1. al-Eissa, Y. A. The impact of the Gulf armed conflict on the health and behaviour of Kuwaiti children. Soc Sci Med. 1995 Oct; 41(7): 1033-7.
Keywords: Adolescence/ Child/ Child Reactive Disorders: diagnosis: epidemiology: *psychology/ Combat Disorders: diagnosis: epidemiology: *psychology/ *Developing Countries/ Female/ Human/ Kuwait: epidemiology/ Male/ *Personality Development/ Refugees: *psychology/ Violence: psychology/ *War
Abstract: This study deals with the psychological reactions of Kuwaiti children to war-related stresses in the early period of the Gulf crisis following the summer 1990 Iraqi invasion of Kuwait. A sample of 106 children was drawn from Kuwaiti displaced families and a comparable control sample was obtained from Saudi families in Riyadh, Saudi Arabia. An interview checklist of symptoms of physical and psychological distress was administered to the index child and a female key informant in each household of cases and controls. Most Kuwaiti children were exposed to unpleasant war experiences. It was found that Kuwaiti children exhibited a substantially greater degree of dysfunctional social and emotional behaviour. The types of adverse behaviours were a function of the child's age, sex and experience of aggression. The findings support the notion that a negative relationship exists between armed conflict and the health and behaviour of the children. The complex needs of children exposed to violence require professionals to seek ways of combining psychodynamic interventions and relief programmes.

2. Allden, K.; Poole, C.; Chantavanich, S.; Ohmar, K.; Aung, N. N., and Mollica, R. F. Burmese political dissidents in Thailand: trauma and survival among young adults in exile. Am J Public Health. 1996 Nov; 86(11): 1561-9.
Keywords: Adaptation, Psychological/ Adolescence/ Adult/ Female/ *Health Status/ Human/ Male/ *Mental Health/ Myanmar: ethnology/ *Politics/ *Refugees/ Social Support/ Stress: *ethnology: *mortality/ Stress, Psychological: ethnology: mortality/ Survival Rate/ Thailand: epidemiology
Abstract: OBJECTIVES: This study assessed the self-reported mental health, physical health, and social functioning of young adult political exiles and relates their psychiatric symptoms to their trauma and survival strategies. METHODS: A 1992/93 survey of Burmese who fled to Bangkok, Thailand, after participating in a 1988 uprising against Burma's government elicited information on employment, education, disability, trauma, survival strategies, and depressive and posttraumatic stress symptoms. RESULTS: The 104 participants reported a mean of 30 trauma events, including interrogation (89%), imprisonment (78%), threats of deportation (70%), and torture (38%). Many reported poor health and lack of social supports, but few reported substantial social disability. The prevalence of elevated symptom scores was 38% for depressive symptoms and 23% for criterion symptoms of posttraumatic stress disorder. Symptoms of avoidance and of increased arousal were the most strongly related to cumulative trauma. Two survival strategies, camaraderie and a Buddhist concept of self-confidence (weria), were associated with somewhat reduced levels of both classes of symptoms. CONCLUSIONS: Burmese political exiles in Thailand are young adults adversely affected by severe trauma. Their psychosocial well being may deteriorate further without legal protections to reduce the continuing stress and violence.

3. American Red Cross; Tulane University School of Public Health and Tropical Medicine; The Congressional Hunger Center; Relief International, and The Joseph L. Mailman School of Public Health of Columbia University. Psychosocial effects of complex emergencies symposium report. Washington, D.C.; 1999 Mar 18-1999 Mar 19.
Notes: Abstract is compilation of quotations from the introduction to the Symposium Report.
Abstract: "The psychosocial health of populations that have experienced complex emergencies has become an important public health problem. The effects of violence and displacement on human health and the subsequent need for psychosocial services has attracted greatly increased attention since the experiences of populations in the Great Lakes Regions of Africa and Eastern Europe. As the field of psychosocial health during and after complex emergencies has expanded, different and at times opposed approaches to program design and implementation have developed. These have included one-on-one psychodynamically oriented programs, group-based programs and interventions focusing on community reconstruction."
"...The primary objectives of the Symposium were: 1) to assess epidemiologic aspects of psychosocial problems caused by complex emergencies, 2) to identify successful program and evaluation approaches, and 3) to create a collaborative action plan for the future." "...It was clear that a great deal of work needs to be done to organize practitioners and formulate universally acceptable theoretical frameworks from which to assess the adequacy of a response to the psychosocial effects of complex emergencies."

4. Bracken, P. J.; Giller, J. E., and Summerfield, D. Psychological responses to war and atrocity: the limitations of current concepts. Soc Sci Med. 1995 Apr; 40(8): 1073-82.
Keywords: Adaptation, Psychological/ Adult/ Bereavement/ Case Report/ Combat Disorders: diagnosis: psychology/ Comparative Study/ Cross-Cultural Comparison/ *Developing Countries/ Female/ Human/ Male/ Patient Care Team/ Psychotherapy/ Social Support/ Social Values/ Stress Disorders, Post-Traumatic: *diagnosis: psychology/ Survival: psychology/ Uganda/ Violence: *psychology/ *War
Abstract: Because of the prevalence of wars, political violence and other forms of man-made disaster in Third World countries many individuals and communities suffer prolonged and often multiple traumas. In Western psychiatry certain conceptions of the response to violence and trauma have been developed, including the widely used category of post- traumatic stress disorder (PTSD). We argue that because concepts such as PTSD implicitly endorse a Western ontology and value system, their use in non-Western groups should be, at most, tentative.

