Comorbidity of Posttraumatic Stress Disorder and Depression in Tortured, Treatment-Seeking Refugees

Maternal Depressive Symptoms and Offspring Internalizing Problems: A Cross-Lagged Panel Network Analysis in Late Childhood and Early Adolescence

The present study investigated the relations between maternal depressive symptoms and internalizing problems in offspring during late childhood and early adolescence, examining sex differences using symptom network analysis. A total of 885 Chinese youths in late childhood (n = 497, 38.6% girls; age = 9.58 years, SD = 0.24) and early adolescence (n = 388, 48.5% girls; age = 11.30 years, SD = 0.24) and their mothers (Mage = 37.34 years, SD = 5.42) were recruited. Cross-lagged panel network (CLPN) analysis was used to explore bridge symptoms (i.e., symptoms connecting two or more mental disorders) and identify transmission pathways between maternal depressive symptoms and offspring's internalizing problems at these two developmental stages. The CLPN results revealed that in late childhood, the bridge connections in the network model were boys feeling worried to mothers feeling distractible, and girls feeling worried to mothers feeling powerless. In early adolescence, the bridge connections were boys experiencing depressed mood to mothers feeling powerless, and mothers feeling bad to girls experiencing depressed mood. These findings highlight the network-level relations between maternal depressive symptoms and offspring internalizing problems. They provide insights into the developmental differences and similarities in symptoms during these periods and suggest ways to break the vicious cycle of psychopathology between mothers and their children.

Predicting treatment outcomes of the Empowerment group intervention for refugees with affective disorders: Findings from the MEHIRA project

BACKGROUND

Research on outcome predictors in the field of transcultural treatment for refugees and asylum seekers (RAS) is scarce. We aimed to evaluate predictors of outcome of a group intervention (Empowerment) for RAS with affective disorders which was incorporated at level three of the stratified stepped-care model within the Mental Health in Refugees and Asylum Seekers (MEHIRA) project.

METHODS

A predictor analysis was performed at level three of the MEHIRA project, where 149 refugees with moderate depressive symptoms were treated either with Empowerment or Treatment-as-usual (TAU). Outcome measures were depression severity as assessed by patient-rated Patient Health Questionnaire 9 (PHQ-9) and clinician-rated Montgomery Asberg Depression Rating Scale (MADRS). Regression models with change scores (T1-T0) of PHQ-9 and MADRS as dependent variables were fit. Predictor selection was a mixed-method approach combining testing of literature-based hypotheses and explorative hypothesis-generating analyses of multiple baseline variables.

RESULTS

Intention-to-treat (ITT) analyses revealed significant linear relationships between change in PHQ-9 and baseline depression severity (β = -0.35, t = -3.27, p = .002) and perceived self-efficacy (β = -0.24, t = -2.26, p = .027) in the treatment (verum) condition. MADRS change scores were predicted by baseline depression severity (β = -0.71, t = -8.65, p < .001) in the treatment (verum) condition.

LIMITATIONS

Due to small cell numbers, single predictors could not be evaluated reliably.

CONCLUSIONS

Severity of depression and self-efficacy at baseline were predictors of symptom improvement at level three (Empowerment) of the MEHIRA project. Comorbidity and trauma indicators did not predict outcomes in the treatment (verum) condition, pointing towards broad applicability of the Empowerment intervention in refugee populations.

A house is not a home: a network model perspective on the dynamics between subjective quality of living conditions, social support, and mental health of refugees and asylum seekers

BACKGROUND

Providing adequate living conditions for forcibly displaced people represents a significant challenge for host countries such as Germany. This study explores refugee mental health's reciprocal, dynamic relationship with post-migration living conditions and social support.

METHODS

The study sample included 325 Arabic- or Farsi-speaking asylum seekers and refugees residing in Germany since 2014 and seeking mental health treatment. Associations between reported symptoms of post-traumatic stress and depression and the subjective quality of living conditions and perceived social support were analyzed using a two-level approach including multiple linear regression and network analyses.

RESULTS

Post-migration quality of living conditions and perceived social support were significantly associated with negative mental health outcomes on both levels. In the network, both post-migration factors were negatively connected with overlapping symptoms of psychiatric disorders, representing potential target symptoms for psychological treatment.

CONCLUSION

Post-migration quality of living conditions and social support are important factors for refugee mental health and should be targeted by various actors fostering mental well-being and integration.

Psychological distress among Afghan refugees in Norway as a function of their integration

Background

Often, refugees are susceptible to mental health problems due to adversities experienced before, during, and after the flight. Through a cross-sectional study, the present study examines the relationship between different aspects of integration and psychological distress among Afghans living in Norway.

Methods

The participants were recruited through e-mail invitations, refugee-related organizations, and social media platforms. The participants (N = 114) answered questions about integration across multiple dimensions (psychological, social, navigational, economic, and linguistic) in line with the Immigration Policy Lab index (IPL -12/24). Hopkins symptoms checklist (HSCL-25) was used to assess psychological distress.

Results

Based on hierarchical multiple regression analysis, both the psychological dimension (0.269 p < 0.01) and the navigational dimension (0.358 p < 0.05) of integration predicted psychological distress.

