Expanding the evidence: key priorities for research on mental health interventions for refugees in high-income countries

Effect of trauma on asylum seekers and refugees receiving a WHO psychological intervention: a mediation model

Background: Scalable psychological interventions such as the WHO's Self-Help Plus (SH+) have been developed for clinical and non-clinical populations in need of psychological support. SH+ has been successfully implemented to prevent common mental disorders among asylum seekers and refugees who are growing in number due to increasing levels of forced migration. These populations are often exposed to multiple, severe sources of traumatisation, and evidence of the effect of such events on treatment is insufficient, especially for non-clinical populations.Objective: We aim to study the effect of potentially traumatic experiences (PTEs) and the mediating role of symptoms of posttraumatic stress disorder (PTSD) on the improvement following SH+.Method: Participants allocated to SH+ who received at least three sessions (N = 345) were extracted from two large, randomised, European prevention trials involving asylum seekers and refugees. Measures of distress, depression, functional impairment, and post-traumatic stress symptoms were administered at baseline and 6 months post-intervention, together with measures of well-being and quality of life. Adjusted models were constructed to examine the effect of PTEs on post-intervention improvement. The possible mediating role of PTSD symptoms in this relationship was then tested.Results: Increasing numbers of PTEs decreased the beneficial effect of SH+ for all measures. This relationship was mediated by symptoms of PTSD when analysing measures of well-being and quality of life. However, this did not apply for measures of mental health problems.Conclusions: Exposure to PTEs may largely reduce benefits from SH+. PTSD symptomatology plays a specific, mediating role on psychological well-being and quality of life of participants who experienced PTE. Healthcare professionals and researchers should consider the role of PTEs and PTSD symptoms in the treatment of migrants and refugees and explore possible feasible add-on solutions for cases exposed to multiple PTEs.

'They tried to evil me': An explanatory model for Black Africans' mental health challenges

This paper explores the explanatory models of mental challenges among Black Africans in England. It argues that understanding these models is critical for providing culturally appropriate care to this population. The study employed qualitative methodology, and interpretative phenomenological analysis (IPA). Twelve mental health service users who are living in England and self-identified as first or second-generation Black Africans were purposively selected. The data were gathered using face-to-face semistructured interviews. Data were manually analysed in accordance with IPA concepts of searching for common, unique and idiosyncratic themes across transcripts. The findings revealed three themes Black Africans associated to their explanatory model of mental health challenges: complexities of migration, African-centred worldview and negative life experiences. To help alleviate the Eurocentric nature of mental health practice in England, it is hoped that this explanatory model will become an integral part of mental health practice in England and around the world.

Mapping the evidence on psychosocial interventions for migrant populations: Descriptive analysis of a living database of randomized studies

Migrant mental health is a pressing public health issue with wide-ranging implications. Many randomized controlled trials (RCTs) have been conducted in this population to assess the effects of psychosocial interventions. However, the available evidence is characterized by controversy and fragmentation, with studies focusing on different migrant populations, interventions, outcomes, delivery modalities and settings. Aiming to promote systematic reviews of the effectiveness of psychosocial interventions in different migrant groups, we have developed a living database of existing RCTs. The development of the database provides an opportunity to map the existing RCT evidence in this population. A total of 135 studies involving 24,859 participants were included in the living database. The distribution of studies by year of publication aligns with the increasing global migrant population in recent years. Most studies focus primarily on adult participants, with a limited representation of children and adolescents, and a prevalence of female participants, which is consistent with epidemiological data, except for older adults, who are underrepresented in research. Studies predominantly focus on refugees and asylum seekers, likely due to their elevated risk of mental health issues, despite the substantial presence of economic migrants worldwide. While studies mainly involve migrants from the Middle East and East Asia, epidemiological data suggest a broader geographic representation, with migrants coming from Eastern Europe, Latin America and South Asia. The present descriptive analysis of RCTs on mental health and psychosocial interventions for migrant populations provides valuable insights into the existing research landscape. It should be used to inform future research efforts, ensuring that studies are more representative of the global migrant population and more responsive to the mental health needs of migrants in different contexts.

Exploring expectations of neurofeedback treatment among trauma-affected refugees

BACKGROUND

The use of Neurofeedback (NF) to assist individuals in learning to regulate their brain wave activity has shown promising results in reducing symptoms of posttraumatic stress disorder (PSTD). However, few studies have focused on the patients' understandings of NF and even fewer explore the perspective of refugees.

PURPOSE

To evaluate NF treatment for trauma-affected refugees by focusing on their expectations and understanding of NF.

METHODS

This qualitative study was a part of a mixed method study carried out at an outpatient mental health centre in Denmark, offering 34 trauma-affected refugees 12 sessions of NF. In this qualitative study, a subsample of seven participants was interviewed. Using in-depth semi-structured interviews, the participants' thoughts and expectations prior to participating in NF treatment were examined. The analysis was carried out in four steps, using a hermeneutic and phenomenological approach.