5. de Jong, K.; Ford, N., and Kleber, R. Mental health care for refugees from Kosovo: the experience of Medecins Sans Frontieres. Lancet. 1999 May 8; 353(9164): 1616-7.
Keywords: *Community Mental Health Services: supply & distribution/ Female/ Human/ Male/ Refugees: *psychology/ *War/ Yugoslavia
Notes: COMMENTS: Comment in: Lancet 1999 Jul 10; 354(9173):165-6 Note: Abstract written by Tulane University. Abstract: Ethnic Albanians being expulsed from Kosovo have witnessed violence, execution, and destruction. However, the psychological impact of war in emergency situations has been a neglected issue. Medicins Sans Frontieres (MSF) has been conducting mental health programs at the border-crossing points of Brazda, in Macedonia, and Kukes, in Albania to help fill this gap. Having learned many lessons in mental health care over the last four years in the former Yugoslavian Republic of Bosnia Herzogovina, MSF felt that they were in a good position to make the transition from the chronic stress situations in Bosnia Herzogovina to the emergency phase and acute mental stress occurring in the Balkans. MSF has identified three objectives for its emergency psychosocial program: 1) identify people who are not able to care for themselves and refer them to health or social service, 2) provide backup for the physicians who are working with refugees, and 3) provide backup services for acute and chronic psychiatry. It is important to initiate mental health programs during the emergency phase of a refugee crisis. Local staff must be identified and trained, time is required to understand the local cultural context, and people need to become aware that such help exists.

6. Dean, A. and Lin, N. The stress-buffering role of social support. Problems and prospects for systematic investigation. J Nerv Ment Dis. 1977 Dec; 165(6): 403-17.
Keywords: Animal/ Community Mental Health Services/ Group Processes/ Human/ Psychiatric Status Rating Scales/ Research Design/ Social Adjustment/ Social Class/ *Social Environment/ *Stress, Psychological/ Support, U.S. Gov't, Non-P.H.S.
Abstract: Over the past 20 years, a sizable body of literature has developed which serves to establish that stressful life events are associated with the onset, incidence, and prevalence of a wide range of physical and psychiatric disorders. As measured by the Holmes and Rahe Social Readjustment Rating Scale, or similar instruments, the stressful life events are fundamentally sociological in nature. Yet, paradoxically, the research has been largely limited in the relevant basic sociological theory and data brought to or yielded from investigation. Recently, however, several prominent researchers have emphasized the importance of studying the role of social support systems as possible buffers or mediators of stress. The most basic objective of this paper is to contribute to the advancement of such studies by clearly identifying key empirical, theoretical and methodological problems and suggesting some approaches to their resolution. Specifically, this paper offers: a) a selective review of the essential status of empirical knowledge; b) an examination of the nature and significance of social support systems; c) clarification of methodological and theoretical problems; and d) detailed proposals for approaching problems of measurement and research design.

7. Edwards, M. L. K. An interdisciplinary perspective on disasters and stress: the promise of an ecological framework. Sociological Forum. 1998; 13(1): 115-132.
Abstract: This integrative literature review examines the sources of the persistent debate over the influence of disasters on individual mental health that characterizes the disaster research literature. Using an interdisciplinary approach, this paper highlights how the connections between individuals and the systems in which they are embedded influence people’s varied responses to disaster. Consistent with the emerging emphasis in the social sciences on contextualizing individual behavior, this paper examines how family, community, social structural, cultural, and environmental factors affect the development of stress in disaster populations. It concludes with recommendations for policy, practice, and research related to disaster recovery.

8. Eisenbruch, M. Cross-cultural aspects of bereavement. I: a conceptual framework for comparative analysis. Cult Med Psychiatry. 1984 Sep; 8(3): 283-309.
Keywords: Child/ Comparative Study/ *Cross-Cultural Comparison/ *Death/ Emigration and Immigration/ Emotions: physiology/ Ethnic Groups: psychology/ Funeral Rites/ *Grief/ Hallucinations: psychology/ Human/ Object Attachment/ Refugees: psychology/ Religion/ Social Change/ Support, Non-U.S. Gov't/ Time Factors
Abstract: This paper reviews some key conceptual questions in the study of cross- cultural aspects of bereavement. Six questions are reviewed in cross-cultural perspective: whether individuals in all societies share the same private experience and public expression of grief; whether the stages of grief occur in the same sequence and at the same rate in all cultures; the nature of the relationship between the individual's private grief and his public mourning; the reactions of children to death, and the reactions of adults to the death of children; the role of religious belief; and the possibility that an ethnic group can experience collective grief in response to uprooting.