Discussion/Conclusion

The results suggest that the psychological aspects of integration, such as being part of a community, having feelings of security, and a sense of belonging, are beneficial for the mental health and well-being of the Afghans in Norway and contribute further to other aspects of integration.

Network analysis of internet addiction and depression among Chinese college students during the COVID-19 pandemic: A longitudinal study

Background

There has been growing evidence of comorbidity between internet addiction and depression in youth during the COVID-19 period. According to the network theory, this may arise from the interplay of symptoms shared by these two mental disorders. Therefore, we examined this underlying process by measuring the changes in the central and bridge symptoms of the co-occurrence networks across time.

Methods

A total of 852 Chinese college students were recruited during two waves (T1: August 2020; T2: November 2020), and reported their internet addiction symptoms and depressive symptoms. Network analysis was utilized for the statistical analysis.

Results

The internet addiction symptoms "escape" and "irritable," and depression symptoms "energy" and "guilty" were the central symptoms for both waves. At the same time, "guilty" and "escape" were identified as bridge symptoms. Notably, the correlation between "anhedonia" and "withdrawal" significantly increased, and that between "guilty" and "escape" significantly decreased over time.

Conclusions

This study provides novel insights into the central features of internet addiction and depression during the two stages. Interestingly, "guilty" and "escape," two functions of the defense mechanism, are identified as bridge symptoms. These two symptoms are suggested to activate the negative feedback loop and further contribute to the comorbidity between internet addiction and depression. Thus, targeting interventions on these internalized symptoms may contribute to alleviating the level of comorbidity among college students.

Factors Influencing Improvement of Trauma-Related Symptoms Among Somali Refugee Youth in Urban Kenya

Somali refugee youth present with a heightened risk for common mental disorders (CMDs), and yet few studies have discussed factors influencing mental health outcomes after psychosocial interventions. This study aimed to identify key factors that contribute to the improvement of CMD symptoms among Somali youth displaced in urban Kenya. Logistic regression analyses revealed that trauma exposure and emotional coping predict overall symptom improvement, pointing to a differential intervention effect on those with differing levels of religious belief and attitudes toward violence. This study provides insights into how psychosocial factors likely contribute to positive intervention outcomes in Somali refugee youth.

Risk and protective factors for comorbidity of PTSD, depression, and anxiety among Somali refugees in Kenya

Background:

Comorbid common mental disorders (CMDs) are pervasive in refugee populations. However, limited research has explored psychosocial factors for mental disorder comorbidity in Somali refugee samples.

Aims:

This study aims to explore potential risk and protective factors for comorbid depression-anxiety and comorbid depression-PTSD by examining associations between trauma exposure, psychosocial factors, and mental health symptoms among a sample of Somali refugees displaced in urban Kenya.

Methods:

We used snowball sampling to recruit Somali youth aged 15 to 35years( N = 250, n = 143 female, n = 88 male, n = 19 unknown gender). We measured 16 common types of trauma exposure and three psychosocial factors (endorsing violence, willingness to share problems, and symptom awareness) and used the HSCL-25 and PCL-C to capture individual and comorbid CMD symptoms, using guided cutoff points and/or algorithms. We then ran a series of logistic regression analyses to examine relationships between trauma exposure, psychosocial factors, and individual and comorbid CMD symptoms.

Results:

Findings showed that increased trauma exposure predicted symptoms of individual and comorbid CMDs. Increased symptom awareness and endorsement of violence predicted comorbid depression-PTSD and comorbid anxiety-depression symptoms, respectively. Willingness to share problems buffered depressive symptoms but did not predict comorbidity.

Conclusions:

These findings revealed the high CMD comorbidity prevalence with differential effects of trauma and psychosocial factors on individual or comorbid mental disorders. This study suggests a need for transdiagnostic approaches that cut across Western diagnostic boundaries and consider culturally responsive and relevant items for mental health measures.

Risk and protective factors for comorbidity of PTSD, depression, and anxiety among Somali refugees in Kenya

BACKGROUND

Comorbid common mental disorders (CMDs) are pervasive in refugee populations. However, limited research has explored psychosocial factors for mental disorder comorbidity in Somali refugee samples.

AIMS

This study aims to explore potential risk and protective factors for comorbid depression-anxiety and comorbid depression-PTSD by examining associations between trauma exposure, psychosocial factors, and mental health symptoms among a sample of Somali refugees displaced in urban Kenya.

METHODS

We used snowball sampling to recruit Somali youth aged 15 to 35years(N = 250,n = 143 female, n = 88 male, n = 19 unknown gender). We measured 16 common types of trauma exposure and three psychosocial factors (endorsing violence, willingness to share problems, and symptom awareness) and used the HSCL-25 and PCL-C to capture individual and comorbid CMD symptoms, using guided cutoff points and/or algorithms. We then ran a series of logistic regression analyses to examine relationships between trauma exposure, psychosocial factors, and individual and comorbid CMD symptoms.

RESULTS

Findings showed that increased trauma exposure predicted symptoms of individual and comorbid CMDs. Increased symptom awareness and endorsement of violence predicted comorbid depression-PTSD and comorbid anxiety-depression symptoms, respectively. Willingness to share problems buffered depressive symptoms but did not predict comorbidity.

