Strengthening mental health care systems for Syrian refugees in Europe and the Middle East: integrating scalable psychological interventions in eight countries

'The doctor doesn't understand Xhosa and the service user doesn't understand English' - exploring the role of security guards acting as informal interpreters in psychiatric care in South Africa

INTRODUCTION

Assigning qualified interpreters is considered one of the most effective approaches to facilitate communication in language-discordant encounters in mental healthcare. However, particularly in settings with fewer resources, they are not always available and informal practices are often used.

OBJECTIVE

This study aimed to investigate informal interpreting practices in mental healthcare in South Africa, focusing on security guards (SGs) serving as interpreters.

METHODS

Guided interviews were conducted with SGs (n = 12) and mental healthcare providers (MHCPs) (n = 18) at a psychiatric hospital in South Africa. The interviews were audio recorded, transcribed verbatim and analyzed using a thematic analysis approach.

RESULTS

Despite recognizing that SGs serving as interpreters is not an ideal solution to overcome language barriers and could potentially jeopardize the quality of treatment and its outcomes, MHCPs reported relying heavily on them due to the underrepresentation of South Africa's linguistic diversity among them. Given the lack of formal interpreting services, the perceived racial, linguistic and socioeconomic similarities between SGs and some service users, as well as their immediate accessibility, were described as beneficial to providing a minimal level of care (e.g. obtaining information about service users' backgrounds, getting an understanding of their symptoms, psychoeducation, explaining treatment options). Drawbacks reported are SGs being pulled away from their actual duties, experiencing emotional distress, juggling multiple sometimes conflicting roles, and the risk of incorrect interpretation, which could compromise ethical standards of care. Additionally, the complexity of power became apparent: While SGs hold little institutional power within the mental healthcare system, they become powerful figures when serving as interpreters.

CONCLUSION

It can be assumed that MHCPs will resort to informal interpreting practices as long as effective alternatives are lacking. In doing so, risks such as reduced quality of care are accepted, and the consequences and effects on those serving as interpreters are neglected, which raises concerns from an ethical point of view.

Tipping the scales for global mental health: A summary of the Presidential Panel at the 39th Annual Meeting of the International Society for Traumatic Stress Studies

In the past decade, there has been an increasing focus within scientific research on how to assist people affected by the negative consequences of trauma and crises around the globe. As many countries struggle with a lack of resources to deliver mental health interventions, scalable strategies have been developed to help more people in need. These scalable strategies were the theme of the 39th annual meeting of the International Society for Traumatic Stress Studies (ISTSS). The presidential panel, chaired by Marit Sijbrandij during her ISTSS presidency, brought together a group of experts in the field of scalable interventions: Kenneth Carswell, Syed Usman Hamdani, Judy Bass, and Eirini Karyotaki. The panel highlighted the current state of the evidence on scalable interventions for adults and children and outlined important next steps for research and implementation. These recommendations include further improving the availability of, and evidence for, scalable interventions through increased training and sustained funding; conducting more studies in underrepresented samples, such as children and adolescents; and promoting open access availability of research findings worldwide. In this paper, we provide an overview of the topics discussed in the panel as well as the key takeaways.

Effectiveness of group problem management plus in distressed Syrian refugees in Türkiye: a randomized controlled trial

AIMS

Despite high levels of psychological distress, mental health service use among Syrian refugees in urban settings is low. To address the mental healthcare gap, the World Health Organization developed group problem management plus (gPM+), a scalable psychological intervention delivered by non-specialist peer facilitators. The study aimed to evaluate the effectiveness of gPM+ in reducing symptoms of depression and anxiety among Syrian refugees in Istanbul, Türkiye.

METHODS

A randomized controlled trial was conducted among 368 distressed (Kessler Psychological Distress Scale, K10 > 15) adult Syrian refugees with impaired functioning (World Health Organization Disability Assessment Schedule, WHODAS 2.0 > 16). Participants were recruited between August 2019 and September 2020 through a non-governmental organization providing services to refugees. Participants were randomly allocated to gPM+ and enhanced care as usual (gPM+/E-CAU) (184 participants) or E-CAU only (184 participants). Primary outcomes were symptoms of depression and anxiety (Hopkins Symptom Checklist (HSCL-25)) at 3-month follow-up. Secondary outcomes were post-traumatic stress disorder (PTSD) symptoms (PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders-5; PCL-5), functional impairment (WHODAS 2.0), and self-identified problems (psychological outcome profiles).

