Mental health care utilisation and access among refugees and asylum seekers in Europe: A systematic review

Health and health-related behaviours in refugees and migrants who self-identify as sexual or gender minority - A National population-based study in Sweden

BACKGROUND

To examine health and health-related behaviors in migrant and refugee individuals who identify as sexual or gender minority, and in comparison to their heterosexual peers.

METHODS

The study included 168,952 individuals (aged 16-84 years, males: 45·9%, sexual or gender minorities: 3·1%) who answered the Swedish National Public Health Survey in 2018 and 2020. Participants were grouped into Swedish-and Western-born (White) heterosexual, White sexual- or gender minority, migrant heterosexual, migrant sexual- or gender minority, refugee heterosexual, and refugee sexual- or gender minority. Outcomes included mental health (for example suicidal ideation, wellbeing), general health, risky behaviors (risk alcohol use, risk gambling, and substance use), and experiences of violence. Associations between 1) sexual- or gender -ethnic identities and 2) gender-ethnic identities and all outcomes were analyzed using logistic and linear regression adjusting for sex, age, and educational level.

FINDINGS

Being a sexual- or gender minority, regardless of ethnic minority status, was associated with worse general health and mental ill-health compared to heterosexual peers including suicidal ideation in refugee sexual- or gender minority individuals (OR 2·42, 95 % CI 1·44-4·08). Ethnic minorities (heterosexual and sexual- or gender minority migrants and refugees) had lower odds of drug and risk alcohol use compared to White heterosexual peers but higher odds of risk gambling (1·88, 1·49-2·37 for refugee heterosexuals). Transgender refugees had high odds for risk gambling (8·62, 1·94-38·40) and exposure to physical violence (7·46, 2·97-18·70).

INTERPRETATION

In this national population-based study, sexual and gender minority individuals have worse mental and general health regardless of ethnic minority status. We did not find evidence for worse health in sexual- or gender minority refugees in comparison to migrant, and White sexual- or gender minorities and their heterosexual peers. Transgender individuals (White and ethnic minority) experienced significantly higher levels of physical violence. Public health policy should emphasize preventive measures to reduce exposure to violence and discrimination in sexual- and gender minority individuals, increase access and use of mental healthcare services and sensitise healthcare professionals about higher rates of health and related issues faced by sexual- and gender minority individuals including those with multiple minority identities.

FUNDING

We received no external funding for this study and hence the funder had no role in the study design, data collection, data analysis, data interpretation, writing of the manuscript and the decision to submit.

Non-European immigrants' self-described strategies for mental health promotion and perceptions of Finnish mental health services: A qualitative descriptive analysis

PURPOSE

This study aims to describe non-European immigrants' perceptions toward mental health care in Finland and the factors that support their mental health.

DESIGN AND METHODS

Participants (N = 17) were interviewed through semistructured interviews, after which interview transcripts were analyzed using a six-phase thematic analysis process.

FINDINGS

The participants reported that developing self-help strategies benefitted their mental health. The participants primarily preferred unprofessional help over professional mental health care. Several structural and cultural barriers to help-seeking were identified.

PRACTICAL IMPLICATION

Health care staff working with immigrants need proper education and knowledge to provide sufficient, holistic care; for this reason, information about the cultural differences among immigrants and cultural sensitivity should be included in basic as well as post-graduate nursing education.

Practitioners' Perspectives on Barriers and Benefits of Telemental Health Services: The Unique Impact of COVID-19 on Resettled U.S. Refugees and Asylees

The COVID-19 pandemic and associated sequelae have disproportionately exacerbated refugee mental health due to health disparities, poverty, and unique risk factors. In response to the pandemic, most mental health providers have shifted to virtual platforms. Given the high need for services in this population, it is essential to understand the effectiveness and potential barriers to serving refugees via telehealth. This study is one of the first to examine the extent that socio-cultural and structural barriers impact telemental health services received by resettled refugees during the COVID-19 pandemic. This study also addresses the potential benefits of telemental health service delivery to refugees. We surveyed 85 providers serving refugee and non-refugee clients in the United States. Statistical analyses revealed that more significant socio-cultural and structural barriers, including access to technology, linguistic challenges, and privacy limitations, exist for refugees compared to non-refugee clients. Potential benefits of telemental health for refugees during the pandemic included fewer cancellations, fewer transportation concerns, and better access to childcare. These results highlight the need to address the disparity in telemental health service delivery to refugees to limit inequities for this population.

Living a frozen life: a qualitative study on asylum seekers' experiences and care practices at accommodation centers in Sweden

Background

Forced migrants fleeing conflict and violence face a high risk of mental health problems due to experiences before displacement, perilous journeys, and conditions in the new host societies. Asylum seekers seem to be in particularly vulnerable situations, indicated by higher prevalence rates of mental health problems compared to resettled refugees. Asylum seekers’ mental health is highly influenced by the conditions they face in host countries while awaiting a decision on their case. In Sweden, 40% of asylum seekers reside in state-provided accommodation centers during the asylum process. Collective accommodation centers for asylum seekers have been said to impose restrictive social conditions and to be associated with poorer mental health outcomes than other housing forms (e.g., self-organized housing). However, there seems to be a scarcity of qualitative studies exploring the experiences of asylum seekers in different contexts. The aim of this study was therefore to explore the experiences of asylum seekers and how they manage their mental wellbeing while living at accommodation centers in Sweden.

Methods

Fourteen semi-structured interviews with asylum seekers were conducted at two accommodation centers in Sweden. Participants were recruited using purposeful sampling and represented a diverse group of asylum seekers regarding age, background, and gender. The data was analyzed using content analysis.

Results

Three overarching categories were identified; 1) Frozen life, 2) Constant worrying and “overthinking”, and 3) Distractions and peer support. Participants experienced a state of being that could be characterized as a frozen life, which was associated with intense feelings of psychological distress, mostly described as manifesting itself in consuming patterns of ruminative thoughts, for instance overthinking and constant worrying. However, despite high levels of distress, participants demonstrated agency in managing negative mental health outcomes through self-care practices, peer support, and the development of care practices in caring for others in need.

Conclusion

This study offers new insights into the everyday challenges that asylum seekers at accommodation centers face. Furthermore, it offers valuable observations of how asylum seekers at accommodation centers cope through self-care practices, peer support, and care practices in caring for peers in need. In order to enable sustainable and empowering support, mental health and psychosocial support services must identify and address both challenges and strengths, be grounded in the lived reality of asylum seekers, and build on existing resources. Moreover, further policy work needs to be done to enable faster asylum processes.

Barriers and opportunities for the mental health of LGBT older adults and older people living with HIV: a systematic literature review

OBJECTIVE

LGBT older adults and older people living with HIV (PLWH) experience a disproportionate burden of behavioral health conditions compared to their heterosexual, cisgender, and HIV-negative peers. This study intends to systematically review the literature regarding accessing mental health care among LGBT older adults and older PLWH.

METHODS

This study was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement framework. Three databases were searched using Boolean search strings, and inclusion/exclusion criteria were developed and applied to the search outcomes to appropriately narrow results. Article quality and evidence of bias were evaluated using the National Heart, Lung, and Blood Institute (NHLBI) quality-assessment tool, and the Critical Appraisal Skills Program (CASP) assessment tool, two instruments used to help reviewers in assessing for internal validity of studies. Two independent researchers coded the articles for themes, and consensus was reached on theme grouping through an iterative process.

RESULTS

Out of 2,031 articles initially screened, 28 met all inclusion criteria and advanced to final analysis. Several key themes emerged, including a lack of provider competency in caring for LGBT patients, lower rates of insurance coverage, greater mental health burden, social and structural determinants of health, policy solutions, and technology and health literacy.

CONCLUSION

There were several domains identified in the literature as barriers to accessing mental healthcare, as well as opportunities to better attend to the mental health needs of these populations. Provider training, implementing health technology solutions, and enacting public policy changes could improve mental health outcomes.

Symptoms of anxiety and depression during the COVID-19 pandemic in six European countries and Australia - Differences by prior mental disorders and migration status

BACKGROUND

Little is known about changes of mental health during the COVID-19 pandemic in potentially disadvantaged groups. We investigated changes in anxiety and depression symptoms during the first year of the pandemic in six European countries and Australia by prior mental disorders and migration status.

METHODS

Overall, 4674 adults answered a web-based survey in May-June 2020 and were followed by three repeated surveys up to February 2021. Information on psychosocial, financial and demographic, living conditions, prior mental disorders, depression and anxiety symptoms during the pandemic and migration status was collected. Weighted general estimation equations modelling was used to investigate the association between prior mental disorders, migration status, and symptoms over time.

RESULTS

Most participants were <40 years old (48%), women (78%) and highly educated (62%). The baseline prevalence of depressive and anxiety symptoms ranged between 19%-45% and 13%-35%, respectively. In most countries, prevalence rates remained unchanged throughout the pandemic and were higher among people with prior mental disorders than without even after adjustment for several factors. We observed interactions between previous mental disorders and symptoms of anxiety or depression over time in two countries. No difference by migration status was noted.

