Drinking to ease the burden: a cross-sectional study on trauma, alcohol abuse and psychopathology in a post-conflict context

English version České info

Background:
It is likely that alcohol use and abuse increase during and after violent conflicts. The most prominent explanation of this phenomenon has been referred to as self-medication hypothesis. It predicts that psychotropic substances are consumed to deal with conflict-related psychic strains and trauma. In northern Uganda, a region that has been affected by a devastating civil war and is characterized by high levels of alcohol abuse we examined the associations between war-trauma, childhood maltreatment and problems related to alcohol use. Deducing from the self-medication hypothesis we assumed alcohol consumption moderates the relationship between trauma-exposure and psychopathology.

Methods:
A cross-sectional epidemiological survey targeting war-affected families in post-conflict northern Uganda included data of male (n = 304) and female (n = 365) guardians. We used standardized questionnaires in an interview format to collect data on the guardians’ socio-demography, trauma-exposure, alcohol consumption and symptoms of alcohol abuse, PTSD and depression.

Results:
Symptoms of current alcohol use disorders were present in 46 % of the male and 1 % of the female respondents. A multiple regression model revealed the unique contributions of emotional abuse in the families of origin and trauma experienced outside the family-context in the prediction of men’s alcohol-related symptoms. We found that alcohol consumption moderated the dose-effect relationship between trauma-exposure and symptoms of depression and PTSD. Significant interactions indicated that men who reported more alcohol-related problems experienced less increase in symptoms of PTSD and depression with increasing trauma-exposure.

Conclusions:
The gradual attenuation of the dose-effect the more alcohol-related problems were reported is consistent with the self-medication hypothesis. Hence, the functionality of alcohol consumption has to be considered when designing and implementing addiction treatment in post-conflict contexts.

Keywords:
Trauma, Addiction, Alcohol, Substance abuse, Self-medication, Depression, PTSD, Mental health, Conflict, War

Autoři: Verena Ertl ^1,2,3*; Regina Saile ^1,2; Frank Neuner ^1,2; Claudia Catani ^1,2
Působiště autorů: Clinical Psychology and Psychotherapy, Department of Psychology, Bielefeld University, Universitätsstraße 5, 615 Bielefeld, Germany. ¹; vivo international, Konstanz, Germany. ²; Clinical Psychology and Psychotherapy, Department of Psychology, Bielefeld University, P. O. Box 10013133501 Bielefeld, Germany ³
Vyšlo v časopise: BMC Psychiatry 2016, 16:202
Kategorie: Research Article
prolekare.web.journal.doi_sk: https://doi.org/10.1186/s12888-016-0905-7

© 2016 The Author(s).
Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
The electronic version of this article is the complete one and can be found online at: https://bmcpsychiatry.biomedcentral.com/articles/10.1186/s12888-016-0905-7

Souhrn

Keywords:
Trauma, Addiction, Alcohol, Substance abuse, Self-medication, Depression, PTSD, Mental health, Conflict, War

Zdroje

1. Felitti VJ, Anda RF, Nordenberg D, Williamson DF, Spitz AM, Edwards V, Koss MP, Marks JS. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. Am J Prev Med. 1998;14:245–58.

2. Anda RF, Whitfield CL, Felitti VJ, Chapman D, Edwards VJ, Dube SR, Williamson DF. Adverse childhood experiences, alcoholic parents, and later risk of alcoholism and depression. Psychiatr Serv. 2002;53:1001–9.

3. Teicher MH, Andersen SL, Polcari A, Anderson CM, Navalta CP, Kim DM. The neurobiological consequences of early stress and childhood maltreatment. Neurosci Biobehav Rev. 2003;27:33–44.

4. Teicher MH, Tomoda A, Andersen SE. Neurobiological consequences of early stress and childhood maltreatment: are results from human and animal studies comparable? Ann N Y Acad Sci. 2006;1071:313–23.

5. Neuner F, Schauer E, Catani C, Ruf M, Elbert T. Post-tsunami stress: a study of posttraumatic stress disorder in children living in three severely affected regions in Sri Lanka. J Trauma Stress. 2006;19:339–47.

6. Porter M, Haslam N. Predisplacement and postdisplacement factors associated with mental health of refugees and internally displaced persons: a meta-analysis. JAMA. 2005;294:602–12.

