Detention of asylum seekers: assault on health, human rights, and social development.
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Adult↗
Biomedical subjects
D Silove
Publications and source records attributed to D Silove.
Parent-child concordance for separation anxiety: a clinical study.
There is tentative evidence supporting a familial basis for separation anxiety. The present study aimed to examine parent-child concordance for that subtype of anxiety. Fifty-four children diagnosed with anxiety disorders and their parents (54 mothers and 29 fathers) were recruited from two juvenile anxiety clinics. Sixty-three percent of children diagnosed with juvenile separation anxiety disorder had at least one parent who suffered from the putative adult variant of the disorder (odds ratio = 11.1) (P < 0.001). Affected parents reported high levels of separation anxiety in their own childhoods. Juvenile separation anxiety disorder in children was not associated with any other parental diagnosis. The small sample size and other potential biases caution against definitive conclusions being drawn, but the present data add to existing evidence that separation anxiety may aggregate in families.
Adult↗
Agreement in symptoms of anxiety and depression between patients and GPs: the influence of ethnicity.
BACKGROUND: Few studies have focused specifically on the role of ethnicity in the identification and treatment of anxiety and depressive symptoms among patients consulting GPs. METHODS: A survey was conducted of 4753 patients aged 18-90 years attending general practices in Sydney, Australia. Three methods of case detection were used: a GHQ-12 score (> or = 3), self-report symptoms (using a checklist) and GP detection of symptoms. Four regional groupings based on country of birth [other English speaking countries (ESB), European, Asian (predominantly south east Asian) and other non-English speaking (other NESB)] were compared with Australian (AB) patients. RESULTS: Compared with AB patients, Asian patients had a lower mean GHQ-12 score (2.04 versus 2.54) and a lower rate of GP detection (10.4% versus 20.5%) but they recorded a similar rate of self-report symptoms (16.7% versus 20.1%). For Asian patients, 24.6% of all cases identified by self-report or by GP detection were identified by both methods, compared with 44% for AB patients. Similar patterns of treatment and referral were observed for detected cases. Compared with AB patients, Asian and other NESB patients were more likely to desire more time to discuss their problems with their GP (18.5% versus 42.0%, 37.3%) and receive an explanation of medications prescribed (18.9% versus 46%, 40.0%). CONCLUSION: These results suggest that there are substantial variations in the rates of detection of anxiety and depressive symptoms in GP patients depending on the screening methods used and the broad ethnic background of patients. Such symptoms may be under-diagnosed in Asian patients in particular.
Adolescent↗
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
Depressive Disorder↗
The rights of the severely mentally ill in post-conflict societies.
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Female↗
Prevalence, detection and management of anxiety and depressive symptoms in unemployed patients attending general practitioners.
INTRODUCTION: This study examined the detection and management of anxiety and depressive symptoms among unemployed patients attending general practitioners (GPs). METHOD: A cross-sectional study was undertaken of anxiety and depressive symptoms in general practice using measures completed by patients and GPs. Eligible patients were adults aged 18 to 64 years either working (n = 2273) or unemployed (n = 392). RESULTS: Eighty per cent of patients were attending their regular GP at the time of the study. Unemployed patients were found to have a higher mean general health questionnaire (GHQ-12) score than employed patients (3.8 compared with 2.4, p < 0.001); were more likely to report symptoms of anxiety and depression which required medical treatment during the previous 4weeks (30.9% compared with 14.6%, p < 0.001); and were more likely to have been treated for anxiety and depression by the GP (27.8% compared with 15.7%, p < 0.001). Among patients who the GPs reported treating for anxiety and depression, unemployed patients were 3.3 times (95% CI: 2.0-5.4) more likely to be prescribed medication than employed patients when severity was controlled but were no more likely to be referred to other health services. Unemployed patients identified increased use of services and were less satisfied with the care that they had received. CONCLUSIONS: Unemployed patients attending GPs have an increased risk of anxiety and depressive symptoms. Increased prescription of medication as opposed to referral suggests that GPs may treat their unemployed patients differently to employed patients. GPs need to be aware of the higher risk and severity of anxiety and depressive symptoms among unemployed patients and their desire to be more actively involved in their treatment. General practice is an important setting for addressing the health needs of unemployed people.