LIMITATIONS

Convenience sampling limits generalizability. Self-assessed symptoms of depression and anxiety might involve some misclassification.

CONCLUSIONS

Depression and anxiety symptoms were worse among individuals with prior mental disorders than without, but there was no clear trend of worsening mental health in the observed groups during the observed period.

Detecting and describing heterogeneity in health care cost trajectories among asylum seekers

BACKGROUND

The mechanism underlying the health care cost trajectories among asylum seekers is not well understood. In the canton of Vaud in Switzerland, a nurse-led health care and medical Network for Migrant Health ("Réseau santé et migration" RESAMI) has established a health care model focusing on the first year after arrival of asylum seekers, called the "community health phase". This model aims to provide tailored care and facilitate integration into the Swiss health care system. The aim of this study is to explore different health care cost trajectories among asylum seekers during this phase and identify the associated factors.

METHODS

We detected different patterns of health care cost trajectories using time-series clustering of longitudinal data of asylum seekers in the canton of Vaud in Switzerland. These data included all adult asylum seekers and recipients of emergency aid who entered the canton between 2012 and 2015 and were followed until 2018. The different clusters of health care cost trajectories were then described using a multinomial logistic regression model.

RESULTS

We identified a concave, an upward trending, and a downward trending cluster of health care cost trajectories with different characteristics being associated with each cluster. The likelihood of being in the concave cluster is positively associated with coming from the Eastern Mediterranean region or Africa rather than Europe and with a higher share of consultations with an interpreter. The likelihood of being in the upward trending cluster, which accrued the highest costs, is positively associated with 20-24-year-olds rather than older individuals, coming from Europe than any other region and having a mental disorder. In contrast to the other two clusters, the likelihood of being in the downward trending cluster is positively associated with having contacted the RESAMI network within the first month after arrival, which might indicate the potential of early intervention. It is also positively associated with older age and living in a group lodge.

CONCLUSIONS

Asylum seekers are heterogeneous in terms of health care cost trajectories. Exploring these differences can help point to possible ways to improve the care and supporting services provided to asylum seekers. Our findings could indicate that early and patient-centered interventions might be well-suited to this aim.

Contact with psychiatric care prior to suicide: are there differences between migrants and the majority population in Sweden? A cohort study of 12 474 persons who died by suicide between 2006 and 2016

AIMS

The aim of this study was to determine possible differences in psychiatric care contact and the type of contact in the year prior to suicide by migrant status and region of origin compared to Swedish persons.

METHODS

A population-based open cohort design, using linked national registers, to study all individuals aged 20-64 years who died by suicide between 1 January 2006 and 31 December 2016 in Sweden (N = 12 474). The primary exposure was migrant status compared to the Swedish majority population in the following categories: non-refugee migrants, refugee migrants and children of migrants. The secondary exposure was region of origin in seven regions: Sweden, other Nordic countries, Europe, Sub-Saharan Africa, the Middle East and North Africa, Asia, the Americas and Oceania. The four outcomes were psychiatric in- and outpatient care, prescribed and purchased psychotropic medication and a variable composing the other variables, all measured the year before death. Logistic regression models adjusted for age, sex, income and marital status estimated the likelihood of psychiatric care utilisation by type of care within the year prior to death by migrant status and region of origin (individually and combined).

RESULTS

Out of all who had died by suicide, 81% had had psychiatric care of any type in the year before death by suicide. Among refugees the prevalence of psychiatric care before death by suicide was 88%. Compared with the Swedish reference group, non-refugees and persons from Asia and Sub-Saharan Africa had a lower likelihood of utilising psychiatric care prior to suicide driven by a lower use of prescribed psychotropic medication. Persons from the Middle East and North Africa had a higher likelihood, driven by higher use of psychiatric outpatient care and prescribed psychotropic medication. Non-refugees' likelihood of utilising care before death by suicide was lower within the first 5 years of living in Sweden.

CONCLUSION

A large share of those who die by suicide use psychiatric care the year before they die. Non-refugee migrants and persons from Asia and Sub-Saharan Africa have a lower likelihood of utilising psychiatric care prior to suicide compared to Swedish, whereas persons from the Middle East and North Africa have a higher likelihood. Health care and policy makers should consider both migrant status, region of origin and time in the new country for further suicide prevention efforts.

Reproductive health practices and use of health services among immigrant Indonesian women working in Malaysia

OBJECTIVE

To describe the reproductive health practices of immigrant Indonesian women working in Malaysia and their accessibility to health services.

METHODS

A cross-sectional study using a validated self-administered questionnaire was conducted with 593 immigrant Indonesian workers who stayed in Malaysia for at least six months and within the reproductive age group.

RESULTS

About 13.5% of the respondents have used health facilities for reproductive health-related problems. Less than half of the respondents preferred to use public health facilities. Only 15% used treatment available in health facilities related to irregular menstrual cycles (34.6%), severe dysmenorrhea (58.7%) and nonspecific symptoms related to menstruation (31.7%). Family planning services were the most required health service. However, only 31.5% met the needs for family planning services. One-third of the respondents had sexual reproductive health problems and required treatment, but only 9.9% sought reproductive health services when needed.

CONCLUSIONS

Strategies to improve the accessibility to sexual reproductive health services requires a collaboration between the Indonesian government representatives in Malaysia and non-governmental organizations to address the reproductive health issues among immigrant Indonesian women in Malaysia. Health policy related to immigrant workers is needed in order to enhance the accessibility to women's health needs for universal health coverage.

Health status assessment of a population of asylum seekers in Northern Italy

Background

Since 2011 Italy has faced an extraordinary increase in migrants arrivals, mainly from the Mediterranean route, one of the world’s most dangerous journeys. The purpose of the present article is to provide a comprehensive picture of the migrants' health status in the "T. Fenoglio" centre, Settimo Torinese (Turin, Italy).

Methods

A retrospective cross-sectional study was conducted using data collected from June 2016 to May 2018 on adult migrants (over 18 years old) from Africa, Middle East and South East Asia (Bangladesh, Cambodia, India, Nepal). Data was collected through the migrants' medical records. Descriptive statistics were performed on socio-demographic variables. The diagnosed diseases were anonymously registered and classified according to the International Classification of Primary Care (ICPC-2).

Conditional Inference Trees were used to perform a descriptive analysis of the sample and to detect the covariates with the strongest association with the variables Disease on arrival, Disease after arrival, ICPC on arrival and ICPC after arrival.

Results

Analyzed observations were 9 857. 81.8% were men, median age was 23 (Interquartile range: 20.0–27.4). 70.3% of the sample came from Sub-Saharan Africa. 2 365 individuals (24%) arrived at the centre with at least one disease. On arrival, skin (27.71%), respiratory (14.46%), digestive (14.73%) and generic diseases (20.88%) were the most frequent. During the stay respiratory diseases were the most common (25.70%). The highest probability of arriving with a disease occurred in 2018 and during the period September–November 2016, in particular for people from the Horn of Africa. During this period and also in the first half of 2017, skin diseases were the most reported. In seasons with lower prevalence of diseases on arrival the most common disease code was generic for both men and women (usually fever or trauma).

Conclusions

This study provides information on the diverse diseases that affect the asylum seekers population. In our sample, the Horn of Africa was the most troubled area of arrival, with severe conditions frequently reported regarding skin diseases, in particular scabies. 2018 was the most critical year, especially for migrants from the Horn of Africa and Sub-Saharan Africa. During the stay at the camp, the prevalence of respiratory diseases increased. However, skin diseases remained the main issue for people from the Horn of Africa. Overall, the most reported diseases in the sample were dermatological, respiratory, digestive and generic diseases, both on arrival and during the stay.

A better understanding of the health status of asylum seekers is an important factor to determine a more efficient reception and integration process and a better allocation of economic resources in the context of migrants' health care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12992-022-00846-0.

Exploring the Use of Hospital and Community Mental Health Services Among Newly Resettled Refugees

IMPORTANCE

Resettled refugees in high-income countries represent a vulnerable population. It is known that refugees have high rates of trauma-related mental health issues; however, ad hoc research has generally revealed low rates of health services use among refugees. Such research usually samples a population at a single point in time and is based on targeted surveys. Because refugee populations change over time, such research becomes expensive and time-consuming for agencies interested in routinely publishing statistics of mental health services use among refugees. The linking of large administrative data sets to establish rates of use of mental health services among resettled refugees is a flexible and relatively inexpensive approach.

OBJECTIVE

To use data linkage to establish rates of mental health services use among resettled refugees relative to the general population.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study implemented data linkage from the Refugee Health Nurse Program for 10 050 refugees who resettled in Sydney, Australia, from October 23, 2012, to June 8, 2017, with data concerning use of community mental health services and mental health hospitalization from New South Wales Health databases. Data were analyzed between June 1, 2019, and December 31, 2021.

