The Journal of nervous and mental disease

In this article, a structure for self-analysis is described and the expanded applicability of self-analysis implied by the suggested structure is examined. Also, the stage of computer psychotherapy programs is reviewed, and an overview of a plan for merging self-analysis and computer psychotherapy is presented.

Deficits in executive, frontally mediated attention processes have been observed in substance abusers. A significant rate of childhood histories of attention deficit hyperactivity disorder has also been reported in this population, creating the question of whether attention problems predated addiction or were secondary to neurological drug or alcohol effects in pathological gamblers. To address this issue, the current study compared 33 non-substance-abusing pathological gamblers with 33 nonaddicted controls on nine attention measures and childhood behavior questionnaires. Gamblers performed significantly worse than controls on higher order attention measures and reported more childhood behaviors consistent with attention deficits. Results suggest attention deficits may be a risk factor for development of addictive disorders.

Research on family caregivers of mentally ill relatives has historically focused on negative aspects of caregiving, often described as caregiver burden. The authors document caregivers' perspectives on both the negative and positive aspects of caregiving. A qualitative approach was used. Data collection involved 20 in-depth, audiotaped, semistructured interviews focusing on caregivers' positive and negative personal experiences with caregiving to a relative with mental illness. Caregivers reported common negative impacts but also beneficial effects, such as feelings of gratification, love, and pride. Main themes included stigma, systems issues, life lessons learned, and love and caring for the ill relative. This study counterbalances the predominantly negative consequences previously reported and adds to the emerging literature on positive aspects of caregiving. Mental health professionals need to help caregiving families make choices to improve their challenging situations and identify the rewards of caregiving, and to advocate for increased systemic supports to ease caregiver burden.

The present paper is a very succinct description of the findings from the 10-year follow-up of a group of 101 patients from Cali, Colombia who were included in the WHO International Pilot Study of Schizophrenia. It is based on a prospective study conducted with the use of standardized instruments and with clinical evaluations performed by the same examiners at the beginning and end phases. A classification of the varieties of clinical course observed throughout the 10-year period is presented, as well as a description of several aspects of the social and clinical condition of cases at the time of the last observation. The possibility of finding predictors of the outcome of the disorder is explored through the use of multivariate methods, and a series of comments and conclusions is formulated.

The aim of the study was to identify predictors of mental symptoms (posttraumatic stress disorder, depression, and anxiety), and of health-related quality of life in refugees 10 years after referral to the Rehabilitation and Research Centre for Torture Victims, and to study changes in mental health over time. The study sample comprises 139 tortured refugees admitted to a pretreatment assessment in 1991 to 1994. Data on background and trauma, and in a subsample on mental symptoms, were collected at baseline. In 2002 and 2003, data on mental symptoms, health-related quality of life, and the participants' social situation were collected. The level of emotional distress was high at follow-up. Social relations and unemployment at follow-up were important predictors of mental health symptoms and low health-related quality of life. A significant decrease in mental symptoms was observed in the subsample. Social relations and unemployment should be taken into account when developing health-related and social interventions.

The authors explore the psychological reactions and functional coping responses of American Airlines (AA) flight attendants, a unique at-risk group of people in the war on terrorism, in the aftermath of the September 11 attacks. Demographic characteristics and standardized questionnaires, including the Posttraumatic Stress Disorder Checklist and the Psychotherapy Outcome Assessment and Monitoring System--Trauma Version, were sent in June 2002 to approximately 26,000 AA flight attendants. Of the 2050 respondents, 18.2% reported symptoms consistent with probable posttraumatic stress disorder (PTSD). Those living alone were 1.48 times more likely to have a probable PTSD diagnosis than those living with someone else. Age or years of service as a flight attendant did not predict probable PTSD; however, marital status did. Substance abuse was not endorsed as a coping strategy. Given the traumatic events experienced by AA flight attendants, and persistent threats of future terrorist attacks, these results reveal that additional assessment and treatment interventions for stress-related symptoms in this population seem warranted.

