 |
 |
|
|
|
 Mental health problems are common among refugees. Epidemiologic studies have identified PTSD and MDE as the most common disorders that affect refugees (1). In the general population, the lifetime prevalence rate of PTSD is estimated to be between 1% and 14%, and the point prevalence of MDE in community samples varies from 3% to 7% (2,3). In refugee populations, studies have found PTSD rates higher than 50% (4–6) and MDE rates from 15% to 80% (5). Given the high prevalence of both disorders, comorbidity is also frequent in refugees. A study of former Vietnamese political prisoners found a prevalence rate of 86% for PTSD and a comorbidity rate of 50% with depression (7), while a study of Bosnian refugees found rates of 26% for PTSD, 39% for depression, and 21% for both conditions (8). Screening for PTSD and Depression in Refugees and Asylum SeekersRecent studies have brought to light valid reasons for undertaking early psychological screening in refugees and asylum seekers (9,10) who regularly solicit health care systems for psychosomatic symptoms, often without receiving a correct diagnosis or appropriate treatment. However, a recent review of psychiatric instruments used in empirical studies for measuring trauma and health status in refugees found that, among the 125 instruments described, only 12 were specifically developed for the target population and 8 were adapted for use with refugees (11). The authors stressed the need for instruments adapted to the measurement of PTSD in refugee populations to allow the development of better prevention models. In most Western countries, asylum policies and procedures are becoming harsher, and this could contribute to an increase in psychopathology in asylum seekers, as a recent study has underscored (12). This is an additional argument for considering early screening for mental disorders in these populations. On the basis of these observations, we integrated a standardized psychiatric instrument into the routine health screening of newly arrived asylum seekers in our facility, the Migrant Heath Centre (Geneva University Hospitals), to detect PTSD and MDE. This article outlines our attempt to adapt a validated psychiatric screening instrument to this culturally heterogeneous population. Methods and MaterialsStudy Setting The population comprised asylum seekers aged over 16 years who underwent a systematic medical examination at the Migrant Health Centre shortly after their arrival in Geneva. In 2004, 142 484 asylum applications were registered in Switzerland, representing 122 different countries of origin, and 773 individuals (5.4%) were assigned to the Geneva Canton. Fifty-two percent of those assigned to Geneva came from Africa, 38% from the Balkans or the former Soviet Republic, 9% from the Near or Middle East, and 1% from Asia. Choice of a Screening Test and Cross-Cultural Validity For this project, we needed to identify a screening instrument that could be used in a primary care setting, with a culturally diverse population. This instrument had to be brief and practical to be used by nurses who had limited training in mental health issues, with no more than 45 minutes per person for both general and mental health screening. We opted to use the PTSD and MDE sections of the MINI (13). This structured diagnostic interview has been developed and validated in France and in the United States and screens for 17 DSM-IV psychiatric disorders. It was tested against the SCID and the Composite International Diagnostic Interview (14) and found to be reliable and valid. The MINI seemed particularly adapted to our study because it is short and can be administered by nonmental health professionals. It has been translated and validated in many languages, which we considered to be a sign of its applicability to diverse cultures (15,16). However, the populations screened in the MINI validation studies were overwhelmingly white (96%) and had a minimum of 12 years of schooling (87%, 17). This put into question the application of the instrument to less educated individuals from non-Western cultures. The Pretest To determine whether the original MDE and PTSD sections of the original MINI could be used in our setting, we conducted a pretest with 20 asylum seekers in English or French or with the assistance of an interpreter. Most pretest participants and interpreters found the questions to be ill-adapted to the context and often culturally too direct or too complex for the respondent’s level of education. Adaptation of the Screening Test We formed a multidisciplinary team composed of health professionals with expertise in the field of refugee health. The first step was to simplify the wording of the questions in the original PTSD and MDE sections of the MINI and to contextualize them for asylum seekers who have recently arrived in the host country (Figure 1). Each group member used the original French and English versions and the DSM-IV criteria for PTSD and MDE to reword the items to obtain a contextually appropriate version. Next, the group met twice to arrive at a consensual version compatible with the objectives of simplicity and applicability to asylum seekers’ situation. This process resulted in the reworded French version.