MAIN OUTCOMES AND MEASURES

Rates of service contacts with community mental health services among the resettled refugees were compared with those of the general population by age, sex, and the most common International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, diagnosis codes. Length of community mental health service sessions and rates of mental health hospitalizations were also compared.

RESULTS

Among the 255 resettled refugees who had contacts with community mental health care services and were not missing data (median age, 35 [range, 4-80] years; 117 [64%] male and 138 [54%] female), 153 (60%) were born in Iraq and 156 (61%) were Arabic speaking. This population was less likely to use mental health services than the general population and had shorter community mental health consultations. The rate of contacts with community mental health services for depressive disorders among the resettled refugee population was 40% (95% CI, 33%-46%) lower than that among the general population. Rates of same-day hospitalization per 10 000 person-years were not significantly different between the refugee population (4 [95% CI, 2-8]) and the general Australian population (7 [95% CI, 7-7]). However, the refugee population was 17% (95% CI, 6%-29%) more likely than the general Australian population to interact with the community mental health system for severe stress- and adjustment disorder-related diagnoses.

CONCLUSIONS AND RELEVANCE

These findings suggest that refugees who have resettled in Australia tend to use fewer mental health services than the general population except for services devoted to stress- and adjustment disorder-related diagnoses. These findings also suggest that it is possible to successfully leverage data linkage to study patterns of mental health services use among resettled refugees.

Cost-effectiveness of the Self-Help Plus Intervention for Adult Syrian Refugees Hosted in Turkey

Importance

The cost-effectiveness of the Self-Help Plus (SH+) program, a group-based, guided, self-help psychological intervention developed by the World Health Organization for people affected by adversity, is unclear.

Objective

To investigate the cost-utility of providing the SH+ intervention combined with enhanced usual care vs enhanced usual care alone for Syrian refugees or asylum seekers hosted in Turkey.

Design, Setting, and Participants

This economic evaluation was performed as a prespecified part of an assessor-blinded randomized clinical trial conducted between October 1, 2018, and November 30, 2019, with 6-month follow-up. A total of 627 adults with psychological distress but no diagnosed psychiatric disorder were randomly assigned to the intervention group or the enhanced usual care group.

Interventions

The SH+ program was a 5-session (2 hours each), group-based, stress management course in which participants learned self-help skills for managing stress by listening to audio sessions. The SH+ sessions were facilitated by briefly trained, nonspecialist individuals, and an illustrated book was provided to group members. Th intervention group received the SH+ intervention plus enhanced usual care; the control group received only enhanced usual care from the local health care system. Enhanced usual care included access to free health care services provided by primary and secondary institutions plus details on nongovernmental organizations and freely available mental health services, social services, and community networks for people under temporary protection of Turkey and refugees.

Main Outcomes and Measures

The primary outcome measure was incremental cost per quality-adjusted life-year (QALY) gained from the perspective of the Turkish health care system. An intention-to-treat analysis was used including all participants who were randomized and for whom baseline data on costs and QALYs were available. Data were analyzed September 30, 2020, to July 30, 2021.

Results

Of 627 participants (mean [SD] age, 31.3 [9.0] years; 393 [62.9%] women), 313 were included in the analysis for the SH+ group and 314 in the analysis for the enhanced usual care group. An incremental cost-utility ratio estimate of T£6068 ($1147) per QALY gained was found when the SH+ intervention was provided to groups of 10 Syrian refugees. At a willingness to pay per QALY gained of T£14 831 ($2802), the SH+ intervention had a 97.5% chance of being cost-effective compared with enhanced usual care alone.

Conclusions and Relevance

This economic evaluation suggests that implementation of the SH+ intervention compared with enhanced usual care alone for adult Syrian refugees or asylum seekers hosted in Turkey is cost-effective from the perspective of the Turkish health care system when both international and country-specific willingness-to-pay thresholds were applied.

Differences in psychiatric care utilization between refugees, non-refugee migrants and Swedish-born youth

BACKGROUND

The study aimed to examine differences in, and characteristics of psychiatric care utilization in young refugees who came to Sweden as unaccompanied or accompanied minors, compared with that of their non-refugee immigrant and Swedish-born peers.

METHODS

This register-linkage cohort study included 746 688 individuals between 19 and 25 years of age in 2009, whereof 32 481 were refugees (2896 unaccompanied and 29 585 accompanied) and 32 151 non-refugee immigrants. Crude and multivariate Cox regression models yielding hazard ratios (HR) and 95% confidence intervals (CI) were conducted to investigate subsequent psychiatric care utilization for specific disorders, duration of residence and age at migration.

RESULTS

The adjusted HRs for psychiatric care utilization due to any mental disorder was significantly lower in both non-refugee and refugee immigrants when compared to Swedish-born [aHR: 0.78 (95% CI 0.76-0.81) and 0.75 (95% CI 0.72-0.77, respectively)]. Within the refugee group, unaccompanied had slightly lower adjusted risk estimates than accompanied. This pattern was similar for all specific mental disorders except for higher rates in schizophrenia, reaction to severe stress/adjustment disorders and post-traumatic stress disorder. Psychiatric health care utilization was also higher in immigrants with more than 10 years of residency in Sweden entering the country being younger than 6 years of age.

CONCLUSIONS

For most mental disorders, psychiatric health care utilization in young refugees and non-refugee immigrants was lower than in their Swedish-born peers; exceptions are schizophrenia and stress-related disorders. Arrival in Sweden before the age of 6 years was associated with higher rates of overall psychiatric care utilization.

Treatment adherence to psychotropic drugs among non-Western migrants: a systematic review

BACKGROUND

Low medication adherence is a significant challenge in all medical fields and particularly in mental health treatment, where a lack of insight into one's own disease can repress the ability to adhere. In recent years, the increase in migration combined with a high prevalence of mental illnesses among migrants and the possible consequences of nonadherence, point towards the need for a focus on adherence with psychotropic drugs among migrants.

AIM

To review current literature, exploring the potential impact of being a migrant from a non-Western country living in a Western country on the level of adherence to psychotropic medication and subsequently to discuss these findings.

METHODS

A systematic review of studies investigating adherence among non-western migrants was conducted. The literature search was conducted using PubMed and Embase databases in October 2020.

RESULTS

Seven observational studies were included, all ranging from moderate to high-quality. Six out of seven studies found an association between being a non-Western migrant in a Western country and low adherence to psychotropic drugs.

CONCLUSION

Studies indicate an association between being a non-Western migrant in a Western country and low adherence to psychotropic drugs. None of the included studies investigated possible causes of the low adherence in migrants. Communication difficulties are, however, considered possible barriers to healthcare access and a contributing factor to nonadherence. There is a need for studies assessing the possible impact of interventions aiming at increasing adherence such as intercultural mediators and training of healthcare providers in cultural competencies.

Scalable psychological interventions for Syrian refugees in Europe and the Middle East: STRENGTHS study protocol for a prospective individual participant data meta-analysis

INTRODUCTION

The World Health Organization's (WHO) scalable psychological interventions, such as Problem Management Plus (PM+) and Step-by-Step (SbS) are designed to be cost-effective non-specialist delivered interventions to reduce symptoms of common mental disorders, such as anxiety, depression and post-traumatic stress disorder (PTSD). The STRENGTHS consortium aims to evaluate the effectiveness, cost-effectiveness and implementation of the individual format of PM+ and its group version (gPM+), as well as of the digital SbS intervention among Syrian refugees in seven countries in Europe and the Middle East. This is a study protocol for a prospective individual participant data (IPD) meta-analysis to evaluate (1) overall effectiveness and cost-effectiveness and (2) treatment moderators of PM+, gPM+ and SbS with Syrian refugees.

METHODS AND ANALYSIS

Five pilot randomised controlled trials (RCTs) and seven fully powered RCTs conducted within STRENGTHS will be combined into one IPD meta-analytic dataset. The RCTs include Syrian refugees of 18 years and above with elevated psychological distress (Kessler Psychological Distress Scale (K10>15)) and impaired daily functioning (WHO Disability Assessment Schedule 2.0 (WHODAS 2.0>16)). Participants are randomised into the intervention or care as usual control group, and complete follow-up assessments at 1-week, 3-month and 12-month follow-up. Primary outcomes are symptoms of depression and anxiety (25-item Hopkins Symptom Checklist). Secondary outcomes include daily functioning (WHODAS 2.0), PTSD symptoms (PTSD Checklist for DSM-5) and self-identified problems (PSYCHLOPS). We will conduct a one-stage IPD meta-analysis using linear mixed models. Quality of evidence will be assessed using the GRADE approach, and the economic evaluation approach will be assessed using the CHEC-list.

ETHICS AND DISSEMINATION

Local ethical approval has been obtained for each RCT. This IPD meta-analysis does not require ethical approval. The results of this study will be published in international peer-reviewed journals.

Assessing Virtual Mental Health Access for Refugees during the COVID-19 Pandemic Using the Levesque Client-Centered Framework: What Have We Learned and How Will We Plan for the Future?

