RECENT REPORT BY THE US Committee for Refugees estimates there are 14.9 million refugees and 22 million internally displaced persons in the world. 1 Most have experienced significant trauma, including torture, 2-4 as evidenced by prevalence studies in clinics and nonrepresentative community samples. [5][6][7][8][9][10][11][12] Health problems of refugees have also been documented. Clinical research demonstrates a high prevalence of posttraumatic stress and depression symptoms, 6,10,[13][14][15] and community studies using self-rated scales [2][3][4]8,10,16 and structured diagnostic interviews 9,17-19 have found wide variation in the prevalence of the symptoms of posttraumatic stress (4%-86%) and depression (5%-31%). Refugees experience multiple symptoms, 4,5,[20][21][22][23][24][25][26] perhaps due to the many types of insults experienced, 4,6,20,23,24,27,28 yet the significance of these symptoms is not clear since many are not characteristic of posttraumatic stress disorder (PTSD), depression, or other defined disorders. [29][30][31][32][33][34][35] A few community studies Author Affiliations are listed at the end of this article.

Imagery rehearsal therapy is a brief, well-tolerated treatment that appears to decrease chronic nightmares, improve sleep quality, and decrease PTSD symptom severity.

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Imagery-rehearsal therapy for chronic nightmares was assessed in a randomized, controlled study of sexual assault survivors with posttraumatic stress disorder (PTSD). Nightmares, sleep quality, and PTSD were assessed at baseline for 169 women, who were randomized into two groups: treatment (n = 87) and wait-list control (n = 82). Treatment consisted of two 3-hr sessions and one 1-hr session conducted over 5 weeks. Of 169 participants, 91 women (Treatment, n = 43, Control, n = 48) completed a 3-month follow-up and 78 did not. At follow-up, nightmare frequency and PTSD severity decreased and sleep quality improved in the treatment group with small to minimal changes in the control group. Treatment effects were moderate to high (Cohen's d ranged from 0.57 to 1.26). Notwithstanding the large dropout rate, imagery-rehearsal therapy is an effective treatment for chronic nightmares in sexual assault survivors with PTSD and is associated with improvement in sleep quality and decreases in PTSD severity.

The purpose of the study was to evaluate the potential efficacy and acceptability of accupuncture for posttraumatic stress disorder (PTSD). People diagnosed with PTSD were randomized to either an empirically developed accupuncture treatment (ACU), a group cognitive-behavioral therapy (CBT), or a wait-list control (WLC). The primary outcome measure was self-reported PTSD symptoms at baseline, end treatment, and 3-month follow-up. Repeated measures MANOVA was used to detect predicted Group X Time effects in both intent-to-treat (ITT) and treatment completion models. Compared with the WLC condition in the ITT model, accupuncture provided large treatment effects for PTSD (F [1, 46] = 12.60; p < 0.01; Cohen's d = 1.29), similar in magnitude to group CBT (F [1, 47] = 12.45; p < 0.01; d = 1.42) (ACU vs. CBT, d = 0.29). Symptom reductions at end treatment were maintained at 3-month follow-up for both interventions. Accupuncture may be an efficacious and acceptable nonexposure treatment option for PTSD. Larger trials with additional controls and methods are warranted to replicate and extend these findings.

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The research literature is replete with reports of barriers to care perceived by rural patients seeking healthcare. Less often reported are barriers perceived by the rural healthcare providers themselves. The current study is an extensive survey of over 1,500 healthcare providers randomly selected from two US states with large rural populations, Alaska and New Mexico. Barriers consistently identified across rural and urban regions by all healthcare professionals were Patient Complexity, Resource Limitations, Service Access, Training Constraints, and Patient Avoidance of Care. Findings confirmed that rural areas, however, struggle more with healthcare barriers than urban and small urban areas, especially as related to Resource Limitations, Confidentiality Limitations, Overlapping Roles, Provider Travel, Service Access, and Training Constraints. Almost consistently, the smaller a provider's practice community, the greater the reports of barriers, with the most severe barriers reported in small rural communities.