7. Catani C, Schauer E, Neuner F. Beyond individual war trauma: domestic violence against children in Afghanistan and Sri Lanka. J Marital Fam Ther. 2008;34:165–76.

8. Catani C, Jacob N, Schauer E, Kohila M, Neuner F. Family violence, war, and natural disasters: a study of the effect of extreme stress on children’s mental health in Sri Lanka. BMC Psychiatry. 2008;8:33.

9. Mollica RF, McInnes K, Pham T, Smith Fawzi MC, Murphy E, Lin L. The doseeffect relationships between torture and psychiatric symptoms in Vietnamese ex-political detainees and a comparison group. J Nerv Ment Dis. 1998;543–53.

10. Kolassa I-T, Ertl V, Eckart C, Kolassa S, Onyut LP, Elbert T. Spontaneous remission from PTSD depends on the number of traumatic event types experienced. Psychol Trauma Theory, Res Pract Policy. 2010;2:169–74.

11. Neuner F, Schauer M, Karunakara U, Klaschik C, Robert C, Elbert T. Psychological trauma and evidence for enhanced vulnerability for posttraumatic stress disorder through previous trauma among West Nile refugees. BMC Psychiatry. 2004;4:34.

12. Heidelberg Institute for International Conflict Research. Conflict Barometer 2014. Heidelberg: Heidelberg Institute for International Conflict Research; 2015.

13. Human Rights Watch. Uprooted and forgotten, vol. 17. 2005. p. 1–76.

14. Roome E, Raven J, Martineau T. Human resource management in postconflict health systems: review of research and knowledge gaps. Confl Heal. 2014;8:1–12.

15. Saxena S, Thornicroft G, Knapp M, Whiteford H. Resources for mental health: scarcity, inequity, and inefficiency. Lancet. 2007;370:878–89.

16. World Health Organization. mhGAP Intervention Guide - for mental, neurological and substance abuse disorders in non-specialized health settings. Geneva: World Health Organization; 2010.

17. Khantzian EJ. The self medication hypothesis of addictive disorders: focus on heroin and cocaine dependence. Am J Psychiatry. 1985;142:1259–64.

18. Khantzian EJ. The self-medication hypothesis of substance use disorders: a reconsideration and recent applications. Harv Rev Psychiatry. 1997;4:231–44.

19. Boscarino JA, Adams RE, Galea S. Alcohol use in New York after the terrorist attacks: a study of the effects of psychological trauma on drinking behavior. Addict Behav. 2006;31:606–21.

20. Chilcoat HD, Menard C. Epidemiological investigations: comorbidity of posttraumatic stress disorder and substance use disorder. In: Ouimette P, Brown PJ, editors. Trauma and substance abuse: causes, consequences, and treatment of comorbid disorders. Washington, DC: American Psychological Publishing; 2003. p. 9–28.

21. Leeies M, Pagura J, Sareen J, Bolton JM. The use of alcohol and drugs to self-medicate symptoms of posttraumatic stress disorder. Depress Anxiety. 2010;27:731–6.

22. Haller M, Chassin L. Risk pathways among traumatic stress, posttraumatic stress disorder symptoms, and alcohol and drug problems: a test of four hypotheses. Psychol Addict Behav. 2014;28:841–51.

23. Lipschitz DS, Rasmusson AM, Anyan W, Gueorguieva R, Billingslea EM, Cromwell PF, Southwick SM. Posttraumatic stress disorder and substance use in inner-city adolescent girls. J Nerv Ment Dis. 2003;191:714–21.

24. Perkonigg A, Kessler RC, Storz S, Wittchen HU. Traumatic events and post-traumatic stress disorder in the community: prevalence, risk factors and comorbidity. Acta Psychiatr Scand. 2000;101:46–59.

25. Douglas KR, Chan G, Gelernter J, Arias AJ, Anton RF, Weiss RD, Brady K, Poling J, Farrer L, Kranzler HR. Adverse childhood events as risk factors for substance dependence: partial mediation by mood and anxiety disorders. Addict Behav. 2010;35:7–13.

26. Wolitzky-Taylor K, Bobova L, Zinbarg RE, Mineka S, Craske MG. Longitudinal investigation of the impact of anxiety and mood disorders in adolescence on subsequent substance use disorder onset and vice versa. Addict Behav. 2012;37:982–5.

