'Tell Your Story': a randomized controlled trial of an online intervention to reduce mental health stigma and increase help-seeking in refugee men with posttraumatic stress

The development and evaluation of a virtual, asynchronous, trauma-focused treatment program for adult survivors of childhood interpersonal trauma

BACKGROUND

The long-term mental and physical health implications of childhood interpersonal trauma on adult survivors is immense, however, there is a lack of available trauma-focused treatment services that are widely accessible. This study, utilizing a user-centered design process, sought feedback on the initial design and development of a novel, self-paced psychoeducation and skills-based treatment intervention for this population.

AIMS

To explore the views and perspectives of adult survivors of childhood interpersonal trauma on the first two modules of an asynchronous trauma-focused treatment program.

METHODS

Fourteen participants from our outpatient hospital service who completed the modules consented to provide feedback on their user experience. A thematic analysis of the three focus groups was conducted.

RESULTS

Four major themes emerged from the focus groups: (1) technology utilization, (2) module content, (3) asynchronous delivery, and (4) opportunity for interactivity. Participants noted the convenience of the platform and the use of multimedia content to increase engagement and did not find the modules to be emotionally overwhelming.

CONCLUSIONS

Our research findings suggest that an asynchronous virtual intervention for childhood interpersonal trauma survivors may be a safe and acceptable way to provide a stabilization-focused intervention on a wider scale.

Improving access to evidence-based interventions for trauma-exposed adults in low- and middle-income countries

In low- and middle-income countries (LMICs), the mental health consequences of trauma exposure pose a substantial personal, societal, and economic burden. Yet, the significant need for evidence-based mental health treatment remains largely unmet. To unlock the potential for mental health care for trauma survivors in lower-resource contexts, it is critical to map treatment barriers and identify strategies to improve access to evidence-based, culturally appropriate, and scalable interventions. This review, based on an International Society for Traumatic Stress (ISTSS) briefing paper, describes the treatment gap facing adults with traumatic stress in LMICs and identifies the barriers that contribute to this gap. We then highlight strategies for enhancing access to effective treatments for these populations, including task-sharing, the use of culturally adapted and multiproblem interventions, and digital tools to scale access to appropriate care. Finally, we offer recommendations for policymakers, researchers, and service providers to guide an agenda for action to close the treatment gap for trauma survivors in LMICs.

Mental health problems and help-seeking behaviours of Syrian refugee adolescents: mediating role of self-stigma

BACKGROUND

Although common mental health problems have been widely studied with self-stigma, few studies have focused on the mediating effect of self-stigma in the relationship between mental health problems and help-seeking behaviours of refugee adolescents. Therefore, the purpose of the present study was to examine whether self-stigma mitigates the adverse effects of stress, anxiety, and depression symptoms on the help-seeking behaviours of Syrian adolescents living in Turkey.

METHODS

The participants of this study included 488 Syrian refugee adolescents (boys, 63.73%; girls, 3627%) living in Turkey. Participants completed the Depression Anxiety Stress Scale and General Help-Seeking Scale and Self-Stigma of Seeking Psychology Help Scale.

RESULTS

The findings revealed that stress (β = 0.19, p < 0.01), anxiety (β = 0.12, p < 0.05), and depression (β = 0.17, p < 0.01) had significant and positive predictive effects on self-stigma, but not on help-seeking behaviours. Also, self-stigma (β = -0.12, p < 0.01) had a significant negative predictive effect on help-seeking behaviours. With regard to the indirect effects, the findings showed that self-stigma fully mediated the associations between stress - help-seeking [effect = -0.05, 95% confidence interval (CI) -0.11 to -0.01], anxiety - help-seeking (effect = -0.04, 95% CI -0.09 to -0.01)], and depression - help-seeking (effect = -0.05, 95% CI -0.12 to -0.01).

CONCLUSIONS

Our findings highlight the potential negative effects of self-stigma on the help-seeking behaviours of Syrian refugee adolescents, both directly and indirectly. These results can be used to develop and implement effective and efficient interventions to address the unmet mental health needs of refugee adolescents.

Digital mental health interventions for the mental health care of refugees and asylum seekers: Integrative literature review

This study aimed to provide a critical analysis of the current literature on the use of digital mental health interventions (DMHIs) for the management and treatment of mental health disorders among refugees and asylum seekers. These groups are among the most disadvantaged compared to the general population in terms of health and socio-economic status, due to conflicts and wars. The number of refugees fleeing their home countries is growing exponentially, and refugees experience trauma, torture, persecution and human right abuses, which have a profound effect on their mental health and overall well-being. The researchers conducted an integrative literature review from electronic databases Medline, CINAHL and Google Scholar, selecting articles published in English from 2010 to 2023. The thematic analysis of the 10 articles identified in the review revealed four main themes and two sub-themes: (1) types of digital health intervention/apps used; (2) barriers encountered in digital health intervention; (3) user experience of the digital health intervention and (4) mapping gaps. Two sub-themes were identified located in Theme 2: (2.1) Language and demographic barriers and (2.2) Structural barriers. The study showed that the use of DMHIs was associated with positive experiences among refugees and asylum seekers. Limited mental health care is offered to refugees and asylum seekers due to a range of logistical, political, economic, geographical, language, cultural and social barriers. DMHIs have the potential to overcome and/or moderate these barriers. The study concludes that the scaled implementation of effective DMHIs holds the possibility to improve the wider distribution of mental health care among refugees and asylum seekers. However, further research is needed to confirm the effectiveness of DMHIs and to scale up studies for their utilisation among this group. In summary, this study highlights the potential of DMHIs in improving the mental health care of refugees and asylum seekers. The results of this study have important implications for mental health service providers, policymakers and researchers to address the mental health needs of this vulnerable/priority group.