Telephone survey methodology was used to examine smoking and drinking after the September 11 terrorist attacks in a representative national sample. Most ever smokers and ever drinkers reported no change in substance use after the attacks. Smokers and drinkers who increased substance use were significantly more likely than those who did not to endorse a number of emotional reactions and functional difficulties. The pattern of associations of decreased use with emotional reactions and functional difficulties differed between smokers and drinkers. In general, decreased smoking was associated with denial of emotional reactions and functional difficulties whereas decreased drinking was associated with endorsement of these reactions and difficulties. The results have implications for research, clinical practice, and public health.

The terrorist attacks of September 11, 2001 inflicted distress beyond those directly exposed, thereby providing an opportunity to examine the contributions of a range of factors (cognitive, emotional, social support, coping) to psychological resilience for those indirectly exposed. In an Internet convenience sample of 1281, indices of resilience (higher well-being, lower distress) at baseline (2.5-12 weeks post-attack) were each associated with less emotional suppression, denial and self-blame, and fewer negative worldview changes. After controlling for initial outcomes, baseline negative worldview changes and aspects of social support and coping all remained significant predictors of 6-month outcomes, with worldview changes bearing the strongest relationship to each. These findings highlight the role of emotional, coping, social support, and particularly, cognitive variables in adjustment after terrorism.

Television viewing has been associated with posttraumatic stress disorder (PTSD) symptoms after disasters and traumas; we examined characteristics that may explain this association among New Yorkers after September 11, 2001. Among 2001 respondents to a random-digit dial telephone survey conducted 4 months after September 11, people who viewed more television images in the 7 days after September 11 had more probable PTSD. People in the highest third of viewing had a 2.32 times greater odds of probable PTSD after September 11 compared with people in the lowest third of viewing; after adjustment for explanatory variables, the relative odds of probable PTSD were 1.66. Adjustment for perievent panic accounted for 44% of the reduction in association between television and probable PTSD, suggesting that perievent emotional reactions may play an important role in the television and psychopathology association. Television may merit consideration as a potential exposure to a traumatic event.

Previous studies of psychological morbidity produced by September 11, 2001, focused primarily on short-term development of posttraumatic stress disorder or depression in East Coast cities targeted. This study aimed to determine whether suicide attempts medically harmful enough to necessitate admission to the general hospital increased in the 2 years following September 11, 2001, in a region not on the East Coast, and if so, to characterize individuals contributing to this increase. This retrospective study compared two time periods: 2 years preceding and 2 years following September 11, 2001. Psychiatric consultation reports for all suicide attempters medically admitted to the University of Michigan Health Systems Hospital in Ann Arbor, Michigan, were examined (N = 254). In the 2-year period following September 11, 2001, there was a 49% increase in the number of individuals making a harmful suicide attempt (p = 0.002). The effect was greatest in the months following the attacks but continued over the next year, with a stepwise decline corresponding to the number of months elapsed since September 11. In the period following September 11, 2001, fewer subjects reported multiple personal stressors (p = 0.03). The subjects in the two time periods were not significantly different in age, gender, prior suicide attempts, prior psychiatric treatment, alcohol abuse, substance abuse, depression, or psychosis. Overrepresentation by those most vulnerable to suicide attempts did not account for the increased number of suicide attempts. The effects of chronic stress in the general population across the United States elicited by the terrorism of September 11, 2001, may have been of greater magnitude and longer lasting than previously realized.

The current study examined stress reactions to the events of September 11, 2001 among African-American college students not directly exposed to the attacks. Within 3 days of September 11, 219 undergraduates (78.3% women) completed self-report measures assessing stress symptoms and other reactions to the attacks. The results indicated that many students experienced a variety of stress symptoms and distressing thoughts and feelings in response to the events of September 11, including academic problems, concerns about family and friends in the military, and fear about war. Most students were highly distressed by specific attack-related news reports and images. Anger toward persons of Middle Eastern descent was not frequently reported. Later college year and having parents not currently together were predictors of overall stress symptom severity as assessed by the Posttraumatic Stress Disorder Checklist. Later college year also predicted academic problems after September 11. The findings are discussed in terms of intervention implications and suggested directions for future research.