RESULTS

Intent-to-treat analyses showed no significant effect of gPM+ on symptoms of anxiety, depression, PTSD and self-identified problems. Yet, there was a significant reduction in functional impairment in gPM+/E-CAU compared to E-CAU at 3-month follow-up (adjusted mean difference 1.66, 95 % CI 0.04, 3.27, p = 0.045, d = 0.19). Post-hoc subgroup analyses among participants with probable baseline depression or anxiety showed that there was a small but significant reduction in depression (adjusted mean difference -0.17, 95 % CI -0.32, -0.02, p = 0.028, d = 0.27) and anxiety (adjusted mean difference -0.21, 95 % CI -0.37, -0.05, p = 0.009, d = 0.30) symptoms comparing gPM+/E-CAU to E-CAU only at 1-week post assessment, but not at 3-month follow-up. There was a significant difference between conditions on functional impairment at 3-month follow-up, favouring gPM+/E-CAU condition (adjusted mean difference -1.98, 95 % CI -3.93, -0.02, p = 0.048, d = 0.26).

CONCLUSION

In this study in an urban setting in Türkiye, gPM+ did not alleviate symptoms of depression and anxiety among Syrian refugees experiencing psychological distress and daily living difficulties. However, participants with higher distress at baseline seemed to benefit from gPM+, but treatment gains disappeared in the long term. Current findings highlight the potential benefit of tailored psychosocial interventions for highly distressed refugees in volatile low-resource settings.

Feasibility and Acceptability Study of a Culturally Adapted Web-Based Intervention to Reduce Suicidal Ideation for Syrian Asylum Seekers and Refugees in the United Kingdom: Protocol for a Mixed Methods Study

BACKGROUND

The war in Syria has displaced over 6.8 million people, more than any other conflict since the Second World War. As a result, Syrian asylum seekers and refugees have experienced several life-changing events, resulting in high rates of anxiety, depression, posttraumatic stress disorder, and suicidal ideation (SI). To address the treatment gap and reduce the burden of help-seeking, a web-based intervention to reduce SI developed for general populations was culturally adapted for and with Syrian asylum seekers and refugees in the United Kingdom. The study revealed the importance of understanding their lived experience with migration and the acculturative process in providing treatment for SI. This study will now assess the feasibility and acceptability of the culturally adapted intervention for this population.

OBJECTIVE

The first phase of the study will include recruiting participants and delivering the web-based intervention (1) to assess the feasibility of meeting recruitment goals and recruitment rates and (2) to assess the feasibility of outcome measures. The second phase of the study will include one-to-one semistructured interviews (1) to assess the suitability of the culturally adapted intervention in terms of recruitment and adherence rates and barriers and facilitators to engagement and (2) to assess the acceptability of the intervention in terms of its cultural relevance and appropriateness.

METHODS

This is a protocol for a single-group, noncontrolled, mixed methods feasibility and acceptability study of a culturally adapted web-based intervention to reduce SI for Syrian asylum seekers and refugees in the United Kingdom. The study will assess the feasibility of recruitment goals, recruitment rates, adherence rates, and outcome measures using individual participant tracking forms, which will be analyzed quantitatively. The suitability and acceptability of the intervention will be assessed using one-to-one semistructured interviews with 12 participants who completed the intervention, which will be analyzed qualitatively.

RESULTS

Recruitment began in February 2024 and will run until 30 participants are recruited to the study or until the end of July 2024. Thus far, 19 participants have provided informed consent, 16 were eligible and enrolled, and 12 have completed a postintervention interview. No data have been analyzed. The study, including the write-up period, is expected to end in December 2024.

CONCLUSIONS

Despite experiencing several stressors related to forced displacement and high rates of mental health issues, access to treatment is still limited for Syrian asylum seekers and refugees in the United Kingdom. To address the treatment gap and reduce the burden of help-seeking, a web-based intervention to reduce SI was culturally adapted in collaboration with Syrian asylum seekers and refugees in the United Kingdom. This study will now assess the feasibility and acceptability of the intervention and culturally appropriate recruitment strategies.

TRIAL REGISTRATION

ISRCTN ISRCTN11417025; https://www.isrctn.com/ISRCTN11417025.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/56957.

Effects of a self-guided digital mental health self-help intervention for Syrian refugees in Egypt: A pragmatic randomized controlled trial

BACKGROUND

Digital mental health interventions for smartphones, such as the World Health Organization (WHO) Step-by-Step (SbS) program, are potentially scalable solutions to improve access to mental health and psychosocial support in refugee populations. Our study objective was to evaluate the effectiveness of SbS as self-guided intervention with optional message-based contact-on-demand (COD) support on reducing psychological distress, functional impairment, symptoms of posttraumatic stress disorder (PTSD), and self-identified problems in a sample of Syrian refugees residing in Egypt.

