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Objective: Providing country-level estimates for prevalence rates of Generalized Anxiety Disorder (GAD), COVID-19 exposure and food insecurity (FI) and assessing the role of persistent threats to survival—exemplified by exposure to COVID-19 and FI—for the mental health crisis in Africa.Methods: Original phone-based survey data from Mozambique, Sierra Leone, Tanzania and Uganda (12 consecutive cross-sections in 2021; n = 23,943) were analyzed to estimate prevalence rates of GAD. Logistic regression models and mediation analysis using structural equation models identify risk and protective factors.Results: The overall prevalence of GAD in 2021 was 23.3%; 40.2% in Mozambique, 17.0% in Sierra Leone, 18.0% in Tanzania, and 19.1% in Uganda. Both COVID-19 exposure (ORadj. 1.4; CI 1.3–1.6) and FI (ORadj 3.2; CI 2.7–3.8) are independent and significant predictors of GAD. Thus, the impact of FI on GAD was considerably stronger than that of COVID-19 exposure.Conclusion: Persistent threats to survival play a substantial role for mental health, specifically GAD. High anxiety prevalence in the population requires programs to reduce violence and enhance social support. Even during a pandemic, addressing FI as a key driver of GAD should be prioritized by policymakers.

Abstract The aftermath of traumatization lives on in the neural and epigenetic traces creating a momentum of affliction in the psychological and social realm. Can psychotherapy reorganise these memories through changes in DNA methylation signatures? Using a randomised controlled parallel group design, we examined methylome-wide changes in saliva samples of 84 female former child soldiers from Eastern DR Congo before and six months after Narrative Exposure Therapy. Treatment predicted differentially methylated positions (DMPs) related to ALCAM, RIPOR2, AFAP1 and MOCOS. In addition, treatment associations overlapped at gene level with baseline clinical and social outcomes. Treatment related DMPs are involved in memory formation—the key agent in trauma focused treatments—and enriched for molecular pathways commonly affected by trauma related disorders. Results were partially replicated in an independent sample of 53 female former child soldiers from Northern Uganda. Our results suggest a molecular impact of psychological treatment in women with war-related childhood trauma. Trial registration: Addressing Heightened Levels of Aggression in Traumatized Offenders With Psychotherapeutic Means (ClinicalTrials.gov Identifier: NCT02992561, 14/12/2016).

Abstract Background One in three individuals who live in Rio de Janeiro experience a traumatic event within a period of 12 months. In the favelas particularly, trauma exposure is ongoing. Psychological sequalae include posttraumatic stress disorder (PTSD), depression and other mental disorders. Trauma-focused therapy approaches have emerged as the treatment of choice when the dangerous events are over, but symptoms have remained for an extended time period. Ideally, the victim is in a safe context during treatment. However, frequently, survivors cannot escape from situations characterised by ongoing threat and traumatic stress. The aim of this study is to research the effectiveness of Narrative Exposure Therapy in a sample of PTSD patients living under these conditions. Methods Individuals fulfilling the criteria for PTSD and who live in conditions of ongoing community violence (i.e. in the favelas) in Rio de Janeiro will be randomly assigned to one of two treatments: Narrative Exposure Therapy (NET) or treatment as usual (TAU). Clinical endpoints will be primarily PTSD and secondarily symptoms of shutdown dissociation, depression, substance involvement and functionality. Discussion Effective treatment for PTSD patients who live in unsafe conditions could substantially reduce suffering of individuals and their families in Brazil. Based on this result, the extent to which such interventions may be useful as a first step in tackling the consequences of violence on a global scale will be discussed. Trial registration Deutsches Register Klinischer Studien (German Clinical Trials Register) DRKS00017843 . Registered on September 24, 2019

