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.

Association Between Dry Eye Disease with Anxiety and Depression Among Medical Sciences Students in Qassim Region: Cortisol Levels in Tears as a Stress Biomarker

Purpose

This study aimed to investigate the relationships between anxiety, depression, and ocular surface health. Cortisol levels were detected in human tears, and their relationship with anxiety levels was determined using a validated questionnaire.

Patients and Methods

In total, 112 participants were recruited for this study. All participants were healthy medical students at the Qassim University. Each participant signed an informed consent form after receiving detailed information about the study. Visual acuity examination, TBUT, Shirmer1 test were performed. Participants were asked to fill out three questionnaires: Taylor Manifest Anxiety Scale, Beck Depression Inventory, and The Ocular Surface Disease Index. Tear samples were extracted from the Schirmer strips and cortisol level was measured using ELISA kits.

Results

A total of 112 college students were included in the study, 58.9% of whom were females. The mean age was 21.9 ± 1.7 years. Subjective reported symptoms of anxiety levels were significantly correlated with depression scores, the OSDI, and reduced Schirmer test measurements. Moreover, cortisol levels detected in tears were positively associated with higher anxiety scores (r=0.328, P<0.05).

Conclusion

Ocular surface health is associated with symptoms of anxiety and depression. The use of tears to measure cortisol levels could be an interesting way to serve as an anxiety biomarker.

Association of pre-migration socioeconomic status and post-migration mental health in Syrian refugees in Lebanon: a descriptive sex-stratified cross-sectional analysis

BACKGROUND

Refugee populations present with high levels of psychological distress, which may vary among sociodemographic characteristics. Understanding the distribution across these characteristics is crucial to subsequently provide more tailored support to the most affected according to their specific healthcare needs. This study therefore seeks to investigate the association between pre-migration socioeconomic status (SES) and post-migration mental health separately for male and female Syrian refugees in Lebanon.

METHODS

In a cross-sectional study, a cluster randomized sample of 599 refugees from Syria were recruited between 2016 and 2019 within 12 months after they fled to Lebanon. Logistic regression was used to determine the association between self-reported pre-migration SES and levels of anxiety and depressive symptoms assessed on the Hopkins Symptoms Checklist-25 (HSCL-25) scale, both for the entire sample and stratified by sex. To assess the informative value of self-reported SES, its correlation with education variables was tested. All analyses were conducted in R version 4.3.

RESULTS

Using complete cases, 457 participants (322 female, 135 male) were included in the analyses. Females showed on average more symptoms of anxiety (Median: 2.5) and depression (Median: 2.4) than males (Median: 2.10 and 2.07, respectively). Below average SES was associated with significantly higher odds for mental illness compared to average SES (anxiety: OR 4.28, 95% CI [2.16, 9.49]; depression: OR 1.85, 95% CI [1.06, 3.36]). For anxiety, differences between SES strata were larger for males than females. The self-reported SES measure showed only a weak positive correlation with education.

CONCLUSIONS

This study adds additional descriptive data highlighting mental health differences in Syrian refugees in Lebanon, whereby below average SES is associated with worse mental health outcomes compared to average SES. These findings demand further research into the underlying mechanisms. Improving our understanding of the observed differences will provide valuable insights that can contribute to the future development of targeted measures.

Internet-based transdiagnostic treatment for emotional disorders in Arabic- and Farsi-speaking refugees: study protocol of a randomized controlled trial

BACKGROUND

Refugee populations have an increased risk for mental disorders, such as depression, anxiety, and posttraumatic stress disorders. Comorbidity is common. At the same time, refugees face multiple barriers to accessing mental health treatment. Only a minority of them receive adequate help. The planned trial evaluates a low-threshold, transdiagnostic Internet-based treatment. The trial aims at establishing its efficacy and cost-effectiveness compared with no treatment.

METHODS

N = 131 treatment-seeking Arabic- or Farsi-speaking patients, meeting diagnostic criteria for a depressive, anxiety, and/or posttraumatic stress disorder will be randomized to either the intervention or the waitlist control group. The intervention group receives an Internet-based treatment with weekly written guidance provided by Arabic- or Farsi-speaking professionals. The treatment is based on the Common Elements Treatment Approach (CETA), is tailored to the individual patient, and takes 6-16 weeks. The control group will wait for 3 months and then receive the Internet-based treatment.