Verification of Content Acceptability With Interpreters and Bicultural Workers To test the face validity of the reworded version for the target population, we submitted it to 14 trained interpreters representing 24 languages. Most of the interpreters working at Geneva University Hospitals are themselves former migrants. We sent the original MINI versions to the interpreters for comments, along with the reworded French version. Then, we interviewed each of the interpreters, asking them to share their comments on the comprehensibility and acceptability of the 3 versions. According to their remarks, we rated each item on a 4-point Likert scale (1 = an item good for translation to 4 = an unusable or completely inadequate item). Finally, the multidisciplinary team evaluated the pertinence of the interpreters’ comments and integrated them into the final French reworded version. Both final French and English versions are available on request. ResultsThe changes made in each item during the 3 steps of the rewording process can be found in Appendices 1 and 2. General Comments Made by Interpreters on the Original Version Overall, several interpreters judged the questionnaire to be inappropriate for cultural, religious, or contextual reasons. For example, people would expect to be examined physically only (as noted by the Chinese interpreter) or would consider traumatic events as God’s will rather than a source of illness (as noted by the African interpreters) or would consider it “natural” to be sad and depressed when separated from one’s country (as noted by the Turkish interpreter). Underscoring Specific Problems Tables 1 and 2 present the interpreters’ comments on the comprehensibility and acceptability of the original French version. Some items were considered particularly problematic, either because their meaning was too difficult to translate into the interpreter’s language or because they sounded inappropriate, even absurd, given the context in which newly arrived asylum seekers find themselves. Regardless of their culture, most interpreters judged as unsuitable those items related to the required duration of symptoms. According to DSM-IV classification, the time criterion is an essential component of the MDE and PTSD diagnosis: several symptoms must occur “most of the time” and last for several weeks to be considered positive. Other questions were problematic owing to differences in the cultural expression of certain symptoms, especially in regard to the evaluation of feelings of guilt, suicidal tendencies, and avoidance and numbing symptoms.
Time Criterion (Appendix 1, A1 to A3-g ). In the MDE section of the MINI, the first questions refer to “the past 2 weeks”. In the PTSD section, most of the questions refer to “the past month.” Many interpreters judged the temporal element of the original questionnaire to be too strict for the target population. They pointed out that the everyday life of newly arrived asylum seekers, especially young single men, lacks structure: they have little social contact, cannot yet work legally, and have few occupations. The Arab interpreter added that, for people from Middle-Eastern cultures, the sense of time, which she called Arab time, “is different from that of the Occident.” For her, asking if something happens “most of the time” may confuse the person, “who will probably be incapable of answering the question.” To make the temporal criteria more understandable, we identified, at the beginning of the questionnaire, a personal event that the asylum seeker had experienced in the last 2 to 4 weeks, for example, his or her arrival at the asylum-seeker residence. All questions refer to this event, allowing the interviewer to situate the symptoms in this time frame. Similarly, interpreters found the last 2 questions of the MDE section (Appendix 1, A5-a and -b) to be problematic. The purpose of these questions is to distinguish between current and recurrent MDE. Considering that all interpreters found their wording complex and their meaning unclear, we withdrew these questions. Indeed, they were not discriminant for initial screening. Evaluation of the Feeling of Guilt (MDE Section, Appendix 1, A3-e). Opinions were polarized concerning guilt as a “cultural value.” The original question was, “did you feel worthless or guilty almost everyday?” The Amharic, Peul, Chinese, and Turkish interpreters found this phrase impolite, even shocking. The Mande interpreter said that “guilt does not exist in our culture because of the notion of fate; when something happens to someone, it was meant to be, and it is not the person’s fault.” The Arab interpreter considered that “guilt is a very important notion,” a kind of “obligation” in her culture. Evaluation of Suicidal Tendencies (MDE Section, Appendix 1, A3-g). All but 3 interpreters were shocked by the following question: “Have you thought on several occasions that you would be better off dead or have you thought about hurting yourself?” However, the reasons why the wording was bothersome differed among interpreters. For example, for the Albanian interpreter, the word “suicide” is taboo, but it is acceptable to ask someone if they had wished they were dead, whereas the opposite was true for the Bulgarian interpreter. The Chinese