During the COVID-19 pandemic, mental health services rapidly transitioned to virtual care. Although such services can improve access for underserved populations, they may also present unique challenges, especially for refugee newcomers. This study examined the multidimensional nature of access to virtual mental health (VMH) care for refugee newcomers during the COVID-19 pandemic, using Levesque et al.'s Client-Centered Framework for Assessing Access to Health Care. One hundred and eight structured and semi structured interviews were conducted in four Canadian provinces (8 community leaders, 37 newcomer clients, 63 mental health or service providers or managers). Deductive qualitative analysis, based on the Client-Centered Framework, identified several overarching themes: challenges due to the cost and complexity of using technology; comfort for VMH outside clinical settings; sustainability post-COVID-19; and communication and the therapeutic alliance. Mental health organizations, community organizations, and service providers can improve access to (virtual) mental health care for refugee newcomers by addressing cultural and structural barriers, tailoring services, and offering choice and flexibility to newcomers.

Mind the Gate: General Practitioner's Attitudes Towards Depressed Patients with Diverse Migration Backgrounds

This study aims to examine (a) whether there are differences in general practitioners' (GPs) attitudes towards native Belgian patients, patients of foreign descent and asylum seeking patients who all express symptoms of major depression, and (b) whether these differences depend on GPs' experience with cultural competency training and interethnic contact. Using a video vignette study among 404 Flemish (Belgium) GPs, we find evidence of a provider bias. While GPs regard a patient of foreign descent as less trustworthy and less able to adhere to medical recommendations than a native Belgian patient, they also hold more pessimistic views on a potential recovery of an asylum seeking patient. In addition, we find that cultural competency training might alter GPs' attitudes of asylum seeking patients in a positive way. Summarized, our research highlights the need to target stereotypes among GPs for interventions designed to reduce migration-based disparities in healthcare use and health status.

Investigating the potential of a novel internet-based cognitive behavioural intervention for Dari and Farsi speaking refugee youth: A feasibility study

OBJECTIVE

Over half of the world's forcibly displaced persons are under the age of 25, with many suffering from symptoms of psychological disorders. Many refugees from Afghanistan or Iran speak either Dari or Farsi, which are mutually intelligible dialects of the Persian language. Previous research on adult refugees and immigrants have shown that internet-based cognitive behavioural therapy (ICBT) can be a valuable complement to other forms of treatment. However, there is a lack of knowledge if ICBT is a feasible and acceptable treatment for adolescents and young adults with a refugee background.

METHOD

Fifteen Dari/Farsi-speaking adolescents and young adults between 15 and 26 years of age participated in a feasibility study of a novel individually tailored guided ICBT intervention targeting symptoms of common mental disorders such as anxiety and depression. Self-reported symptoms of anxiety and depression were assessed using the Hopkins Symptom Checklist-25 (HSCL-25) as the primary outcome measure. Four of the treatment participants and three additional non-treatment participants consented to be interviewed regarding the programme's acceptability. The interviews were analysed using Thematic Analysis.

RESULTS

The intervention suffered from low adherence, with only 3 participants completing the post-treatment assessment and with participants completing 0.9 modules on average, which meant that the intended quantitative analysis of the pre to post change was not possible. The thematic analysis resulted in two overarching categories, barriers and facilitators, that each contained four themes and related subthemes. Overall, the intervention was deemed culturally relevant and easy to understand. The most salient barriers to participation across interviews concerned interference of symptoms such as concentration difficulties, low energy, and a lack of human contact and support.

CONCLUSION

The current version of the ICBT program demonstrated low feasibility and acceptability in the target population, which mainly seemed to be related to the delivery format. Future studies should investigate if a blended treatment format with regular phone/video calls with a therapist can increase adherence to the intervention.

Differences in labour market marginalisation between refugees, non-refugee immigrants and Swedish-born youth: Role of age at arrival and residency duration

AIMS

We investigated if the risk of long-term unemployment (LTU) and disability pension (DP) differs between young refugees and non-refuge immigrants compared to the Swedish-born. The role of age at arrival, duration of residency and morbidity in this association was also investigated.

METHODS

All 19- to 25-year-olds residing in Sweden on 31 December 2004 (1691 refugees who were unaccompanied by a parent at arrival, 24,697 accompanied refugees, 18,762 non-refugee immigrants and 621,455 Swedish-born individuals) were followed from 2005 to 2016 regarding LTU (>180 days annually) and DP using nationwide register data. Cox regression models were used to estimate crude and multivariate-adjusted (adjusted for several socio-demographic, labour market and health-related covariates) hazard ratios (aHRs) with 95% confidence intervals.

RESULTS

Compared to the Swedish-born, all migrant groups had around a 1.8-fold higher risk of LTU (range aHR=1.71-1.83) and around a 30% lower risk of DP (range aHR=0.66-0.76). Older age at arrival was associated with a higher risk of LTU only for non-refugee immigrants. Both older age at arrival and a shorter duration of residency were associated with a lower risk of DP for all migrant groups. Psychiatric morbidity had the strongest effect on subsequent DP, with no significant differences between migrant groups and the Swedish-born (range aHR=5.1-6.1).

CONCLUSIONS

Young immigrants had a higher risk of LTU and a lower risk of DP than their Swedish-born peers. No differences between the different immigrant groups were found. Age at arrival, psychiatric morbidity and duration of residency are strong determinants of being granted DP.

Mental Health Screening Approaches for Resettling Refugees and Asylum Seekers: A Scoping Review

Refugees and asylum seekers often face delayed mental health diagnoses, treatment, and care. COVID-19 has exacerbated these issues. Delays in diagnosis and care can reduce the impact of resettlement services and may lead to poor long-term outcomes. This scoping review aims to characterize studies that report on mental health screening for resettling refugees and asylum seekers pre-departure and post-arrival to a resettlement state. We systematically searched six bibliographic databases for articles published between 1995 and 2020 and conducted a grey literature search. We included publications that evaluated early mental health screening approaches for refugees of all ages. Our search identified 25,862 citations and 70 met the full eligibility criteria. We included 45 publications that described mental health screening programs, 25 screening tool validation studies, and we characterized 85 mental health screening tools. Two grey literature reports described pre-departure mental health screening. Among the included publications, three reported on two programs for women, 11 reported on programs for children and adolescents, and four reported on approaches for survivors of torture. Programs most frequently screened for overall mental health, PTSD, and depression. Important considerations that emerged from the literature include cultural and psychological safety to prevent re-traumatization and digital tools to offer more private and accessible self-assessments.

Qualitative research on maternal care access among Arabic-speaking refugee women in the USA: study protocol

BACKGROUND

Refugees tend to have greater health needs and pre-existing medical conditions due to poor living conditions, lack of health services, exposure to a variety of risk factors, and a high level of stress and trauma prior to entry to a host country. Notwithstanding distinctive needs and inherent conditions, there is a paucity of literature on refugee maternal health, especially for Arabic-speaking refugee women resettled in the USA.

METHODS AND ANALYSIS

The paper delineates a qualitative study protocol to explore the experiences of Arabic-speaking refugee women in the USA when accessing maternal care. Informed by social cognitive theory, the study will employ two qualitative research methods; in-depth interviews and 'go-along' interviews with Arabic-speaking refugee women. Go-along interview will be used to elicit spatial experiences in situ to explore perceptions of environments among study participants and environmental and structural barriers. 20 refugee women who meet the inclusion criteria will be recruited through snowball sampling with support from community partners. Two researchers will code the transcription and fieldnotes using MAXQDA 2020 (VERBI Software, 2019). The analysis will involve deductive content analysis using a structured categorisation matrix based on the theory while also incorporating inductive codes that may emerge through the process.

ETHICS AND DISSEMINATION

The study has been reviewed and approved by the Human Subjects Protection Programme at the University of Arizona (IRB 2104716241). The study results will be condensed in a summary report, which will be shared with community partners, including refugee resettlement agencies and relevant staff at the state department. Also, community feedback will be garnered from the dissemination workshops to inform community discussions for actions and an intervention to address the identified needs.

Involuntary psychiatric hospitalization among migrants in Italy: A matched sample study

BACKGROUND

Immigrants in Europe appear to be at higher risk of psychiatric coercive interventions. Involuntary psychiatric hospitalization poses significant ethical and clinical challenges. Nonetheless, reasons for migration and other risk factors for involuntary treatment were rarely addressed in previous studies. The aims of this study are to clarify whether immigrant patients with acute mental disorders are at higher risk to be involuntarily admitted to hospital and to explore clinical and migratory factors associated with involuntary treatment.

METHODS

In this cross-sectional matched sample study, we compared the rates of involuntary treatment in a sample of first-generation immigrants admitted in a Psychiatric Intensive Care Unit of a large metropolitan academic hospital to their age-, gender-, and psychiatric diagnosis-matched native counterparts. Clinical, sociodemographic, and migratory variables were collected. The Brief Psychiatric Rating Scale-expanded (BPRS-E) and the Clinical Global Impression-Severity (CGI-S) scale were administered. McNemar test was used for paired categorical variables and a binary logistic regression analysis was performed.