DISCUSSION

The planned trial will result in an estimate of the efficacy of a low-threshold and scalable treatment option for the most common mental disorders in refugees.

TRIAL REGISTRATION

German Registry for Clinical Trials DRKS00024154. Registered on February 1, 2021.

Mapping the availability of translated versions of posttraumatic stress disorder screening questionnaires for adults: A scoping review

Background: The most used questionnaires for PTSD screening in adults were developed in English. Although many of these questionnaires were translated into other languages, the procedures used to translate them and to evaluate their reliability and validity have not been consistently documented. This comprehensive scoping review aimed to compile the currently available translated and evaluated questionnaires used for PTSD screening, and highlight important gaps in the literature.Objective: This review aimed to map the availability of translated and evaluated screening questionnaires for posttraumatic stress disorder (PTSD) for adults.Methods: All peer-reviewed studies in which a PTSD screening questionnaire for adults was translated, and which reported at least one result of a qualitative and /or quantitative evaluation procedure were included. The literature was searched using Embase, MEDLINE, and APA PsycInfo, citation searches and contributions from study team members. There were no restrictions regarding the target languages of the translations. Data on the translation procedure, the qualitative evaluation, the quantitative evaluation (dimensionality of the questionnaire, reliability, and performance), and open access were extracted.Results: A total of 866 studies were screened, of which 126 were included. Collectively, 128 translations of 12 different questionnaires were found. Out of these, 105 (83.3%) studies used a forward and backward translation procedure, 120 (95.2%) assessed the reliability of the translated questionnaire, 60 (47.6%) the dimensionality, 49 (38.9%) the performance, and 42 (33.3%) used qualitative evaluation procedures. Thirty-four questionnaires (27.0%) were either freely available or accessible on request.Conclusions: The analyses conducted and the description of the methods and results varied substantially, making a quality assessment impractical. Translations into languages spoken in middle- or low-income countries were underrepresented. In addition, only a small proportion of all translated questionnaires were available. Given the need for freely accessible translations, an online repository was developed.HIGHLIGHTS We mapped the availability of translated PTSD screening questionnaires.The quality of the translation and validation processes is very heterogenous.We created a repository for translated, validated PTSD screening questionnaires.

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

INTRODUCTION

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

METHODS AND ANALYSIS

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

ETHICS AND DISSEMINATION

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

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

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

START adolescents: study protocol of a randomised controlled trial to investigate the efficacy of a low-threshold group treatment programme in traumatised adolescent refugees

Introduction

No evaluated therapeutic approaches, that can efficiently be established in routine mental healthcare, are currently available for traumatised adolescent refugees in Germany. This study evaluates the efficacy of the Stress-Traumasymptoms-Arousal-Regulation-Treatment (START) programme to reduce trauma-related symptoms and psychological distress in traumatised adolescent refugees based in Germany.

Methods and analysis

This randomised, waiting-list-controlled, multicentre trial with a 12-week follow-up will include 174 refugee minors with partial or full post-traumatic stress disorder who are fluent in either Arabic, Dari, English, German or Somali. Eligible refugee minors will be randomised to the START or waiting-list control groups. The manualised 8-week START programme is based on techniques of dialectical behaviour therapy (DBT), fosters adaptive coping with emotional distress and traumatic symptoms and comprises eight therapy modules and a booster session. Study assessments are planned at baseline, post-treatment (ie, after programme participation or waiting time), booster session at week 12 or 12-week waiting time, and at the 12-week follow-up. Primary and coprimary outcomes are changes in psychological distress and traumatic symptoms at post-treatment and will be analysed as response variables in linear mixed regression models. Secondary outcomes are changes in further trauma-related and other psychopathological symptoms, emotion regulation and intermediate effects of the programme at follow-up. We will also assess effects of the programme with ecological momentary assessments and on neuroendocrine stress parameters using hair cortisol.

Ethics and dissemination

This study has been approved by the lead ethics committee of Rhineland-Palatinate and the ethics committees of participating sites. The study results will be disseminated through peer-reviewed publications and scientific conferences.