interpreter stated that the only way not to shock Chinese participants with the question was to ask, “Is it difficult for you to distance yourself from things?” In Chinese culture, when someone commits suicide, it is said that he or she was not able to distance him- or herself. The Amharic, Mande, Turkish, and Arab interpreters said it was not possible to ask the first part of the question because, in the Muslim religion, only God decides on life and death. However, it could be acceptable to ask whether the person had wished he or she were dead. Evaluation of Avoidance and Numbing Symptoms (PTSD Section, Appendix 2, I-3a to I-3f). These symptoms constitute 1 of the 4 criteria required for the diagnosis of PTSD according to the DSM-IV classification. Six of the original MINI questions are devoted to these symptoms. Item I-3d, which states, “Do you feel detached from everything or do you feel as though you’ve become a stranger to others?” seemed especially ill-adapted for newly arrived asylum seekers, who are inevitably strangers in the host country. Thus the question was changed to read the following: “Compared to before this event, do you feel as though you no longer care about the people or things around you, or as though you’ve become a different person?” Similarly, questions I-3e, “Have you had difficulty feeling your emotions, for example do you feel you are no longer capable of love?” and I-3f, “Do you feel that your life will never be the same again, and do you no longer view the future in the same way as before?” were nonsensical, since most asylum seekers are separated from their families and have no idea what the future in the host country holds for them. Since neither the members of our team nor the interpreters could find a way to adapt question I-3f, and because there are other items that explore numbing symptoms, we withdrew the question. DiscussionAs demonstrated by Hollifield (11), appropriate instruments to screen for MDE and PTSD among refugees are lacking. Our choice to adapt an existing screening questionnaire for cross-cultural use was dictated by our desire to work with a validated instrument. However, this was a complex undertaking for several reasons. Problems Linked to the Comorbidity and Overlap Between MDE and PTSD The categorical organization of contemporary psychiatric classifications leaves room for the possible cooccurrence of distinct disorders. Differentiating between MDE and PTSD can be complicated because of symptom overlap, in particular, markedly diminished interest in significant activities, difficulty staying or falling asleep, and difficulty concentrating. Other symptoms, such as irritability or guilt, are commonly found in both conditions, whereas the distinctive features of PTSD are the exaggerated startle response, reexperiencing symptoms, and physiological reactivity to trauma-related cues. The high rates of comorbidity in asylum seekers may also complicate the detection of each individual disorder. Further, studies in the general population have shown that 80% of patients with a PTSD diagnosis also receive another psychiatric diagnosis, the most frequent ones being depression, generalized anxiety disorder, and substance abuse (18). Limitations Linked to the Transcultural Validity of Psychiatric Diagnoses The use of culturally nonspecific instruments to screen for mental health problems in a culturally diverse population is a conceptual choice, and the present work was undertaken with this perspective. However, the assumption that mental disorders represent basic units of psychopathology that can be recognized independently of the individual’s culture is debated. Some authors find that this approach is too culturally reductive: they consider that the expressive and phenomenological dimensions of the symptoms vary across ethnocultural groups. Therefore, they question whether the application of the PTSD diagnosis to people from non-Western cultures is reliable (4,19–21). Conversely, many researchers consider that psychiatric diagnostic classifications can be used with ethnically diverse individuals, provided that the cultural considerations integrated into the diagnostic system are taken into account (22). Early cross-cultural studies stressed the similarities between Western and non-Western concepts of mental health (23,24). More recently, several PTSD studies have found that most individual reactions to traumatic events are similar across ethnic backgrounds (25,26). Ethnographic methods have been used to support this theory. For example, 5 years after the war in Rwanda, Bolton used randomized interviews to explore the perceptions of the genocide’s effects on mental health in rural areas (27,28). He found that the local descriptions of reactions to the genocide contained most of the DSM-IV criteria for PTSD and depression. He suggested that “content validity of instrument based on DSMI-IV criteria is supported . . . and could be improved by adding questions on the local symptoms” (29, p 247) The debate between advocates of a universalistic (that is, medical and psychiatric) approach and those of a relativistic (that is, anthropological) approach has been ongoing for decades. For some authors, resolution of this conflict is neither possible nor, perhaps, even