RESULTS

A total of 234 patients were included in the analysis. Involuntary treatment rates were significantly higher in immigrants as compared to their matched natives (32% vs. 24% respectively; p < .001). Among immigrants, involuntary hospitalization was found to be more frequent in those patients whose length of stay in Italy was less than 2 years (OR = 4.2, 95% CI [1.4-12.7]).

CONCLUSION

Recently arrived immigrants appear to be at higher risk of involuntary admission. Since coercive interventions can be traumatic and negatively affect outcomes, strategies to prevent this phenomenon are needed.

Mental disorder and first-time marriage formation among non-Western migrant women: A national register study

PURPOSE

Studies show that there is a mental health selection into marriage among the general population. This study explored the association between mental disorder and marriage formation among non-Western migrant women living in Norway, and whether the association varied with region of origin, income, education and having a dependent child.

METHODS

Using linked national register data, we followed 49,329 non-Western never married migrant women aged 18-60 living in Norway between 2006 and 2014. As a proxy for mental disorders, we investigated whether outpatient mental health service use was associated with marital formation using discrete time logistic regression analyses.

RESULT

Overall, outpatient mental health service use was associated with lower odds of marital formation, even after controlling for sociodemographic factors. Interaction analyses suggested that the relationship was weaker for South Asian women, who had the highest odds of marriage formation, compared with Sub-Saharan African women, who had the lowest. The relationship was also stronger for women with children and women with low incomes.

CONCLUSION

Mental health selection effects may depend on the universality of marriage. Since marriage may be associated with psychosocial and economic benefits, it is important to identify and treat mental disorder among non-Western migrant women, particularly those with childcare responsibilities and low income.

New directions in the mental health care of migrants, including refugees-A randomized controlled trial investigating the efficacy of value-based counselling

OBJECTIVE

Specialized literature has identified a need for evidence-based, low-threshold, short-term, and intracultural psychological interventions that can be made available to migrants, including refugees, who suffer from psychological symptoms in host countries. The objective of the present study is to measure the efficacy of value-based counselling (VBC) as such an intervention.

METHOD

We conducted a pragmatic, rater-blinded randomized controlled trial employing a pre-post control group design to assess the efficacy of VBC based on a study sample of 103 migrants, including refugees, who resided in Germany at the time. A set of instruments was used to evaluate primary outcome measures of depression, posttraumatic stress disorder (PTSD) symptoms, perceived stress, generalized anxiety, and somatic complaints.

RESULTS

Per protocol analysis included 42 participants in the VBC group, and 43 in the waiting list. Compared with participants in the waiting-list group, the VBC group, following an average of four counselling sessions, experienced a clinically meaningful reduction of depression (adjusted difference 7.06, 95% CI [4.86, 9.26], effect size 0.68, p < .001), PTSD (adjusted difference 17.15, 95% CI [10.49, 23.81], effect size 0.76, p < .001), perceived stress (adjusted difference 9.25, 95% CI [6.23, 12.27], effect size 0.75, p < .001), anxiety (adjusted difference 5.34, 95% CI [3.47, 7.20], effect size 0.70, p < .001), and somatic complaints (adjusted difference 5.52, 95% CI [3.30, 7.74], effect size 0.72, p < .001). The positive outcomes were maintained at 3-month follow-up. Utilization of mental health services was significantly reduced at the 3-month follow-up conducted with participants of the VBC group.

CONCLUSIONS

VBC, a culturally sensitive and strength-based mental health service, is an effective short-term intervention which meets the specific mental health needs of migrants, including refugees.

Feasibility of a randomised trial of Teaching Recovery Techniques (TRT) with refugee youth: results from a pilot of the Swedish UnaccomPanied yOuth Refugee Trial (SUPpORT)

Background

Although post-traumatic stress is prevalent among unaccompanied refugee minors (URM), there are few evidence-based psychological interventions for this group. Teaching Recovery Techniques (TRT) is a brief, manualised intervention for trauma-exposed youth, which has shown promising results in exploratory studies. The aim of the present study was to assess the feasibility of conducting a randomised controlled trial (RCT) evaluating the use of TRT among URM by investigating key uncertainties relating to recruitment, randomisation, intervention delivery and data collection.

Methods

A 3-month long non-blinded internal randomised pilot trial with a parallel-group design assessed the feasibility of a planned nationwide multi-site RCT. URM with or without granted asylum were eligible if they were 14 to 20 years old, had arrived in Sweden within the last 5 years and had screened positive for symptoms of post-traumatic stress disorder (PTSD). Quantitative data were collected pre- and post-intervention, and 18 weeks after randomisation. On-site individual randomisation (1:1) followed directly after pre-intervention assessment. Participants allocated to the intervention were offered seven weekly group-based TRT sessions. Quantitative pilot outcomes were analysed using descriptive statistics. Qualitative information was gathered through on-site observations and follow-up dialogue with group facilitators. A process for Decision-making after Pilot and feasibility Trials (ADePT) was used to support systematic decision-making in moving forward with the trial.

Results

Fifteen URM (mean age 17.73 years) with PTSD symptoms were recruited at two sites. Three of the youths were successfully randomised to either TRT or waitlist control (TRT n = 2, waitlist n = 1). Fourteen participants were offered TRT for ethical reasons, despite not being randomised. Six (43%) attended ≥ 4 of the seven sessions. Seventy-three percent of the participants completed at least two assessments, with a response rate of 53% at both post-intervention and follow-up.

Conclusions

The findings demonstrated a need for amendments to the protocol, especially with regard to the procedures for recruitment and randomisation. Upon refinement of the study protocol and strategies, an adequately powered RCT was pursued, with data from this pilot study excluded.

Trial registration

ISRCTN47820795, prospectively registered on 20 December 2018

Professional Mental Health Help-Seeking Amongst Afghan and Iraqi Refugees in Australia: Understanding Predictors Five Years Post Resettlement

The current longitudinal study sought to identify predictors of professional help seeking for mental health problems amongst Afghan and Iraqi refugees five years post-settlement utilising the Building a New Life in Australia dataset (BNLA). Data were collected via face-to-face or phone interviews across five waves from October 2013 to March 2018. Afghan and Iraqi born refugees numbering 1180 and over 18 years of age with a permanent humanitarian visa were included in this study. The results suggest differences in help-seeking behaviors amongst the two ethnic groups. Amongst the Afghan sample, older adults with high psychological distress were more likely to seek help, while living in regional Australia, not requiring interpreters, and knowing how to find out information about government services were related to lower likelihood of help-seeking. Within the Iraqi sample, poor overall health and knowing how to find out about services were related to a greater likelihood of help-seeking, while fewer financial hardships decreased the likelihood of help-seeking. Amongst those with probable PTSD, disability was associated with an increased likelihood of help-seeking while experiencing fewer financial hardships and living in regional Australia resulted in a lower likelihood of help-seeking in this group. These results have implications for promotional material and mental health interventions, suggesting that more integrated services tailored to specific characteristics of ethnic groups are needed.

[Psychological Burden of Refugees in Temporary Accommodations in the Rhine-Neckar Region, Baden-Wuerttemberg]

OBJECTIVE

Due to pre-, peri-, and post-migration stress factors, the prevalence of mental illnesses among refugees is higher than in the average population. To survey the prevalence of symptoms of posttraumatic stress disorder, depression and anxiety disorder among refugees who have been living in Germany for a longer period of time in a low threshold manner, a study with short questionnaires in temporary accommodations in the Rhine-Neckar region was conducted.

METHODS

To determine the prevalence of psychological stress symptoms, all adult refugees in 7 temporary accommodations in the Rhine-Neckar region were approached. If they agreed to participate and spoke one of the 7 available languages, psychological stress was assessed using PC-PTSD-5 and PHQ-4 (n=106).

RESULTS

On average, the participants experienced 3.18 (SD 2.48) traumatic events. 47.2% showed symptoms of posttraumatic stress disorder, 37.7% of depression and 29.2% of anxiety disorder. Neither gender nor age was significantly related to certain traumatic events or the diagnoses mentioned.

DISCUSSION

This study shows a high prevalence of traumatization and psychological distress among refugees that have been living in Germany for several months or years. However, both the identification of affected persons and mental health care is associated with numerous challenges.

CONCLUSION

Even after a longer stay in Germany, the prevalence of psychological distress is significantly higher in both genders and across all age groups compared to the general population. There is a great need to identify mentally ill refugees systematically and to close existing gaps in mental health care.