9. Eisenbruch, M. The cultural bereavement interview: a new clinical research approach for refugees. Psychiatr Clin North Am. 1990 Dec; 13(4):715-35.
Keywords: *Acculturation/ Adjustment Disorders: diagnosis: *psychology/ Depressive Disorder: diagnosis: *psychology/ Grief/ Human/ Interview, Psychological/ Object Attachment/ Refugees: *psychology/ Stress Disorders, Post-Traumatic: diagnosis: *psychology/ Support, Non-U.S. Gov't
Abstract: The large number of refugees in the world must cope with the loss of family and homeland. This paper proposes a new concept of cultural bereavement and presents a framework for its identification in the clinical interview with refugees. The cultural bereavement interview explores reactions to personal losses and to losses of both the social systems and the cultural meanings. Eleven areas are systematically explored, the first nine are indicators of bereavement and the tenth and eleventh are "antidotes" to cultural bereavement. The cultural bereavement interview can provide a clinical framework for exploring the patient's personal and cultural bereavement, clarify the "structure" of the patient's reactions to loss, complement the currently used psychiatric diagnostic categories, acknowledge the cultural system of meaning held by the patient, and provide information to be used in planning social supports or interventions.

10. Eisenbruch, M. From post-traumatic stress disorder to cultural bereavement: diagnosis of Southeast Asian refugees. Soc Sci Med. 1991; 33(6): 673-80.
Keywords: Adolescence/ Adult/ Australia/ *Bereavement/ Buddhism/ Cambodia: ethnology/ *Cultural Characteristics/ Female/ Human/ Interview, Psychological/ Male/ Refugees: *psychology/ Stress Disorders, Post-Traumatic: diagnosis: *ethnology: psychology/ Support, Non-U.S. Gov't
Abstract: There are pitfalls in the singular application of western categories in diagnosing psychiatric disorders and distress among refugees. Based on my research with Cambodian refugees I argue that cultural bereavement, by mapping the subjective experience of refugees, gives meaning to the refugee's distress, clarifies the 'structure' of the person's reactions to loss, frames psychiatric disorder in some refugees, and complements the psychiatric diagnostic categories. Cultural bereavement includes the refugees' picture--what the trauma meant to them; their cultural recipes for signaling their distress; and their cultural strategies for overcoming it--and the cultural interpretation of symptoms commonly found among refugees that resemble post-traumatic stress disorder. Cultural bereavement may identify those people who have post-traumatic stress disorder on the Diagnostic and Statistical Manual (DSM) criteria but whose 'condition' is a sign of normal, even constructive, rehabilitation from devastatingly traumatic experiences. Cultural bereavement should be given appropriate status in the nosology.

11. Eisenbruch, M. Toward a culturally sensitive DSM: cultural bereavement in Cambodian refugees and the traditional healer as taxonomist. J Nerv Ment Dis. 1992 Jan; 180(1): 8-10.
Keywords: *Bereavement/ Cambodia: ethnology/ Classification/ Cross-Cultural Comparison/ *Culture/ Human/ *Medicine, Traditional/ Mental Disorders: classification: *diagnosis/ Refugees: *psychology
Notes: Abstract written by Tulane University.
Abstract: The author states, "Early additions of the DSM took each disorder as a psychological reaction, and etiology played a vital role; however, with DSM-III, etiology was deliberately stripped from the taxonomy in an effort to make it more standardized." Studies show that this taxonomy is not being used is conjunction with criteria of patients’ cultural, ethical, social, or religious backgrounds. The article presents information on the way in which clinical diagnosis of refugees is particularly difficult using the current DSM, with posttraumatic stress disorder (PTSD) being the most frequent diagnosis of refugees from any cultural background. In working with Cambodian refugee children in Boston, the author determined that cultural bereavement is often seen in people who have lost their social structures, cultural values, and self-identity. Recognizing cultural bereavement may enable the clinician to focus on prevention and to recognize distinctions between signs of pathology and the bereavement process. The article further states that intervention by a traditional healer may offer strong predictive validity in situations where the patient’s cultural background attributes more importance to etiology than to cultural features.

12. Felsman, J. K.; Leong, F. T.; Johnson, M. C., and Felsman, I. C. Estimates of psychological distress among Vietnamese refugees: adolescents, unaccompanied minors and young adults. Soc Sci Med. 1990; 31(11): 1251-6.
Keywords: Adolescence/ Adult/ *Anxiety/ Case Report/ *Depression/ Female/ Human/ Male/ Philippines: epidemiology/ Psychological Tests/ Refugees: *psychology/ Stress, Psychological: *epidemiology/ Support, Non-U.S. Gov't/ Support, U.S. Gov't, Non-P.H.S./ Vietnam
Abstract: This study focuses on the assessment of psychological distress among three subgroups of Vietnamese refugee youth: adolescents, unaccompanied minors, and young adults. Using translated and back-translated instruments, data was gathered in refugee camps in the Philippines in order to provide baseline measurement for future comparisons, as well as to begin to develop normative standards for these populations. A rationale for the choice of instruments (Vietnamese Depression Scale, Hopkins Symptom Checklist-25 and General Health Questionnaire) is offered and mean scores and percentages scoring above established clinical cut-offs are presented. Results indicate relatively high levels of depression and anxiety for the young adult group, although anxiety appeared high across all three groups. All three groups also scored poorly on self-reports of general health, with the young adults and unaccompanied minors being especially overrepresented in the clinical range. Significant method problems were noted regarding construct validity in the assessment of depression, and instructional set differences that may account for the relatively low intercorrelations between seemingly similar measures.