27. Bremner JD, Southwick SM, Darnell A, Charney DS. Chronic PTSD in Vietnam combat veterans: course of illness and substance abuse. Am J Psychiatry. 1996;153:369–75.

28. Ouimette P, Read JP, Wade M, Tirone V. Modeling associations between posttraumatic stress symptoms and substance use. Addict Behav. 2010;35:64–7.

29. Jakupcak M, Tull MT, McDermott MJ, Kaysen D, Hunt S, Simpson T. PTSD symptom clusters in relationship to alcohol misuse among Iraq and Afghanistan war veterans seeking post-deployment VA health care. Addict Behav. 2010;35:840–3.

30. Gradus JL, Street AE, Kelly K, Stafford J. Sexual harassment experiences and harmful alcohol use in a military sample: differences in gender and the mediating role of depression. J Stud Alcohol Drugs. 2008;69:348–51.

31. Ouimette P, Coolhart D, Funderburk JS, Wade M, Brown PJ. Precipitants of first substance use in recently abstinent substance use disorder patients with PTSD. Addict Behav. 2007;32:1719–27.

32. Waldrop AE, Back SE, Verduin ML, Brady KT. Triggers for cocaine and alcohol use in the presence and absence of posttraumatic stress disorder. Addict Behav. 2007;32:634–9.

33. Norman SB, Tate SR, Anderson KG, Brown SA. Do trauma history and PTSD symptoms influence addiction relapse context? Drug Alcohol Depend. 2007;90:89–96.

34. Hodgins DC, El-Guebaly N, Armstrong S, Dufour M. Implications of depression on outcome from alcohol dependence: a 3-year prospective follow-up. Alcohol Clin Exp Res. 1999;23:151–7.

35. Sellman JD, Joyce PR. Does depression predict relapse in the 6 months following treatment for men with alcohol dependence? Aust N Z J Psychiatry. 1996;30:573–8.

36. Cottler LB, Compton WM, Mager D, Spitznagel EL, Janca A. Posttraumatic stress disorder among substance users from the general population. Am J Psychiatry. 1992;149:664–70.

37. Chilcoat HD, Breslau N. Investigations of causal pathways between PTSD and drug use disorders. Addict Behav. 1998;23:827–40.

38. Dickstein BD, Suvak M, Litz BT, Adler AB. Heterogeneity in the course of posttraumatic stress disorder: trajectories of symptomatology. J Trauma Stress. 2010;23:331–9.

39. Olema DK, Catani C, Ertl V, Saile R, Neuner F. The hidden effects of child maltreatment in a war region: correlates of psychopathology in two generations living in northern Uganda. J Trauma Stress. 2014;27:35–41.

40. Potthast N, Neuner F, Catani C. The contribution of emotional maltreatment to alcohol dependence in a treatment-seeking sample. Addict Behav. 2014;39:949–58.

41. Gilbert R, Widom CS, Browne K, Fergusson D, Webb E, Janson S. Burden and consequences of child maltreatment in high-income countries. Lancet. 2009;373:68–81.

42. Tonmyr L, Thornton T, Draca J, Wekerle C. A review of childhood maltreatment and adolescent substance use relationship. Curr Psychiatr Rev. 2010;6:223–34.

43. McLeod DS, Koenen KC, Meyer JM, Lyons MJ, Eisen S, True W, Goldberg J. Genetic and environmental influences on the relationship among combat exposure, posttraumatic stress disorder symptoms, and alcohol use. J Trauma Stress. 2001;14:259–75.

44. Ezard N. Substance use among populations displaced by conflict: a literature review. Disasters. 2012;36:533–57.

45. Weaver H, Roberts B. Drinking and displacement: a systematic review of the influence of forced displacement on harmful alcohol use. Subst Use Misuse. 2010;45:2340–55.

46. Roberts B, Murphy A, Chikovani I, Makhashvili N, Patel V, McKee M. Individual and community level risk-factors for alcohol use disorder among conflict-affected persons in Georgia. PLoS One. 2014;9:e98299.

47. Roberts B, Felix Ocaka K, Browne J, Oyok T, Sondorp E. Alcohol disorder amongst forcibly displaced persons in northern Uganda. Addict Behav. 2011;36:870–3.