Seventy-six male inpatients with diagnoses of schizophrenia, primary affective disorder, post-traumatic stress disorder, borderline personality disorder, other personality disorder, and primary substance abuse disorder were screened for the use of marijuana by determination of urinary delta-9-tetrahydrocannabinol-11-oic acid. Screening was performed to detect marijuana use in asymptomatic patients returning to the ward after passes, and also to elucidate changes in mental state in newly admitted patients and patients who had decompensated during hospitalization. Ward personnel found the screening procedure quite useful and incorporated it into psychotherapeutic and chemotherapeutic interventions. Although susceptible and resistant individuals were found in all diagnostic categories studied, no consistent features were found to distinguish those individuals who exhibited behavioral change in association with marijuana smoking, from those who did not.

Research published in the aftermath of the 9/11 terrorist attack reported elevated rates of posttraumatic stress disorder (PTSD) in the US population (4.3%-17.0%), attributable to indirect exposure through the media. We use data from a national survey conducted in 2004 to 2005 (National Epidemiologic Survey on Alcohol and Related Conditions Wave 2) (n = 34,653). The list of traumatic events covered in the survey included indirect exposure to 9/11 through media coverage. Respondents who endorsed more than 1 traumatic event were asked to single out "the worst event" they had ever experienced. The worst event (or the only event) was the index event for diagnosing PTSD. Indirect experience of 9/11 had the lowest PTSD risk of all the traumatic events in the list, 1.3%. In the subset that endorsed only 9/11 indirect exposure (n = 3981), the PTSD risk was 0.3%. Of the total sample, 0.7% experienced PTSD in relation to indirect 9/11. Explanations for the lower estimates are discussed.

Although anger is an important feature of posttraumatic stress disorder (PTSD) it is unclear whether it is simply concomitant or plays a role in maintaining symptoms. A previous study of disaster workers responding to the terrorist attacks of September 11, 2001 () indicated that those with PTSD evidenced more severe anger than those without. The purpose of this study was to conduct a 1-year follow-up to assess the role of anger in maintaining PTSD. Workers with PTSD continued to report more severe anger than those without; there were statistically significant associations between changes in anger, PTSD severity, depression, and psychiatric distress. Multiple regression analysis indicated initial anger severity to be a significant predictor of PTSD severity at follow-up, which is consistent with the notion that anger maintains PTSD. One implication is that disaster workers with high anger may benefit from early intervention to prevent chronic PTSD.

Secondary traumatization from the tragic events of September 11, 2001 was studied among an ethnically diverse group of refugees who had been previously traumatized in their native war torn countries. A brief clinically oriented questionnaire was developed and administered to a clinic population of Vietnamese, Cambodian, Laotian, Bosnian and Somalian refugees in the Intercultural Psychiatric Program at Oregon Health & Science University. Traumatic symptoms and responses to the widely televised images from September 11 were assessed among the five ethnic groups, and the differential responses among patients with posttraumatic stress disorder (PTSD), depression, and schizophrenia also were assessed. The strongest responses were among Bosnian and Somalian patients with PTSD, and the Somalis had the greatest deterioration in their subjective sense of safety and security. Regardless of ethnic group, PTSD patients reacted most intensely, and patients with schizophrenia the least. Although patients largely returned to their baseline clinical status after two to three months, this study shows that cross-cultural reactivation of trauma has a significant clinical impact. It is essential that clinicians anticipate PTSD symptom reactivation among refugees when they are reexposed to significant traumatic stimuli.

Psychological reactions and functional coping of East Coast and West Coast-based flight attendants were compared after the attacks on September 11. Demographics and standardized questionnaires were sent in June 2002 to approximately 26,000 flight attendants. The 2,050 returned surveys were separated into East Coast-based flight crews (513 from Boston, New York, and Washington, DC) and West Coast-based flight crews (353 from Los Angeles and San Francisco). Despite demographic differences between the flight crews, most notably that the East Coast members were more than twice as likely to know someone who perished in the wake of September 11, there was no difference between them regarding probable PTSD (19.1% and 18.3%, respectively) or life functioning. We suggest that a psychological contagion effect occurred in this at-risk group of workers in the war on terrorism. Public health implications, including multicomponent treatment interventions, are suggested.