13. Flaherty, J. A.; Gaviria, F. M.; Pathak, D.; Mitchell, T.; Wintrob, R.; Richman, J. A., and Birz, S. Developing instruments for cross-cultural psychiatric research. J Nerv Ment Dis. 1988 May; 176(5): 257-63.
Keywords: *Cross-Cultural Comparison/ Human/ Language/ Mental Disorders: *diagnosis: epidemiology/ Peru/ Psychiatric Status Rating Scales/ *Psychological Tests/ Psychometrics/ *Research Design/ Social Adjustment/ Transients and Migrants
Abstract: The growth of cross-cultural psychiatry is now occurring at a time when psychiatry in general is emphasizing diagnostic clarity and the use of quantifiable and reliable methods of collecting clinical and research data. It is now imperative that cross-cultural psychiatry also examine its methods for developing instruments for use in cross-cultural research. This paper outlines a method for developing instruments designed in one culture for use in a second, and particular attention is given to cross-cultural validity or equivalence. Five types of equivalence are enumerated and defined: content, semantic, technical, criterion, and conceptual equivalence. These concepts are illustrated by examples from the authors' experience in research on internal migrants in Peru.

14. Goldfeld, A. E.; Mollica, R. F.; Pesavento, B. H., and Faraone, S. V. The physical and psychological sequelae of torture. Symptomatology and diagnosis. JAMA. 1988 May 13; 259(18): 2725-9.
Keywords: Child/ Craniocerebral Trauma: epidemiology/ Female/ Human/ Human Rights/ Male/ Medical History Taking/ Pregnancy/ Psychology/ Refugees: psychology/ Sex Offenses/ Stress Disorders, Post-Traumatic: diagnosis: epidemiology/ *Torture
Abstract: We present a review of the international literature on the medical and psychological effects of torture. Our review reveals that certain tortures and their physical and emotional sequelae are more prevalent than previously appreciated. They include the common occurrence of sexual violence during the torture of women and female adolescents and the high frequency of head injury and associated neuropsychiatric consequences. We recommend the use of standardized diagnostic criteria in the evaluation of patients who have survived torture; this will facilitate patient care and the documentation of human rights violations.

15. Green, B. L. Assessing levels of psychological impairment following disaster: consideration of actual and methodological dimensions. J Nerv Ment Dis. 1982 Sep; 170(9): 544-52.
Keywords: Data Collection/ *Disasters/ Follow-Up Studies/ Human/ Interview, Psychological/ Mental Disorders: epidemiology: *etiology/ Questionnaires/ Research: methods/ Research Design: standards/ Support, Non-U.S. Gov't/ Support, U.S. Gov't, P.H.S.
Abstract: It is noted that research on the psychological effects of disaster, particularly with regard to rates of impairment, has turned up confusing and sometimes contradictory results. Two sets of dimensions salient to such investigations are noted: those which are aspects of disasters per se and affect actual rates of impairment ("true scores") and those which could be expected to affect estimates of impairment rates ("error variance") following disaster. Dimensions of disasters per se suggested by others are reviewed, and an additional dimension is proposed. Four methodological dimensions affecting reported impairment rates are described (sampling of subjects, level of data, case identification, and time of follow-up). Studies of long term psychological effects of disaster where some estimate of impairment was given are reviewed in order to demonstrate the noncomparability of findings from study to study due to methodological differences.

16. Harding, T. W.; de Arango, M. V.; Baltazar, J.; Climent, C. E.; Ibrahim, H. H.; Ladrido-Ignacio, L.; Murthy, R. S., and Wig, N. N. Mental disorders in primary health care: a study of their frequency and diagnosis in four developing countries. Psychol Med. 1980 May; 10(2): 231-41.
Keywords: Adult/ *Developing Countries/ Human/ Mental Disorders: *diagnosis: epidemiology/ Neurotic Disorders: diagnosis/ Primary Health Care/ Psychophysiologic Disorders: diagnosis
Abstract: 1624 patients who were attending primary health facilities in 4 developing countries were examined to determine how many were suffering from mental disorder. Using stringent criteria to establish the presence of psychiatric morbidity, 225 cases were found, indicating an overall frequency of 13.9%. The great majority of cases were suffering from neurotic illnesses and for most the presenting complaint was of a physical symptom, such as headache, abdominal pain, cough or weakness. The health workers following their normal procedure correctly detected one third of the psychiatric cases.

17. Hourani, L. L.; Armenian, H.; Zurayk, H., and Afifi, L. A population-based survey of loss and psychological distress during war. Soc Sci Med. 1986; 23(3): 269-275. Abstract: Research on the psychological effects of war has been conducted on a limited number of population groups and has generally failed to study the experience of particular losses while warfare was still in progress. This paper presents the results of a household surveillance study of 5788 displaced and non-displaced civilians conducted during the summer 1982 war in Lebanon. In order to determine demographic differences in the psychological response to war, and help identify population groups possibly at risk for mental disorder, an interview checklist of symptoms of psychological distress was developed and administered to a key informant in each household. The occurrence of psychological distress symptoms varied significantly by age, sex, nationality, socio-economic status, loss of physical health and economic loss. A more detailed analysis of the psychological effect of displacement of loss of one’s home during war is presented. Displacement group differentials suggest that psychological distress may be more frequently perceived post-war and that both social integration and social isolation may play important roles in mediating the perception of psychological distress during war.

