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Among the controversies about existing formulations of PTSD are concerns about its overuse in populations exposed to natural or man-made disasters.7,8 One problem has been the application of the diagnosis when populations are still being actively exposed to extreme stressors--eg, continuing conflict, uprooting to unsafe locations, or earthquake aftershocks--which makes differentiation between PTSD, adaptive fear reactions, and grief difficult, especially when the definition of PTSD includes non-specific symptoms. [...]there is a concern that an overemphasis on PTSD could contribute to clinicians failing to recognise other commonly occurring mental disorders, especially depression.11 Nonetheless, the appropriate use of a clearly defined PTSD category is one aspect of progress in evidence-based mental health care in humanitarian settings.12 The Working Group has recommended a refocus on the diagnosis of PTSD on three core elements, and removal of non-specific symptoms that are also part of other disorders.13,14 The proposed diagnostic guidelines need re-experiencing of the traumatic event, in which the event is not only remembered but experienced as occurring again; avoidance of reminders likely to produce re-experiencing of the traumatic event(s); and a perception of heightened current threat, as indicated by various forms of arousal.15 These elements must have developed after exposure to an event of an extremely threatening or horrific nature, but the diagnosis is mainly based on symptom presentation rather than on determination of whether or not the event constitutes an eligible traumatic stressor. According to the DSM-5 proposal, PTSD is operationalised by 20 symptoms grouped into four clusters, yielding more than 10 000 combinations of symptoms by which a person can meet the minimum criteria for PTSD.

The crisis in Syria has resulted in vast numbers of refugees seeking asylum in Syria's neighbouring countries as well as in Europe. Refugees are at considerable risk of developing common mental disorders, including depression, anxiety, and posttraumatic stress disorder (PTSD). Most refugees do not have access to mental health services for these problems because of multiple barriers in national and refugee specific health systems, including limited availability of mental health professionals. To counter some of challenges arising from limited mental health system capacity the World Health Organization (WHO) has developed a range of scalable psychological interventions aimed at reducing psychological distress and improving functioning in people living in communities affected by adversity. These interventions, including Problem Management Plus (PM+) and its variants, are intended to be delivered through individual or group face-to-face or smartphone formats by lay, non-professional people who have not received specialized mental health training, We provide an evidence-based rationale for the use of the scalable PM+ oriented programmes being adapted for Syrian refugees and provide information on the newly launched STRENGTHS programme for adapting, testing and scaling up of PM+ in various modalities in both neighbouring and European countries hosting Syrian refugees.

Wietse Tol and colleagues discuss some of the key challenges for implementation of new WHO guidelines for stress-related mental health disorders in low- and middle-income countries. Please see later in the article for the Editors' Summary.

Armed conflicts continue to wreak havoc on children and families around the world with profound effects. In 2017, 420 million children—nearly one in five—were living in conflict-affected areas, an increase in 30 million from the previous year. The recent surge in war-induced migration, referred to as a \"global refugee crisis\" has made migration a highly politicized issue, with refugee populations and host countries facing unique challenges. We know from research related to asylum seeking families that it is vital to think about children and families in relation to what it means to stay together, what it means for parents to be separated from their children, and the kinds of everyday tensions that emerge in living in dangerous, insecure, and precarious circumstances. In Global Child, the authors draw on what they have learned through their collaborative undertakings, and highlight the unique features of participatory, arts-based, and socio-ecological approaches to studying war-affected children and families, demonstrating the collective strength as well as the limitations and ethical implications of such research. Building on work across the Global South and the Global North, this book aims to deepen an understanding of their tri-pillared approach, and the potential of this methodology for contributing to improved practices in working with war-affected children and their families.

BackgroundIn the aftermath of the devastating 2015 earthquakes in Nepal, three non-governmental organizations collaborated to develop a program responding to the immediate mental health and psychosocial support (MHPSS) needs in three severely affected districts: Dhading, Gorkha, and Sindhuli. The program was implemented between April 2015 and February 2017 and aimed to (i) strengthen health worker capacity to provide integrated MHPSS services; and (ii) increase access to mental health services. This paper describes the program's implementation and the results of a pragmatic evaluation of the program's overall reach, effectiveness, and lessons learned.MethodsThe mixed-methods evaluation used routine program data, quantitative data from pre- and post-tests conducted with trainees and service users, and qualitative data from stakeholder interviews and focus group discussions.ResultsA total of 1041 health workers received MHPSS training and supervision. Participants demonstrated significant improvements in skills, knowledge, and self-rated perceived competency. Trainees went on to provide MHPSS services to 3422 people. The most commonly identified presenting problems were epilepsy (29%) and depression (26%). A total of 67% of service users reported being ‘completely satisfied’ with the services received and 83% of those experiencing severe functional impairments on enrollment demonstrated improvement after receiving services.ConclusionsDespite operational challenges, the program successfully engaged both laypeople and health workers to provide MHPSS in the aftermath of the crisis. Lessons learned can inform the planning and implementation of future training and integration programs to provide large-scale MHPSS efforts in humanitarian settings.