METHODS AND FINDINGS

We conducted a 2-arm pragmatic randomized controlled trial. A total of 538 Syrians residing in Egypt with elevated levels of psychological distress (Kessler Psychological Distress Scale; K10 > 15) and reduced psychosocial functioning (WHODAS 2.0 > 16) were randomized into SbS + CAU (N = 266) or CAU only (N = 272). Primary outcomes were psychological distress (Hopkins Symptom Checklist 25) and impaired functioning (WHO Disability Assessment Schedule 2.0) at 3-month follow-up. Secondary outcomes were symptoms of PTSD (PTSD Checklist for DSM-5 short form, PCL-5 short) and self-identified problems (Psychological Outcomes Profiles Scale, PSYCHLOPS). Intention-to-treat (ITT) analyses showed significant but small effects of condition on psychological distress (mean difference: -0.15; 95% CI: -0.28, -0.02; p = .02) and functioning (mean difference: -2.04; 95% CI: -3.87, -0.22; p = .02) at 3-month follow-up. There were no significant differences between groups on symptoms of PTSD and self-identified problems. Remission rates did not differ between conditions on any of the outcomes. COD was used by 9.4% of participants for a median of 1 contact per person. The main limitations are high intervention dropout and low utilization of COD support.

CONCLUSIONS

The trial provides a real-world implementation case, showing small positive effects of a digital, potentially scalable and self-guided mental health intervention for Syrian refugees in Egypt in reducing psychological distress and improving overall functioning. Further user-centered adaptations are required to improve adherence and effectiveness while maintaining scalability.

TRIAL REGISTRATION

German Register for Clinical Studies DRKS00023505.

Parenting and family interventions in lower and middle-income countries for child and adolescent mental health: A systematic review

BACKGROUND

Given the protective effect of nurturing caregivers and families for child and adolescent mental health, there is a need to review and synthesize research evidence regarding the effectiveness of parenting and family interventions in low and middle-income countries, including humanitarian settings. To advance practice, further understanding of the active ingredients of such interventions and implementation factors that lead to effectiveness are essential.

METHOD

This systematic review, an update from a previous review, included studies on any parenting or family intervention for children and adolescents aged 0-24, living in a low- or middle-income country, that quantitatively measured child or adolescent mental health outcomes. We searched Global Health, PubMed, PsychINFO, PILOTS and the Cochrane Library databases on the 9th July 2020, and updated on the 12th August 2022. Risk of bias was assessed using an adapted version of the NIH Quality Assessment Tool. We extracted data on: effectiveness outcomes, practice elements included in effective interventions, and implementation challenges and successes.

MAIN FINDINGS

We found a total of 80 studies (n = 18,193 participants) representing 64 different family or parenting interventions, 43 of which had evidence of effect for a child or adolescent mental health outcome. Only 3 studies found no effect on child, adolescent or caregiver outcomes. The most common practice elements delivered in effective interventions included caregiver psychoeducation, communication skills, and differential reinforcement. Key implementation strategies and lessons learned included non-specialist delivery, the engagement of fathers, and integrated or multi-sector care to holistically address family needs.

PRELIMINARY CONCLUSIONS

Despite a high level of heterogeneity, preliminary findings from the review are promising and support the use of parenting and family interventions to address the wider social ecology of children in low resource and humanitarian contexts. There are remaining gaps in understanding mechanisms of change and the empirical testing of different implementation models. Our findings have implications for better informing task sharing from specialist to non-specialist delivery, and from individual-focused to wider systemic interventions.

Implementing a Non-Specialist Delivered Psychological Intervention for Young Adolescents in a Protracted Refugee Setting: a Qualitative Process Evaluation in Lebanon

There has been an increase in the evaluation and implementation of non-specialist delivered psychological interventions to address unmet mental health needs in humanitarian emergencies. While randomized controlled trials (RCTs) provide important evidence about intervention impact, complementary qualitative process evaluations are essential to understand key implementation processes and inform future scaling up of the intervention. This study was conducted as part of an RCT of the Early Adolescents Skills for Emotions (EASE) psychological intervention for young adolescents with elevated psychological distress (predominantly with a Syrian refugee background) in Lebanon. Our aims were firstly to conduct a qualitative process evaluation to understand stakeholder experiences and perceived impact of the intervention and identify barriers and facilitators for implementation, and secondly to explore considerations for scaling up. Eleven key informant interviews and seven focus groups were conducted with 39 respondents including adolescent and caregiver participants, trainers, providers, outreach workers, and local stakeholders. Data were analyzed using inductive and deductive thematic analysis. Respondents perceived the intervention to be highly needed and reported improvements in adolescent mental health and wellbeing. Key implementation factors that have potential to influence engagement, adherence, and perceived impact included the socio-economic situation of families, mental health stigma, coordination within and between sectors (particularly for scaling up), embedding the intervention within existing service pathways, having clear quality and accountability processes including training and supervision for non-specialists, and sustainable funding. Our findings provide important context for understanding effectiveness outcomes of the RCT and highlights factors that need to be considered when implementing a mental health intervention on a larger scale in a complex crisis.