The Development and Validation of a Measure of Mental Health, Help-Seeking Beliefs in Arabic-Speaking Refugees

Despite reporting elevated rates of posttraumatic stress disorder (PTSD), refugees are less likely than other groups to seek psychological treatment. Relatively little attention has been paid to the role of negative help-seeking beliefs in influencing treatment uptake. The current study sought to develop and psychometrically validate a novel measure indexing negative help-seeking beliefs for refugees (Help-Seeking Beliefs Scale [HSBS]). In this study, 262 Arabic-speaking refugee participants completed an online survey consisting of the HSBS along with measures indexing similar constructs (self-stigma of PTSD and help-seeking, perceived stigma, negative help-seeking attitudes, and help-seeking intentions). Factor analysis revealed a three-factor structure aligning with key themes identified in the literature: (a) Fear of Negative Consequences, (b) Inappropriateness, and (c) Perceived Necessity. The scale demonstrated excellent internal consistency, convergent validity, and predicted reduced help-seeking intentions. Results support the utility of a novel measure capturing a prominent help-seeking barrier in a population with high psychopathology and low treatment uptake.

Variability in Stigma Severity During the COVID-19 Pandemic

Objective The aim of this study was to investigate change in the stigma that emerged during the COVID-19 pandemic over time and the factors responsible for the change. Methods Individuals with COVID-19 who presented to Ankara Medicalpark and VM Medicalpark Hospitals' Internal Diseases and Chest Diseases polyclinic between May 2021 and April 2022 were examined. The volunteers were divided into two groups: those who had COVID-19 within the first six months of the pandemic (group 1) and those who had it in the second six months (group 2). The questionnaire assessing stigma consisted of 29 propositions that participants could mark whether they agreed with them or not. Results The median age of the volunteers was 38 years. Eighty-eight (69.3%) had the disease in the first six months of the pandemic and 39 (30.7%) in the second six months. Moreover, 76.1% of the participants in the first group and 94.9% of those in the second group did not agree with the statement "I thought COVID-19 was a punishment for me" (p=0.011). Further, 56.8% of the participants in the first group and 97.4% of those in the second group stated that they did not agree with the statement "Employers may terminate the employment of employees who they find out have contracted COVID-19" (p<0.001). 80.7% of the participants in the first group and 38.5% of those in the second group agreed with the statement "There was social discrimination against people who caught COVID-19" (p<0.001).  Conclusions At the beginning of the pandemic, the participants had concerns about losing their status and jobs, but this anxiety decreased over time. Stigma in the first six months of the pandemic was greater than that in the second six months, and discrimination related to stigma decreased with recognition of the disease and the increase in experience.

Self-Stigma and PTSD: Conceptualization and Implications for Research and Treatment

Preliminary empirical evidence suggests that self-stigma may be a significant problem for those with posttraumatic stress disorder (PTSD). Although research on self-stigma for persons with PTSD is limited, some PTSD symptoms, such as negative thoughts about oneself, feelings of shame, and avoidance-particularly of social interactions-may be conceptually related to self-stigma, potentially explaining the co-occurrence and relevance of self-stigma in PTSD. This Open Forum reviews how the social cognitive model may explain the co-occurrence of self-stigma and PTSD, considers how this model may inform treatment approaches for self-stigma in PTSD, and identifies next steps to empirically test the proposed theory.

The Use of Mobile Assessments for Monitoring Mental Health in Youth: Umbrella Review

BACKGROUND

Improving mental health in youth is a major concern. Future approaches to monitor and intervene in youth mental health problems should rely on mobile tools that allow for the daily monitoring of mental health both actively (eg, using ecological momentary assessments [EMAs]) and passively (eg, digital phenotyping) by capturing individuals' data.

OBJECTIVE

This umbrella review aims to (1) report the main characteristics of existing reviews on mental health and young people, including mobile approaches to mental health; (2) describe EMAs and trace data and the mental health conditions investigated; (3) report the main results; and (4) outline promises, limitations, and directions for future research.

METHODS

A systematic literature search was carried out in 9 scientific databases (Communication & Mass Media Complete, Psychology and Behavioral Sciences Collection, PsycINFO, CINAHL, ERIC, MEDLINE, the ProQuest Sociology Database, Web of Science, and PubMed) on January 30, 2022, coupled with a hand search and updated in July 2022. We included (systematic) reviews of EMAs and trace data in the context of mental health, with a specific focus on young populations, including children, adolescents, and young adults. The quality of the included reviews was evaluated using the AMSTAR (Assessment of Multiple Systematic Reviews) checklist.