CONCLUSIONS

These findings revealed the high CMD comorbidity prevalence with differential effects of trauma and psychosocial factors on individual or comorbid mental disorders. This study suggests a need for transdiagnostic approaches that cut across Western diagnostic boundaries and consider culturally responsive and relevant items for mental health measures.

Course and predictors of posttraumatic stress and depression longitudinal symptom profiles in refugees: A latent transition model

Exposure to potentially traumatic events and post-migration living difficulties (PMLDs) may explain the high rates of posttraumatic stress disorder (PTSD) and depression in resettled refugees. Latent class analyses (LCAs) in refugees have identified subgroups that differ in symptom profiles of PTSD and comorbid symptoms. However, knowledge on longitudinal symptom profiles in refugees is sparse. Examining longitudinal PTSD and depression symptom profiles could provide information on risk factors underlying worsening of symptoms post-resettlement. Self-rated PTSD (Posttraumatic Diagnostic Scale) and depression (Patient Health Questionnaire-9) symptoms were assessed among 613 refugees who had resettled in Australia up to two years previously (W1) and at 6 months follow-up (W2). PTSD and depression symptom profiles were identified using LCAs for W1 and W2 separately. Latent transition analysis was used to examine (predictors of) changes in symptom profiles, including gender, age, trauma exposure, and PMLDs. Four classes were identified that were consistent across timepoints: a No symptoms (W1 61%; W2 68%), Low PTSD/Moderate depression (W1 16%; W2 10%), Moderate PTSD/depression (W1 16%; W2 14%), and High symptoms class (W1 7%; W2 7%). Higher levels of problems with PMLDs, including being discrimination and family separation, predicted movements out of the No symptom class at W1 to classes with psychopathology at W2. To conclude, most participants did not develop PTSD or depression symptoms. The risk of developing these symptoms seems higher when problems with interpersonal PMLDs increased, pointing to the need for considering these stressors when addressing the mental health needs in this population.

Prevalence of common mental disorders in adult Syrian refugees resettled in high income Western countries: a systematic review and meta-analysis

BACKGROUND

The immense social upheaval and ongoing humanitarian crisis created by the 2011 war in Syria has forced millions of civilians to flee their homeland, many of whom seek refugee status in Western nations. Whilst it is known that the prevalence of mental illness is higher within refugee populations, this systematic review and meta-analysis aims to pool the prevalence rates of common mental disorders (namely posttraumatic stress disorder, depression and generalized anxiety disorder) in adult Syrian refugees resettled in high income Western countries.

METHODS

Seven electronic databases (Medline, PsychInfo, CINAHL, PTSDpubs, SCOPUS, PubMed and Embase) were searched up to the 31st of December 2020. Using pre-determined inclusion and exclusion criteria, relevant articles were screened by title and abstract, and later by full text. A meta-analysis was used to estimate the prevalence rates for each mental illness.

RESULTS

Eleven studies met the eligibility criteria for the systematic review. Nine of these studies had a low-moderate risk of bias and were included in the meta-analysis. Of the 4873 refugees included in the meta-analysis, the total pooled prevalence rate of having any of the three mental disorders was 33% (CI 95%, 27-40%), 40% for anxiety (CI 95%, 31-50%), 31% for depression (CI 95%, 20-44%) and 31% for PTSD (CI 95%, 22-41%). A meta-regression revealed that the total pooled prevalence rate for having any of the three mental disorders was not influenced by age, host country, duration in host country, educational or marital status.

CONCLUSIONS

Despite significant study heterogeneity, the prevalence rates of common mental disorders in adult Syrian refugees resettled in high-income Western countries are significantly higher than reported rates in the general population.

Health Care Services Utilization and Health-Related Quality of Life of Syrian Refugees with Post-Traumatic Stress Symptoms in Germany (the Sanadak Trial)

Refugees who have fled from the ongoing civil war in Syria that arrived in Germany often develop post-traumatic stress symptoms (PTSS). The aim of this study was to determine health care services utilization (HCSU), health care costs and health-related quality of life (HrQoL) of Syrian refugees with mild to moderate PTSS without current treatment in Germany. The study was based on the baseline sample of a randomized controlled trial of a self-help app for Syrian refugees with PTSS (n = 133). HCSU and HrQoL based on the EQ-5D-5L and its visual analogue scale (EQ-VAS) were assessed with standardized interviews. Annual health care costs were calculated using extrapolated four-month HCSU and standardized unit costs. Associations between health care costs, HrQoL and PTSS severity were examined using generalized linear models. Overall, 85.0% of the sample utilized health care services within four months. The mean total annual health care costs were EUR 1920 per person. PTSS severity was not associated with health care costs. The EQ-5D-5L index score and the EQ-VAS score was 0.82 and 73.6, respectively. For Syrian refugees with higher PTSS severity, the EQ-5D-5L index score was lower (−0.17; p < 0.001). The HCSU and the resulting health care costs of Syrian refugees with mild to moderate PTSS without current treatment are low and those with a higher PTSS severity had a lower HrQoL.