18. Kroll, J.; Habenicht, M.; Mackenzie, T.; Yang, M.; Chan, S.; Vang, T.; Nguyen, T.; Ly, M.; Phommasouvanh, B.; Nguyen, H. and others. Depression and posttraumatic stress disorder in Southeast Asian refugees. Am J Psychiatry. 1989 Dec; 146(12): 1592-7.
Keywords: Acculturation/ Adult/ Asia, Southeastern: ethnology/ Community Mental Health Services/ Depressive Disorder: diagnosis: *epidemiology/ Female/ Human/ Life Change Events/ Male/ Marriage/ Middle Age/ Minnesota: epidemiology/ Pain: diagnosis/ Refugees: *psychology/ Sex Factors/ Single Person/ Sleep Disorders: diagnosis/ Stress Disorders, Post-Traumatic: diagnosis: *epidemiology
Abstract: The authors report on 404 Southeast Asian refugees seen at a community clinic. Approximately three-quarters of these patients met DSM-III criteria for major depressive episode, and 14% had posttraumatic stress disorder. Complaints of pain and sleep disturbances were the predominant presenting symptoms. Most of the men were married, but more than 40% of the women were widowed. Between 15% and 30% of the patients reported specific traumatic experiences either in their homeland or during their escape. Widowhood and such traumatic experiences were positively correlated with more symptoms of depression and anxiety.

19. Lima, B.; Pai, S.; Santacruz, H.; Lozano, J.; Chavez, H., and Samaniego, N. Conducting research on disaster mental health in developing countries: a proposed model. Disasters. 1989; 13(2): 177-184.
Abstract: The psychological consequences of disasters are known to be significant, but research efforts in developing countries have been sporadic. This paper reports a successful collaborative project conducted in Armero, Colombia, and in Ecuador. It outlines its origins, summarizes its findings, and identifies the essential ingredients that were responsible for its positive outcome. It is recommended that these guidelines be adhered to for the development of similar projects elsewhere, to ensure a significant impact on advancing the field, policy-making, delivering appropriate mental health care, and training of providers.

20. McCallin, M. Psychological needs of Mozambican refugees--a community-based approach. Trop Doct. 1991; 21 Suppl 1:67-9.
Keywords: Adaptation, Psychological/ Adolescence/ Adult/ Child/ Community Health Services: *organization & administration/ Female/ Human/ Male/ Mozambique/ *Refugees/ Social Support/ Stress Disorders, Post-Traumatic: *psychology
Notes: Abstract written by Tulane University.
Abstract: This paper describes the way in which the psychological needs of refugees must remain distinct from their physical needs and be addressed differently by health and relief services. The results of a structured questionnaire of 110 female Mozambican refugees and their children show that a majority of the women had experienced or witnessed a traumatic event, and they had considerable stress related to these events. Children were found to be most vulnerable to trauma-related stress if they were the direct victims in a traumatic incident or their parents had been victims of an incident. The author concludes that in working victims of trauma in a refugee population the following factors should be taken into consideration: (1) identify the most vulnerable in the population including people without family support and people with a feeling of hopelessness, revenge, and lack of worth, (2) do not limit techniques to those developed in countries with ample resources, (3) identify support groups in the community, (4) help the victims to cope with normal, everyday routines, and (5) work with the victims, and within the community development programs and the culture, to ensure that the victims have a part in decision-making, are not overpowered, develop self-confidence, and bring the strengths of the community to the program.

21. Mollica, R. F.; Caspi-Yavin, Y.; Bollini, P.; Truong, T.; Tor, S., and Lavelle, J. The Harvard Trauma Questionnaire. Validating a cross-cultural instrument for measuring torture, trauma, and posttraumatic stress disorder in Indochinese refugees. J Nerv Ment Dis. 1992 Feb; 180(2): 111-6.
Keywords: China: ethnology/ Cross-Cultural Comparison/ Human/ Questionnaires/ Refugees/ Reproducibility of Results/ Stress Disorders, Post-Traumatic: *diagnosis: psychology/ Torture/ *Trauma Severity Indices/ United States
Abstract: There are no valid and reliable cross-cultural instruments capable of measuring torture, trauma, and trauma-related symptoms associated with the DSM-III-R diagnosis of posttraumatic stress disorder (PTSD). Generating such standardized instruments for patients from non-Western cultures involves particular methodological challenges. This study describes the development and validation of three Indochinese versions of the Harvard Trauma Questionnaire (HTQ), a simple and reliable screening instrument that is well received by refugee patients and bicultural staff. It identifies for the first time trauma symptoms related to the Indochinese refugee experience that are associated with PTSD criteria. The HTQ's cultural sensitivity may make it useful for assessing other highly traumatized non-Western populations.