RESULTS

The analysis resulted in two themes: (1) Rationale and working mechanisms of NF and (2) Motivators for participating in the study.

CONCLUSION

The findings show that NF treatment for trauma affected refugees was challenged by difficulties in communicating the message about the NF equipment capabilities as well as the expected treatment outcome. These challenges included e.g. health professionals' ability to explain and the participants' cultural frame of reference. This is consistent with previous research, showing that compared to the native population, the dissemination of health information to refugees is more difficult and comprehensive. Further studies on how to ensure mutual understanding of the content of NF and expected treatment outcome are needed.

TRIAL REGISTRATION

ClinicalTrials.gov ID: NCT05055037. Retrospectively registered on the 06/07-2021.

Effectiveness of a stepped-care programme of WHO psychological interventions in migrant populations resettled in Italy: Study protocol for the RESPOND randomized controlled trial

Introduction

Migrant populations, including workers, undocumented migrants, asylum seekers, refugees, internationally displaced persons, and other populations on the move, are exposed to a variety of stressors and potentially traumatic events before, during, and after the migration process. In recent years, the COVID-19 pandemic has represented an additional stressor, especially for migrants on the move. As a consequence, migration may increase vulnerability of individuals toward a worsening of subjective wellbeing, quality of life, and mental health, which, in turn, may increase the risk of developing mental health conditions. Against this background, we designed a stepped-care programme consisting of two scalable psychological interventions developed by the World Health Organization and locally adapted for migrant populations. The effectiveness and cost-effectiveness of this stepped-care programme will be assessed in terms of mental health outcomes, resilience, wellbeing, and costs to healthcare systems.

Methods and analysis

We present the study protocol for a pragmatic randomized study with a parallel-group design that will enroll participants with a migrant background and elevated level of psychological distress. Participants will be randomized to care as usual only or to care a usual plus a guided self-help stress management guide (Doing What Matters in Times of Stress, DWM) and a five-session cognitive behavioral intervention (Problem Management Plus, PM+). Participants will self-report all measures at baseline before random allocation, 2 weeks after DWM delivery, 1 week after PM+ delivery and 2 months after PM+ delivery. All participants will receive a single-session of a support intervention, namely Psychological First Aid. We will include 212 participants. An intention-to-treat analysis using linear mixed models will be conducted to explore the programme's effect on anxiety and depression symptoms, as measured by the Patient Health Questionnaire-Anxiety and Depression Scale summary score 2 months after PM+ delivery. Secondary outcomes include post-traumatic stress disorder symptoms, resilience, quality of life, resource utilization, cost, and cost-effectiveness.

Discussion

This study is the first randomized controlled trial that combines two World Health Organization psychological interventions tailored for migrant populations with an elevated level of psychological distress. The present study will make available DWM/PM+ packages adapted for remote delivery following a task-shifting approach, and will generate evidence to inform policy responses based on a more efficient use of resources for improving resilience, wellbeing and mental health.

Clinical trial registration

ClinicalTrials.gov, identifier: NCT04993534.

Mental health professionals' perspective on a brief transdiagnostic psychological intervention for Afghan asylum seekers and refugees

Background

While many elaborated treatment protocols focus on post-traumatic stress symptoms, a large number of refugees suffer from a range of mental health problems. Thus, brief and transdiagnostic psychological interventions may be helpful first interventions for help-seeking refugees and asylum seekers in a stepped-care approach. Critically, there is limited research on how transdiagnostic interventions are received in general practice in non-specialized mental healthcare settings in high-income countries, where often only mental health professionals (MHPs) are legally allowed to treat people with mental disorders. MHPs may thus deliver such interventions, but their perspective towards them has not yet been investigated.

Objective

We aimed to investigate MHPs' perception of the usability of adapted Problem Management Plus (aPM+), a brief transdiagnostic psychological intervention for refugees, which we adapted to address distress caused by post-migration living difficulties (PMLDs).

Method

Employing an e-learning tool, we introduced the aPM+ intervention to 59 MHPs and assessed their perspective towards the intervention. We then used an inductive approach to analyse their perspective towards the intervention with open-ended questions.

Results

Altogether, 59 MHPs enrolled in the webinar and 29 provided feedback on the intervention. MHPs had a positive view on the intervention but emphasized the importance of situation-specific adaptations to the structure of the manual. The most favoured specific strategies were 'managing stress/slow-breathing', the 'tree of capabilities', and the 'riding the anger' exercise. The last two were additionally developed to reduce distress caused by PMLDs by either enhancing self-efficacy or reducing anger regulation difficulties.

Conclusions

An adaptation to aPM+ regarding more flexibility of the manual may enhance the likelihood of MHPs implementing the intervention in their daily practice. Strategies addressing coping with PMLDs could be particularly helpful.Trial registration: German Clinical Trials Register identifier: DRKS00016538.