Trial registration number

DRKS00020771.

Feasibility trial of a scalable transdiagnostic group psychological intervention for Syrians residing in a refugee camp

Background: Approximately 10% of Syrian refugees currently reside in camp settings, which can impose additional post-migration stressors. With elevated rates of psychological distress and few available resources, task-shifting psychosocial programmes are necessary to provide adequate care. One such programme developed by the World Health Organization (WHO) is Group Problem Management Plus (GroupPM+). Objective: This study aimed to test the safety and acceptability of GroupPM+ in a refugee camp and to identify areas for adaptation in preparation for a definitive RCT. Method: A feasibility randomized controlled trial (RCT) was conducted in Azraq refugee camp in Jordan. Inclusion criteria were: (1) Syrian adults aged ≥18 years, (2) parent of a child aged 10-16 years, (3) experiencing psychological distress as defined by a score of ≥16 on the Kessler Distress Scale, and (4) ≥17 on the WHO Disability Assessment Schedule 2.0. Following baseline assessments, participants were randomized to receive GroupPM+ or enhanced treatment-as-usual. Post-assessments were conducted one week following the last GroupPM+ session. Primary outcomes were feasibility and acceptance of GroupPM+; symptoms of anxiety, depression, PTSD, prodromal psychosis, grief, and child's self-reported psychological distress were also assessed. Results: Of the 207 persons screened, 64 (31%) screened positive for psychological distress. Of the 35 randomized into the GroupPM+ intervention, 24 (69%) completed the intervention. No adverse events were reported throughout the trial. Children whose parents received GroupPM+ had greater reductions in internalizing and externalizing symptoms at posttreatment. 55 (86%) participants completed the post-assessment follow-up. These results demonstrate both the feasibility of conducting the trial in a camp and acceptance of the GroupPM+ intervention by Syrian refugees. Conclusions: Following the feasibility trial, both the implementation procedures and intervention were safe and culturally acceptable. The results support the readiness for a definitive RCT to determine the effectiveness and cost-effectiveness of the intervention in camp settings.

Is only one cognitive technique also effective? Results from a randomized controlled trial of two different versions of an internet-based cognitive behavioural intervention for post-traumatic stress disorder in Arabic-speaking countries

BACKGROUND

Internet-based cognitive-behavioural interventions seem to be effective for the treatment of posttraumatic stress disorder (PTSD) in Arabic-speaking countries in the MENA region. However, due to high prevalence rates of trauma-related mental disorders in this region, it is important to scale up existing Internet-based interventions in order to increase the number of clients.

OBJECTIVE

The aim of the study was to examine whether a brief Internet-based intervention with one cognitive technique (TF-short, 6 assignments) results in the same PTSD symptom change and lower dropouts compared to a longer intervention with two cognitive techniques (TF-reg, 10 assignments).

METHOD

A total of 224 Arab participants (67.4% female; M = 25.3 years old) with PTSD were randomly assigned to Internet-based CBT with either a TF-reg protocol (n = 110) or a TF-short protocol (n = 114). Symptoms of PTSD and secondary outcomes (anxiety, depression, somatic complaints, quality of life) were self-assessed online at baseline and post-treatment. Treatment-associated changes were estimated using multigroup latent difference score models.

RESULTS

The overall PTSD score assessed with the PDS decreased by about 15 points in both conditions. The between-group differences (TF-reg vs. TF-short) at post-assessment were non-significant, Δ = 0.29, p = .896, d = 0.02, 95% CI [-0.30, 0.34]. Like the primary outcome, all within-group changes for the secondary outcomes throughout the intervention were statistically significant and all between-group effects were non-significant. Overall, the dropout rates did not differ between the two conditions, χ2 (1/N = 175) = 0.83, p = .364.

CONCLUSIONS

The findings suggest that the shorter condition results in the same symptom change and dropout rate as the longer condition. This highlights the potential of shorter, more scalable Internet-based interventions in socially restricted and (post-)conflict societies.

CLINICALTRIALSGOV ID

NCT01508377.