RESULTS

After the screening process, 30 reviews (published between 2016 and 2022) were included in this umbrella review, of which 21 (70%) were systematic reviews and 9 (30%) were narrative reviews. The included systematic reviews focused on symptoms of depression (5/21, 24%); bipolar disorders, schizophrenia, or psychosis (6/21, 29%); general ill-being (5/21, 24%); cognitive abilities (2/21, 9.5%); well-being (1/21, 5%); personality (1/21, 5%); and suicidal thoughts (1/21, 5%). Of the 21 systematic reviews, 15 (71%) summarized studies that used mobile apps for tracing, 2 (10%) summarized studies that used them for intervention, and 4 (19%) summarized studies that used them for both intervention and tracing. Mobile tools used in the systematic reviews were smartphones only (8/21, 38%), smartphones and wearable devices (6/21, 29%), and smartphones with other tools (7/21, 33%). In total, 29% (6/21) of the systematic reviews focused on EMAs, including ecological momentary interventions; 33% (7/21) focused on trace data; and 38% (8/21) focused on both. Narrative reviews mainly focused on the discussion of issues related to digital phenotyping, existing theoretical frameworks used, new opportunities, and practical examples.

CONCLUSIONS

EMAs and trace data in the context of mental health assessments and interventions are promising tools. Opportunities (eg, using mobile approaches in low- and middle-income countries, integration of multimodal data, and improving self-efficacy and self-awareness on mental health) and limitations (eg, absence of theoretical frameworks, difficulty in assessing the reliability and effectiveness of such approaches, and need to appropriately assess the quality of the studies) were further discussed.

TRIAL REGISTRATION

PROSPERO CRD42022347717; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=347717.

A multicomponent digital intervention to promote help-seeking for mental health problems and suicide in sexual and gender diverse young adults: A randomized controlled trial

BACKGROUND

LGBTQ+ community's higher susceptibility to worse mental health outcomes and more help-seeking barriers compared to the cis-heterosexual population. Despite the LGBTQ+ population facing higher mental health risks, there has been a dearth of research focusing on developing tailored interventions targeting them. This study aimed to assess the effectiveness of a digital multicomponent intervention in promoting help-seeking for mental health issues in LGBTQ+ young adults.

METHODS AND FINDINGS

We recruited LGBTQ+ young adults aged between 18 and 29 who scored moderate or above on at least 1 dimension of the Depression Anxiety Stress Scale 21 and did not have help-seeking experiences in the past 12 months. Participants (n = 144) were stratified by gender assigned at birth (male/female) and randomly allocated (1:1 ratio) to the intervention or active control parallel condition by generating a random number table, so they were blinded to the intervention condition. All participants received online psychoeducational videos, online facilitator-led group discussions, and electronic brochures in December 2021 and January 2022, with the final follow-up in April 2022. The contents of the video, discussion, and brochure are help-seeking for the intervention group and general mental health knowledge for the control group. The primary outcomes were help-seeking intentions for emotional problems and suicidal ideation and attitudes toward seeking help from mental health professionals at the 1-month follow-up. The analysis was performed by including all participants based on their randomized group regardless of adherence to the protocol. A linear mixed model (LMM) was used for analysis. All models were adjusted for baseline scores. Chinese Clinical Trial Registry: ChiCTR2100053248. A total of 137 (95.1%) participants completed a 3-month follow-up, and 4 participants from the intervention condition and 3 from the control condition did not complete the final survey. Compared with the control group (n = 72), a significant improvement was found in help-seeking intentions for suicidal ideation in the intervention group (n = 70) at post-discussion (mean difference = 0.22, 95% CI [0.09, 0.36], p = 0.005), 1-month (mean difference = 0.19, 95% CI [0.06, 0.33], p = 0.018), and 3-month follow-ups (mean difference = 0.25, 95% CI [0.11, 0.38], p = 0.001). There was also a significant improvement in the intervention condition on the help-seeking intention for emotional problems at 1-month (mean difference = 0.17, 95% CI [0.05, 0.28], p = 0.013) and 3-month follow-ups (mean difference = 0.16, 95% CI [0.04, 0.27], p = 0.022) compared with the control group. Participants' depression and anxiety literacy and help-seeking encouragement related knowledge in intervention conditions showed significant improvements. There were no significant improvements in actual help-seeking behaviors, self-stigma toward seeking professional assistance, depression, and anxiety symptoms. No adverse events or side effects were observed. However, the follow-up time point was limited to 3 months which might not be long enough for drastic mindset and behavioral changes in help-seeking to occur.

CONCLUSIONS

The current intervention was an effective approach in promoting help-seeking intentions, mental health literacy, and help-seeking encouragement-related knowledge. Its brief yet integrated intervention format could also be utilized in treating other imminent concerns confronted by LGBTQ+ young adults.

TRIAL REGISTRATION

Chictr.org.cn, ChiCTR2100053248.

Digital Methods in the Promotion of Well-Being in Immigrants: A Systematic Review : Author Note

Migration is a disruptive experience that undermines immigrants' well-being. This systematic review explores the diversity of digital methods available to promote their well-being. The review includes 13 studies (6 were RCTs), comprising 8181 participants, collected through EBSCOhost web, b-ON, Scopus, SciELO and ProQuest, with no time restriction (to access all available literature). Primary outcomes were well-being (mental health; quality of life), and the secondary were stigma, integration and connection. Study quality was assessed by the QuADS tool. Digital methods are a valuable tool for improving immigrants' well-being. M-integration methods tend to focus on promoting mental health in immigrants, developing individual resilience while participatory methods address the quality of life in refugees, contributing to social resilience. Digital methods must not only be part of the guidelines of interventions for immigrants and refugees but also be a foundation upon which those guidelines are outlined.