Background Interpersonal violence damages mental health and frequently leads to aggressive defence strategies. If survivors are subsequently blamed for the events, both consequences worsen. Stigma flourishes, especially when survivors are silenced so that details of the trauma remain unknown. Breaking the secrecy both at the individual and collective level is key to enable the healing and reconciliation of individuals and communities living under continuous threat. Method The NETfacts health system is a stepped care model with three components: (1) Narrative Exposure Therapy (NET), an evidence-based trauma therapy that includes survivor testimony (2) NET for Forensic Offender Rehabilitation (FORNET) acknowledges that perpetrators are frequently also victims and assists in reducing aggression and the attraction to violence, and (3) a community intervention disseminating and discussing Facts derived from NET treatment (NETfacts) to challenge the collective avoidance of atrocities and other traumatic material. The intervention was piloted in a community with 497 adult residents in Eastern Democratic Republic of Congo. The willingness of clients to consent to sharing their anonymised testimonies (with a focus on sexual violence survivors and ex-combatants) was investigated, together with other components of feasibility including security and clinical safety, extent of support of respected local authorities and participation rates. As secondary outcomes, clinical and social measures were assessed before and post NETfacts among 200 village residents of whom 160 self-enrolled and 40 had not participated in any form of treatment. Results Implementation was feasible with 248 clients from a partner project giving consent to use their testimonies and high support of respected local authorities and participation rates (56% of residents self-enrolled in NETfacts). Immediate beneficial effects were shown for posttraumatic stress and rejection of rape myths among NETfacts participants who experienced multiple traumatic events in their own past. Attitudes towards ex-combatants improved and the perceived lack of social acknowledgement after trauma increased independent from participation. No significant change was observed for depressive symptoms. Conclusion NETfacts is a feasible and promising approach to challenge the culture of secrecy surrounding trauma, suppression and social exclusion. Long term effectiveness requires further evaluation.

BackgroundInterpersonal violence damages mental health and frequently leads to aggressive defence strategies. If survivors are subsequently blamed for the events, both consequences worsen. Stigma flourishes, especially when survivors are silenced so that details of the trauma remain unknown. Breaking the secrecy both at the individual and collective level is key to enable the healing and reconciliation of individuals and communities living under continuous threat.MethodThe NETfacts health system is a stepped care model with three components: (1) Narrative Exposure Therapy (NET), an evidence-based trauma therapy that includes survivor testimony (2) NET for Forensic Offender Rehabilitation (FORNET) acknowledges that perpetrators are frequently also victims and assists in reducing aggression and the attraction to violence, and (3) a community intervention disseminating and discussing Facts derived from NET treatment (NETfacts) to challenge the collective avoidance of atrocities and other traumatic material. The intervention was piloted in a community with 497 adult residents in Eastern Democratic Republic of Congo. The willingness of clients to consent to sharing their anonymised testimonies (with a focus on sexual violence survivors and ex-combatants) was investigated, together with other components of feasibility including security and clinical safety, extent of support of respected local authorities and participation rates. As secondary outcomes, clinical and social measures were assessed before and post NETfacts among 200 village residents of whom 160 self-enrolled and 40 had not participated in any form of treatment.ResultsImplementation was feasible with 248 clients from a partner project giving consent to use their testimonies and high support of respected local authorities and participation rates (56% of residents self-enrolled in NETfacts). Immediate beneficial effects were shown for posttraumatic stress and rejection of rape myths among NETfacts participants who experienced multiple traumatic events in their own past. Attitudes towards ex-combatants improved and the perceived lack of social acknowledgement after trauma increased independent from participation. No significant change was observed for depressive symptoms.ConclusionNETfacts is a feasible and promising approach to challenge the culture of secrecy surrounding trauma, suppression and social exclusion. Long term effectiveness requires further evaluation.