Adolescent↗
Nosological implications of psychotic symptoms in patients with established posttraumatic stress disorder.
OBJECTIVE: We describe three patients with chronic posttraumatic stress disorder (PTSD) who later developed psychotic symptoms. The nosological implications are discussed. CLINICAL PICTURE: All three patients had no prior history of psychotic illness. The content of the psychotic symptoms was restricted to core features of the traumatic experiences which initially led to PTSD. TREATMENT: The patients received low-dose antipsychotic medications in addition to other treatments for PTSD and/or depression. OUTCOME: All three patients developed severe extrapyramidal side effects, particularly akathisia, and discontinued drug treatment. CONCLUSION: Psychotic symptoms occasionally can complicate chronic PTSD, but uncertainty remains about their aetiology and nosological status.
Adult↗
Health and human rights of the East Timorese.
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Australia↗
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.
Adult↗
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.
Adult↗
Parental representations associated with adult separation anxiety and panic disorder--agoraphobia.
OBJECTIVE: Early bonding abnormalities have been associated with a range of anxiety and depressive disorders in adulthood, but no specific parental patterns have emerged for particular disorders. The present study investigated the possibility that parental overprotectiveness may be linked to a risk of separation anxiety (SA) in adulthood. METHOD: Two samples were recruited: volunteers (n = 34) whose major anxieties focused on separation concerns, and adult anxiety clinic patients (n = 37) who were diagnosed with panic disorder. Parental characteristics and early SA were assessed by dichotomising the combined sample first according to adult SA categorisation and then by panic disorder status. RESULTS: Subjects assigned to the adult SA category reported high levels of juvenile SA and exposure to maternal overprotectiveness, whereas patients diagnosed with panic disorder reported few differences in their bonding histories compared to residual anxious patients. CONCLUSIONS: The findings of this study suggest that early SA and parental overprotectiveness may not be associated with panic disorder per se, but rather with persisting SA symptoms in adulthood. The overlapping samples and retrospectivity of some measures are important limitations of the study.
Adult↗
The psychosocial effects of torture, mass human rights violations, and refugee trauma: toward an integrated conceptual framework.
Torture is a complex trauma that often occurs within the context of widespread persecution and human rights violations. In addition, the nature of modern warfare is such that whole populations are at risk of suffering extensive trauma, injustices, loss, and displacement. Refugees, in particular, experience sequential stresses that may compound each other over prolonged periods of time. The present overview examines whether contemporary notions of trauma, and especially a focus on the category of posttraumatic stress disorder (PTSD), are adequate in assessing the multiple effects of such experiences. Recent studies are reviewed to indicate the strengths and limitations of current research approaches. Rates of PTSD in such studies have varied with relatively low rates being found in recent epidemiologic studies undertaken on refugee populations. It is suggested that a focus on intervening psychosocial adaptive systems may assist in delineating more clearly the pathways that determine whether traumatized persons achieve psychosocial restitution or are at risk of ongoing psychiatric disability. A model is proposed which suggests that torture and related abuses may challenge five core adaptive systems subserving the functions of "safety," "attachment," "justice," "identity-role," and "existential-meaning." It is argued that a clearer delineation of such adaptive systems may provide a point of convergence that may link research endeavors more closely to the subjective experience of survivors and to the types of clinical interventions offered by trauma treatment services.
Adaptation, Psychological↗
Subpopulations of early separation anxiety: relevance to risk of adult anxiety disorders.