"I Have No Capacities That Can Help Me": Young Asylum Seekers in Norway and Serbia - Flight as Disturbance of Developmental Processes

Most studies on refugee populations are organized around trauma-related issues and focus on explaining pathological factors. Few studies are anchored in general developmental psychology with the aim of exploring normal age-specific developmental tasks and how the special circumstances associated with forced migration can influence how developmental tasks are negotiated. This study is part of a larger mixed method study seeking to identify resilience-promoting and resilience-inhibiting factors, on individual and contextual levels, among asylum seekers and refugees on the move (passing through Serbia) and settled in reception centers in Norway. A strategic sample of 20 adolescent and young adult refugees/asylum seekers during flight in Serbia (10) and after arrival in Norway (10) was chosen from a sample of 178 refugees interviewed in depth in Serbia and at receptions centers in Norway. The sample reflects the focus of this paper, which is to explore adolescent and young adult refugees/asylum seekers' psychological and social needs and resources during flight to and after arrival in the host country, including how developmental tasks are negotiated. Through qualitative analysis, experiences associated with the developmental changes the participants experienced before, during, and after flight are contextualized. Their sense of self, their relationships with their families and their perceptions of their situation as adolescents or young adults in a highly unpredictable situation are presented in the light of relevant theory and findings from similar refugee studies. All the participants have fled from dangerous and intolerable situations in their home countries. They describe extreme dangers during flight in contexts that are unpredictable and where they feel lonely and unsupported. Most have unmet psychosocial needs and have received little support or help for their mental health issues during flight or after arrival in Norway. Suggestions for interventions and resilience-promoting actions are given based on the findings of the study.

Exploring stigma associated with mental health conditions and alcohol and other drug use among people from migrant and ethnic minority backgrounds: a protocol for a systematic review of qualitative studies

BACKGROUND

Stigma is a social process that impedes access to support for mental health conditions and alcohol and other drug (AOD) use, particularly for people from migrant and ethnic minority backgrounds. There is limited understanding, however, of people's experiences of stigma, the underlying drivers, intersections with ethnicity, gender, and citizenship status, and how powerful discourses and social institutions create and perpetuate systems of stigma. This review aims to synthesise and critically analyse qualitative evidence to understand how stigma associated with mental health conditions and AOD use operates among people from migrant and ethnic minority groups.

METHODS

Qualitative evidence will be identified using MEDLINE, Embase, PsycINFO, CINAHL, Applied Social Sciences Index and Sociological Abstracts. Two reviewers will screen the titles, abstracts and full-text articles. Eligible studies will include original, empirical, peer-reviewed qualitative evidence, published in English since 1990. Studies must examine stigma in relation to mental health conditions, illicit drug use or alcohol consumption among participants who are from migrant and ethnic minority backgrounds. Studies will be critically appraised using the Joanna Briggs Institute Critical Appraisal Checklist for qualitative studies and the level of confidence in the findings will be assessed using Confidence in the Evidence from Reviews of Qualitative research. Data will be analysed using the 'best fit' framework synthesis approach, drawing on the Health Stigma and Discrimination Framework.

DISCUSSION

This review will provide an in-depth understanding of the stigma associated with mental health conditions and AOD use among people from migrant and ethnic minority backgrounds. The findings will inform culturally responsive interventions that aim to reduce the negative impact of stigma on individuals, families and communities.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42021204057.

Refugees' Agency: On Resistance, Resilience, and Resources

This study set out to answer the question ‘Which kinds of agency do refugees perform when dealing with mental health problems of themselves and their children?’. Aiming to gain more insight in why it seems harder for refugee parents and minors than for the native population to talk to health professionals about their mental health and wellbeing, we combined two theoretical notions of agency to investigate a broad spectrum of informants’ behaviour. We conducted 25 interviews with 30 refugees from 8 countries (Syria, Yemen, Iran, Afghanistan, Armenia, Eritrea, Turkish Kurdistan, Vietnam), whose Dutch residence permit varied from 26 years to less than one year. Data were analysed through open and axial coding, followed by pattern analyses. Although sometimes refugees seek (mental) healthcare, at other times they show agency by doing ‘nothing’ or by deliberately using distracting activities to deal with severe stress. Making use of resources available to them, oftentimes refugees show agency in ways that are less visible to healthcare professionals, by surviving, showing resilience, and suffering. In these cases, we think healthcare for refugees should intervene in a non-medical way, e.g., by supporting them to obtain resources that help refugees to (re)gain agency.

Health professionals' experiences of and attitudes towards mental healthcare for migrants and refugees in Europe: A qualitative systematic review

Migrants living in Europe constitute over half of the world's international migrants and are at higher risk of poor mental health than non-migrants, yet also face more barriers in accessing and engaging with services. Furthermore, the quality of care received is shaped by the experiences and attitudes of health professionals. The aim of this review was to identify professionals' attitudes towards migrants receiving mental healthcare and their perceptions of barriers and facilitators to service provision. Four electronic databases were searched, and 23 studies met the inclusion criteria. Using thematic synthesis, we identified three themes: 1) the management of multifaceted and complex challenges associated with the migrant status; 2) professionals' emotional responses to working with migrants; and 3) delivering care in the context of cultural difference. Professionals employed multiple strategies to overcome challenges in providing care yet attitudes towards this patient group were polarized. Professionals described mental health issues as being inseparable from material and social disadvantage, highlighting a need for effective collaboration between health services and voluntary organizations, and partnerships with migrant communities. Specialist supervision, reflective practice, increased training for professionals, and the adoption of a person-centered approach are also needed to overcome the current challenges in meeting migrants' needs. The challenges experienced by health professionals in attempting to meet migrant needs reflect frustrations in being part of a system with insufficient resources and without universal access to care that effectively stigmatizes the migrant status.

Feasibility and acceptability of Problem Management Plus (PM+) among Syrian refugees and asylum seekers in Switzerland: a mixed-method pilot randomized controlled trial

BACKGROUND

Syrian refugees in Switzerland face several barriers in accessing mental health care. Cost-effective psychological interventions are urgently needed to meet the mental health needs of refugees. Problem Management Plus (PM+) is an evidence-based, psychological intervention delivered by trained non-specialist 'helpers'.

OBJECTIVE

To assess the feasibility and acceptability of PM+ among Syrian refugees in Switzerland.

METHODS

We conducted a single-blind pilot randomized controlled trial (RCT) with Syrian refugees impaired by psychological distress (K10 > 15 and WHODAS 2.0 > 16). Participants were randomized to PM+ or Enhanced Treatment As Usual (ETAU). Participants were assessed at baseline, and 1 week and 3 months after the intervention, and completed measures indexing mental health problems and health care usage. Semi-structured interviews were conducted with different stakeholders.

RESULTS

N = 59 individuals were randomized into PM+ (n = 31) or ETAU (n = 28). N = 18 stakeholders were interviewed about facilitators and barriers for the implementation of PM+. Retention rates in the trial (67.8%) and mean intervention attendance (M = 3.94 sessions, SD = 1.97) were high. No severe events related to the study were reported. These findings indicate that the trial procedures and PM+ were feasible, acceptable and safe.

CONCLUSIONS

The findings support the conduct of a definitive RCT and show that PM+ might have the potential to be scaled-up in Switzerland. The importance, as well as the challenges, of implementing and scaling-up PM+ in high-income countries, such as Switzerland, are discussed.

Engaging Refugees With a Culturally Adapted Digital Intervention to Improve Sleep: A Randomized Controlled Pilot Trial

Refugees are exposed to multiple stressors affecting their mental health. Given various barriers to mental healthcare in the arrival countries, innovative healthcare solutions are needed. One such solution could be to offer low-threshold treatments, for example by culturally adapting treatments, providing them in a scalable format, and addressing transdiagnostic symptoms. This pilot trial examined the feasibility, acceptance, and preliminary effectiveness of a culturally adapted digital sleep intervention for refugees. Sixty-six refugees participated, with 68.2% of them seeking psychological help for the first time. Only three participants did not show clinically significant insomnia severity, 93.9% reported past traumatic experiences. Participants were randomly assigned to the intervention group (IG) or the waitlist control group (CG). Insomnia severity, measured by the Insomnia Severity Index, and secondary outcomes (sleep quality, fear of sleep, fatigue, depression, wellbeing, mental health literacy) were assessed at baseline, 1 and 3 months after randomization. The self-help intervention included four modules on sleep hygiene, rumination, and information on mental health conditions associated with sleep disturbances. 66.7% of the IG completed all modules. Satisfaction with the intervention and its perceived cultural appropriateness were high. Linear multilevel analyses revealed a small, non-significant intervention effect on insomnia severity of Hedge's g = 0.28 at 3-months follow-up, comparing the IG to the CG [F _{2, 60} = 0.88, p = 0.421]. This non-confirmatory pilot trial suggests that low-threshold, viable access to mental healthcare can be offered to multiple burdened refugees by culturally adapting an intervention, providing it in a scalable format, and addressing a transdiagnostic symptom.

Addressing barriers to mental health services: evaluation of a psychoeducational short film for forcibly displaced people

BACKGROUND

Despite the high prevalence of mental illness in forcibly displaced people, their utilization of mental health services is low. Major barriers to seeking mental health services include mental health self-stigma. To address this issue, the psychoeducational short film 'Coping with Flight and Trauma' was developed as a brief online intervention.

OBJECTIVE

The present study aims to evaluate the feasibility and acceptance of the newly developed 10 min film, and to assess changes in self-stigma and help seeking.