HIGHLIGHTS

Mental health professionals had a positive view on a brief transdiagnostic psychological intervention for refugees but emphasized the importance of situation-specific adaptations to the structure of the manual.Low -intensity interventions may be useful not only in low- and middle-income countries but also in high-income countries as part of a stepped-care approach, even if distributed by MHPs instead of trained laypersons.

Preventing the mental health consequences of war in refugee populations

The refugee experience is associated with several potentially traumatic events that increase the risk of developing mental health consequences, including worsening of subjective wellbeing and quality of life, and risk of developing mental disorders. Here we present actions that countries hosting forcibly displaced refugees may implement to decrease exposure to potentially traumatic stressors, enhance subjective wellbeing and prevent the onset of mental disorders. A first set of actions refers to the development of reception conditions aiming to decrease exposure to post-migration stressors, and a second set of actions refers to the implementation of evidence-based psychological interventions aimed at reducing stress, preventing the development of mental disorders and enhancing subjective wellbeing.

Barriers and facilitators to access mental health services among refugee women in high-income countries: a systematic review

BACKGROUND

Based on the Global Trends report from the United Nations High Commissioner for Refugee, in high-income countries, there are 2.7 refuges per 1000 national population, girls and women account for nearly 50% of this refuge population. In these high-income countries, compared with the general population refuge women have higher prevalence of mental illness. Thus, this review was conducted to examine the barriers to and facilitators of access to mental health services for refugee women in high-income countries for refugee resettlement.

METHODS

We searched MEDLINE, EMBASE, PsycINFO, and CINAHL databases for research articles written in English with qualitative component. The last search date was on March 14, 2020. A narrative synthesis was conducted to gather key synthesis evidence. Refugee women (aged 18 and older) that could receive mental health services were included. Men and women under non-refugee migrant legal status were excluded. Studies were evaluated studies using the Critical Appraisal Skills Programme (CASP) qualitative checklist.

RESULTS

Of the four databases searched, 1258 studies were identified with 12 meeting the inclusion criteria. Three studies were cross-sectional by design, eight studies used a qualitative approach and one studies used mixed approach. The major barriers identified were language barriers, stigmatization, and the need for culturally sensitive practices to encourage accessing mental health care within a religious and cultural context. There were several studies that indicated how gender roles and biological factors played a role in challenges relating to accessing mental health services. The major facilitators identified were service availability and awareness in resettlement countries, social support, and the resilience of refugee women to gain access to mental health services.

CONCLUSION

This review revealed that socio-economic factors contributed to barriers and facilitators to accessing mental health among women refugees and asylum seekers. Addressing those social determinants of health can reduce barriers and enhance facilitators of access to mental health care for vulnerable populations like refugee women. A key limitation of the evidence in this review is that some data may be underreported or misreported due to the sensitive and highly stigmatizing nature of mental health issues among refugee populations.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020180369.

Trajectories of psychosocial symptoms and wellbeing in asylum seekers and refugees exposed to traumatic events and resettled in Western Europe, Turkey, and Uganda

Background: Longitudinal studies examining mental health trajectories in refugees and asylum seekers are scarce. Objectives: To investigate trajectories of psychological symptoms and wellbeing in refugees and asylum seekers, and identify factors associated with these trajectories. Method: 912 asylum seekers and refugees from the control arm of three trials in Europe (n = 229), Turkey (n = 320), and Uganda (n = 363) were included. We described trajectories of psychological symptoms and wellbeing, and used trauma exposure, age, marital status, education, and individual trial as predictors. Then, we assessed the bidirectional interactions between wellbeing and psychological symptoms, and the effect of each predictor on each outcome controlling for baseline values. Results: Symptom improvement was identified in all trials, and for wellbeing in 64.7% of participants in Europe and Turkey, versus 31.5% in Uganda. In Europe and Turkey domestic violence predicted increased symptoms at post-intervention (ß = 1.36, 95% CI 0.17-2.56), whilst murder of family members at 6-month follow-up (ß = 1.23, 95% CI 0.27-2.19). Lower wellbeing was predicted by murder of family member (ß  = -1.69, 95% CI -3.06 to -0.32), having been kidnapped (ß  = -1.67, 95% CI -3.19 to -0.15), close to death (ß =  -1.38, 95% CI -2.70 to -0.06), and being in the host country ≥2 years (ß =  -1.60, 95% CI -3.05 to -0.14). In Uganda at post-intervention, having been kidnapped predicted increased symptoms (ß = 2.11, 95% CI 0.58-3.65), and lack of shelter (ß  = -2.51, 95% CI -4.44 to -0.58) and domestic violence predicted lower wellbeing (ß  = -1.36, 95% CI -2.67 to -0.05). Conclusion: Many participants adapt to adversity, but contextual factors play a critical role in determining mental health trajectories.

From Formative Research to Cultural Adaptation of a Face-to-Face and Internet-Based Cognitive-Behavioural Intervention for Arabic-Speaking Refugees in Germany

Background

This study aims to provide a transparent and replicable documentation approach for the cultural adaptation of a cognitive-behavioural transdiagnostic intervention (Common Elements Treatment Approach, CETA) for Arabic-speaking refugees with common mental disorders in Germany.