desirable (30). From a pragmatic perspective, it is important to remember that both approaches have their limitations and strengths and that, to carry out clinically useful cross-cultural psychiatric research, an integration of methods and concepts is required (31). Even if diagnostic categories such as major depression and PTSD possess a universal validity, culture will influence symptomatic presentation, explanatory models, and help-seeking behaviours. Open-mindedness and awareness of these nuances allows clinicians and their patients to work together (32). Problems Linked to the Content of the Original Versions The original English version of the MINI is not a direct translation of the original French version, whereas the first step of the adaptation process was based on a mixed rewording of the 2 original versions. For example, in the original French version (literal English translation), the PTSD item “Do you feel that your life will never be the same again and do you no longer view the future in the same way as before?” (Appendix 2, I-3f) reads in English, “Have you felt that your life will be shortened or that you will die sooner than other people.” This observation corroborates our perceived need for an adapted instrument. Problems Linked to the Cultural Equivalence of Symptoms Several interpreters found that some items overlapped because, in their language, there is only one word to express the different feelings evoked by these questions. They brought to our attention the need to put these questions into context, to make them more understandable and to avoid “cultural overlapping,” which could be a source of confusion and overestimation of the prevalence of both disorders. Finally, some difficulties were linked to the cultural prejudices of interpreters themselves. For example, evoking suicide may be less acceptable for some interpreters than for individuals with depression of the same ethnic origin who experience current suicidal ideation. Problems Linked to the Mandatory Context of the Initial Health Assessment Asylum procedures are becoming harsher in most European countries, partly because governments consider that many people use asylum channels for economic migration rather than for escaping political repression. However, even if refugee status has been denied, severe mental illness can be a motive for allowing a person to stay temporarily in the host country. Therefore, it is possible that some people who are aware of this fact are tempted to exaggerate their psychological symptoms to acquire some benefit for their stay. However, even if this possibility exists, there is no evidence that this happens. On the contrary, in a recent study comparing the mental health status of 2 groups of Iraqi asylum seekers, Laban found that individuals living in The Netherlands for less than 6 months presented fewer psychiatric disorders than did those residing there for more than 2 years (12). ConclusionOur decision to reword the questions according to the life context of our target population, rather than according to cultural specificities, was dictated by rapidly changing migration patterns. Indeed, the geographical diversity of asylum seekers varies constantly according to political events worldwide. In the primary care settings of many host countries, our approach could be considered as the most pragmatic option for carrying out screening. Funding and SupportThis work was funded by the United Nations Special Fund for Victims of Torture (project P201) and the Quality of Care Program of Geneva University Hospitals (project 2001/17). AcknowledgementsWe thank Dr L Loutan, Travel and Migration Unit (Geneva University Hospitals), for his encouragement and support throughout all stages of the project; interpreters from the Geneva Red Cross; and patients, for their participation and valuable input. We also thank the nurses of the Migrant Health Centre, who gave important practical recommendations and conducted the interviews, in particular, C Equoy, I Segui, and E Mouton. Thanks to Professor Y Lecrubier and to MT Hergueta (INSERM U 302, Paris, France) for their methodological advice.
References1. Steel Z, Silove D, Phan T, Bauman A. Long-term effect of psychological trauma on the mental health of Vietnamese refugees resettled in Australia: a population-based study. Lancet 2002;360:1056–62. 2. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. Washington (DC): APA; 1994. 3. Ustun TB, Ayuso-Mateos JL, Chatterji S, Mathers C, Murray CJ. Global burden of depressive disorders in the year 2000. Br J Psychiatry 2004;184:386–92. 4. Marsella AJ, Friedman MJ, Gerrity M, Scurfield RM. Ethnocultural aspects of posttraumatic stress disorder: issues, research and clinical aspects. Washington (DC): American Psychological Association; 1996. 5. Silove D, Sinnerbrink I, Field A, Manicavasagar V, Steel Z. Anxiety, depression and PTSD in asylum-seekers: associations with pre-migration trauma and post-migration stressors. Br J Psychiatry 1997;170:351–7. 6. Favaro A, Maiorani M, Colombo G, Santonastaso P. Traumatic experiences, posttraumatic stress disorder, and dissociative symptoms in a group of refugees from former Yugoslavia. J Nerv Ment Dis 1999;187:306–8. 