Arabic-language digital interventions for depression in German routine health care are acceptable, but intervention adoption remains a challenge

Migrants face many barriers to mental health care, such as different cultural concepts of distress, unfamiliar pathways to care, and language. Digital mental health interventions are effective and scalable in multi-language versions. However, their implementation into routine care is in its infancy. Here, we report on the Arabic- and German-language implementation of two digital interventions in Germany: The iFightDepression® website, providing information about depression to the public, and the iFightDepression® tool, offering guided self-management for depression. Our main goal is to gain empirical knowledge about the success of their implementation and provide evidence-based recommendations for improvement. Data for the current analyses stem from convenience samples, utilizing anonymized user logs of the iFightDepression® website and 15.307 user accounts in the iFightDepression® tool. We found that the acceptability (time on page, usage behavior) of both digital interventions was comparable between the two user groups. The website pervasiveness of the target populations was nine times lower among Arab migrants in Germany than Germans (89 vs. 834 unique page views/ 100,000 inhabitants), but the increase in views was superior and sustained over three years. The adoption of the tool was lower among Arabic than German users (conversion rate from invitation to completed registration: 30.8% vs. 59.0%, p < 0.001) and appropriateness was challenged as Arabic users reported higher depression severities upon first registration (p = 0.027). Our results show that the uptake of digital interventions for migrants requires facilitation and further tailoring to the needs of the target group.

Prevalence and predictors of depression, anxiety, and stress among refugees in Egypt

BACKGROUND

Many Refugees show multiple distressing psychological and mental health problems associated with stressful and adverse conditions in host countries. Even though Egypt is one of the top five destination countries hosting refugees and asylum-seekers in the MENA region, there is a lack of studies investigating mental health problems among refugees in Egypt. This study aimed to assess the prevalence and predictors of depression, anxiety, and stress symptoms among refugees living in Egypt.

METHODS

A total of 398 refugees aged 18 and above were interviewed from migrants'/refugees' community centers in Giza, Alexandria, Dakahlia, and Damietta governorates. A predesigned structured interview questionnaire was used to collect socio-demographic and migration-related variables. The Arabic Version of Depression Anxiety Stress Scales (DASS-21) was used to assess the presence and severity of the three negative emotional states.

RESULTS

Nearly two-thirds of the participants were Syrian (66.4%). The majority resided in Alexandria and Giza governorates (75.9%), were females (73.4%), and were married (71.1%). The most reported migration difficulty was housing (41.5%). Anxiety symptoms were reported among 63.3% (95% CI: 58.59%- 68.05%) of sampled refugees, followed by depression (61.3%, 95% CI: 56.52%-66.10%), and stress symptoms (51.5%, 95% CI: 46.56%-56.36%). Results of regression analysis showed that; female gender predicted anxiety (aOR 2.419, 95% CI: 1.485-3.941, p < 0.001) and stress (aOR 2.053, 95% CI: 1.197-3.519, p = 0.009), while younger age groups (18-25 yr. and 26-50 yr.) compared to the older age group (51 yr. and older) predicted depression (aOR 4.529, 95% CI: 1.696-12.097, p = 0.003 and aOR 2.177, 95% CI: 1.270- 3.733, p = 0.005, respectively) and stress (aOR 4.334, 95% CI: 1.556-12.074, p = 0.005 and aOR 1.808, 95% CI: 1.023-3.193, p = 0.041, respectively). Residence in Alexandria, housing, and employment difficulties predicted anxiety (aOR 2.354, 95% CI: 1.420-3.902, p < 0.001, aOR 1.726, 95% CI: 1.073-2.778, p = 0.025, and aOR 3.044, 95% CI: 1.248-7.425, p = 0.014, respectively), depression (aOR 1.949, 95% CI: 1.163-3.266, p = 0.011, aOR 1.666, 95% CI: 1.036-2.681, p = 0.035, and aOR 3.216, 95% CI: 1.321-7.828, p = 0.010, respectively), and stress (aOR 2.450, 95% CI: 1.431-4.195, p < 0.001, aOR 1.911, 95% CI: 1.187-3.078, p = 0.008, and aOR 4.482, 95% CI: 1.867-10.760, p < 0.001, respectively).