Method

A mixed-methods approach was used, including literature review, interviews, expert decisions and questionnaires, in order to adapt the original CETA as well as an internet-based guided version (eCETA). The process of cultural adaptation was based on a conceptual framework and was facilitated by an adaptation monitoring form as well as guidelines which facilitate the reporting of cultural adaptation in psychological trials (RECAPT).

Results

Consistent with this form and the guidelines, the decision-making process of adaptation proved to be coherent and stringent. All specific CETA treatment components seem to be suitable for the treatment of Arabic-speaking refugees in Germany. Adaptations were made to three different elements: 1) Cultural concepts of distress: a culturally appropriate explanatory model of symptoms was added; socially accepted terms for expressing symptoms (for eCETA only) and assessing suicidal ideation were adapted; 2) Treatment components: no adaptations for theoretically/empirically based components of the intervention, two adaptations for elements used by the therapist to engage the patient or implement the intervention (nonspecific elements), seven adaptations for skills implemented during sessions (therapeutic techniques; two for eCETA only) and 3) Treatment delivery: 21 surface adaptations (10 for eCETA only), two eCETA-only adaptations regarding the format.

Conclusion

The conceptual framework and the RECAPT guidelines simplify, standardise and clarify the cultural adaptation process.

Cultural adaptation of internet- and mobile-based interventions for mental disorders: a systematic review

Providing accessible and effective healthcare solutions for people living in low- and middle-income countries, migrants, and indigenous people is central to reduce the global mental health treatment gap. Internet- and mobile-based interventions (IMI) are considered scalable psychological interventions to reduce the burden of mental disorders and are culturally adapted for implementation in these target groups. In October 2020, the databases PsycInfo, MEDLINE, Embase, Cochrane Central Register of Controlled Trials, and Web of Science were systematically searched for studies that culturally adapted IMI for mental disorders. Among 9438 screened records, we identified 55 eligible articles. We extracted 17 content, methodological, and procedural components of culturally adapting IMI, aiming to consider specific situations and perspectives of the target populations. Adherence and effectiveness of the adapted IMI seemed similar to the original IMI; yet, no included study conducted a direct comparison. The presented taxonomy of cultural adaptation of IMI for mental disorders provides a basis for future studies investigating the relevance and necessity of their cultural adaptation.PROSPERO registration number: CRD42019142320.

Refugee Mental Health, Global Health Policy, and the Syrian Crisis

The most recent global refugee figures are staggering, with over 82.4 million people forcibly displaced and 26.4 million registered refugees. The ongoing conflict in Syria is a major contributor. After a decade of violence and destabilization, over 13.4 million Syrians have been displaced, including 6.7 million internally displaced persons and 6.7 million refugees registered in other countries. Beyond the immediate political and economic challenges, an essential component of any response to this humanitarian crisis must be health-related, including policies and interventions specific to mental health. This policy and practice review addresses refugee mental health in the context of the Syrian crisis, providing an update and overview of the current situation while exploring new initiatives in mental health research and global health policy that can help strengthen and expand services. Relevant global health policy frameworks are first briefly introduced, followed by a short summary of recent research on refugee mental health. We then provide an update on the current status of research, service provision, and health policy in the leading destinations for Syrians who have been forcibly displaced. This starts within Syria and then turns to Turkey, Lebanon, Jordan, and Germany. Finally, several general recommendations are discussed, including the pressing need for more data at each phase of migration, the expansion of integrated mental health services, and the explicit inclusion and prioritization of refugee mental health in national and global health policy.

Effectiveness of Self-Help Plus in Preventing Mental Disorders in Refugees and Asylum Seekers in Western Europe: A Multinational Randomized Controlled Trial

INTRODUCTION

Self-Help Plus (SH+) is a group-based psychological intervention developed by the World Health Organization for managing stress.

OBJECTIVE

To assess the effectiveness of SH+ in preventing mental disorders in refugees and asylum seekers in Western Europe.

METHODS

We conducted a randomized controlled trial in 5 European countries. Refugees and asylum seekers with psychological distress (General Health Questionnaire score ≥3), but without a Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) or ICD/10 diagnosis of mental disorder, as assessed with the Mini International Neuropsychiatric Interview (MINI), were randomized to SH+ or enhanced treatment as usual (ETAU). The primary outcome was the frequency of mental disorders with the MINI at 6 months. Secondary outcomes included the frequency of mental disorders at postintervention, self-identified problems, psychological symptoms, and other outcomes.

RESULTS

Four hundred fifty-nine individuals were randomly assigned to SH+ or ETAU. For the primary outcome, we found no difference in the frequency of mental disorders at 6 months (Cramer V = 0.007, p = 0.90, RR = 0.96; 95% CI 0.52-1.78), while the difference significantly favored SH+ at after the intervention (secondary outcome, measured within 2 weeks from the last session; Cramer V = 0.13, p = 0.01, RR = 0.50; 95% CI 0.29-0.87).