Peer-provided Problem Management Plus (PM+) for adult Syrian refugees: a pilot randomised controlled trial on effectiveness and cost-effectiveness

Aims

Common mental disorders are highly prevalent among Syrian refugees. Problem Management Plus (PM+) is a brief, transdiagnostic, non-specialist helper delivered, psychological intervention targeting psychological distress. This single-blind pilot randomised controlled trial (RCT) on PM+ delivered by peer-refugees examined trial procedures in advance of a definitive RCT, evaluated PM+ 's acceptability and feasibility, and investigated its likely effectiveness and cost-effectiveness among Syrian refugees in the Netherlands.

Methods

Adult Syrian refugees (N = 60) with elevated psychological distress (Kessler Psychological Distress Scale (K10) score >15) and reduced pychosocial functioning (WHO Disability Assessment Schedule 2.0 (WHODAS) score >16) were randomised into PM+ in addition to care as usual (CAU) (PM+/CAU; n = 30) or CAU alone (n = 30). Primary outcomes were symptoms of depression and anxiety (Hopkins Symptom Checklist; HSCL-25) at 3-month follow-up. Secondary outcomes were pychosocial functioning (WHO Disability Assessment Schedule; WHODAS 2.0), symptoms of posttraumatic stress disorder (PTSD) (PTSD Checklist for DSM 5; PCL-5) and self-identified problems (Psychological Outcomes Profiles; PSYCHLOPS). Changes in service utilisation and time out of employment and/or adult education were estimated (adapted version of the Client Service Receipt Inventory; CSRI). Semi-structured interviews on the implementation of PM+ were conducted with stakeholders (i.e. six PM+ participants, five non-specialist helpers and five key informants).

Results

Recruitment, randomization and blinding procedures were successful. PM+ was generally perceived positively by stakeholders, especially regarding the intervention strategies, accommodation of the intervention and the helpers. Two serious adverse events not attributable to the trial were reported. At 3-month follow-up, the HSCL-25 total score was significantly lower for the PM+/CAU group (n = 30) than CAU group (n = 30) (p = 0.004; d = 0.58). Significant differences in favour of PM+/CAU were also found for WHODAS psychosocial functioning (p = 0.009, d = 0.73), PCL-5 symptoms of PTSD (p = 0.006, d = 0.66) and PSYCHLOPS self-identified problems (p = 0.005, d = 0.81). There were no significant differences in mean health service costs (p = 0.191) and the mean costs of lost productive time (p = 0.141). This suggests PM+ may potentially be cost-effective with an incremental cost from a health system perspective of €5047 (95% CI €0–€19 773) per additional recovery achieved.

Conclusions

Trial procedures and PM+ delivered by non-specialist peer-refugee helpers seemed acceptable, feasible and safe. Analyses indicate that PM+ may be effective in improving mental health outcomes and psychosocial functioning, and potentially cost-effective. These results support the development of a definitive RCT with a larger sample of refugees and a longer follow-up period.

Dimensionality of DSM-5 PTSD symptoms: Validation of the Chinese version of the posttraumatic diagnostic scale for DSM-5 across multiple trauma samples

The Posttraumatic Diagnostic Scale for DSM-5 (PDS-5) is an updated DSM-5 version of the PDS, a widely used measure for PTSD. The PDS-5 has recently been shown to possess sound psychometric properties and awaits cross-cultural validation. The present study aimed first, to evaluate the psychometric properties of the Chinese version of the PDS-5; second, to evaluate alternative factor models of DSM-5 PTSD symptoms with multiple trauma samples. Data were collected from five samples of Taiwanese trauma-exposed individuals (total N = 903): 138 burn injury survivors, 403 earthquake survivors, 181 trauma-exposed young adults, 91 trauma-exposed undergraduates, and 90 female domestic violence survivors. The Chinese PDS-5 possessed excellent internal consistency (α s = .94-.95) and satisfactory five-week (r = .80) and one-year temporal stability (r = 0.76). Convergent, concurrent, and discriminant validity were also established. Consistent with recent studies, confirmatory factor analyses demonstrated the best fit of a seven-factor Hybrid model, followed by a six-factor Anhedonia model across multiple trauma samples.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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