The Ebola virus disease (EVD) epidemic killed almost 12,000 people across Sierra Leone, Liberia and Guinea, causing significant psychological distress and suffering. This paper describes International Medical Corps’ innovative and comprehensive model for integrating mental health and psychosocial support (MHPSS) considerations and activities into Ebola treatment units (ETUs) across Sierra Leone and Liberia. This includes staff capacity building as well as psychosocial considerations and activities to address needs and challenges at the ETUs. This model was aimed at reducing patient and family distress and promoting healthy behaviours and recovery. We also include data describing mental health-related symptoms reported by our ETU patients, as well as psychosocial support interventions utilised. We discuss recommendations and lessons learnt and conclude that in line with global guidelines, MHPSS considerations and activities should be integral to all aspects of EVD care. Key implications for practicePatients admitted to ETUs face several stressors and challenges related to the ETU environment and procedures, separation from families and effects of EVDMental health and psychosocial support considerations should be an integral part of all aspects of care provided at the ETUParaprofessional psychosocial support workers can play a key role in meeting patient needs at the ETU in line with global mental health and psychosocial support guidelines.

Background Several recent reviews have evaluated evidence on the efficacy of Mindfulness-Based Stress Reduction (MBSR) among fibromyalgia sufferers, and concluded that more research should test effects on both psychological and physiological functioning. Purpose We conducted a randomized prospective trial of MBSR among female fibromyalgia patients. Methods Effects on perceived stress, pain, sleep quality, fatigue, symptom severity, and salivary cortisol were tested in treatment ( n  = 51) versus wait-list control participants ( n  = 40) using data at baseline, post-program, and 2-month follow-up. Results Analyses revealed that MBSR significantly reduced perceived stress, sleep disturbance, and symptom severity, with gains maintained at follow-up. Greater home practice at follow-up was associated with reduced symptom severity. MBSR did not significantly alter pain, physical functioning, or cortisol profiles. Conclusion MBSR ameliorated some of the major symptoms of fibromyalgia and reduced subjective illness burden. Further exploration of MBSR effects on physiological stress responses is warranted. These results support use of MBSR as a complementary treatment for women with fibromyalgia (ISRCTN: 34628811).

[...] his statement that \"Japan's health system is ill prepared to address long-term mental health problems triggered by the disaster\" does not accurately reflect the situation. [...] we were concerned about the inclusion of comments from Stephen McDonald of Save the Children on the fear expressed by a child he had interviewed, and the assertion that lack of counselling in the early phase can lead to subsequent mental and behavioural problems.

Objectives Fibromyalgia, a chronic pain syndrome, is often accompanied by psychological distress and increased basal sympathetic tone. In a previous report it was shown that mindfulness-based stress-reduction (MBSR) reduced depressive symptoms in patients with fibromyalgia with gains maintained at two months follow-up (Sephton et al., Arthr Rheum 57:77–85, 2007). This second study explores the effects of MBSR on basal sympathetic (SNS) activation among women with fibromyalgia. Methods Participants ( n  = 24) responded to a television news appearance, newspaper, and radio advertisements. Effects on anxiety, depressive symptoms, and SNS activation measures were tested before and after MBSR using a within-subjects design. Results The MBSR treatment significantly reduced basal electrodermal (skin conductance level; SCL) activity ( t  = 3.298, p  = .005) and SCL activity during meditation ( t  = 4.389, p  = .001), consistent with reduced SNS activation. Conclusions In this small sample, basal SNS activity was reduced following MBSR treatment. Future studies should assess how MBSR may help reduce negative psychological symptoms and attenuate SNS activation in fibromyalgia. Further clarification of psychological and physiological responses associated with fibromyalgia may lead to more beneficial treatment.

Though cumulative emotional and physical effects of disasters may diminish evacuees’ short and long-term mental and physical health, social factors may buffer such consequences. We approached survivors of the October 2007 San Diego, California firestorms. We gathered data during the evacuation and 3 months afterward. Questionnaires measured social support as well as PTSD, depression, and anxiety symptoms. Saliva samples were used to assess the stress hormone, cortisol. Analyses, adjusting for age, gender, and socioeconomic status, showed PTSD symptoms were associated with flattening of the diurnal cortisol rhythm during evacuation. Secondary analyses showed those reporting a family emphasis on moral and religious values had lower psychological distress. Though anxiety symptoms had significantly decreased in the overall sample at follow-up, blunted cortisol rhythms persisted among those individuals with continued high anxiety. Results highlight a possible psychological, and perhaps a physiological, benefit of social and existential factors in disaster situations. Future work should explore the role of psychosocial factors and stress physiology in the development of long-term health concerns among individuals exposed to disaster.