BACKGROUND: The present study aims to examine whether discrete subpopulations can be identified according to their levels of early separation anxiety (SA), and if so, whether such a typology of SA influences risk to particular adult anxiety disorders. METHODS: Mixture analysis was applied to early SA scores provided retrospectively by a composite group (n=1800) of adult community and patient samples. The distribution of adult anxiety diagnoses across the SA categories was assessed in a community (n=136) and a clinic (n=74) sample. RESULTS: The mixture analysis yielded two subpopulations according to SA scores. Odds ratios for assignment to the high SA category for the various anxiety disorders ranged from 3.6 to 6.7. A logistic regression analysis revealed that when comorbidity was taken into account, the panic disorder-agoraphobia (PD-Ag) group was the only anxiety disorder to be associated with the high SA category. CONCLUSION: Assignment to a high early SA category appears to increase risk to adult anxiety disorders, particularly PD-Ag. Several possible pathways may account for such a risk including the persistence of separation anxiety disorder into adulthood. LIMITATIONS: Assessment of early SA was made using a retrospective measure and the samples included groups which were known to have high SA scores. CLINICAL RELEVANCE: Only a subpopulation of anxiety sufferers may have elevated levels of SA. Identification of this group may be important for early detection and intervention.
Adult↗
Is posttraumatic stress disorder an overlearned survival response? An evolutionary-learning hypothesis.
Contemporary learning theories of posttraumatic stress disorder (PTSD) provide an explanation for the phobic avoidant features but do not account fully for the intrusive phenomena that are so characteristic of the disorder. This article hypothesizes that a primitive learning center in the limbic system rehearses traumatic memories immediately following exposure to trauma, thus inducing durable memories of the sources of novel threat. It is postulated that the mechanism developed during early evolution when, in the absence of cognitive mechanisms, automatic learning following single exposure to novel threat would have conferred survival value on the species. With evolution of the brain, a second cortical pathway developed for the cognitive processing of trauma memories. It is possible that synchrony between the two phylogentically distinct pathways may be lost in vulnerable individuals under conditions of extreme stress resulting in failure of cortical inhibition of limbic trauma rehearsal mechanisms. A mismatch between archaic biological mechanisms and novel cues in the modern environment also may play a role in triggering traumatic memories and associated fight and flight reactions. The intrusive phenomena of PTSD thus may reflect an "overlearned survival response" in those in whom the putative limbic rehearsal mechanism evades cortical control. The heuristic value and limitations of such an evolutionary-learning theory are discussed.
Animals↗
Psychosocial factors associated with depression: a study of socially disadvantaged women with young children.
This study aims to use valid measures to a) estimate the prevalence of depressive disorder and b) identify psychosocial factors associated with depression in a sample of socially disadvantaged women with children. One hundred ninety-three women, recruited through a doorknock of public housing estates completed an interview that included the Diagnostic Interview Schedule to identify cases of depression and the Mannheim Interview for Social Support. The women also completed self-report questionnaires assessing psychological morbidity, life events, perceptions of intimate relationships, and personality factors. The 6-month prevalence of major depression was 17% and the lifetime prevalence 29%. Major depression was associated with perceptions of low parental care during childhood and low care from current partner, vulnerable personality style, increased reporting of life events, and an unsatisfactory social support network.
Adolescent↗
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.
Acculturation↗
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.
Acculturation↗
The influence of culture on psychiatric assessment: the Vietnamese refugee.
The influence of culture on psychiatric diagnostic assessments remains controversial. The authors outline differences between the emic approach to assessment, which is informed by ethnographic concepts of the centrality of culture in shaping the psyche and its expressions, and the etic approach, which downplays cultural effects and focuses on the universal elements in manifestations of psychological distress. Based on the experience of assessing Vietnamese refugees in Australia, the authors explore semantic, contextual, and conceptual factors that may impede the psychiatric assessment of patients from other cultures. Areas of misinterpretation are illustrated using examples from the Vietnamese language. The authors discuss how variations in politicohistorical experiences within ethnic populations may result in differences in the modes of expressing and understanding mental illness. Recognition of the tension between etic and emic perspectives allows the clinician to draw on the most useful elements of each in assessing and treating individual patients.
Cross-Cultural Comparison↗