Public beliefs about trauma and its consequences: Profiles and correlates of stigma

Public stereotypes about trauma exposure and its likely consequences have the potential to influence levels of support extended to survivors in the larger community. The current project sought to examine unique profiles of stereotype endorsement both within and across participants sampled from distinct populations. Trauma-related stereotypes involving symptom course, dangerousness, employability, social functioning, predictability, character, and treatment need were examined in undergraduate (N ₁ = 404; N ₂ = 502) and MTurk (N ₃ = 364) samples. Sympathizing [low overall endorsement], Fearful [high overall endorsement], Pejorative [high endorsement + moralizing beliefs], Safety-Focused [intermediate endorsement + dangerousness], and Performance-Focused [intermediate endorsement + employability] groups were replicated in latent profile models across all samples. Stereotype profiles demonstrated hypothesized associations with general perspectives of mental illness although support for consistent relations with respondent characteristics (e.g., sex; personal exposure to trauma; reported exposure in friends/family) was limited. Data suggest that trauma stereotypes are endorsed at high frequencies in the general community and conform to systematic patterns of prejudice that may be overlooked in more global assessments of stigma.

Smartphone-delivered mental health care interventions for refugees: A systematic review of the literature

According to the United Nations, an estimated 26.6 million people worldwide were refugees in 2021. Experiences before, during, and after flight increase psychological distress and contribute to a high prevalence of mental disorders. The resulting high need for mental health care is generally not reflected in the actual mental health care provision for refugees. A possible strategy to close this gap might be to offer smartphone-delivered mental health care. This systematic review summarizes the current state of research on smartphone-delivered interventions for refugees, answering the following research questions: (1) Which smartphone-delivered interventions are available for refugees? (2) What do we know about their clinical (efficacy) and (3) nonclinical outcomes (e.g., feasibility, appropriateness, acceptance, and barriers)? (4) What are their dropout rates and dropout reasons? (5) To what extent do smartphone-delivered interventions consider data security? Relevant databases were systematically searched for published studies, gray literature, and unpublished information. In total, 456 data points were screened. Twelve interventions were included (nine interventions from 11 peer-reviewed articles and three interventions without published study reports), comprising nine interventions for adult refugees and three for adolescent and young refugees. Study participants were mostly satisfied with the interventions, indicating adequate acceptability. Only one randomized controlled trial (RCT; from two RCTs and two pilot RCTs) found a significant reduction in the primary clinical outcome compared to the control group. Dropout rates ranged from 2.9 to 80%. In the discussion, the heterogeneous findings are integrated into the current state of literature.

Mobile Health-Supported Virtual Reality and Group Problem Management Plus: Protocol for a Cluster Randomized Trial Among Urban Refugee and Displaced Youth in Kampala, Uganda (Tushirikiane4MH, Supporting Each Other for Mental Health)

BACKGROUND

Although mental health challenges disproportionately affect people in humanitarian contexts, most refugee youth do not receive the mental health support needed. Uganda is the largest refugee-hosting nation in Africa, hosting over 1.58 million refugees in 2022, with more than 111,000 living in the city of Kampala. There is limited information about effective and feasible interventions to improve mental health outcomes and mental health literacy, and to reduce mental health stigma among urban refugee adolescents and youth in low- and middle-income countries (LMICs). Virtual reality (VR) is a promising approach to reduce stigma and improve mental health and coping, yet such interventions have not yet been tested in LMICs where most forcibly displaced people reside. Group Problem Management Plus (GPM+) is a scalable brief psychological transdiagnostic intervention for people experiencing a range of adversities, but has not been tested with adolescents and youth to date. Further, mobile health (mHealth) strategies have demonstrated promise in promoting mental health literacy.

OBJECTIVE

The aim of this study is to evaluate the feasibility and effectiveness of two youth-tailored mental health interventions (VR alone and VR combined with GMP+) in comparison with the standard of care in improving mental health outcomes among refugee and displaced youth aged 16-24 years in Kampala, Uganda.

METHODS

A three-arm cluster randomized controlled trial will be implemented across five informal settlements grouped into three sites, based on proximity, and randomized in a 1:1:1 design. Approximately 330 adolescents (110 per cluster) are enrolled and will be followed for approximately 16 weeks. Data will be collected at three time points: baseline enrollment, 8 weeks following enrollment, and 16 weeks after enrollment. Primary (depression) and secondary outcomes (mental health literacy, attitudes toward mental help-seeking, adaptive coping, mental health stigma, mental well-being, level of functioning) will be evaluated.

RESULTS

The study will be conducted in accordance with CONSORT (Consolidated Standards of Reporting Trials) guidelines. The study has received ethical approval from the University of Toronto (#40965; May 12, 2021), Mildmay Uganda Research Ethics Committee (MUREC-2021-41; June 24, 2021), and Uganda National Council for Science & Technology (SS1021ES; January 1, 2022). A qualitative formative phase was conducted using focus groups and in-depth, semistructured key informant interviews to understand contextual factors influencing mental well-being among urban refugee and displaced youth. Qualitative findings will inform the VR intervention, SMS text check-in messages, and the adaptation of GPM+. Intervention development was conducted in collaboration with refugee youth peer navigators. The trial launched in June 2022 and the final follow-up survey will be conducted in November 2022.