The perception of being safe, perceived safety, is an important component of health and the ability to work after exposure to traumatic events of all kinds. The relationship of perceived safety to posttraumatic stress disorder and depression has rarely been examined. This study examined symptoms of posttraumatic stress disorder, depression, and perceived safety in disaster workers 2 weeks after the 9/11 terrorist attacks. Perceived safety was lower in those with greater exposure (e.g., those who felt they were in physical danger, worked with dead bodies, or witnessed someone being killed or seriously injured). Lower perceived safety was associated with greater symptoms of intrusion and hyperarousal but not avoidance. Safety was negatively correlated with depression and peritraumatic dissociation. Lowered perceptions of safety following terrorist events have implications for social and work-related behaviors that can affect long-term health, morale, and productivity in disaster workers and other first responders.

The need for permanent housing for the chronically mentally ill has received a great deal of attention over the last several years. One response to the problem has been the development of supportive housing, that is, non-facility-based permanent homes with placement based on clients' functional capabilities and preferences. However, little research has focused on assessing the match between clients and environmental requirements. This study begins to identify the social and clinical characteristics of clients that contribute to selection into different types of housing environments. Ninety-one clients were sampled from the supportive housing services of a major provider in two New England states. Logistic regression was used to estimate the probability that clients will be placed into apartments vs. other, more restricted settings, based on their clinical and social characteristics. Findings show that the primary determinants of placement were clinical severity, early family history, and adequacy of family support. The less severely ill and better functioning the client, the more likely that he or she was placed in an apartment. This was mitigated, however, by the availability and adequacy of family support. In addition, clients with early family disruptions were also less likely to be placed in apartments. Findings are discussed in light of their implications for providing permanent housing placements for chronically mentally ill persons and for factors in future research to evaluate the success of placement.

The September 11, 2001 (9/11) terrorist attacks led to speculation about the vulnerability of psychiatric patients to psychological distress following such events. This study examined the impact of national terrorist attacks on psychiatric and medical outpatients living approximately 150 to 200 miles from the attack sites (N = 308). Two to 3 weeks following 9/11, patients were given questionnaires assessing background information, healthcare service utilization, and posttraumatic stress disorder (PTSD) symptoms. Psychiatric patients (33%) were significantly more likely than medical patients (13%) to report distressing symptoms meeting criteria for PTSD (except for the duration criterion) despite no differences in learning about the attacks or personal involvement with the victims. Patients meeting PTSD criteria were more likely to schedule an appointment to speak with their physician about their reactions. Psychiatric patients not directly impacted by the 9/11 terrorist attacks are at increased risk for experiencing distressing symptoms following national terrorist attacks.

The range of symptoms experienced by refugees of war has not been empirically assessed. The New Mexico Refugee Symptom Checklist-121 (NMRSCL-121) was developed utilizing established guidelines and evaluated for its psychometric properties. Community-dwelling Kurdish and Vietnamese refugees reported 48 (SD = 31) persistent and bothersome somatic and psychological symptoms on the NMRSCL-121. Internal consistency and test-retest reliability for the total scale and for most subscales were acceptable, and construct and concurrent validity for the NMRSCL-121 data was shown. There were modest ethnic group differences on symptom severity and psychometric properties of NMRSCL-121 subscales. The NMRSCL-121 produces reliable and valid assessments of a wide range of symptoms in 2 broad community samples of displaced adult refugees.

The burden of disease attributable to mental illnesses has major costs and human services implications in the United States. Mexican Americans compose two thirds of the nation's largest and fastest-growing minority group, Latinos. We report 12-month DSM-III-R psychiatric disorder rates among Mexican Americans derived from a population survey of immigrants and US-born adults of Mexican origin conducted in rural and urban areas of central California. Rates of 12-month total mood, anxiety, and substance disorders were 14.2% for immigrant women, 12.6% for immigrant men, 27.8% for US-born women, and 27.2% for US-born men. For immigrants, younger age of entry and longer residence in the United States were associated with increased rates of psychiatric disorders. Three dominant explanations are reviewed to explain these differences: selection, social assimilation and stress, and measurement artifact. Our results and other research studies collectively support a social assimilation explanation based on aversive impact on health behaviors and protective resources such as families. Greater social assimilation increases psychiatric morbidity, with rates for subjects who are US-born of Mexican origin approximately the same as rates for the US general population.

