting and in turn, higher levels of child conduct problems (β=0·049, p=0·0214), hyperactivity (β=0·044, p=0·0241), emotional symptoms (β=0·041, p=0·0218), and peer problems (β=0·007, p=0·047). There was also a direct path from primary caregiver PTSD to children's emotional problems (β=0·144, p=0·0001).InterpretationPTSD in refugees is associated with harsh parenting styles, leading to adverse effects on their children's mental health. Programmes to enhance refugee children's mental health should account for PTSD in parents and caregivers, and the parenting behaviours that these children are exposed to.FundingNational Health and Medical Research Council.Richard A Bryant, Ben Edwards, Mark Creamer, Meaghan O’Donnell, David Forbes, Kim L Felmingham, Derrick Silove, Zachary Steel, Angela Nickerson, Alexander C McFarlane, Miranda Van Hooff, Dusan Hadzi-Pavlovi

Global Protection and the Health Impact of Migration Interception

In the fourth article in a six-part PLoS Medicine series on Migration & Health, Zachary Steel and colleagues discuss the interception phase of migration and the specific health risks and policy needs associated with this phase

Mechanisms of Psychological Distress following War in the Former Yugoslavia: The Role of Interpersonal Sensitivity

This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.This study was funded by a grant from the European Commission, contract number INCO-CT-2004-509176. AN was supported by a Clinical Early Career Research Fellowship (113295) and a Project Grant (104288