CONCLUSIONS

This study will contribute to the knowledge of youth-tailored mental health intervention strategies for urban refugee and displaced youth living in informal settlements in LMIC contexts. Findings will be shared in peer-reviewed publications, conference presentations, and with community dissemination.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05187689; https://clinicaltrials.gov/ct2/show/NCT05187689.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/42342.

e-Health for Traumatized Refugees: A Scoping Review

Background: High prevalence of post-traumatic stress disorder (PTSD) is reported among refugees exposed to traumatic experiences, while escaping from their home country, entering a third country, and adjusting to a new society. Electronic health (e-health) treatments have been utilized to overcome challenges such as high costs, limited access to care, and a shortage of resources faced by traumatized refugees. Objective: The aim of this scoping review was to summarize the current science on e-health to screen and treat PTSD in traumatized refugees, examine its benefits and challenges, and suggest strategies for future research. Methods: We conducted a scoping review guided by Arksey and O'Malley's 6-stage scoping review framework. Results: Of the 2,782 articles identified, 8 studies were included for the final analysis. Due to the heterogeneity of studies, the synthesis of results was not feasible. However, the findings of individual studies were examined. The most commonly used technology modality was the smartphone (n = 5). One study revealed the possibility of telephonic screening of PTSD to be equally efficacious as in-person screening, and all interventions through smartphone and the internet reported high feasibility and acceptability. Conclusion: e-Health is suggested to be a novel and scalable platform to provide mental health care in settings with limited resources. Larger and highly robust studies in refugee populations with PTSD-targeted, theory-based approaches and diverse technological formats such as video conferencing and virtual reality are warranted.

The impact of digital interventions on help-seeking behaviour for mental health problems: a systematic literature review

PURPOSE OF REVIEW

Interventions that facilitate help-seeking could help individuals to get care earlier on which could also help avert some mental health crises. Delivering interventions via a digital format could mitigate some key barriers to mental healthcare. We reviewed the literature for digital interventions which facilitate formal or informal help-seeking for mental health problems. We examined the impact of identified interventions on actual and intended help-seeking and attitudes towards help-seeking.

RECENT FINDINGS

We identified 35 interventions. About half (51%) of studies showed an improvement in at least one help-seeking outcome with the greatest number showing an improvement in help-seeking intentions and the fewest studies showing an improvement in actual behaviour (29%). Findings suggest that interventions that promote active participation and personal involvement through sharing one's own narrative seem to be promising practices to facilitate help-seeking.

SUMMARY

Our findings suggest digital interventions can improve help-seeking for mental health problems among a range of populations. Given speciality mental health resources are scarce, further research needs to consider how these interventions could best target the most vulnerable groups to link them with mental healthcare and how these interventions might facilitate earlier intervention in a way that might reduce need for crisis care and support.

Beliefs About Causes and Cures of Prolonged Grief Disorder Among Arab and Sub-Saharan African Refugees

Background

Many refugees have experienced the death of a loved one under traumatic circumstances. Accordingly, the prevalence of Prolonged Grief Disorder (PGD) among refugees is high. Culture-specific symptoms of PGD have been described previously, but beliefs about causes and cures of PGD among refugees remain unknown. We therefore aimed at identifying illness beliefs and treatment expectations regarding PGD among refugees.

Method

We focused on refugees from Arab countries (n = 14) and from Sub-Sahara Africa (n = 9) and applied qualitative and quantitative methods. In a semi-structured interview, participants first answered questions about assumed causes and potential cures for prototypical PGD symptoms according to ICD-11 that were presented in a vignette as representatives of their own culture. In the quantitative part, they completed the Cause Subscale of the Illness Perception Questionnaire (IPQ-R) that included additional culture-specific items. Interviews were analyzed with Qualitative Content Analysis.

Results

In both groups of refugees, PGD symptoms were predominantly attributed to a close relationship to the deceased, lack of social support, personal vulnerabilities, and circumstances of the death. Participants also named a number of flight-related causes (e.g., inability to perform or participate in rituals, feeling isolated in the host country). None of the participants attributed PGD symptoms to supernatural causes. Descriptive analyses of responses on the IPQ-R indicated that participants predominantly attributed PGD symptoms to psychological causes. Participants believed that PGD can be cured and predominantly mentioned social and religious support. Psychological help was only mentioned by a minority of participants. In both groups, participants emphasized that a therapist must be familiar with the patient's culture and rituals. Participants also mentioned stigma associated with seeking psychological help.

Conclusion

Results suggest specific beliefs of refugees regarding causes and cures of PGD as well as similarities with Western conceptualizations. A culture-sensitive approach to the treatment of PGD in refugees that can include knowledge of culture-specific rituals and incorporating religious beliefs as well as decreasing stigma and increasing mental health literacy seem important. The study is limited by its focus on only two groups of refugees and its small sample size.

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.