CONCLUSIONS

This is the first randomized indicated prevention study with the aim of preventing the onset of mental disorders in asylum seekers and refugees in Western Europe. As a prevention effect of SH+ was not observed at 6 months, but rather after the intervention only, modalities to maintain its beneficial effect in the long term need to be identified.

A network meta-analysis of psychosocial interventions for refugees and asylum seekers with PTSD

INTRODUCTION

Refugees and asylum seekers are vulnerable to common mental disorders, including post-traumatic stress disorder (PTSD). Using a network meta-analysis (NMA) approach, the present systematic review compared and ranked psychosocial interventions for the treatment of PTSD in adult refugees and asylum seekers.

METHODS

Randomised studies of psychosocial interventions for adult refugees and asylum seekers with PTSD were systematically identified. PTSD symptoms at postintervention was the primary outcome. Standardised mean differences (SMDs) and ORs were pooled using pairwise and NMA. Study quality was assessed with the Cochrane Risk of Bias (RoB) tool, and certainty of evidence was assessed through the Confidence in Network Meta-Analysis application.

RESULTS

A total of 23 studies with 2308 participants were included. Sixteen studies were conducted in high-income countries, and seven in low-income or middle-income countries. Most studies were at low risk of bias according to the Cochrane RoB tool. NMA on PTSD symptoms showed that cognitive behavioural therapy (CBT) (SMD=-1.41; 95% CI -2.43 to -0.38) and eye movement desensitisation and reprocessing (EMDR) (SMD=-1.30; 95% CI -2.40 to -0.20) were significantly more effective than waitlist (WL). CBT was also associated with a higher decrease in PTSD symptoms than treatment as usual (TAU) (SMD -1.51; 95% CI -2.67 to -0.36). For all other interventions, the difference with WL and TAU was not significant. CBT and EMDR ranked best according to the mean surface under the cumulative ranking. Regarding acceptability, no intervention had less dropouts than inactive interventions.

CONCLUSION

CBT and EMDR appeared to have the greatest effects in reducing PTSD symptoms in asylum seekers and refugees. This evidence should be considered in guidelines and implementation packages to facilitate dissemination and uptake in refugee settings.

Self-help plus for refugees and asylum seekers; study protocol for a series of individual participant data meta-analyses

BACKGROUND

Refugees and asylum seekers face various stressors due to displacement and are especially vulnerable to common mental disorders. To effectively manage psychological distress in this population, innovative interventions are required. The World Health Organization (WHO) Self-Help Plus (SH+) intervention has shown promising outcomes in reducing symptoms of common mental disorders among refugees and asylum seekers. However, individual participant differences in response to SH+ remain largely unknown. The Individual Participant Data (IPD) meta-analysis synthesizes raw datasets of trials to provide cutting-edge evidence of outcomes that cannot be examined by conventional meta-analytic approaches.

OBJECTIVES

This protocol outlines the methods of a series of IPD meta-analyses aimed at examining the effects and potential moderators of SH+ in (a) reducing depressive symptoms at post-intervention and (b) preventing the six-month cumulative incidence of mental disorders in refugees and asylum seekers.

METHOD

RCTs on SH+ have been identified through WHO and all authors have agreed to share the datasets of the trials. The primary outcomes of the IPD meta-analyses are (a) reduction in depressive symptoms at post-intervention, and (b) prevention of six-month cumulative incidence of mental disorders. Secondary outcomes include post-traumatic stress disorder symptoms, well-being, functioning, quality of life, and twelve-month cumulative incidence of mental disorders. One-stage IPD meta-analyses will be performed using mixed-effects linear/logistic regression. Missing data will be handled by multiple imputation.

CONCLUSIONS

These results will enrich current knowledge about the response to SH+ and will facilitate its targeted dissemination. The results of these IPD meta-analyses will be published in peer-reviewed journals.

Therapeutic Nature Activities: A Step Toward the Labor Market for Traumatized Refugees

BACKGROUND

Globally, the number of refugees is growing. For many refugees, entering the labor market in their new country of residence is challenging. Some remain forever dependent on welfare services, and this not only weakens their chances of integration, but also harms their health and well-being.

METHODS

This qualitative single case study focused on a group of war-stricken refugees in Denmark. The study investigated the impact of an eight-month horticultural vocational program aimed at improving their ability to complete an education program or to work. A total of 29 interviews were conducted and analyzed using the interpretative phenomenological analysis (IPA) method.

RESULTS

The natural environment in the eco-village evoked a feeling of safety as well as positive memories in the participants, in contrast to the traumatic memories they had of their flight. Horticultural activities and the positive and respectful attitude from staff initiated a recovery process. New skills were achieved at an individual pace, and feelings of isolation decreased. These findings can be implicated in future interventions.