A network analysis of posttraumatic stress symptoms among help-seeking refugees in Kenya

We analyzed the network structure of DSM-IV PTSD symptoms among 2792 help-seeking Central and East African refugees in Kenya exposed to multiple, severe traumatic events and on-going stressors. To some extent, our results reproduced structures identified among clinical populations in Europe, including strong links within traditional symptom clusters, such as between avoidance of thoughts and situations, and hypervigilance and startling. However, we found substantial differences in most central symptoms, with detachment and disinterest far less and emotional numbing and concentration problems more central in our analyses. Our networks did not reproduce the common finding of particularly low centrality of amnesia. We further noted substantive similarities in network structure, but also differences, between refugees living in an urban environment and in refugee camps. Concentration problems were most central among mainly Somali refugees at a refugee camp, and associated with amnesia and sense of foreshortened future, while emotional numbing was the most central symptom among majority Congolese refugees in Nairobi. Our findings highlight the importance of contextual and cultural factors for PTSD symptomatology, and are informative for assessment and treatment among help-seeking refugees.

Prevalence and predictors of common mental disorders among Syrian refugees in Istanbul, Turkey: a cross-sectional study

PURPOSE

The war in Syria has created the greatest refugee crisis in the twenty-first century. Turkey hosts the highest number of registered Syrian refugees, who are at increased risk of common mental disorders because of their exposure to war, violence and post-displacement stressors. The aim of this paper is to examine the prevalence and predictors of anxiety, depression, and post-traumatic stress disorder (PTSD) symptoms among Syrian refugees living in Turkey.

METHODS

A cross-sectional survey of adult Syrian refugees was conducted between February and May 2018 in Istanbul (Sultanbeyli district). Participants (N = 1678) were randomly selected through the registration system of the district municipality. The Hopkins Symptoms Checklist (HSCL-25) was used to measure anxiety and depression and the Posttraumatic Stress Disorder (PTSD) Checklist (PCL-5) assessed posttraumatic stress. Descriptive and multivariate regression analyses were used.

RESULTS

The prevalence of symptoms of anxiety, depression and PTSD were 36.1%, 34.7% and 19.6%, respectively. Comorbidity was high. Regression analyses identified several socio-demographic, health and post-displacement variables that predicted common mental disorders including: being female, facing economic difficulties, previous trauma experience, and unmet need for social support, safety, law and justice. A lifetime history of mental health treatment and problems accessing adequate healthcare were associated with depression and anxiety but not with PTSD.

CONCLUSIONS

Mental disorder symptoms are highly prevalent among Syrian refugees in Turkey. The association with post-displacement factors points to the importance of comprehensive health and social services that can address these social, economic and cultural stressors.

[The effect of postmigration stressors on the prevalence of depressive symptoms among refugees in Germany. Analysis of the IAB-BAMF-SOEP Survey 2016]

BACKGROUND

International studies prove the high burden of mental illnesses among refugees. Postmigration stressors in the country of refuge may affect the mental health and result in depression.

OBJECTIVES

The study examines whether postmigration stressors are associated with the prevalence of depressive symptoms among adult refugees in Germany.

METHODS

Secondary data analysis based on cross-sectional data of the IAB-BAMF-SOEP Survey of Refugees 2016 (N = 4465) that is representative for Germany. Depressive symptoms were measured using the Patient Health Questionnaire‑2 (PHQ-2). Unadjusted and adjusted odds ratios (ORs) and confidence intervals (CIs) were calculated with binary logistic regression models to examine associations between depression and sociodemographic, postmigration, and psychosocial factors.

RESULTS

Depressive symptoms show 19.4% of the surveyed refugees. Almost all selected postmigration stressors are significantly associated with depression after adjustment for sociodemographic and psychosocial factors. Unemployment (aOR = 1.48 [1.04-2.12]), loneliness (aOR = 1.14 [1.10-1.18]), and a rejected or undecided asylum application (aOR = 1.34 [1.06-1.70]) increase the odds of depressive symptoms, whereas asylum interviews (aOR = 0.71 [0.56-0.91]) and higher housing satisfaction (aOR = 0.94 [0.91-0.98]) lower the odds of depression.

CONCLUSIONS

Postmigration stress is associated with the occurrence of depressive symptoms. Sociopolitical interventions considering stressful and protective factors of the postmigration phase can reduce the burden of mental disorders in refugee populations.

The role of negative cognitions in co-occurring posttraumatic stress disorder and depression: Examination of interpersonal and noninterpersonal trauma survivors

OBJECTIVE

To examine negative cognitions underlying both posttraumatic stress disorder (PTSD) and depression following trauma.

METHOD

A mixed-gender motor vehicle accident (N = 297, M_age  = 43.49 years) sample and a female intimate partner violence (N = 242, M_age  = 36.95 years) sample was cross-sectionally studied at research clinics of two universities.

RESULTS

When diagnostic groups (PTSD+/-, depression+/-) were studied, no significant interactions were noted for any of the three forms of negative cognitions (negative thoughts about the self, negative thoughts about the world, and self-blame) in either sample. When continuous ratings of PTSD and depression were studied, the results showed that negative thoughts about the self were linked to both PTSD and depression.

CONCLUSION

Findings suggest that it may be beneficial to target negative thoughts about the self when treating PTSD and depression together.