A Refugee Rose of competencies and capabilities for mental healthcare of refugees

In this paper, I set out the challenges of care for refugees and suggest approaches to assessment and intervention. I discuss clinical interventions that can address the immediate concern of the clinician in a bio-psycho-social framework, and the value of considering eco-social and structural influences that can hinder recovery and perpetuate inequalities. Refugees face multiple adversities before, during and after escaping from life-threatening situations, political violence, torture and persecution. They present with complex health needs and encounter hostility from host countries and public services, which see their needs as an additional demand on the public purse. Regrettably, existing care practice and training of professionals do not often include skills for working across cultures, including cultural formulations and fair assessment, cultural adaptation of interventions, cultural competence and cultural consultation methods, including clinical ethnography and exploration of cultural identity and explanatory models. There are little data on effective and kind models of interpretation and translation. Care systems are rarely designed to fully address the needs of refugees. Health practitioners are not trained to address structural and institutional racism and discrimination, which leads to exclusion of the most marginalised, with little attention to social justice and fair processes as part of appropriate healthcare.

Remote Psychological Interventions for Fear of Cancer Recurrence: Scoping Review

BACKGROUND

Patients with cancer and survivors may experience the fear of cancer recurrence (FCR), a preoccupation with the progression or recurrence of cancer. During the spread of COVID-19 in 2019, patients and survivors experienced increased levels of FCR. Hence, there is a greater need to identify effective evidence-based treatments to help people cope with FCR. Remotely delivered interventions might provide a valuable means to address FCR in patients with cancer.

OBJECTIVE

The aim of this study is to first discuss the available psychological interventions for FCR based on traditional cognitive behavioral therapies (CBTs) or contemporary CBTs, in particular, mindfulness and acceptance and commitment therapy, and then propose a possible approach based on the retrieved literature.

METHODS

We searched key electronic databases to identify studies that evaluated the effect of psychological interventions such as CBT on FCR among patients with cancer and survivors.

RESULTS

Current evidence suggests that face-to-face psychological interventions for FCR are feasible, acceptable, and efficacious for managing FCR. However, there are no specific data on the interventions that are most effective when delivered remotely.

CONCLUSIONS

CBT interventions can be efficacious in managing FCR, especially at posttreatment, regardless of whether it is delivered face to face, on the web, or using a blended approach. To date, no study has simultaneously compared the effectiveness of face-to-face, web-based, and blended interventions. On the basis of the retrieved evidence, we propose the hypothetical program of an intervention for FCR based on both traditional CBT and contemporary CBT, named Change Of Recurrence, which aims to improve the management of FCR in patients with cancer and survivors.

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.

Are we on the same page? Mental health literacy and access to care: a qualitative study in young Hazara refugees in Melbourne

Hazaras, mostly aged <30 years, constituted the greatest number of people resettled under Australia's migration resettlement between 2009 and 2013. This group is at high risk of mental health issues due to pre- and post-forced migration experiences. This study explored the understanding of mental health and barriers to accessing primary mental health care in young Hazara refugees in Melbourne. Seventeen Hazaras aged 18-30 years were recruited for two sex-segregated focus groups; two individual semistructured interviews were also conducted (with one male and one female participant). Discussions were audiotaped, transcribed and analysed thematically. Participants had varied perspectives on mental health issues stemming from historical and current beliefs. Lack of knowledge and concerns over confidentiality within Hazaras were considered major barriers to seeking help. Community education through existing community groups and through the women could potentially help overcome barriers to mental health access by young Hazaras.

Effects of online stigma-reduction programme for people experiencing mental health conditions: A systematic review and meta-analysis

Despite the increased awareness of mental health-related issues, people experiencing mental health conditions have continued to face stigmatization worldwide. The literature on help-seeking behaviours has frequently highlighted the development of self-stigma because of public stigma and emphasized the need to address public stigmatization faced by them. Given the increasing acceptance of digital services in recent years, this systematic review aimed to examine the effects of online and face-to-face anti-stigma interventions in reducing public stigma towards people experiencing mental health conditions. A search was conducted on the Cochrane Library, CINAHL, PubMed, Embase, PsycInfo, and ProQuest from inception of the databases to October 2020. Studies were included in this review if they have explored: (i) public stigmatization towards people of all ages with different types of mental health conditions; (ii) online interventions; and (iii) face-to-face interventions. Nine studies were included in this review, of which only five were included in the meta-analysis as the remaining four had incomplete data. The meta-analysis included an aggregate of 1203 participants while the four excluded studies included 713 participants. Results revealed that online interventions performed favourably with small effect sizes in comparison to face-to-face, wait-list control, and no-intervention groups. Results from the studies excluded from the meta-analysis also found a significant reduction of public stigmatization with online interventions. Such findings provide insightful evidence for the effectiveness of online interventions in reducing public stigmatization. Hence, mental health organizations and groups can consider adopting online interventions suitable for their target audience and type of mental health conditions.