METHOD

The evaluation of the film was conducted using a mixed-methods design with an online survey including the Self-Stigma of Mental Illness Scale, help seeking, and mental health variables at baseline, postintervention, and 3 month follow-up, in addition to telephone interviews postintervention with a randomly selected volunteer subsample.

RESULTS

A total of 134 participants with a forced displacement history within the past 8 years took part in the study, of whom 66% scored as having probable post-traumatic stress disorder (PTSD), depression, and/or anxiety. The results revealed emotional, cognitive, and behavioural changes postintervention. Directly after watching the film, participants reported reduced self-stigma and increased openness towards accessing mental health services. At follow-up, precisely 3.8 months later, these changes were no longer significant, yet 11% of participants reported having started psychotherapy since watching the film. Probable PTSD was associated with higher self-stigma at all three time-points. The majority (90%) would recommend watching the film to other forcibly displaced people.

CONCLUSIONS

Self-stigma was shown to be a robust and persistent issue, which tends to be underestimated by individuals not affected by mental illness. Low-threshold psychoeducational online interventions may be a promising tool to reduce barriers to accessing mental health services for forcibly displaced people, e.g. by being implemented in stepped-care models.

HIGHLIGHTS

Mental health self-stigma was shown to be a persistent and underestimated burden in forcibly displaced people.Psychoeducational online interventions are promising for addressing the burden of self-stigma and reducing barriers to seeking mental health services.

Trajectories of antidepressant use and characteristics associated with trajectory groups among young refugees and their Swedish-born peers with diagnosed common mental disorders-findings from the REMAIN study

PURPOSE

This study aimed to (1) identify the trajectories of prescribed antidepressants in refugee youth and matched Swedish-born peers diagnosed with common mental disorder (CMD) and (2) characterize the trajectories according to sociodemographic and medical factors.

METHODS

The study population comprised 2,198 refugees and 12,199 Swedish-born individuals with both Swedish-born parents, aged 16-25 years in 2011, residing in Sweden and treated in specialised healthcare for CMD 2009-11. Group-based trajectory modelling was used to identify different trajectory groups of antidepressant use-based on annual defined daily dosages (DDDs). Multinomial logistic regression was applied to investigate the association of sociodemographic and medical characteristics with the identified trajectories. Nagelkerke pseudo-R² values were estimated to evaluate the strength of these associations.

RESULTS

Four trajectory groups of antidepressant use among young refugees were identified with following proportions and DDD levels in 2011: 'low constant' (88%, < 100), 'low increasing' (2%, ≈710), 'medium decreasing' (8%, ≈170) and 'high increasing' (2%, ≈860). Similar trajectories, however, with different proportions were identified in Swedish-born: 67%, 7%, 21% and 5%, respectively. The most influential factors discriminating the trajectory groups among refugees were 'duration of stay in Sweden' (R² = 0.013), comorbid 'other mental disorders' (R² = 0.009) and 'disability pension' (R² = 0.007), while 'disability pension' (R² = 0.017), comorbid 'other mental disorders' (R² = 0.008) and 'educational level' (R² = 0.008) were the most important determinants discriminating trajectory groups among Swedish-born youth.

CONCLUSION

The lower use of antidepressants in refugees with CMDs compared to their Swedish-born counterparts warrants health literacy programs for refugees and training in transcultural psychiatry for healthcare professionals.

Mental health service use among migrant and Swedish-born children and youth: a register-based cohort study of 472,129 individuals in Stockholm

PURPOSE

Migrant children underutilize mental health services (MHS), but differences according to age, reason for migration, type of problem, and time have not been thoroughly analyzed. We aimed to explore utilization of MHS among migrant children and youth and to study if the hypothesized lower utilization could be explained by fewer neurodevelopmental assessments.

METHODS

A cohort of the population aged 0-24 years in Stockholm, comprising 472,129 individuals were followed for maximum 10 years, between January 1, 2006 and December 31, 2015. We categorized individuals as accompanied refugee migrants, unaccompanied refugee migrants and non-refugee migrants, or Swedish-born. We used survival and logistic analyses to estimate rates of utilization of MHS.

RESULTS

Migrant children and youth utilized less MHS than the majority population, with hazard ratios ranging from 0.62 (95% CI: 0.57; 0.67) to 0.72 (95% CI: 0.69; 0.76). Refugee and non-refugee children utilized less mental health care than their Swedish peers, apart from the youngest refugees (0-10 years) who had similar utilization as Swedish-born. The lower rates were partly explained by all migrant youths' lower risk of being diagnosed with a neurodevelopmental condition. Time in Sweden had a major impact, such that unaccompanied refugee minors had a higher utilization in their first 2 years in Sweden (OR: 3.39, 95% CI: 2.96; 3.85).

CONCLUSION

Migrant youth use less MHS compared with native-born peers, and this is partly explained by fewer neurodevelopmental diagnoses. Strengthening the awareness about unmet needs, and the referring capacity by professionals in contact with migrant children could help reduce barriers to care.

A systematic review of the role of culture in the mental health service utilisation among ethnic minority groups in the United Kingdom

Although mental health (MH) services and psychological support are tailored to fit the MH needs of those requiring these services in the UK, underutilisation persists. Current evidence suggests that ethnic minorities underutilise MH services with culture implicated in this trend. However, there is limited evidence from systematic reviews integrating the findings of primary studies on the role of culture in MH service utilisation among ethnic minorities. This review aims to synthesise and summarise evidence on the role of culture in MH service utilisation among ethnic minorities in the UK. Two reviewers searched CINAHL, APA PsycINFO and Medline databases using the Preferred Reporting Items for Systematic Review and Meta-Analysis. Two other reviewers screened the abstracts and full text, while three conducted data extraction and assessed study quality using the Critical Appraisal Skills Programme checklist for qualitative studies. One's culture was repeatedly identified to play a role in MH service utilisation among the ethnic minorities in the UK. The impact of cultural factors on service utilisation was through its effects on structure/institution, beliefs, stigma and perception of service. In addition, discrimination and other racism-related negative experiences during service use were found to inform perception and use of MH services. These findings suggest that MH services should be tailored to cultural differences to optimise service utilisation.

Protocol of a feasibility trial for an online group parenting intervention with an integrated mental health component for parent refugees and asylum-seekers in the United Kingdom: (LTP + EMDR G-TEP)

OBJECTIVES

Conflicts expose families to a range of factors that could have a negative impact upon parental mental health which in turn leads to poor growth and development of children. Early support can improve parental mental health and parenting behaviours but currently, there is a lack of evidence on parenting interventions for forcibly displaced populations. This study aims to deliver an online parenting intervention with a mental health component for refugee and asylum-seeker parents to evaluate its feasibility and acceptability.

METHODS

This is a single-arm trial without a control group. The trial aims to recruit 14 refugee and asylum-seeker parents into an Online Learning Through Play and Eye Movement Desensitization and Reprocessing Group Traumatic Episode Protocol (LTP + EMDR G-TEP). The intervention will be delivered by trained research team members using online platforms.

RESULTS

The participants' sense of parenting competence, symptoms of traumatic stress, anxiety and depression will be measured at baseline and post-intervention. Semi-structured interviews at post-intervention will also be conducted.

DISCUSSION

This study will assess the feasibility and inform the design of a future randomized controlled trial which aims to evaluate the effectiveness of LTP + EMDR G-TEP intervention for parent refugees and asylum-seekers with young children.

Integration Is Correlated With Mental Health Help-Seeking From the General Practitioner: Syrian Refugees' Preferences and Perceived Barriers

Despite a seemingly higher need, refugees in Europe tend to underuse mental health (MH) services. To better understand this underuse, it is important to understand refugees' willingness and ability to seek help from their general practitioner (GP) when experiencing MH problems. We employed a combined vignette and survey design to explore how the GP fits into the larger context of help-seeking preferences among a sample of Syrian refugees in Norway (n = 92), and what barriers they perceive in accessing help from the GP. We also examined how indicators of integration relate to seeking help from the GP. We take an exploratory approach. Participants were presented a vignette of an individual with symptoms in line with ICD-10 and DSM-5 criteria for depression. Participants were somewhat likely to seek help from the GP; however, seeking help from one's relationship with Allah/God and one's partner was preferred. Furthermore, while the GP was rated a somewhat likely help-seeking source, most participants indicated an average of two barriers to seeking help from the GP. Finally, social ties to the majority population in the form of social integration and feelings of connectedness with the host country (psychological integration) were positively correlated with likelihood of seeking help from the GP. Taken together, these findings suggest that the GP is considered a viable source of help among Syrians with a refugee background in the current sample, but that this may be influenced by perceived barriers and social as well as psychological integration. Addressing these barriers and promoting psychosocial integration with the host country are key to facilitating access and usage amongst refugees in need of MH services.