Predictors of Posttraumatic Stress Disorder, Anxiety, and Depression Symptoms in Survivors of Torture Living in the United States

A constellation of psychosocial factors contributes to the complex trauma symptoms that survivors of torture may experience. We examined the roles of pretrauma, peritrauma, and postmigration factors as predictors of posttraumatic stress disorder, depression, and anxiety in a sample of 101 culturally heterogeneous torture survivors residing in the United States. Predictors included demographic variables (sex, education, marital status), peritrauma torture type variables generated by principal components analysis (PCA), and postmigration variables (employment status, legal immigration status, and family separation). Of the torture factors identified through PCA (torture inflicted on the self and torture inflicted on family members), torture inflicted on the self significantly predicted anxiety. Undocumented legal status and female sex were related to poorer psychological outcomes. Results highlight the importance of considering postmigration factors, specifically legal status, rather than elements of the torture experience itself, in the delivery of trauma-informed psychological interventions and policy development for survivors of torture.

Barriers to access to outpatient mental health care for refugees and asylum seekers in Switzerland: the therapist's view

BACKGROUND

More than 120,000 refugees and asylum seekers are currently living in Switzerland. The prevalence of mental disorders among this population is significantly higher than that in the general population. While effective treatment options and cross-cultural, specialized treatment centers exist, they tend to be overloaded by their target populations. General outpatient primary health care providers might be able to compensate for the lack of specialized treatment slots. To date, however, it is unknown how often and under what conditions (e.g., length of waiting lists) refugees and asylum seekers are treated outside of specialized centers and whether there are barriers that prevent providers in outpatient settings from treating more patients in this subgroup. The present study aimed to assess the challenges and barriers faced by psychiatrists and psychotherapists working in outpatient settings in Switzerland in treating refugees and asylum seekers to determine the potential capacity of this group to provide mental health care.

METHODS

An online survey was conducted during the winter of 2017/2018. The survey was constructed in three official languages and took 10-15 min to complete. Spearman's correlations, Mann-Whitney U-Tests, and Chi-squared tests were conducted to analyze the data.

RESULTS

Eight hundred and sixty-seven (N = 867) psychotherapists and psychiatrists working in outpatient settings completed the survey: 43% of them reported having treated between 1 and 9 refugees or asylum seekers in the past 12 months, and a further 13% reported treating 10 or more. Interpreters were used for almost every other patient with a refugee or asylum-seeker background. At the same time, the funding of interpreters, as well as the funding of treatment in general, were reported to be the biggest hurdles to treating more refugees and asylum seekers.

CONCLUSIONS

Given the low number of patients rejected for capacity reasons (between 2 and 5%) and the median waiting times for the admission of new patients ranging between 2 and 3 weeks, outpatient primary mental health care providers might treat more refugees and asylum seekers and relieve specialized treatment centers. However, barriers such as lack of funding of interpreters seem to hinder them. Appropriate steps by the authorities are needed to improve the current situation.

Same same but different? DSM-5 versus ICD-11 PTSD among traumatized refugees in Germany

OBJECTIVE

The recent changes in diagnostic criteria for posttraumatic stress disorder (PTSD) in the 5th edition of the DSM and the 11th edition of the ICD marked a shift towards two perspectives on the same disorder. Previous studies indicate lower prevalence rates for the ICD-11-model as compared to the DSM-5 model. Main purpose of this study is to examine the concordance between ICD-11 and DSM-5 PTSD rates, and to assess the overlap of the two PTSD definitions with anxiety and depression among refugees.

METHODS

167 traumatized refugees were assessed with the PCL-5 for the DSM-5 PTSD model. A subset of the items was used as criteria for the ICD-11 model. Depression and anxiety were measured with the HSCL-25.

RESULTS

The DSM-5-algorithm for PTSD identified significantly more cases (n = 147; 88%) than the ICD-11 algorithm (80%; n = 134). Level of agreement between the diagnostic systems was substantial (Κ = 0.67, p < .001) and 9% (n = 15) met criteria under one diagnostic system only. Overlap with depression and anxiety was high under both diagnostic systems.

CONCLUSION

PTSD rates indicated a highly distressed sample of survivors of war and trauma. Our data provide further evidence that the DSM-5 diagnoses a larger number of persons than the ICD-11. Although the level of agreement was substantial, the observed discrepancies represent a challenge for research and practice to reliably identify individuals with PTSD. Especially for refugees, this might affect their access to mental health care and appropriate treatment during an asylum procedure.

Research ethics and refugee health: a review of reported considerations and applications in published refugee health literature, 2015-2018

Introduction

Public health investigations, including research, in refugee populations are necessary to inform evidence-based interventions and care. The unique challenges refugees face (displacement, limited political protections, economic hardship) can make them especially vulnerable to harm, burden, or undue influence. Acute survival needs, fear of stigma or persecution, and history of trauma may present challenges to ensuring meaningful informed consent and establishing trust. We examined the recently published literature to understand the application of ethics principles in investigations involving refugees.

Methods

We conducted a preliminary review of refugee health literature (research and non-research data collections) published from 2015 through 2018 available in PubMed. Article inclusion criteria were: participants were refugees, topic was health-related, and methods used primary data collection. Information regarding type of investigation, methods, and reported ethics considerations was abstracted.