48. Maguen S, Vogt DS, King LA, King DW, Litz BT, Knight SJ, Marmar CR. The impact of killing on mental health symptoms in Gulf War veterans. Psychol Trauma Theory, Res Pract Policy. 2011;3:21–6.

49. Maguen S, Lucenko B. The impact of reported direct and indirect killing on mental health symptoms in Iraq war veterans. J Trauma Stress. 2010;23:86–90.

50. Saile R, Ertl V, Neuner F, Catani C. Does war contribute to family violence against children? Findings from a two-generational multi-informant study in northern Uganda. Child Abuse Negl. 2014;38:135–46.

51. Saile R, Ertl V, Neuner F, Catani C. Children of the postwar years: a twogenerational multilevel risk assessment of child psychopathology in northern Uganda. Dev Psychopathol. 2015;27:1–4.

52. Flaherty JA, Gaviria FM, Pathak D, Mitchell T, Wintrob R, Richman JA, Birz S. Developing instruments for cross-cultural psychiatric research. J Nerv Ment Dis. 1988;176:257–63.

53. van Ommeren M, Sharma B, Thapa S, Makaju R, Prasain D, Bhattarai R, de Jong J. Preparing instruments for transcultural research: use of the translation monitoring form with Nepali-speaking Bhutanese refugees. Transcult Psychiatry. 1999;36:285–301.

54. Bremner JD, Vermetten E, Mazure CM. Development and preliminary psychometric properties of an instrument for the measurement of childhood trauma: the early trauma inventory. Depress Anxiety. 2000;12:1–12.

55. Bernstein DP, Fink L, Handelsman L, Foote J, Lovejoy M, Wenzel K, Sapareto E, Ruggiero J. Initial reliability and validity of a new retrospective measure of child-abuse and neglect. Am J Psychiatry. 1994;151:1132–6.

56. Catani C, Schauer E, Elbert T, Missmahl I, Bette JP, Neuner F. War trauma, child labor, and family violence: life adversities and PTSD in a sample of school children in Kabul. J Trauma Stress. 2009;22:163–71.

57. Ertl V, Pfeiffer A, Saile R, Schauer E, Elbert T, Neuner F. Validation of a mental health assessment in an African conflict population. Psychol Assess. 2010;22:318–24.

58. Ertl V, Pfeiffer A, Schauer-Kaiser E, Elbert T, Neuner F. The challenge of living on: psychopathology and its mediating influence on the readjustment of former child soldiers. PLoS One. 2014;9:e102786.

59. Blake DD, Weathers FW, Nagy LM, Kaloupek DG, Klauminzer G, Charney DS, Keane TM. A clinician rating scale for assessing current and lifetime PTSD: The CAPS-1. Behav Ther. 1990;13:187–8.

60. Babor T, Higgins-Biddle J, Saunders J, Monteiro M. AUDIT the alcohol use disorders identification test - guidelines for use in primary care. 2nd ed. Geneva: World Health Organization; 2001.

61. Saunders JB, Aasland OG, Babor TF, de la Fuente JR, Grant M. Development of the Alcohol Use Disorders Identification Test (AUDIT): WHO collaborative project on early detection of persons with harmful alcohol consumption–II. Addiction. 1993;88:791–804.

62. Saunders JB, Aasland OG, Amundsen A, Grant M. Alcohol consumption and related problems among primary health care patients: WHO collaborative project on early detection of persons with harmful alcohol consumption–I. Addiction. 1993;88:349–62.

63. Allen JP, Litten RZ, Fertig JB, Babor T. A review of research on the Alcohol Use Disorders Identification Test (AUDIT). Alcohol Clin Exp Res. 1997;21:613–9.

64. Foa E. Posttraumatic Diagnostic Scale Manual. National Computer Systems: Minneapolis; 1995.

65. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. Washingtion DC: American Psychiatric Association; 1994.

66. Derogatis LR, Lipman RS, Rickels K, Uhlenhuth EH, Covi L. The Hopkins

Symptom Checklist (HSCL): a self-report symptom inventory. Behav Sci. 1974;19:1–15.

67. Bolton P, Neugebauer R, Ndogoni L. Prevalence of depression in rural Rwanda based on symptom and functional criteria. J Nerv Ment Dis. 2002;190:631–7.