7. Smith Fawzi MC, Murphy E, Pham T, Lin L, Poole C, Mollica RF. The validity of screening for post-traumatic stress disorder and major depression among Vietnamese former political prisoners. Acta Psychiatr Scand 1997;95(2):87–93. 8. Weine SM, Razzano L, Brkic N, Ramic A, Miller K, Smajkic A, and others. Profiling the trauma related symptoms of Bosnian refugees who have not sought mental health services. J Nerv Ment Dis 2000;188:416–21. 9. Sondergaard HP, Ekblad S, Theorell T. Screening for post-traumatic stress disorder among refugees in Stockholm. Nord J Psychiatry 2003;57:185–9. 10. Drozdek B. Chronic PTSD and medical services utilization by asylum seekers. J Refugee Studies 2003;16:202–11. 11. Hollifield M, Warner TD, Lian N, Krakow B, Jenkins JH, Kesler J, and others. Measuring trauma and health status in refugees: a critical review. Jama 2002;288:611–21. 12. Laban CJ, Gernaat HB, Komproe IH, Schreuders BA, De Jong JT. Impact of a long asylum procedure on the prevalence of psychiatric disorders in Iraqi asylum seekers in The Netherlands. J Nerv Ment Dis 2004;192:843–51. 13. Lecrubier Y, Sheehan DV, Weiller E, Amorim P, Bonora I, Harnett Sheehan K, and others. The MINI International Neuropsychiatric Interview (MINI). A short diagnostic structured interview: reliability and validity according to the CIDI. Eur Psychiatry 1997;12:224–31. 14. Sheehan DV, Lecrubier Y, Sheehan KH, Amorim P, Janavs J, Weiller E, and others. The Mini-International Neuropsychiatric Interview (MINI): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. J Clin Psychiatry 1998;59 (Suppl 20):22–33. 15. Flaherty JA, Gaviria FM, Pathak D, Mitchell T, Wintrob R, Richman JA, and others. Developing instruments for cross-cultural psychiatric research. J Nerv Ment Dis 1988;176:257–63. 16. Kadri N, Agoub M, El Gnaoui S, Mchichi Alami K, Hergueta T, Moussaoui D. Moroccan colloquial Arabic version of the Mini International Neuropsychiatric Interview (MINI): qualitative and quantitative validation. Eur Psychiatry 2005;20:193–5. 17. Sheehan DV, Lecrubier Y, Sheehan KH, Janavs J, Weiller E, Keskiner E, and others. The validity of the MINI Inernational Neuropsychiatric Interview (MINI) according to the SCIP-P and its reliability. Eur Psychiatry 1997;12:232–41. 18. Brewin CR, Dalgleish T, Joseph S. A dual representation theory of posttraumatic stress disorder. Psychol Rev 1996;103:670–86. 19. Bracken PJ, Giller JE, Summerfield D. Psychological responses to war and atrocity: the limitations of current concepts. Soc Sci Med 1995;40:1073–82. 20. Briere J. Psychological assessment of adult posttraumatic states. Washington (DC): American Psychological Association; 1997. 21. Pelzer K. Ethnocultural construction of posttraumatic stress symptoms in African context. J Psychology Africa 1998. 22. Mezzich JE, Kirmayer LJ, Kleinman A, Fabrega H, Jr, Parron DL, Good BJ, and others. The place of culture in DSM-IV. J Nerv Ment Dis 1999;187:457–64. 23. Beiser M, Burr WA, Ravel JL, Collomb H. Illnesses of the spirit among the Serer of Senegal. Am J Psychiatry 1973;130:881–6. 24. Beiser M, Ravel JL, Collomb H, Egelhoff C. Assessing psychiatric disorder among the Serer of Senegal. J Nerv Ment Dis 1972;154:141–51. 25. Frueh BC, Brady KL, de Arellano MA. Racial differences in combat-related PTSD: empirical findings and conceptual issues. Clin Psychol Rev 1998;18:287–305. 26. Frueh BC, Hamner MB, Bernat JA, Turner SM, Keane TM, Arana GW. Racial differences in psychotic symptoms among combat veterans with PTSD. Depress Anxiety 2002;16:157–61. 27. Bolton P. Local perceptions of the mental health effects of the Rwandan genocide. J Nerv Ment Dis 2001;189:243–8. 28. Bolton P. Cross-cultural validity and reliability testing of a standard psychiatric assessment instrument without a gold standard. J Nerv Ment Dis 2001;189:238–42. 29. Bolton P. Local Perceptions of the Mental Health Effects of the Rwandan Genocide. J Nerv Ment Dis 2001;189:243–48. 30. Skultans V. The case of cross-cultural psychiatry: squaring the circle? Int Rev Psychiatry 1993;5:125–8. 31. Patel V. Culture health systems and psychiatric disorders. Curr Opin Psychiatry 2000;13:221–6. 32. Bhugra D. Cross-cultural psychiatry revisited. Int Rev Psychiatry 1999;11:91. Author(s)Manuscript received July 2005, revised, and accepted April 2006. This paper was presented as a poster at the 28th annual meeting of the American Society of Internal General Medicine. 2005 May 11–14; New Orleans (LA) and at the 13th World Congress of Psychiatry. 2005 Sept 10–15; Cairo, Egypt. 1. Clinical Unit Director, Migrant Health Centre, Department of Community Medicine, Geneva University Hospitals, Geneva, Switzerland. 2. Clinical and Research Psychologist, Department of Community Medicine, Geneva University Hospitals, Geneva, Switzerland. 3. Senior Lecturer, Medical Outpatient Clinic, Adult Psychiatric Service, Department of Psychiatry, Geneva University Hospitals, Geneva, Switzlerand. 4. Clinical Unit Director, Adult Psychiatric Service, Department of Psychiatry, Geneva University Hospitals, Geneva, Switzerland. Address for correspondence: Dr S Durieux-Paillard, Migrant Health Centre, Department of Community Medicine, Geneva University Hospitals, 89 rue de Lyon, CH-1203 Geneva, Switzerland e-mail: sophie.durieux@hcuge.ch
1 | 2
|
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||