Results

We examined 288 articles. Results indicated 33% of investigations were conducted before resettlement, during the displacement period (68% of these were in refugee camps). Common topics included mental health (48%) and healthcare access (8%). The majority (87%) of investigations obtained consent. Incentives were provided less frequently (23%). Most authors discussed the ways in which community stakeholders were engaged (91%), yet few noted whether refugee representatives had an opportunity to review investigational protocols (8%). Cultural considerations were generally limited to gender and religious norms, and 13% mentioned providing some form of post-investigation support.

Conclusions

Our analysis is a preliminary assessment of the application of ethics principles reported within the recently published refugee health literature. From this analysis, we have proposed a list of best practices, which include stakeholder engagement, respect for cultural norms, and post-study support. Investigations conducted among refugees require additional diligence to ensure respect for and welfare of the participants. Development of a refugee-specific ethics framework with ethics and refugee health experts that addresses the need for stakeholder involvement, appropriate incentive use, protocol review, and considerations of cultural practices may help guide future investigations in this population.

Psychological burden, stressors and resources of social workers working with women and children who suffered extreme violence by the 'Islamic state': A mixed method study

OBJECTIVE

This explorative study aimed to determine the extent of psychological burden in social workers working with traumatized refugees. In addition, distressing and helpful factors determining the psychosocial burden were to be identified and described.

METHODS

Cross-sectional, mixed method design using quantitative and qualitative methods. The quantitative part included the Perceived Stress Questionnaire (PSQ) and items to assess specific factors of the working-context. The qualitative part is based on 5 focus groupdiscussions and 16 individual interviews. Evaluation was carried out using qualitative content analysis (QCA) including cross-analysis along the subscales of the PSQ to organise the qualitative material.

RESULTS

N = 54 social workers completed the questionnaire. High scores were found for all subscales of the PSQ. The distressing factor rated the highest was need of interpreters to communicate (M = 5.1, SD = 1.71), the helpful factor rated the highest was communication skills (M = 6.35, SD = 0.73). In the QCA, aspects of distressing and helpful factors were identified and further detailed.

CONCLUSION

According to the here presented study results, the psychological burdens of social workers working with refugees seem to be high. The impact of distressing factors such as working with interpreters and exposure to trauma content or PTSD symptoms might be reduced by offering specific education and supervision. The individual extent of psychological burden should be considered and (re-)evaluated on a regular basis as secondary prevention. Helpful factors like self-care, teamwork, networking and cooperation are evident and should be supported by implementing professional and psychological support.

Stress on local and international psychotherapists in the crisis region of Iraq

BACKGROUND

Local and international Psychotherapists working with war survivors are confronted with a whole variety of burdens. The close contact to their clients and the conversations about terror, flight and genocides, they are frequently subject to vicarious traumatization resulting from these events and reveal a risk of developing secondary traumatization.

METHODS

We interviewed 54 local psychotherapists and 28 psychotherapists originating from abroad who were treating survivors of ISIS terror in refugee camps organised by non-government organisations (NGOs).

RESULTS

The results show that local and non-local psychotherapists who work in a context of humanitarian crises reveal a risk of developing secondary traumatization. The results of this present study would also indicate that the secondary traumatization depends both on individual characteristics such as bonding styles and personal experiences and also on the ambient characteristics such as the degree of traumatization of the patients.

CONCLUSION

The study revealed that the local and non-local psychotherapists had a range of different pressure factors and helpful resources which indicated that better caring/support, supervision and organization are needed to enable psychotherapists to perform more effectively in war regions from the point of view of preventive healthcare.

Evaluation of Neurofeedback for Posttraumatic Stress Disorder Related to Refugee Experiences Using Self-Report and Cognitive ERP Measures

Background. Neurofeedback holds promise as an intervention for the psychophysiological dysfunction found in posttraumatic stress disorder (PTSD). Few empirical studies have assessed the efficacy of neurofeedback for PTSD, and none in individuals with refugee trauma. A proposed mechanism for neurofeedback efficacy in PTSD is through remediating deficits in cognitive control. We assessed pre- and postchanges in symptoms and neurocognitive functioning of refugee clients participating in a neurofeedback intervention for PTSD. Methods. Clinical data for 13 adult refugees with chronic PTSD who participated in neurofeedback combined with trauma counseling (NFT) was compared with 13 adult refugees placed on a waitlist to receive neurofeedback. Waitlist clients continued to receive trauma counseling alone (TC). NFT was additionally assessed pre- and posttherapy for changes in event-related potentials (ERPs) and behavioral indices of cognitive control using a visual continuous performance task (VCPT). Comparison VCPT data from healthy controls (HC) was available from the Human Brain Index database. Results. Posttherapy, NFT had significantly lower symptoms of trauma, anxiety, and depression compared with TC. NFT demonstrated an increased P3 amplitude and improved behavioral performance suggesting a normalization of cognitive control. Conclusions. These preliminary observations are consistent with a possible benefit of neurofeedback for remediating PTSD. This may be achieved at least partially by an improvement in cognitive control. Further confirmation of the effectiveness of the treatment now requires a randomized controlled trial that considers issues such as placebo response, nonspecific therapist effects, and duration of treatment.