68. Onyut LP, Neuner F, Ertl V, Schauer E, Odenwald M, Elbert T. Trauma, poverty and mental health among Somali and Rwandese refugees living in an African refugee settlement - an epidemiological study. Confl Heal. 2009;3:6.

69. Roberts B, Ocaka KF, Browne J, Oyok T, Sondorp E. Factors associated with post-traumatic stress disorder and depression amongst internally displaced persons in northern Uganda. BMC Psychiatry. 2008;8:38.

70. Saile R, Neuner F, Ertl V, Catani C. Prevalence and predictors of partner violence against women in the aftermath of war: a survey among couples in Northern Uganda. Soc Sci Med. 2013;86:17–25.

71. JMP^®, Version 10.0. SAS Institute Inc., Cary, NC, 1989-2007. http://www.jmp.com/support/notes/35/282.html.

72. World Health Organisation. Global Status Report on Alcohol and Health 2014. Geneva: WHO Press; 2014.

73. Mugisha J, Muyinda H, Malamba S, Kinyanda E. Major depressive disorder seven years after the conflict in northern Uganda: burden, risk factors and impact on outcomes (The Wayo-Nero Study). BMC Psychiatry. 2015;15:48.

74. Widom CS, DuMont K, Czaja SJ. A prospective investigation of major depressive disorder and comorbidity in abused and neglected children grown up. Arch Gen Psychiatry. 2007;64:49–56.

75. Edwards VJ, Holden GW, Felitti VJ, Anda RF. Relationship between multiple forms of childhood maltreatment and adult mental health in community respondents: results from the adverse childhood experiences study. Am J Psychiatry. 2003;160:1453–60.

76. Norman RE, Byambaa M, De R, Butchart A, Scott J, Vos T. The long-term health consequences of child physical abuse, emotional abuse, and neglect: a systematic review and meta-analysis. PLoS Med. 2012;9:e1001349.

77. Carr CP, Martins CMS, Stingel AM, Lemgruber VB, Juruena MF. The role of early life stress in adult psychiatric disorders: a systematic review according to childhood trauma subtypes. J Nerv Ment Dis. 2013;201:1007–20.

78. Vaughn MG, Salas-Wright CP, Huang J, Qian Z. Terzis LD. Adverse Childhood Experiences Among Immigrants to the United States. J Interpers Violence: Helton JJ; 2015.

79. Moore SE, Scott JG, Ferrari AJ, Mills R, Dunne MP, Erskine HE, Devries KM, Degenhardt L, Vos T, Whiteford HA, McCarthy M, Norman RE. Burden attributable to child maltreatment in Australia. Child Abuse Negl. 2015;48:208–20.

80. Widom CS, Horan J, Brzustowicz L. Childhood maltreatment predicts allostatic load in adulthood. Child Abuse Negl. 2015;47:59–69.

81. Miller AB, Esposito-Smythers C, Weismoore JT, Renshaw KD. The relation between child maltreatment and adolescent suicidal behavior: a systematic review and critical examination of the literature. Clin Child Fam Psychol Rev. 2013;16(2):146–72.

82. Haj-Yahia MM, Abdo-Kaloti R. The rates and correlates of the exposure of Palestinian adolescents to family violence: toward an integrative-holistic approach. Child Abus Negl. 2003;27:781–806.

83. Sriskandarajah V, Neuner F, Catani C. Predictors of violence against children in Tamil families in northern Sri Lanka. Soc Sci Med. 2015;146:257–65.

84. Ouimette PC, Finney JW, Moos RH. Two-year posttreatment functioning and coping of substance abuse patients with posttraumatic stress disorder. Psychol Addict Behav. 1999;13:105–14.

85. Brown PJ, Stout RL, Mueller T. Substance use disorder and posttraumatic stress disorder comorbidity: addiction and psychiatric treatment rates. Psychol Addict Behav. 1999;13:115–22.

86. Driessen M, Schulte S, Luedecke C, Schaefer I, Sutmann F, Ohlmeier M, Kemper U, Koesters G, Chodzinski C, Schneider U, Broese T, Dette C, Havemann-Reinicke U, Reis O, Sylvester EH, Hoppe M, Stuppe M, Pletke C. Trauma and PTSD in patients with alcohol, drug, or dual dependence: a multi-center study. Alcohol Clin Exp Res. 2008;32:481–8.