Predictors of psychological distress in Syrian refugees with posttraumatic stress in Germany

Syria has been the main country of citizenship of refugees in Germany since 2013. Syrians face numerous human rights violations in their country that can be accompanied by the experience of potentially traumatic events, loss and displacement. Along the migration process, refugees are exposed to various factors that can have an impact on mental health. The aim of this study is to investigate sociodemographic, war- and flight-related as well as post-migration factors as predictors of posttraumatic stress, depression, somatization and anxiety in Syrian refugees with posttraumatic stress symptoms based in Germany. Data were based on the baseline sample of the "Sanadak" randomized-controlled trial. A total of 133 adult Syrian refugees participated in the study. A questionnaire covered sociodemographic and flight-related questions as well as standardized instruments for symptoms of PTSD (PDS-5), depression (PHQ-9), somatization (PHQ-15), anxiety (GAD-7), generalized self-efficacy (GSE), religiousness (Z-Scale), social support (ESSI) and mental health stigma (SSMIS-SF). Linear regression models were executed to predict mental health outcomes. Sociodemographic predictors (i.e., female sex, higher education) and flight-related predicting factors (i.e., variability of traumatic events) have a negative impact on mental health in Syrian refugees with posttraumatic stress symptoms in Germany. Mental health stigma predicts worse mental health outcomes. Post-migration factors have a major impact on mental health, such as low income, lack of social support, low life satisfaction or a strongly felt connection to Syria. Somatization is an important manifestation of mental distress in Syrian refugees with posttraumatic stress symptoms. Our study showed a range of factors predicting the mental health of Syrian refugees with posttraumatic stress symptoms. Measures to foster mental health could be securing financial security, promoting gender equality and tailored psychosocial programs addressing mental health stigma, loss and social support networks.

A Self-Help App for Syrian Refugees With Posttraumatic Stress (Sanadak): Randomized Controlled Trial

Background

Syrian refugees residing in Germany often develop posttraumatic stress as a result of the Syrian civil war, their escape, and postmigration stressors. At the same time, there is a lack of adequate treatment options. The smartphone-based app Sanadak was developed to provide cognitive behavioral therapy–based self-help in the Arabic language for Syrian refugees with posttraumatic stress.

Objective

The aim of this study was to evaluate the effectiveness and cost-effectiveness of the app.

Methods

In a randomized controlled trial, eligible individuals were randomly allocated to the intervention group (IG; app use) or control group (CG; psychoeducational reading material). Data were collected during structured face-to-face interviews at 3 assessments (preintervention/baseline, postintervention/after 4 weeks, follow-up/after 4 months). Using adjusted mixed-effects linear regression models, changes in posttraumatic stress and secondary outcomes were investigated as intention-to-treat (ITT) and per-protocol (PP) analysis. Cost-effectiveness was evaluated based on adjusted mean total costs, quality-adjusted life years (QALYs), and cost-effectiveness acceptability curves using the net benefit approach.

Results

Of 170 screened individuals (aged 18 to 65 years), 133 were eligible and randomized to the IG (n=65) and CG (n=68). Although there was a pre-post reduction in posttraumatic stress, ITT showed no significant differences between the IG and CG after 4 weeks (Posttraumatic Diagnostic Scale for DSM-5, Diff –0.90, 95% CI –0.24 to 0.47; P=.52) and after 4 months (Diff –0.39, 95% CI –3.24 to 2.46; P=.79). The same was true for PP. Regarding secondary outcomes, ITT indicated a treatment effect for self-stigma: after 4 weeks (Self-Stigma of Mental Illness Scale/SSMIS–stereotype agreement: d=0.86, 95% CI 0.46 to 1.25; stereotype application: d=0.60, 95% CI 0.22 to 0.99) and after 4 months (d=0.52, 95% CI 0.12 to 0.92; d=0.50, 95% CI 0.10 to 0.90), the IG showed significantly lower values in self-stigma than the CG. ITT showed no significant group differences in total costs and QALYs. The probability of cost-effectiveness was 81% for a willingness-to-pay of €0 per additional QALY but decreased with increasing willingness-to-pay.

Conclusions

Sanadak was not more effective in reducing mild to moderate posttraumatic stress in Syrian refugees than the control condition nor was it likely to be cost-effective. Therefore, Sanadak is not suitable as a standalone treatment. However, as the app usability was very good, no harms detected, and stigma significantly reduced, Sanadak has potential as a bridging aid within a stepped and collaborative care approach.

Trial Registration

German Clinical Trials Register DRKS00013782; https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00013782

International Registered Report Identifier (IRRID)

RR2-10.1186/s12888-019-2110-y

Controlled Study of the Impact of a Virtual Program to Reduce Stigma Among University Students Toward People With Mental Disorders

Stigma toward mental disorders is one of today's most pressing global issues. The Covid-19 pandemic has exacerbated the barriers to social inclusion faced by individuals with mental disorders. Concurrently, stigma reduction interventions, especially those aimed at university students, have been more difficult to implement given social distancing and campus closures. As a result, alternative delivery for programs contributing to stigma reduction is required, such as online implementation. This paper reports the results of a controlled study focused on an online multi-component program on reducing stigma toward mental illness that included project-based learning, clinical simulations with standardized patients and E-Contact with real patients. A total of 40 undergraduate students from the Universidad del Desarrollo in Santiago, Chile, participated in the study. They were randomly divided between an intervention and control group. The intervention group participated in the online multi-component program, while the control group participated in an online educational program on cardiovascular health. We assessed the impact of the program by using the validated Spanish-language versions of the Attribution Questionnaire AQ-27 and the Questionnaire on Student Attitudes toward Schizophrenia with both groups, before and after the intervention. In addition, an ad hoc Likert scale ranging from 0 to 5 was used with the intervention group in order to assess the learning strategies implemented. Following the intervention, the participants belonging to the intervention group displayed significantly lower levels of stereotypes, perception of dangerousness, and global score toward people with schizophrenia (p < 0.001). In addition, participants presented lower levels of dangerousness-fear, avoidance, coercion, lack of solidarity, and global score (p < 0.001). The control group displayed no statistically significant differences in the level of stigma before and after the evaluation, for all of the items assessed. Finally, the overall assessment of each of the components of the program was highly positive. In conclusion, the study shows that online programs can contribute to reducing stigma toward mental disorders. The program assessed in this study had a positive impact on all the dimensions of stigma and all of the components of the program itself were positively evaluated by the participants.