Identifying the critical time points for mental health of asylum seekers and refugees in high-income countries

AIMS

High heterogeneity was found in the prevalence rates of mental disorders in adult asylum seekers and refugees in high-income countries. This may be related to different problems. Among them, there is a changing exposure to risk and protective factors for mental health at different phases of these people's life before migration, and during the migratory journey and resettlement. This study aimed at identifying and distinguishing time points in which distinct risk and protective factors for the mental health of asylum seekers and refugees may occur.

METHODS

Systematic review and narrative synthesis. A systematic search was carried out for the period January 2017-August 2019, given the existence of systematic reviews of the evidence up to January 2017.

RESULTS

Two hundred and fifty-two studies were identified with our search and 31 studies were included. The critical time points identified are: (a) before the travel; (b) during the travel; (c) at initial settlement in the host country; (d) when attempting to integrate in the host country; (e) when the immigration status is challenged or revoked. Some factors such as sense of belonging in the host country can be risk factors or protective factors depending on the time point.

CONCLUSIONS

These five critical time points can guide the development and selection of well-timed preventive and treatment interventions. They could also be used to stratify samples in epidemiological studies and meta-analyses. At present, we know much more on risk factors than on protective factors. Knowing more about protective factors may inform the development of interventions to foster them.

Identifying distinctive psychological symptom profiles among a nationally representative sample of refugees resettled in Australia

OBJECTIVE

The number of refugees worldwide is unprecedented in recent history. Little is known, however, about profiles of psychological symptoms following persecution and displacement.

METHODS

This study reports on a latent class analysis that identified profiles of posttraumatic stress disorder (PTSD), depression and anxiety symptoms in a nationally representative sample of 1625 refugees in Australia. The association between specific symptom profiles, exposure to potentially traumatic events and post-migration stressors, and overall health and help-seeking was examined.

RESULTS

Latent class analysis yielded an optimal five-class solution. These classes comprised the Pervasive Symptom class (19.2%), the High PTSD Symptom class (17.1%), the High Depression/Anxiety Symptom class (16.4%), the Moderate PTSD Symptom class (16.2%) and the Low Symptom class (31.1%). Participants in the symptomatic classes were more likely to be female, older and report greater post-migration stressors than those in the Low Symptom class. In addition, individuals in classes characterized by PTSD symptoms had been exposed to more types of potentially traumatic events. Membership in symptomatic classes was associated with poorer overall heath and greater help-seeking.

CONCLUSION

Qualitatively distinct symptom profiles were observed in a nationally representative sample of refugees. In addition to a group of people who reported high symptoms across psychological disorders and may warrant clinical intervention, we identified two subclinical classes who may be missed by existing diagnostic classification systems. Post-migration stressors play an important role in influencing refugee symptom profiles over and above exposure to potentially traumatic events. Clinicians should consider specific symptom profiles and contextual factors when planning interventions with refugees.

Does Duration of Residency in the United States Influence Psychological Symptoms and Postmigration Stressors Among Refugees? Potential Implications of Populism for Refugee Mental Health

After relocation, refugees may experience significant difficulty adjusting to a host culture, and this difficulty may persist even after many years following resettlement. However, the influence of time on postmigration living difficulties (PMLD) and psychological distress has not been extensively investigated. In this investigation, we used regression analyses to examine whether length of residence in the United States would moderate the relationship between psychological symptoms and PMLD in a sample of 52 adult East African refugees. The sample was predominantly male (female n = 13) with a mean age of ∼37 years ( SD = 20.91) and mean length of residence in the United States of 9.9 years ( SD = 5.85). The moderating effect of years living in the United States on the depression–PMLD relationship was significant, and explained an additional 9% of variance in PMLD. The relationship between depressive symptoms and PMLD became significantly related at ∼7 years of residence in the United States, and became more positive as values in the sample approached the longest duration in the United States (30 years). No such moderating effect was found for the association between posttraumatic stress disorder symptoms and PMLD. These results highlight the risk of marginalization as well as the need for early and sustained psychosocial interventions for refugee populations in the United States.

Mental Health of Refugees and Torture Survivors: A Critical Review of Prevalence, Predictors, and Integrated Care

Civilian war trauma and torture rank among the most traumatic life experiences; exposure to such experiences is pervasive in nations experiencing both internal and external conflict. This has led to a high volume of refugees resettling throughout the world with mental health needs that primary care physicians may not be screening for and prepared to effectively address. In this article, we review the literature on demographics, predictors, mental health outcomes of torture, and integrated care for the mental health needs of refugees. We searched PubMed and PSYCINFO databases for original research articles on refugees and mental health published in the English language between 2010 and present. Nine percent of 720 adults in conflict areas in Nepal, with predominance of literate married males, met the threshold for Post-Traumatic Stress Disorder (PTSD), 27.5% for depression, and 22.9% for anxiety. While, PTSD rate has been documented as high as 88.3% among torture survivors from Middle East (ME), Central Africa (CA), South Asia (SA), Southeast Europe (SE). Depression was recorded as high as 94.7% among 131 African torture survivors and anxiety as high as 91% among 55 South African torture survivors. Torture severity, post-migration difficulties, and wait time to receive clinical services were significantly associated with higher rate of mental health symptoms. Mental health screening is not a standard component of initial physical exams for refugees, yet these individuals have had high trauma exposure that should inform clinical care. Integrated care models are lacking but would greatly benefit this community to prevent progression to greater severity of mental health symptoms.