87. Palmer JA, Palmer LK, Williamson D. Childhood abuse as a factor in attrition from drug rehabilitation. Psychol Rep. 1995;76:879–82.

88. Odenwald M, Semrau P. Dropout among patients in qualified alcohol detoxification treatment: the effect of treatment motivation is moderated by Trauma Load. Subst Abuse Treat Prev Policy. 2013;8:14.

89. Kozarić-Kovacić D, Ljubin T, Grappe M. Comorbidity of posttraumatic stress disorder and alcohol dependence in displaced persons. Croat Med J. 2000;41:173–8.

90. McFall ME, Mackay PW, Donovan DM. Combat-related posttraumatic stress disorder and severity of substance abuse in Vietnam veterans. J Stud Alcohol. 1992;53:357–63.

91. Saladin ME, Brady KT, Dansky BS, Kilpatrick DG. Understanding comorbidity between PTSD and substance use disorders: two preliminary investigations. Addict Behav. 1995;20:643–55.

92. Ertl V, Preusse M, Saile R, Neuner F, Catani C. Treating alcohol-related disorders in post-conflict Uganda: Evaluation of the status quo. Vilnius: Paper presented at the ESTSS Conference – Trauma in Changing Societies; 2015.

93. Stewart SH, Conrod PJ. Psychosocial models of functional associations between posttraumatic stress disorder and substance use disorder. In: Ouimette P, Brown PJ, editors. Trauma and substance abuse: causes, consequences, and treatment of comorbid disorders. Washington, DC: American Psychological Publishing; 2003. p. 29–55.

94. Dolan CG. Understanding war and its continuation: the case of Northern Uganda. London: University of London; 2005.

95. Colder CR. Life stress, physiological and subjective indexes of negative emotionality, and coping reasons for drinking: is there evidence for a selfmedication model of alcohol use? Psychol Addict Behav. 2001;15:237–45.

96. Hahn JA, Bwana MB, Javors MA, Martin JN, Emenyonu NI, Bangsberg DR. Biomarker testing to estimate under-reported heavy alcohol consumption by persons with HIV initiating ART in Uganda. AIDS Behav. 2010;14:1265–8.

97. Vinck P, Pham PN, Stover E, Weinstein HM. Exposure to war crimes and implications for peace building in northern Uganda. JAMA. 2007;298:543–54.

98. Fulu E, Jewkes R, Roselli T, Garcia-Moreno C. Prevalence of and factors associated with male perpetration of intimate partner violence: findings from the UN multi-country cross-sectional study on men and violence in Asia and the Pacific. Lancet Glob Heal. 2013;1:e187–207.

99. Gage AJ. Women’s experience of intimate partner violence in Haiti. Soc Sci Med. 2005;61:343–64.

100. Jewkes R, Levin J, Penn-Kekana L. Risk factors for domestic violence: findings from a South African cross-sectional study. Soc Sci Med. 2002;55:1603–17.

101. Koenig MA, Lutalo T, Zhao F, Nalugoda F, Wabwire-Mangen F, Kiwanuka N, Wagman J, Serwadda D, Wawer M, Gray R. Domestic violence in rural Uganda: evidence from a community-based study. Bull World Health Organ. 2003;81:53–60.

102. Abramsky T, Devries K, Kiss L, Francisco L, Nakuti J, Musuya T, Kyegombe N, Starmann E, Kaye D, Michau L, Watts C. A community mobilisation intervention to prevent violence against women and reduce HIV/AIDS risk in Kampala, Uganda (the SASA! Study): study protocol for a cluster randomised controlled trial. Trials. 2012;13:96.

103. Obot IS, Room R. Alcohol, gender and drinking problems: perspectives from low and middle income countries. Geneva: WHO Press; 2005.

104. Silove D, Manicavasagar V, Mollica R, Thai M, Khiek D, Lavelle J, Tor S. Screening for depression and PTSD in a Cambodian population unaffected by war: comparing the Hopkins Symptom Checklist and Harvard Trauma Questionnaire with the structured clinical interview. J Nerv Ment Dis. 2007;195:152–7.