The study of unsolicited psychiatric patients who became ill because of their experience in a natural disaster can assist in the design of future disaster research. A clinical report of 36 such patients illustrates the problems of case detection, the delayed presentation of much of the morbidity, and the need to separate stress-related symptoms which are common in disaster victims from psychiatric illness. Unless these issues are taken into account, estimates of the prevalence of psychiatric disorders after major disasters may be subject to substantial error. The role of vulnerability factors assessed to be operating in these patients suggests that exposure and losses sustained in the disaster alone are inadequate predictors of psychiatric disorder. The risk factors for the development of disaster-related psychiatric morbidity will be more accurately defined if the contribution of a range of constitutional, personality, and social factors as well as the personal impact of the disaster are investigated in future research.

Confusional arousals, or sleep drunkenness, occur upon awakening and remain unstudied in the general population. We selected a representative sample from the United Kingdom, Germany, and Italy (N = 13,057) and conducted telephone interviews. Confusional arousals were reported by 2.9% of the sample: 1% (95% confidence interval: .8 to 1.2%) of the sample also presented with memory deficits (53.9%), disorientation in time and/or space (71%), or slow mentation and speech (54.4%), and 1.9% (1.7% to 2.1%) reported confusional arousals without associated features. Younger subjects (< 35 years) and shift or night workers were at higher risk of reporting confusional arousals. These arousals were strongly associated with the presence of a mental disorder with odds ratios ranging from 2.4 to 13.5. Bipolar and anxiety disorders were the most frequently associated mental disorders. Furthermore, subjects with Obstructive Sleep Apnea Syndrome (OSAS), hypnagogic or hypnopompic hallucinations, violent or injurious behaviors, insomnia, and hypersomnia are more likely to suffer from confusional arousals. Confusional arousals appears to occur quite frequently in the general population, affecting mostly younger subjects regardless of their gender. Physicians should be aware of the frequent associations between confusional arousals, mental disorders, and OSAS. Furthermore, the high occurrence of confusional arousals in shift or night workers may increase the likelihood of inappropriate response by employees sleeping at work.

Forty-nine families from the University of Rochester Child and Family Study were followed up 10 to 14 years after initial assessment. Two inclusion criteria were applied: at least one of the parents had been hospitalized for a functional psychiatric disorder before initial assessment and, second, the male index offspring should be 18 years or older at follow-up. Initial measures included observationally based coding of the family's level of disqualifying communication toward the index offspring, index child's scores on the Child Manifest Anxiety Scale, and ratings of the index child's social competence carried out by peers, teachers, and parents. Offspring outcome was measured by the Mental Health Inventory, Global Assessment Scale (GAS), and hospitalization for psychiatric disorder. The results showed that every measure of offspring outcome was predicted by the amount of disqualification directed to the offspring from the other family members. In addition, GAS score and mental health were predicted by the offspring's competence as a child. Family disqualification, childhood competence, and socioeconomic status accounted for 63% of the variance in adult GAS scores.

This study examines the applications of civil commitment criteria for prolonged (14-day) involuntary hospitalization of individuals judged to be dangerous to others by reason of mental illness. The California Civil Commitment Statute (Lanterman-Petris-Short, LPS) provides for such commitment, after a 72-hour period of observations. For a sample of 71 males on an acute inpatient unit, we examined the relationship between 14-day certification by reason of dangerousness to others (DO) under the LPS and measures of prehospitalization dangerousness, prior legal status, assaultive behavior in hospital, and mental status. The 31 per cent of subjects who were certified as DO were found to have been significantly more often held initially for 72-hour observation on the DO grounds than were patients who were certified for other reasons. However, subjects in the DO group were no different from the contrast groups on ratings of assaultiveness of preadmission behavior and of violent acts while in hospital. The implications of these results for the evaluation of civil commitment proceedings are discussed.