Perceptions of mental health and perceived barriers to mental health help-seeking amongst refugees: A systematic review

Despite elevated rates of psychological disorders amongst individuals from a refugee background, levels of mental health help-seeking in these populations are low. There is an urgent need to understand the key barriers that prevent refugees and asylum-seekers from accessing help for psychological symptoms. This review synthesises literature examining perceptions of mental health and barriers to mental health help-seeking in individuals from a refugee background. Our analysis, which complies with PRISMA reporting guidelines, identified 62 relevant studies. Data extraction and thematic analytic techniques were used to synthesise findings from quantitative (n = 26) and qualitative (n = 40) studies. We found that the salient barriers to help-seeking were: (a) cultural barriers, including mental health stigma and knowledge of dominant models of mental health; (b) structural barriers, including financial strain, language proficiency, unstable accommodation, and a lack of understanding of how to access services, and (c) barriers specific to the refugee experience, including immigration status, a lack of trust in authority figures and concerns about confidentiality. We discuss and contextualise these key themes and consider how these findings can inform the development of policies and programs to increase treatment uptake and ultimately reduce the mental health burden amongst refugees and asylum-seekers.

The relationship between post-traumatic stress disorder and suicidal ideation among shidu parents: the role of stigma and social support

BACKGROUND

Losing an only child is a particularly traumatic and heartbreaking event for parents, which can trigger a lot of emotional responses, including PTSD and suicidal ideation (SI). The objectives of this study were mainly to identify predictors of SI and examine the interactions of PTSD with stigma and social support on SI among shidu parents.

METHODS

A total of 507 shidu parents from Shenyang, China were included in this cross-sectional study. Bivariate logistic regression analyses were conducted to explore risk or protective factors associated with SI. Interactions of PTSD with stigma and social support on SI were also examined by bivariate logistic regression analyses.

RESULTS

The prevalence of SI among shidu parents was 11.24%. PTSD (OR = 2.23, p < 0.05) and stigma (OR = 4.66, p < 0.01) were positively associated with SI. Social support was negatively associated with SI (OR = 0.90, p < 0.01). For individuals with PTSD, the presence of stigma was more likely to lead to SI. For individuals with PTSD, an increased level of social support was less likely to lead to SI.

CONCLUSIONS

SI is a serious issue among shidu parents. Stigma aggravated the effect of PTSD on SI, while social support buffered the effect of PTSD on SI among shidu parents.

Community Intervention for Syrian Refugees in Baltimore City: The Lay Health Educator Program at a Local Mosque

This study focused on a partnership with a mosque in Baltimore, MD, and its impact on the local Syrian refugee population through a peer-to-peer healthcare training program. We implemented the Lay Health Educator Program over a 6-week period in an effort to teach members of the mosque about healthcare-related topics that they could then disseminate to the Syrian refugee population that attends the mosque. Physicians and nurses instructed community members on health, healthcare resources, and healthcare information during 2-h long sessions once a week. A total of 18 community members took part in the program, and their participation highlighted that the most significant health issues for the Syrian refugees are "access to healthcare," "mental health," and insight into certain noncommunicable disease. Finally, the community program graduates implemented several health-related campaigns over 2 years in an effort to disseminate information taught to them. In doing so, they significantly impacted the ability of the refugees to assimilate to the US healthcare system.

Barriers to Mental Health Help-Seeking Amongst Refugee Men

Rates of help-seeking for mental health problems are low amongst refugee communities, despite the high prevalence of PTSD reported amongst these individuals. Research suggests that the key barriers to seeking help for psychological problems include structural barriers (e.g., unstable housing), cultural barriers (e.g., mental health stigma), and barriers specific to refugees and asylum seekers (e.g., visa status). This study examined the effect of structural, cultural and refugee specific barriers on the relationship between PTSD symptom severity and intentions to seek help from professional, social, and community sources. Data was collected from 103 male refugees and asylum seekers with an Arabic-, Farsi-, or Tamil-speaking background. Participants completed measures indexing demographics, trauma exposure, PTSD symptoms, mental health stigma, and help-seeking intentions. Path analyses indicated that PTSD severity was associated with lower help-seeking intentions indirectly via mental health stigma (self-stigma for seeking help and self-stigma for PTSD) and visa security. PTSD severity was also associated with greater help-seeking intentions from community members indirectly via structural barriers. These findings are important to consider when identifying key barriers to mental health help-seeking and developing interventions designed to increase help-seeking for psychological problems, within this group.