This proposal is for a cross-sectional study of Bosnian refugee survivors of torture in primary care medical settings in the United States. The project involves identifying 413 Bosnian refugees with post-traumatic stress disorder (PTSD), depression, or neither, using a two stage screening and interview process. All persons who screen positive for PTSD or depression, and a random sample of those who screen negative, will be selected for an in-depth interview. The interview will include the Diagnostic Interview Schedule for DSM-IV and sections pertaining to: 1) exposure to torture 2) functional status 3) somatic symptoms and 4) health and mental health care utilization. Important covariates, including refugee stressors and resilience factors will also be measured. Techniques for maximizing cross-cultural validity, including translation and back-translation, will be used. The overarching aim of this proposal is to understand the relation between the psychological effects of torture and help-seeking behaviors among refugee survivors of torture in the United States. The first specific aim is to identify the prevalence of PTSD, depression, and somatic symptoms among survivors of torture in primary care and their association with exposure factors, including characteristics of the experience of torture. The second specific aim is to understand formal and informal help seeking and utilization of services by survivors of torture, and the factors that affect them. The third specific aim is to produce a well described sample of primary care help-seeking refugee survivors of torture that can be compared, in future studies, to survivors of torture in the community who do not seek help, and that can be followed longitudinally to determine long-term outcome. Although most of the existing research on torture has been conducted in referral settings, most refugee survivors of torture are seen in primary care. However, the type of presenting symptoms, functional impairment, course and response to treatment may be different in these settings. Further, primary care may be the optimal point of contact for identifying psychiatric morbidity and addressing it in the context of an ongoing relationship with a health care professional. An adequate response to mental health problems among refugee survivors of torture requires an understanding of their clinical epidemiology in primary medical care and an appreciation of related health services issues. The proposed research will provide information that will be vital in designing services that are appropriate to the needs and service orientations of Bosnian refugee survivors of torture.