22. Mollica, R. F.; Donelan, K.; Tor, S.; Lavelle, J.; Elias, C.; Frankel, M., and Blendon, R. J. The effect of trauma and confinement on functional health and mental health status of Cambodians living in Thailand-Cambodia border camps. JAMA. 1993 Aug 4; 270(5): 581-6.
Keywords: Adult/ Aged/ Cambodia: ethnology/ Cross-Cultural Comparison/ Family Characteristics/ Female/ *Health Status/ Human/ Male/ *Mental Health/ Middle Age/ *Political Systems/ Social Adjustment/ *Social Alienation: psychology/ *Social Conditions: statistics & numerical data/ Support, Non-U.S. Gov't/ Thailand/ *Wounds and Injuries: epidemiology: psychology
Abstract: OBJECTIVE--To assess the long-term impact of trauma and confinement on the functional health and mental health status of Cambodian displaced persons living on the Thailand-Cambodia border. DESIGN--Household survey of 993 adults randomly selected from household rosters. Household sample selection by multistage area probability sample. SETTING--Site 2, the largest Cambodian displaced-persons camp on the Thailand-Cambodia border. PARTICIPANTS--Adults 18 years of age and older selected at random within households; 98% of eligible persons selected agreed to participate. RESULTS--From 1975 through 1979 (Khmer Rouge regime), more than 85% reported lack of food, water, shelter, and medical care, brainwashing, and forced labor; 54% reported murder of a family member or friend; 36% reported torture; 18% reported head injury; and 17% reported rape or sexual abuse. During the refugee period between 1980 and 1990, 56% reported lack of food or water, 44% reported lack of shelter, 28% reported lack of medical care, 24% reported brainwashing, and 8% reported torture. Since 1980, reports of murder of a family member, head injury, and rape/sexual abuse have decreased to 5%. Reports of experiencing combat situations and shelling attacks have remained consistent between the two time periods, approximately 44% and 30%, respectively. From 1989 to 1990, 25% reported experiencing lack of food or water, and 5% to 10% reported serious injury, combat, and shelling conditions. More than 80% said they were in fair or poor health, felt depressed, and had a number of somatic complaints despite good access to medical services. Fifty-five percent and 15% had symptom scores that correlate with Western criteria for depression and posttraumatic stress disorder, respectively. Fifteen percent to 20% reported health impairments limiting activity, and moderate or severe bodily pain. Despite reported high levels of trauma and symptoms, social and work functioning were well preserved in the majority of respondents. CONCLUSIONS--Reports of extensive trauma, poor health status, and depressive symptoms of this population are of concern in predicting future morbidity and mortality. The health and mental health needs of Cambodian displaced persons and their impact on social and economic behavior should be addressed now that the Cambodians have been repatriated.

23. Mollica, R. F.; Poole, C.; Son, L.; Murray, C. C., and Tor, S. Effects of war trauma on Cambodian refugee adolescents' functional health and mental health status. J Am Acad Child Adolesc Psychiatry. 1997 Aug; 36(8): 1098-106.
Keywords: Adaptation, Psychological/ Adolescence/ *Adolescent Psychology/ Cambodia: ethnology/ Child/ Confidence Intervals/ Environmental Exposure: adverse effects: statistics & numerical data/ Female/ *Health Status/ Health Surveys/ Human/ Male/ Mental Disorders: epidemiology: etiology/ Odds Ratio/ *Refugees: psychology: statistics & numerical data/ Stress Disorders, Post-Traumatic: *epidemiology/ Stress, Psychological: *epidemiology/ Support, Non-U.S. Gov't/ Thailand: epidemiology/ *War
Abstract: OBJECTIVE: To measure the effect of war trauma on the functional health and mental health status of Cambodian adolescents living in a refugee camp on the Thai-Cambodian border. METHOD: A multistage probability sample identified 1,000 households in the camp known as Site Two. Interviews were conducted in each household with randomly selected adults 18 years of age and older. All adolescents aged 12 and 13 years old, along with one parent were interviewed. One hundred eighty-two adolescents (94 girls, 88 boys) and their parents participated. Culturally sensitive instruments were used including Cambodian versions of the Child Behavior Checklist (CBCL) and the Youth Self-Report (YSR). RESULTS: Parents and adolescents reported the latter having experienced high levels of cumulative trauma, especially lack of food, water, and shelter. Mean Total Problem scores were in ranges similar to those of adolescents receiving clinical care in the United States, Netherlands, and Israel. Nearly 54% (53.8%) had Total Problem scores in the clinical range by parent report on the CBCL and 26.4% by adolescent report on the YSR. The most commonly reported symptoms were somatic complaints social withdrawal attention problems, anxiety, and depression. The dose- effect relationship between cumulative trauma and symptoms was strong for parent reporting on the CBCL; the subscales on both the YSR and CBCL for Anxious/Depressed and Attention Problems revealed dose-effect associations. Dose-effect relationships between cumulative trauma and social functioning or health status were lacking. CONCLUSION: The high levels of emotional distress in this population of Cambodian adolescents and corresponding dose-effect relationships reveal the important negative psychosocial impact of violence on Cambodian adolescents. Lack of findings related to physical health status and the presence of positive social functioning of many youths should not deter health care providers and public health officials from diagnosing and treating underlying high levels of psychological distress.