An overview of systematic reviews on mental health promotion, prevention, and treatment of common mental disorders for refugees, asylum seekers, and internally displaced persons

BACKGROUND

Migrants who have been forced to leave their home, such as refugees, asylum seekers, and internally displaced persons (IDP), are likely to experience stressors which may lead to mental health problems. The efficacy of interventions for mental health promotion, prevention, and treatment may differ in this population.

OBJECTIVES

With this overview of systematic reviews, we will map the characteristics and methodological quality of existing systematic reviews and registered systematic review protocols on the promotion of mental health and prevention and treatment of common mental disorders among refugees, asylum seekers, and IDPs. The findings from this overview will be used to prioritise and inform future Cochrane reviews on the mental health of involuntary migrants.

METHODS

We searched Ovid MEDLINE (1945 onwards), Ovid Embase (1974 onwards), Ovid PsycINFO, ProQuest PTSDpubs, Web of Science Core Collection, Cochrane Database of Systematic Reviews, NIHR Journals Library, CRD databases (archived), DoPHER, Epistemonikos, Health Evidence, 3ie International Initiative for Impact Evaluation, and PROSPERO, to identify systematic reviews of mental health interventions for involuntary migrants. We did not apply any restrictions on date, language, or publication status to the searches. We included systematic reviews or protocols for systematic reviews of interventions aimed at refugees, asylum seekers, and internally displaced persons. Interventions must have been aimed at mental health promotion (for example, classroom-based well-being interventions for children), prevention of mental health problems (for example, trauma-focussed Cognitive Behavioural Therapy to prevent post-traumatic stress disorder), or treatment of common mental disorders and symptoms (for example, narrative exposure therapy to treat symptoms of trauma). After screening abstracts and full-text manuscripts in duplicate, we extracted data on the characteristics of the reviews, the interventions examined in reviews, and the number of primary studies included in each review. Methodological quality of the included systematic reviews was assessed using AMSTAR 2.

MAIN RESULTS

The overview includes 23 systematic reviews and 15 registered systematic review protocols. Of the 23 published systematic reviews, meta-analyses were conducted in eight reviews. It was more common for the search strategy or inclusion criteria of the reviews to state that studies involving refugees were eligible for inclusion (23/23), than for asylum seekers (14/23) or IDPs (7/23) to be explicitly mentioned. In most reviews, study eligiblity was either not restricted by participant age (9/23), or restricted to adults (10/23). Reviews commonly reported on studies of diagnosis or symptoms of post-traumatic stress disorder or trauma (11/23) and were less likely to report on depression or anxiety (6/23). In 15 reviews the intervention of interest was focused on/ specific to psychological therapy. Across all 23 reviews, the interventions most commonly identified from primary studies were general Cognitive Behavioural Therapy, Narrative Exposure Therapy, and a range of different integrative and interpersonal therapies. Even though many reviews included studies of participants without a diagnosis of a mental health problem, they often assessed mental health treatments and did not usually distinguish between promotion, prevention, and treatment in the review aims. Together the 23 systematic reviews included 336 references, of which 175 were unique primary studies. Limitations to the methodological quality of reviews most commonly related to reporting of selection criteria (21/23), absence of a protocol (19/23), reporting of study design (20/23), search strategy (22/23), and funding sources of primary studies (19/23).

AUTHORS' CONCLUSIONS

Gaps exist in the evidence on mental health interventions for refugees, asylum seekers, and internally displaced persons. Most reviews do not specify that internally displaced persons are included in the selection criteria, even though they make up the majority of involuntary migrants worldwide. Reviews specific to mental health promotion and prevention of common mental disorders are missing, and there is more evidence available for adults or mixed populations than for children. The literature is focused on post-traumatic stress disorder and trauma-related symptoms, with less attention for depression and anxiety disorders. Better quality systematic reviews and better report of review design and methods would help those who may use these reviews to inform implementation of mental health interventions.

Cultural adaptation of Internet- and mobile-based interventions for mental disorders: a systematic review protocol

BACKGROUND

Internet- and mobile-based interventions (IMI) are an effective and scalable low-threshold solution to reach people who are undersupplied by current healthcare. Adapting interventions to the cultural and ethnic background of the target group enhances their acceptance and effectiveness. However, no systematic approach to cultural adaptation of IMI has been established so far. Therefore, this review aims to summarise components and procedures commonly used in the cultural adaptation of IMI for mental disorders, as well as the current evidence base on whether such a cultural adaptation leads to an increased acceptance, adherence, and effectiveness of IMI for mental disorders.

METHODS

A systematic literature search will be performed using the following databases: MEDLINE, Embase, PsycINFO, CENTRAL, and WoS. The search term will include keywords related to cultural adaptation, IMI, and mental disorders/disturbances. Two independent reviewers will evaluate studies against inclusion and exclusion criteria and extract study and intervention characteristics, details on the cultural adaptation approach, and outcome data. Quality of evidence will be assessed using the Quality Assessment Tool for Reviewing Studies with Diverse Designs, and results will be synthesised qualitatively.