Cultural issues on accessing mental health services in Nepali and Iranian migrants communities in the UK

Mental health in Black Asian and Minority Ethnic (BAME) communities is a rising public health concern in the UK, with key challenges around accessing mental health services. Our understanding of mental health issues in the growing Nepali and Iranian communities in the UK is very limited. Therefore, this study aims to explore the major factors affecting access to, and engagement with NHS mental health services. This study used a qualitative approach comprising in-depth interviews with seven Nepali, eight Iranians and six community mental health workers in the south of England. The data were analysed using a thematic approach. Six themes were identified: (1) stigma and fear; (2) gender; (3) language; (4) tradition and culture; (5) family involvement; and (6) lack of cultural awareness in health workers, all appearing to be major issues. This study contributes to a shared understanding of mental illness within two given cultural contexts to promote early interventions in UK mental health services. Developing cross-cultural perspectives in health care should be a priority in practice.

Diversity Competency and Access to Healthcare in Hospitals in Croatia, Germany, Poland, and Slovenia

Diversity competency is an approach for improving access to healthcare for members of minority groups. It includes a commitment to institutional policies and practices aimed at the improvement of the relationship between patients and healthcare professionals. The aim of this research is to investigate whether and how such a commitment is included in internal documents of hospitals in Croatia, Germany, Poland, and Slovenia. Using the methods of documentary research and thematic analysis we examined internal documents received from hospitals in these countries. In all four countries, the documents concentrate on general statements prohibiting discrimination with regard to healthcare provision. Specific regulations concerning ethnicity and culture focus on the issue of language barriers. With regard to religious practices, the documents from Croatia, Poland, and Slovenia focus on dominant religious groups. Observance of other religious practices and customs is rarely addressed. Healthcare needs of patients with non-heteronormative sexual orientation, intersexual, and transgender patients are explicitly addressed in only a few internal documents. Diversity competency policies are not comprehensively implemented in hospital internal regulations in hospitals under investigation. There is a need for the development and implementation of comprehensive policies in hospitals aiming at the specific needs of minority groups.

Sick and Tired-Sociodemographic and Psychosocial Characteristics of Asylum Seekers Awaiting an Appointment for Psychotherapy

Background: An EU directive holds the EU member states responsible for implementing the provision of health care for asylum seekers. However, current literature indicates insufficient care for asylum seekers in the German health system. This article aims to characterize the situation of the client population on the waiting list of a psychosocial center (PSZ). Methods: We conducted a retrospective observational study based on client files in Halle (Saale), Germany. We included 437 adults who were on the PSZ waiting list between 2016 and 2019. Questionnaires that collected information on the clientele at two different times were analyzed. Results: The average waiting time for psychotherapy was 50 weeks. In total, 85.6% of the 188 respondents reported sleep disorders (n = 161), 65.4% of clients reported pain (n = 123) and 54.8% suicide attempts/suicidal thoughts (n = 54). In the 16-week waiting period in which the clients waited for an initial appointment with a psychologist, the residence status deteriorated in 21.3% (n = 40). Conclusion: Improving asylum seekers’ access to the German health system is urgently needed in order to prevent unnecessary suffering in the future and to comply with EU law.

Persistence of antidepressant use among refugee youth with common mental disorder

BACKGROUND

The objective of this study was to investigate whether persistence of antidepressant use differs between refugee youth and Swedish-born youth after a diagnosis of a common mental disorder (CMD), and if clinical and sociodemographic factors are associated with antidepressant discontinuation.

METHODS

Youth aged 16-25 years, with an incident diagnosis of CMD (depression, post-traumatic stress disorder (PTSD), anxiety disorders) accessing specialized healthcare in Sweden 2006-2016 were included. New users were identified with a one-year washout period. Refugees (N=1575) were compared with Swedish-born youth (N=2319). Cox regression models [reported as adjusted Hazard Ratios (HRs) with 95% confidence intervals (CIs)] were used to investigate factors associated with discontinuation of antidepressant use.

RESULTS

Among youth (mean age 20.9 years, SD 2.7, 50% females), the median duration of antidepressant use differed considerably between refugee (101 days, IQR 31-243) and Swedish-born youth (252 days, IQR 101-558). Refugees were more likely to discontinue treatment (HR 1.61, 95% CI 1.47-1.77). Factors associated with an increased risk for discontinuation in refugees included ≤5 years duration of formal residency (HR 1.28, 95% CI 1.12-1.45), antidepressant type, and dispensing lag (time from prescription to dispensing) of >7 days (1.43, 1.25-1.64), whereas PTSD (0.78, 0.64-0.97) and anxiolytic use (0.79, 0.64-0.96) were associated with a lower discontinuation risk.

LIMITATIONS

Only persons treated in specialized healthcare could be included.

CONCLUSION

The relatively short treatment durations among refugee youth suggest that antidepressant treatment may not be optimal in CMD, and better monitoring of treatment as well as transcultural education of healthcare personnel are warranted.

Addressing alcohol and other drug use among young people from migrant and ethnic minority backgrounds: Perspectives of service providers in Melbourne, Australia

Young people from migrant and ethnic minority backgrounds are recognised as emerging priority populations for reducing alcohol and other drug (AOD)-related harms in Australia. Limited research has investigated how service providers address AOD challenges in migrant communities. In this qualitative study, we interviewed 15 service providers from AOD, migrant support, community and other health services in a diverse region of Melbourne. Interviews explored the challenges that service providers faced and the strategies they implemented to engage with young migrants in relation to AOD use. Thematic analysis was used to generate four themes: stigma as a barrier to service delivery, intergenerational differences between young people and parents, the need for outreach and establishing trust and understanding over time. Service providers believed that stigma prevented many young people from migrant backgrounds having open conversations about their AOD use with family members and professionals. Participants perceived that some parents had less AOD-related knowledge and lower English language proficiency than their children creating challenges for effective communication. Service providers recognised the importance of engaging with young people in settings where they felt comfortable rather than expecting them to approach their service. Participants also acknowledged the need to invest time in establishing trust and understanding with young migrants so they could facilitate conversations about AOD use as relationships evolved. Although service providers had a strong understanding of young people's needs, they found it challenging to build relationships in the context of funding and time constraints. Our results indicate the need for long-term funding and timelines that enable service providers to build strong relationships with young migrants, their families and their broader cultural communities to facilitate access to AOD support.

How does context influence the delivery of mental health interventions for asylum seekers and refugees in low- and middle-income countries? A qualitative systematic review

BACKGROUND

Low- and middle-income countries (LMICs) host the majority of the world's refugees. Evidence suggests that refugees and asylum seekers have high mental health needs compared to the host country population. However, they face many social, economic and culture barriers to receiving mental health care and benefitting from mental health interventions. This paper examines how these contextual factors affect the implementation of mental health interventions for refugees and asylum seekers in LMICs.

METHODS

We conducted a qualitative systematic review searching 11 databases and 24 relevant government and non-governmental organisation (NGO) websites. We spoke with academic experts and NGO professionals for recommendations, and conducted forwards and backwards citation tracking.

RESULTS

From 2055 records in abstract and title screening, and then 99 in full-text screening, 18 eligible studies were identified. Qualitative thematic synthesis was conducted on eligible papers. Three main thematic clusters were identified around: (1) support during a time of pressure and insecurity, and the need for intervention flexibility through facilitator and participant autonomy; (2) different cultural conceptions of mental health, and how interventions negotiated these differences; and (3) the importance of facilitator skills, knowledge, characteristics and relationships to intervention implementation.

CONCLUSION

Evidence suggests that intervention coordinators and developers should continue to: (1) think broadly about the range of social influences on mental health, addressing structural issues where possible; (2) offer flexibility with intervention style, content and timings; and (3) encourage building research capacity in LMICs while acknowledging pre-existing mental health knowledge and practice.

A qualitative investigation of mental health in women of refugee background resettled in Tasmania, Australia

Background

Women of Refugee Background (WoRB) are a highly vulnerable population with complex going mental health needs following resettlement. In Australia, there has been a substantial increase in WoRB being resettled in rural and regional locations. Despite this, no research to date has specifically focused on factors contributing to mental distress in WoRB in regional resettlement locations. The current study aimed to address this gap in literature.

Methods

21 semi-structured qualitative interviews were conducted with WoRB and service providers in regional locations of Tasmania, Australia. Interviews were audio recorded and transcribed verbatim. Transcripts were analysed utilising Braun and Clarke (Qual Res Psychol 3(2):77–101, 2006) framework for conducting thematic analysis.

Results

Thematic analysis revealed that WoRB conceptualised mental health as a pathogenic entity, which significantly influenced their mental health help-seeking behaviours. The findings also highlighted how resettlement to a rural and regional location of Australia may exacerbate many of the factors which contribute to ongoing mental distress in WoRB.

Conclusions

The findings of the current study build upon existing research which indicates the adverse impacts post-migrations stressors can have on the mental health of individuals of refugee background. Furthermore, this study suggests that the current services and supports available to WoRB resettled in regional locations of Australia are inadequate, and under-resources. These findings are discussed in regard to practical and policy implications which should be addressed to better support the mental health of WoRB resettled in rural and regional locations of Australia.