24. Mollica, R. F.; Wyshak, G.; de Marneffe, D.; Khuon, F., and Lavelle, J. Indochinese versions of the Hopkins Symptom Checklist-25: a screening instrument for the psychiatric care of refugees. Am J Psychiatry. 1987 Apr; 144(4):497-500.
Keywords: Anxiety: diagnosis/ Cambodia: ethnology/ Depression: diagnosis/ *Ethnic Groups/ Human/ Language/ Laos: ethnology/ Mental Disorders: *diagnosis/ *Personality Inventory/ Psychometrics/ Rape/ Refugees: *psychology/ Stress, Psychological: diagnosis: psychology/ Torture/ United States/ Vietnam: ethnology/ War Crimes
Abstract: The United States is accepting the largest number of displaced persons since World War II. Over 70% are Southeast Asians; many have suffered serious war trauma and torture. Cultural differences in health-seeking behavior and lack of specialized mental health services make the recognition of psychiatric distress in Southeast Asia refugees difficult for American health care providers. The authors describe the development and validation of Cambodian, Laotian, and Vietnamese versions of the Hopkins Symptom Checklist-25. This brief, simple, and reliable instrument is well received by refugee patients, offers an effective screening method for the psychiatric symptoms of anxiety and depression, and is especially helpful for evaluating trauma victims.

25. Mollica, R. F.; Wyshak, G., and Lavelle, J. The psychosocial impact of war trauma and torture on Southeast Asian refugees. Am J Psychiatry. 1987 Dec; 144(12): 1567-72.
Keywords: Cambodia: ethnology/ Comparative Study/ Depressive Disorder: diagnosis: epidemiology/ Dreams/ *Ethnic Groups/ Female/ Human/ Laos: ethnology/ Life Change Events/ Male/ Mental Disorders: diagnosis: epidemiology/ Refugees: *psychology/ Sex Factors/ Single Person: psychology/ Stress Disorders, Post-Traumatic: *diagnosis: epidemiology/ *Torture/ United States/ Vietnam: ethnology
Abstract: More than 700,000 refugees from Southeast Asia have settled in the United States since 1975. Although many have suffered serious trauma, including torture, few clinical reports have described their trauma- related symptoms and psychosocial problems. The authors conducted a treatment study of 52 patients in a clinic for Indochinese. They found that these patients were a highly traumatized group; each had experienced a mean of 10 traumatic events and two torture experiences. Many of the patients had concurrent diagnoses of major affective disorder and posttraumatic stress disorder as well as medical and social disabilities associated with their history of trauma. The authors also found that Cambodian women without spouses demonstrated more serious psychiatric and social impairments than all other Indochinese patient groups.

26. Mollica, R. F.; Wyshak, G.; Lavelle, J.; Truong, T.; Tor, S., and Yang, T. Assessing symptom change in Southeast Asian refugee survivors of mass violence and torture. Am J Psychiatry. 1990 Jan; 147(1): 83-8.
Keywords: Acculturation/ Adaptation, Psychological/ Adult/ Cambodia: ethnology/ Community Mental Health Services/ Depressive Disorder: diagnosis: psychology: therapy/ Female/ Human/ Laos: ethnology/ Male/ Outcome and Process Assessment (Health Care)/ Personality Inventory/ Refugees: *psychology/ Social Adjustment/ Stress Disorders, Post-Traumatic: diagnosis: psychology: *therapy/ Support, U.S. Gov't, Non-P.H.S./ *Torture/ United States/ Vietnam: ethnology/ Violence
Abstract: The authors evaluated changes in symptoms and levels of perceived distress of 21 Cambodian, 13 Hmong/Laotian, and 18 Vietnamese patients before and after a 6-month treatment period. Most of the patients improved significantly. Cambodians had the greatest and Hmong/Laotians had the least reductions in depressive symptoms. Although psychological symptoms improved, many somatic symptoms worsened. The authors conclude that refugee survivors of multiple traumata and torture can be aided by psychiatric care. They recommend investigations with larger samples and suitable control groups to further clarify the relative contributions of trauma, diagnosis, and acculturation stress to treatment outcome.

27. Neugebauer, R. The uses of psychosocial epidemiology in promoting refugee health. Am J Public Health. 1997 May; 87(5): 726-8.
Keywords: Epidemiologic Methods/ *Health Status/ Human/ International Cooperation/ Psychology/ Refugees: *psychology: *statistics & numerical data/ World Health Organization
Notes: Abstract written by Tulane University.
Abstract: There is no established body of population-based findings on psychological distress and psychiatric disorder among refugees and internally displaced persons. There a division in the international community on what is the appropriate recovery method for these populations. The two opposing approaches are treatments focused on the individual versus community reconstruction. In order to avoid negative consequences associated with the chosen method of recovery, there is a need for epidemiologic research on rates of psychological impairment and frank psychiatric disorder, risk factors for these conditions, and program safety, efficacy, and efficiency.

28. Raphael, B.; Lundin, T., and Weisaeth, L. A research method for the study of psychological and psychiatric aspects of disaster. Acta Psychiatrica Scandinavica. 1989; 80(Suppl 352): 1-75.
Abstract: This paper attempts to draw together some of the current questions related to the methodology of exploring the psychological and psychiatric aspects of human response to disaster. It sets out some of the key areas in which research questions might be mounted. A range of relevant instruments are suggested. The value of a structured interview which can explore issues of relevance to disaster victims is demonstrated. Early screening measures and proposals regarding these, as well as the particular instruments for longer term follow-up and assessment of outcome are discussed in considerable detail. The article concludes with an overview of the principal issues to be addressed in methodology research, and emphasizes the need for a collaborative approach using core items so that studies embracing different disasters and different countries can have some comparative basis.