DISCUSSION

Providing adequate mental healthcare regardless of cultural backgrounds is a major global health challenge. The planned systematic review will lay the foundation for the further development of the cultural adaptation of IMI for mental disorders by summarising the current state and providing recommendations for future research.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42019142320.

Barriers and facilitators to access mental health services among refugee women in high-income countries: study protocol for a systematic review

BACKGROUND

According to the United Nation High Commissioner for Refugee Global Trends report in 2019, on average, there are 2.7 refugees per 1000 national population in high-income countries, where girls and women attributed to 48% of the refugee population. Evidence shows high prevalence of mental health disorder among women refugees in comparison to the general population. To our knowledge, no systematic reviews have addressed access to mental health services for refugee women. The aim of this study will be to examine existing barriers and facilitators to accessing mental health services for refugee women in leading high-income countries for refugee resettlement.

METHODS

We designed and registered a study protocol for a systematic review. We will conduct a literature search (from inception onwards) in MEDLINE, EMBASE, PsycINFO, and CINAHL. Research articles having a qualitative component (i.e., qualitative, mixed, or multi-method) will be eligible. Study populations of interest will be refugee women at any age that can receive mental health services in leading high-income countries for refugee resettlement (e.g., 14 countries from North America, Europe, and Oceania). Eligibility will be restricted to studies published in English. The primary outcome will be all barriers and facilitators related to accessing mental health services. Two reviewers will independently screen all citations, full-text articles, and abstract data. Potential conflicts will be resolved through discussion. The study methodological quality (or bias) will be appraised using appropriate tools. Reporting will follow the Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) statement. A narrative synthesis will be conducted, and summary of findings tables will be produced. As it will be a systematic review, without human participants' involvement, there will be no requirement for ethical approval.

DISCUSSION

The systematic review will present key evidence on barriers and facilitators to access mental health services among refugee women in leading resettlement countries. The findings will be used to inform program developers, policymakers, and other stakeholders to enhance mental health services for refugee women. The final manuscript will be disseminated through a peer-reviewed journal and scientific conferences.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020180369.

A brief transdiagnostic psychological intervention for Afghan asylum seekers and refugees in Austria: a randomized controlled trial

BACKGROUND

Asylum seekers and refugees are at great risk for developing mental disorders. Afghan refugees are a particularly vulnerable group with a low average education and mental health literacy level. Traumatic experiences and hardship before and during migration are predictive of mental health problems. However, post-migration living difficulties (PMLDs) also account for a large proportion of mental distress in such populations, which, critically, are not sufficiently considered in treatment protocols and research investigations. Indeed, the evidence base for the treatment of refugees and asylum seekers is sparse and limited mainly to trauma-specific treatments, where refugees may likely suffer from other mental health problems such as depression or anxiety.

METHODS/DESIGN

This trial is the first evaluation of a short-term, transdiagnostic treatment protocol for treatment-seeking Afghan refugees which addresses mental health problems and PMLDs while using an adapted version of the Problem Management Plus (PM+) protocol. Here, we will investigate the efficacy of an intervention manual with a prospective, single-center, randomized, assessor-blind, two-group trial among refugees who are on a waiting list for professional mental health treatment. Furthermore, we will investigate participants' subjective experiences with the intervention manual via in-depth interviews. One hundred twenty people will be assessed and randomly allocated to either the intervention arm or a treatment-as-usual arm. Clinical psychologists will conduct the treatment, and the sessions will take place with a Dari interpreter. The protocol consists of six 90-min sessions. The primary endpoint is the general symptom distress measure, assessed with the General Health Questionnaire 28 (GHQ-28). Secondary endpoints are the Post-Migration Living Difficulties Checklist (PMLDC), the International Trauma Questionnaire (ITQ), the World Health Organization Quality of Life Questionnaire (WHOQOL-BREF), the Psychological Outcome Profile (PSYCHLOPS), service and health care use (assessed with several items), and the Immigrant Integration Index (IPL-12).

DISCUSSION

This trial may provide substantial evidence for a brief transdiagnostic psychological intervention. Here, we intend to contribute to the treatment of mental health problems among Afghan refugees. The assessment of subjective experience with this treatment manual, as well as the evaluation of its clinical applicability, may optimize treatment acceptance and outcomes across a wide range of mental health problems among refugees.

TRIAL REGISTRATION

German Clinical Trials Register (DRKS) registration number: DRKS00016538. Universal Trial Number: U1111-1226-3285. Registered on January 7, 2019. https://www.drks.de/drks_web/setLocale_EN.do.

Cultural adaptation of internet interventions for refugees: Results from a user experience study in Germany

BACKGROUND

The estimated number of refugees worldwide resulting from persecution, conflict, violence, or human rights violations reached 25.4 million in 2017. An increased prevalence of mental disorders combined with language and socio-cultural barriers pose a challenge for healthcare systems. Internet-based interventions can help to meet this challenge. For the effective use of such interventions in refugees, cultural adaptations are necessary. The variety of their cultural backgrounds thereby is particularly challenging.