A group of hospitalized psychiatric patients whose (otherwise normal) EEGs showed the 14 and 6 per second positive spike pattern (PSP) was compared with matched normal EEG patients. A group of siblings of psychiatric patients with PSP was similarly compared with matched normal EEG siblings. Comparisons on a variety of measures including pregnancy and birth histories, developmental variables obtained from mothers' reports and school records, psychiatric ratings and psychological tests revealed few significant differences between PSP and normal EEG patients or siblings. The findings were viewed as offering little to indicate a distinctive clinical significance for the PSP pattern, but further study was suggested.

Most meta-analyses have concluded that psychotherapy and pharmacotherapy yield roughly similar efficacy in the short-term treatment of depression, with psychotherapy showing some advantage at long-term follow-up. However, a recent meta-analysis found that selective serotonin reuptake inhibitors medications were superior to psychotherapy in the short-term treatment of depression. To incorporate results of several recent trials into the meta-analytic literature, we conducted a meta-analysis of trials which directly compared psychotherapy to second-generation antidepressants (SGAs). Variables potentially moderating the quality of psychotherapy or medication delivery were also examined, to allow the highest quality comparison of both types of intervention. Bona fide psychotherapies showed equivalent efficacy in the short-term and slightly better efficacy on depression rating scales at follow-up relative to SGA. Non-bona fide therapies had significantly worse short-term outcomes than medication (d = 0.58). No significant differences emerged between treatments in terms of response or remission rates, but non-bona fide therapies had significantly lower rates of study completion than medication (odds ratio = 0.55). Bona fide psychotherapy appears as effective as SGAs in the short-term treatment of depression, and likely somewhat more effective than SGAs in the longer-term management of depressive symptoms.

This is a report of studies of the sexual behavior of the ARL Colony chimpanzees from July, 1966, through August, 1967. The ARL Colony has an innovation designated the DPS Chimpanzee Consortium which permits the containment of social groups of chimpanzees on 30 acres of New Mexico desert. The solicitation, mounting and copulatory behavior of the consortium animals was similar in form to that reported in field studies. However, the incidence of both copulatory and masturbatory behavior was much higher than in the wild. In spite of this overall high incidence of copulatory behavior, three of the five adult males, who were cage-reared and presumably sex-segregated until maturity, were not observed to copulate when they had the opportunity to do so. However, they seemed to show no reduction in sexual drive. Two masturbated frequently and all three practiced perverse sexual acts. Both adolescent and juvenile males were interested in estrous females and actively solicited, mounted and copulated with them frequently. Three of the four adult consortium females tended to avoid copulation. However, this reluctance of adult females to copulate could be overcome by a large aggressive male and all of the adult consortium females became pregnant. It is hypothesized that feral-born but cage-reared, sex-segregated chimpanzees are capable of normal mating behavior if they are given an opportunity to experiment and learn before a critical period occurring during late adolescence and early adulthood. An adult who has passed this critical period is either unable to learn to copulate or to orient adequately toward an estrous female, although the sexual drive is manifested in masturbation and other ways. There was also a higher incidence of nonsexual mounting and presenting by consortium animals of both sexes than has been reported in the wild. The older females frequently "mothered" small juveniles, but most noteworthy was the fact that many male chimpanzees also interacted with small juveniles in a maternal-like manner. Unlike wild females, the consortium females frequently displayed aggressive dominance behavior toward males as well as other females. The consortium females were also the frequent victims of male aggression, which has been rarely noted in the field. Hypotheses to explain these apparent gender role shifts are offered.

In a prior study, we identified factors of psychopathology in the interview, ward behavior and self-report ratings of 124 depressed patients from 9 hospitals. The present study attempts to replicate these findings in a sample of 648 depressed patients from 10 hospitals. The criteria for patient selection and the factor analytic methods employed were identical in both studies. The major factors of psychopathology identified in the first study were replicated in the second study. Further, the loadings of the key items on these factors were highly similar in both studies. However, the factors in the second study encompassed a narrower range of psychopathology than those in the first. As a consequence, more factors were extracted for the same evaluation instruments in the second study. The 12 major categories of psychopathology discernible from these analyses were: 1) depressive mood, 2) feelings of guilt and worthlessness, 3) hostility, 4) anxiety-tension, 5) cognitive loss and subjective uncertainty, 6) interest and involvement in activities, 7) somatic complaints, 8) sleep disturbance, 9) retardation in speech and behavior, 10) bizarre thoughts and behavior, 11) excitement and 12) denial of illness. The break-up of some of the larger, global factors from the first study into smaller and more narrowly defined factors in the second study was a distinct asset in later efforts to discern the differential effects of various antidepressant drugs. The results from both studies also highlighted the advantages of using different rating instruments and sources of information about the patient. First, within a particular category of psycho-pathology, such as hostility, nuances of behavior across rating instruments would have been missed had we sampled only one aspect of patient behavior. Second, some categories of psychopathology, such as depressed mood, emerged as strong factors on certain rating instruments and were either poorly represented or absent on others.