Gender differences (GD) in mental health have come under renewed scrutiny during the COVID-19 pandemic. While rapidly emerging evidence indicates a deterioration of mental health in general, it remains unknown whether the pandemic will have an impact on GD in mental health. To this end, we investigate the association of the pandemic and its countermeasures affecting everyday life, labor, and households with changes in GD in aggression, anxiety, depression, and the somatic symptom burden. We analyze cross-sectional data from 10,979 individuals who live in Germany and who responded to the online survey “Life with Corona” between October 1, 2020 and February 28, 2021. We estimate interaction effects from generalized linear models. The analyses reveal no pre-existing GD in aggression but exposure to COVID-19 and COVID-19 countermeasures is associated with sharper increases in aggression in men than in women. GD in anxiety decreased among participants with children in the household (with men becoming more anxious). We also observe pre-existing and increasing GD with regards to the severity of depression, with women presenting a larger increase in symptoms during the hard lockdown or with increasing stringency. In contrast to anxiety, GD in depression increased among participants who lived without children (women > men), but decreased for individuals who lived with children; here, men converged to the levels of depression presented by women. Finally, GD in somatic symptoms decreased during the hard lockdown (but not with higher stringency), with men showing a sharper increase in symptoms, especially when they lived with children or alone. Taken together, the findings indicate an increase in GD in mental health as the pandemic unfolded in Germany, with rising female vulnerability to depression and increasing male aggression. The combination of these two trends further suggests a worrying mental health situation for singles and families. Our results have important policy implications for the German health system and public health policy. This public health challenge requires addressing the rising burden of pandemic-related mental health challenges and the distribution of this burden between women and men, within families and for individuals who live alone.

Abstract Reintegration of ex‐combatants involves multiple challenges. In addition to the trauma‐related psychological sequelae, social obstacles in the community can aggravate psychopathological aggressive tendencies and lead to the continuation of violence in civilian life. However, the association between others’ negative attitudes and ex‐combatants’ ongoing perpetration of violence remains largely unexplored. Between September 2018 and May 2019, we assessed a representative community sample of adults in Eastern DR Congo (N = 1,058) and measured trauma exposure, perpetration, mental health problems (PTSD, depression, and appetitive aggression), perceived stigma (shame, perceived lack of social acknowledgement), experienced stigma, and skepticism toward reintegration with ex‐combatants. Male ex‐combatants (12%, n = 129) had more past trauma and violence perpetration than other community members and a greater number of recent conflicts (including both victimization and perpetration) within the community and with strangers/organized violence. They reported more experienced stigma, more severe PTSD symptoms but were less skeptical about reintegration. Ex‐combatants’ ongoing violence was predicted by an interplay of the community's skepticism toward reintegration and ex‐combatants’ perceived and recently experienced stigma (often attributed to the armed group history) and mental health problems, in addition to lifetime traumatization. These findings promote the need for combined interventions that address individual mental health problems including aggression and collective discriminatory attitudes and behaviors.

Background: Survivors of sexual violence are frequently condemned and socially excluded. Myths about rape may translate into stigmatization, diminish disclosure, prevent help-seeking from support structures and worsen mental health. Areas of conflict or organized violence remain the evident hotspots of sexual victimization. However, little is known about prevalence and predictors of rape myths in these settings or their association with survivors’ disclosure, stigmatization and psychopathology. Method: Between September 2018 and May 2019, we assessed in a representative sample of 1066 individuals from six communities in Eastern DRC traumatic exposure, sexual perpetration, threats to social integrity, perceived stigmatization (perceived lack of social acknowledgement, shame), stigmatizing attitudes towards survivors (negative attitudes and willingness to provide support, rape myths acceptance), and mental illness (PTSD, depression). Results: Survivors of sexual violence (33%, n = 184 of women, 16%, n = 84 of men) reported more traumatic exposure, threats to social integrity, shame, perceived lack of social acknowledgement, PTSD symptoms and depression. Their social environment affirmed various stigmatizing attitudes (5-89% affirmations). Beliefs in rape myths were predicted by its average acceptance in the community, education, and witness of others’ sexual victimization. The rates of cases whose history of sexual victimization was socially disclosed were higher in communities and among survivors with low rape myths acceptance and disclosure showed associations with perceived stigmatization. Rape myths acceptance among individuals without a history of sexual victimization was associated with survivors’ recently experienced threats to social integrity which predicted their stigma perceptions and mental illness. Conclusion: Rape myths acceptance in the community is associated with stigma and trauma-related mental illness of sexual violence survivors. This adds up to the psychic burden of trauma.

