Letters

Health needs of asylum seekers and refugees

Specific treatments are effective in cases of post-traumatic stress disorder

Head injury needs to be taken into consideration in survivors of torture

Specific treatments are effective in cases of post-traumatic stress disorder

EDITORBurnett and Peel described the social and family background regarding asylum seekers and refugees in Britain. ^{1 2} Unfortunately their articles make many confusing generalisations and have several inaccuracies regarding mental health.

Burnett and Peel say that the most therapeutic event for a child can be to become part of the local school community.² Everybody would agree that schools can promote children's psychological development, but it is important to bear in mind the higher rate of psychiatric disorder in refugee children than in their peers. Even among refugee children who had largely not been exposed to war the rate of psychiatric disorder was found to be almost twice as high as among peers of the same age.³ It is likely to be even higher among those who have been exposed to war and experienced recent flight and settlement. Our experience of work in inner London schools is that many refugee children are impaired with a range psychological problems and disorders, and benefit from mental health intervention.⁴

Burnett and Peel are inappropriately negative about diagnosing post-traumatic stress disorder, claiming that the disorder is hard to diagnose in people from diverse cultures, and that recovery is intrinsically linked to the reconstruction of social networks. This disorder has been shown in numerous studies to be remarkably similar across cultures. Investigation of children who had survived years in Cambodia in the concentration camps set up by the country's former ruler Pol Pot, but who had settled in the United States, showed the longstanding nature of post-traumatic stress disorder.⁵ When first assessed in adolescence, 50% had post-traumatic stress disorder and 48% had depressive disorder. When reassessed 12 years later, 35% had post-traumatic stress disorder and 14% had depression. Whereas the post-traumatic stress disorder is relatively persistent, the depression has diminished significantly, in association with settlement and development of social ties. These data showing the different course of the disorders also support the validity of the diagnostic categories. Exposure to single incident stressors may also result in surprisingly persistent post-traumatic stress disorder.

In practical terms, the reasons for making a psychiatric diagnosislike a diagnosis in any branch of medicineinclude the selection of appropriate treatments. Many randomised controlled trials have shown that specific psychological treatments such as cognitive and behavioural approaches using exposure are effective for post-traumatic stress disorder.⁶ These treatments may complement general supportive measures with refugee families and communities.

Matthew Hodes, senior lecturer in child and adolescent psychiatry. 
Imperial College School of Medicine, St Mary's Campus, London W2 1PG m.hodes{at}ic.ac.uk

Head injury needs to be taken into consideration in survivors of torture

EDITORBurnett and Peel raise important issues about the physical and psychological problems of survivors of torture. ^{1 2} We would like to add a further observation we have notedthat frontal lobe syndromes need to be sought in such patients.

Tortured patients may be referred to neurological outpatients with multiple symptoms, often presented in a chaotic fashion. Such patients' symptoms may easily be wrongly ascribed to psychological factors when they are due to cognitive difficulties secondary to head injury. Many have received repeated forceful blows to the head but do not recount this unless directly asked. Screening neurological examination may show only subtle changes. "Bedside" cognitive testing can, however, show profound frontal deficits.³

Patients we have seen include several who complained of minor symptoms such as daily headache or mechanical back pain. On attempting to take a history they were uncooperative with the medical interview to the point of inappropriateness; general examination gave normal results, but cognitive examination showed distractibility, perseveration, motor programming deficits, and concrete thinking.

As patients with frontal syndromes may show apathy, aggression, inappropriate social behaviour, and impulsivity they may be perceived as irascible and difficult rather than as brain damaged. Such patients need to be identified and referred for appropriate treatment as there is evidence for the efficacy of neurorehabilitation even late after head injury, especially for cognitive training.⁴

B K MacDonald, specialist registrar in neurology. 
King's College Hospital bridget{at}macdachy.freeserve.co.uk

C J Mummery, specialist registrar in neurology. 
King's College Hospital

D Heaney, clinical research fellow. 
Institute of Psychiatry, Academic Neuroscience Centre, King's College Hospital, London SE5 9RS