No longer are the high rates of psychiatric morbidity associated with mass violence in refugee populations invisible to the humanitarian assistance community. However, identification of mental health risk and protective factors that can be utilized by policy planners is still lacking. The objective of this report is to provide an analytic approach to determining these factors. A description is provided from the first large-scale epidemiological study of Cambodian refugees confined to the Thailand-Cambodian border in the 1980s and 1990s. The original data from this study are reanalyzed to evaluate the mental health impact of psychosocial factors subject to the influence of camp authorities, such as opportunities in the refugee camp environment and personal behaviors, in addition to trauma. The results suggest the extraordinary capacity of refugees to protect themselves against mental illness despite horrific life experiences. The recommendation emerges for refugee policy makers to create programs that support work, indigenous religious practices, and culture-based altruistic behavior among refugees. As refugee mental health policy receives increasing attention from the international community, it must consist of recommendations and practices based on scientific analysis and empirical evidence.

This paper reports the 16-mth clinical course of 96 ambulatory patients who met the Research Diagnostic Criteria for nonbipolar, nonpsychotic, primary major depressive disorder. In the first 4 mth, the patients participated in a clinical trial comparing the efficacy of short term interpersonal psychotherapy with amitriptyline alone and in combination as treatments of depression. Seventy-two of the patients were re-evaluated 12 mth after they completed study treatment. Over the 16-mth period, none of the patients developed episodes of mania, hypomania, schizophrenia, or any other disorder which would have necessitated reclassification of the initial diagnosis. For most patients, the course of depressive symptoms and social functioning was one of improvement both during the 4-mth study treatment period and during the subsequent 12 mth. However, despite 4 mth of study treatment, 14% of the patients had not experienced a symptomatic recovery. At the follow-up evaluation 12 mth after the study, 12% were still depressed and 14% had, during the poststudy period, experienced a relapse from which they had recovered. Although 3% of the patients had made suicide attempts during the poststudy period, there were no completed suicides. The majority of patients sought additional outpatient psychotherapy, pharmacotherapy, or a combination of both treatments during the 12-mth poststudy period, although the duration of any treatment they received was usually less than 6 mth. During this period also, 7% of the patients were hospitalized. Evaluation of the treatment received by relapsers and chronically depressed patients revealed that most of the patients who relapsed during the poststudy period and sought treatment had recovered. The 9 (13%) patients who were depressed at the 12-mth poststudy evaluation consisted of 5 (7%) who had been inadequately treated during the poststudy period and 4 (6%) treatment resistant depressives who remained symptomatic despite adequate treatment. The findings suggest (a) the stability of the Research Diagnostic Criteria diagnosis of nonbipolar primary major depression; and (b) the need for the continuing availability and accessibility of follow-up psychiatric care for patients who have received brief outpatient interventions as treatment for a major depressive episode.

In the present study the relationship between MMPI variables and adequacy of function in verbal and performance intelligence, concept formation, sensory-perceptual and motor skills was examined in 129 subjects with definite evidence of cerebral lesions. Patients with greater impairment of abilities showed higher elevations on the MMPI variables, suggesting more emotional difficulties. Based on the present results and those of two previous studies by the same authors it was concluded that: a) MMPI variables are more closely related to measures of adequacy of function in adaptive abilities than they are to measures of lesion localization based upon pathoanatomical characteristics of the brain; and b) except for verbal skills the relationship between the MMPI variables and various adaptive skills is relatively minor. Interpretive limitations of the MMPI with brain-damaged patients and the need for devising other tests sensitive to the nuances of emotional difficulties of patients with brain lesions were discussed.