29. Silove, D. The psychosocial effects of torture, mass human rights violations, and refugee trauma: toward an integrated conceptual framework. J Nerv Ment Dis. 1999 Apr; 187(4): 200-7.
Keywords: Adaptation, Psychological/ Anger/ Existentialism/ Female/ Human/ Human Rights/ Identification (Psychology)/ Life Change Events/ Male/ Models, Psychological/ Object Attachment/ Refugees: *psychology/ Research Design/ Role/ Social Justice/ Stress Disorders, Post-Traumatic: epidemiology: *psychology/ Survivors: psychology/ Torture: *psychology
Abstract: 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.

30. Stewart, A. L.; Hays, R. D., and Ware, J. E. Jr. The MOS short-form general health survey. Reliability and validity in a patient population. Med Care. 1988 Jul; 26(7): 724-35.
Keywords: Adult/ Aged/ Aged, 80 and over/ Boston/ California/ Chicago/ Evaluation Studies/ Female/ Health Surveys: *methods/ Human/ Male/ Middle Age/ Outcome and Process Assessment (Health Care): *methods/ Questionnaires/ Support, Non-U.S. Gov't
Notes: Abstract written by Tulane University.
Abstract: Surveys to measure health in clinic settings need to be thorough enough to provide reliable, valid results yet short and simple enough to be acceptable to a population that is sick and has many demands on its attention and time. This study reports the results of using a survey designed to meet these requirements. The 11,186 patients in the sample were participants in the Medical Outcomes Study (MOS). The patients completed a self-administered questionnaire, which included a subset of health items regarding physical functioning, role and social functioning, mental health, health perceptions, and pain. The results were analyzed and then compared with the results of a more lengthy survey. In general, it was found that the reliability and validity of the short-form were acceptable and were comparable to that of the long-form, but further study is needed. Based on this experiment, the concept of using short-form surveys seems promising.

31. Summerfield, D. A critique of seven assumptions behind psychological trauma programmes in war-affected areas. Soc Sci Med. 1999 May; 48(10): 1449-62.
Keywords: Adolescence/ Adult/ Altruism/ Child/ Counseling: organization & administration/ Data Collection/ Europe/ Female/ Human/ Knowledge, Attitudes, Practice/ Male/ Mental Health Services: *organization & administration/ Program Development/ Program Evaluation/ Stress Disorders, Post-Traumatic: *therapy/ United Nations/ *War/ World Health Organization
Abstract: Programmes costing millions of dollars to address 'posttraumatic stress' in war zones have been increasingly prominent in humanitarian aid operations, backed by UNICEF, WHO, European Community Humanitarian Office and many nongovernmental organisations. The assumptions underpinning this work, which this paper critiques with particular reference to Bosnia and Rwanda, reflect a globalisation of Western cultural trends towards the medicalisation of distress and the rise of psychological therapies. This paper argues that for the vast majority of survivors posttraumatic stress is a pseudocondition, a reframing of the understandable suffering of war as a technical problem to which short-term technical solutions like counselling are applicable. These concepts aggrandise the Western agencies and their 'experts' who from afar define the condition and bring the cure. There is no evidence that war-affected populations are seeking these imported approaches, which appear to ignore their own traditions, meaning systems, and active priorities. One basic question in humanitarian operations is: whose knowledge is privileged and who has the power to define the problem? What is fundamental is the role of a social world, invariably targeted in today's 'total' war and yet still embodying the collective capacity of survivor populations to mourn, endure and rebuild.

32. Vitaliano, P. P.; Maiuro, R. D.; Bolton, P. A., and Armseden, G. C. A psychoepidemiologic approach to the study of disaster. J Comm Psych. 1987; 15:99-122.
Abstract: Several researchers have called for an interdisciplinary approach to the study of disaster. In this article, the authors discuss conceptual issues related to stress, distress, and disaster; survey pertinent contributions by researchers; and provide a rationale for the sue of a comprehensive, psychoepidemiologic model of distress as a possible means of systematizing research in the area. A review of the model’s components, which include exposure to stressors, vulnerability, and psychological and social resources, is presented. Various ways to implement the model practically and methodologically in disaster research also are discussed.

33. Willis, G. B. and Gonzalez, A. Methodological issues in the use of survey questionnaires to assess the health effects of torture. J Nerv Ment Dis. 1998 May; 186(5):283-9.
Keywords: Data Collection: methods: *standards/ *Health Status Indicators/ Human/ Life Change Events/ Outcome Assessment (Health Care)/ Quality of Life/ Questionnaires: standards/ Refugees: *psychology/ Reproducibility of Results/ Research Design: standards/ Stress Disorders, Post-Traumatic: diagnosis: epidemiology/ Survivors: *psychology/ Torture: *psychology
Abstract: It has become increasingly important to identify torture survivors among subgroups of the American population and to assess the continuing health effects of torture experience. To determine whether survey questionnaires can be effectively used to make such assessments, we reviewed the recent literature on refugee health, on the measurement and treatment of trauma, and in the related areas of survey methodology and cognitive psychology. We conclude that, if properly conducted, the survey approach represents an effective method, and we propose specific recommendations concerning procedures that may be used in surveys of torture survivors to maximize study validity.