Predictors of the co-occurrence of posttraumatic stress disorder and depressive disorder in psychiatric outpatients

INTRODUCTION

We explored the predictors of co-occurring depressive disorder (DD) in individuals with posttraumatic stress disorder (PTSD) in an outpatient psychiatric setting.

METHODS

Participants (N = 170; mean age = 40.78, SD = 16.15 years; 58.8% women) included 71 adult patients who met the criteria for a PTSD diagnosis and 99 adult patients who met the criteria for a comorbid PTSD/DD diagnosis. Potential predictors included trauma types (focusing on trauma characteristics), history of previous traumatic experiences (i.e., the number of lifetime traumatic events before current trauma and childhood maltreatment), and post-trauma variables (i.e., elapsed time since the current traumatic event and the severity of PTSD symptoms).

RESULTS

A logistic regression analysis-including demographic variables, trauma types, history of previous traumatic experiences, and post-trauma variables that showed significant differences between the two groups-was conducted. The effects of repeated trauma (OR = 13.18, 95% CI [3.44, 50.48], p < .001), the number of lifetime traumatic events (OR = 1.04, 95% CI [1.01, 1.51], p = .044), and childhood maltreatment (OR = 1.23, 95% CI [1.01, 1.51], p = .004) were associated with a greater likelihood of concurrent PTSD/DD.

CONCLUSION

Cumulative characteristics such as maltreatment and the number of lifetime traumatic events before the current trauma as well as repetitive properties of the most recent trauma present a key risk factor for co-occurring PTSD/DD.

Development and validation of a mental health screening tool for asylum-seekers and refugees: the STAR-MH

BACKGROUND

There is no screening tool for major depressive disorder (MDD) or post-traumatic stress disorder (PTSD) in asylum-seekers or refugees (ASR) that can be readily administered by non-mental health workers. Hence, we aimed to develop a brief, sensitive and rapidly administrable tool for non-mental health workers to screen for MDD and PTSD in ASR.

METHODS

The screening tool was developed from an extant dataset (n = 121) of multiply screened ASR and tested prospectively (N = 192) against the M.I.N.I. (Mini International Neuropsychiatric Interview) structured psychiatric interview. Rasch, Differential Item Functioning and ROC analyses evaluated the psychometric properties and tool utility.

RESULTS

A 9-item tool with a median administration time of six minutes was generated, comprising two 'immediate screen-in' items, and a 7-item scale. The prevalence of PTSD &/or MDD using the M.I.N.I. was 32%, whilst 99% of other diagnosed mental disorders were comorbid with one or both of these. Using a cut-score of ≥2, the tool provided a sensitivity of 0.93, specificity of 0.75 and predictive accuracy of 80.7%.

CONCLUSIONS

A brief sensitive screening tool with robust psychometric properties that was easy to administer at the agency of first presentation was developed to facilitate mental health referrals for asylum-seekers and new refugees.

Secondary Traumatization in Caregivers Working With Women and Children Who Suffered Extreme Violence by the "Islamic State"

Introduction: Refugees fleeing persecution, torture, or sexual violence are at high risk of developing both acute and chronic psychological disorders. Systematic violence, as committed against the Yazidi minority in Northern Iraq by the terror organization known as the Islamic State (IS), can be seen as a particularly traumatic burden to the victims, but also to caregivers providing treatments and assistance to them. The intense exposure to traumatic content may cause secondary traumatization in respective caregivers. This study aims (1) to identify the prevalence of secondary traumatization in caregivers working with traumatized women and children from Northern Iraq; (2) to determine the specific distressing factors and resources of the caregivers; as well as (3) to analyze whether caregivers' personal history of trauma or flight, attachment styles, working arrangements as well as support offers qualify as risk or resilience factors for secondary traumatization. Materials and Methods: In this cross-sectional study, N = 84 caregivers (social workers, psychotherapists/physicians, and interpreters) in the context of a Humanitarian Admission Program (HAP) for women and children traumatized by the so called IS were investigated about their work-related burdens and resources. Secondary traumatization was assessed with the Questionnaire for Secondary Traumatization (FST). To identify relevant determinants for secondary traumatization multiple linear regression analyses were performed. Results: Secondary traumatization was present in 22.9% of the participating caregivers, with 8.6% showing a severe symptom load. A personal history of traumatic experiences, a personal history of flight, a higher number of hours per week working in direct contact with refugees as well as a preoccupied attachment style were detected as risk factors for secondary traumatization. A secure attachment style could be identified as a resilience factor for secondary traumatization. Discussion: Caregivers working with traumatized refugees are at high risk of developing secondary traumatization. Based on the findings of this study and theoretical considerations, a framework of classification for different types of trauma-associated psychological burdens of caregivers working with traumatized refugees is proposed. Implications for the training and supervision of professionals in refugee- and trauma-care are discussed.