The aim of this article is to present a research-based rationale for NETfacts, a newly developed integrated approach at the individual and the community level in order to mitigate the mental and social sequelae of war and crisis. To this end, we provide a selective review of relevant literature from neuroscience, clinical psychology, and social science. In psychotraumatology, individual avoidance describes the effort to prevent exposure to trauma reminders. Among patients with post-traumatic stress disorder (PTSD), this becomes pathological, exacerbating distress and preventing recovery. This silence resonates in traumatized communities and consequently taboo builds – ultimately to the advantage of the perpetrators. The resulting collective avoidance leads to a fragmented collective memory about trauma or human rights violations in the community so that a shared account of the group’s history becomes impossible. The deficient collective memory promotes ambiguous truths and anxiety, enabling a reactive construction of safety based on selective information that leads to an endorsement of extreme opinions. Ongoing insecurity, violence and crime lead to increasing anxiety and fear. The self-interest of the perpetrators and the abnormal behaviour of survivors leads to an escalation in stigma and social exclusion resulting in the prevention or limitation of community exposure to traumatic material, i.e., to reduce tension and protect the construction of safety. The exposure to and recognition of traumatic facts subject to avoidance is key to a coherent collective memory and sense of communion, and to prevent further cycles of violence. The NETfacts health system combines individual and community-based intervention to treat the structure of memory at both the individual and collective levels. Abbreviations: NET: narrative exposure therapy; FORNET: narrative exposure therapy for forensic offender rehabilitation; NETfacts: facts derived from narrative exposure therapy

ObjectiveFormer combatants are exposed to multiple traumatic stressors during conflict situations and usually participate in perpetration of violence. Ongoing perpetration of violence in post conflict areas, linked to mental health problems and appetitive aggression, destabilises peace keeping efforts. The aim of this study is to investigate lifetime exposure to violence and the relationship between this exposure and mental health and current violent behaviour in a sample of female former child soldiers with a history of perpetration of violence in Eastern DR Congo.Methods98 female former child soldiers who had been abducted and forcibly recruited during the M23 insurgency (2012–2014) were assessed for lifetime exposure to trauma including perpetration of violence, clinical outcomes (PTSD and appetitive aggression), and current violent behaviour.ResultsFemale former child soldiers had been exposed to extremely high levels of trauma including perpetration of violence and presented with high levels of mental health problems. Linear regression models showed that current violent behaviour was predicted by both PTSD and appetitive aggression.ConclusionsTrauma exposure predicts ongoing perpetration of violence post conflict via the resulting mental health problems. The findings imply that if PTSD and appetitive aggression symptoms are successfully treated, ongoing violent behaviour in the community post conflict will also decrease.

Background: Compared to DSM-IV, the criteria for diagnosing posttraumatic stress disorder (PTSD) have been modified in DSM-5. Objective: The first aim of this study was to examine how these modifications impact rates of PTSD in a sample of Congolese ex-combatants. The second goal of this study was to investigate whether PTSD symptoms were associated with perpetrator-related acts or victim-related traumatic events. Method: Ninety-five male ex-combatants in the eastern Democratic Republic of Congo were interviewed. Both the DSM-IV and the DSM-5 PTSD symptom criteria were assessed. Results: The DSM-5 symptom criteria yielded a PTSD rate of 50% (n=47), whereas the DSM-IV symptom criteria were met by 44% (n=42). If the DSM-5 would be set as the current “gold standard,” then DSM-IV would have produced more false negatives (8%) than false positives (3%). A minority of participants (19%, n=18) indicated an event during which they were involved as a perpetrator as their most stressful event. Results of a regression analysis (R 2=0.40) showed that, after accounting for the number of types of traumatic events, perpetrated violent acts were not associated with the symptom severity of PTSD. Conclusions: The findings demonstrate that more diagnostic cases were produced with the DSM-5 diagnostic rules than were dropped resulting in an increase in PTSD rates compared to the DSM-IV system. The missing association between PTSD symptoms and perpetrated violent acts might be explained by a potential fascinating and excited perception of these acts.