METHODS

We conducted this explorative qualitative study in order to identify elements of Internet-based interventions that need cultural adaptation to be suitable for refugees. Six refugees from Syria, Iran, Eritrea, Algeria, and Iraq, and six healthcare providers (two social workers, two psychologists, one physiotherapist, one physician) working with refugees went through an intervention for individuals with sleeping problems (eSano Sleep-e). Possible threats to user experience were identified using the Think Aloud method and semi-structured interviews. Statements were analysed based on the grounded theory method.

RESULTS

Results indicate the necessity to adapt the intervention to the specifics of refugees including aspects related to the flight (i.e., past and current stressors) and non-western characteristics (i.e., habits, disease and treatment concepts). Elements of adaptation should include pictures, role models, language, psychoeducational elements, structure of modules, and format of presentation.

CONCLUSIONS

Cultural adaptation can be used to facilitate the identification with an intervention, which seems crucial to increase the acceptance among refugees. In spite of their diverse cultural backgrounds, it appears feasible to create interventions that allow identification by refugees from different home countries.

Efficacy and acceptability of psychosocial interventions in asylum seekers and refugees: systematic review and meta-analysis

AimsIn the past few years, there has been an unprecedented increase in the number of forcibly displaced migrants worldwide, of which a substantial proportion is refugees and asylum seekers. Refugees and asylum seekers may experience high levels of psychological distress, and show high rates of mental health conditions. It is therefore timely and particularly relevant to assess whether current evidence supports the provision of psychosocial interventions for this population. We conducted a systematic review and meta-analysis of randomised controlled trials (RCTs) assessing the efficacy and acceptability of psychosocial interventions compared with control conditions (treatment as usual/no treatment, waiting list, psychological placebo) aimed at reducing mental health problems in distressed refugees and asylum seekers.

METHODS

We used Cochrane procedures for conducting a systematic review and meta-analysis of RCTs. We searched for published and unpublished RCTs assessing the efficacy and acceptability of psychosocial interventions in adults and children asylum seekers and refugees with psychological distress. Post-traumatic stress disorder (PTSD), depressive and anxiety symptoms at post-intervention were the primary outcomes. Secondary outcomes include: PTSD, depressive and anxiety symptoms at follow-up, functioning, quality of life and dropouts due to any reason.

RESULTS

We included 26 studies with 1959 participants. Meta-analysis of RCTs revealed that psychosocial interventions have a clinically significant beneficial effect on PTSD (standardised mean difference [SMD] = -0.71; 95% confidence interval [CI] -1.01 to -0.41; I2 = 83%; 95% CI 78-88; 20 studies, 1370 participants; moderate quality evidence), depression (SMD = -1.02; 95% CI -1.52 to -0.51; I2 = 89%; 95% CI 82-93; 12 studies, 844 participants; moderate quality evidence) and anxiety outcomes (SMD = -1.05; 95% CI -1.55 to -0.56; I2 = 87%; 95% CI 79-92; 11 studies, 815 participants; moderate quality evidence). This beneficial effect was maintained at 1 month or longer follow-up, which is extremely important for populations exposed to ongoing post-migration stressors. For the other secondary outcomes, we identified a non-significant trend in favour of psychosocial interventions. Most evidence supported interventions based on cognitive behavioural therapies with a trauma-focused component. Limitations of this review include the limited number of studies collected, with a relatively low total number of participants, and the limited available data for positive outcomes like functioning and quality of life.

CONCLUSIONS

Considering the epidemiological relevance of psychological distress and mental health conditions in refugees and asylum seekers, and in view of the existing data on the effectiveness of psychosocial interventions, these interventions should be routinely made available as part of the health care of distressed refugees and asylum seekers. Evidence-based guidelines and implementation packages should be developed accordingly.

Recent approaches to provision of mental healthcare in refugee populations

PURPOSE OF REVIEW

The present review provides an overview of key issues and concepts on the provision of mental healthcare to refugees with mental health conditions.

RECENT FINDINGS

Several barriers to mental healthcare for refugees have been described, and principles for good mental care in this group have been framed. Evidence for specific interventions for refugees is available for trauma-related mental health problems. The best evidence is available for psychosocial interventions for the treatment of posttraumatic stress disorder.

SUMMARY

The worldwide increase in the number of refugees and the substantial burden of psychological distress and mental health problems associated with this condition has led to an increased research and policy interest for optimizing the provision of effective mental healthcare. To date, with the exception of trauma-related conditions, there is almost no evidence on the efficacy of psychosocial interventions for anxiety and depressive conditions, and there is no information on how mental healthcare should be embedded into existing health and social care services. Existing research and implementation activities will hopefully contribute to better characterize the effective components and elements of mental healthcare programmes for refugees.