CONCLUSION

Mental health problems are prevalent among the refugee population in Egypt that are compounded by the difficult post-migration socio-economic situation. Multisectoral attention towards refugees' mental health is urgently needed.

Effect of Cultural Adaptation of a Smartphone-Based Self-Help Programme on Its Acceptability and Efficacy: Randomized Controlled Trial

Background

Research on cultural adaptation of psychological interventions indicates that a higher level of adaptation is associated with a higher effect size of the intervention. However, direct comparisons of different levels of adaptations are scarce.

Aims

This study used a smartphone-based self-help programme called Step-by-Step (Albanian: Hap-pas-Hapi) for the treatment of psychological distress among Albanian-speaking immigrants in Switzerland and Germany. Two levels of cultural adaptation (i.e., surface vs. deep structure adaptation) were compared. We hypothesised that the deep structure adaptation would enhance the acceptance and efficacy of the intervention.

Method

We conducted a two-arm, single-blind randomised controlled trial. Inclusion criteria were good command of the Albanian language, age above 18, and elevated psychological distress (Kessler Psychological Distress Scale score above 15). Primary outcome measures were the total score of the Hopkins Symptom Checklist and the number of participants who completed at least three (out of five) sessions. Secondary outcomes were global functioning, well-being, post-traumatic stress, and self-defined problems.

Results

Two-hundred-twenty-two participants were included, of which 18 (8%) completed the post-assessments. The number of participants who completed the third session was equal in both conditions, with N = 5 (5%) and N = 6 (6%) respectively.

Discussion

Drop-out rates were high in both conditions, and no group difference was found regarding the acceptance of the intervention. The high drop-out rate stands in contrast with other trials testing Step-by-Step. Future research should examine cultural factors impacting recruitment strategies, as insights could help to reduce participant drop-out rates in clinical trials.

Health system responsiveness to the mental health needs of Syrian refugees: mixed-methods rapid appraisals in eight host countries in Europe and the Middle East

Background

Syrian refugees have a high burden of mental health symptoms and face challenges in accessing mental health and psychosocial support (MHPSS). This study assesses health system responsiveness (HSR) to the MHPSS needs of Syrian refugees, comparing countries in Europe and the Middle East to inform recommendations for strengthening MHPSS systems.

Methods

A mixed-methods rapid appraisal methodology guided by an adapted WHO Health System Framework was used to assess HSR in eight countries (Egypt, Germany, Jordan, Lebanon, Netherlands, Sweden, Switzerland, and Türkiye). Quantitative and qualitative analysis of primary and secondary data was used. Data collection and analysis were performed iteratively by multiple researchers. Country reports were used for comparative analysis and synthesis.

Results

We found numerous constraints in HSR: i) Too few appropriate mental health providers and services; ii) Travel-related barriers impeding access to services, widening rural-urban inequalities in the distribution of mental health workers; iii) Cultural, language, and knowledge-related barriers to timely care likely caused by insufficient numbers of culturally sensitive providers, costs of professional interpreters, somatic presentations of distress by Syrian refugees, limited mental health awareness, and stigma associated to mental illness; iv) High out-of-pocket costs for psychological treatment and transportation to services reducing affordability, particularly in middle-income countries; v) Long waiting times for specialist mental health services; vi) Information gaps on the mental health needs of refugees and responsiveness of MHPSS systems in all countries. Six recommendations are provided to address these issues.

Conclusions

All eight host countries struggle to provide responsive MHPSS to Syrian refugees. Strengthening the mental health workforce (in terms of quantity, quality, diversity, and distribution) is urgently needed to enable Syrian refugees to receive culturally appropriate and timely care and improve mental health outcomes. Increased financial investment in mental health and improved health information systems are crucial.

Mental health and conflict: a pilot of an online eye movement desensitisation and reprocessing (EMDR) intervention for forcibly displaced Syrian women

Background

The Syrian conflict has been ongoing since 2011. Practical and scalable solutions are urgently needed to meet an increase in need for specialised psychological support for post-traumatic stress disorder given limited availability of clinicians. Training forcibly displaced Syrians with a mental health background to remotely deliver specialised interventions increases the availability of evidence based psychological support. Little is known about the effectiveness of online therapy for forcibly displaced Syrian women provided by forcibly displaced Syrian women therapists.

Purpose

To pilot an evidence-based trauma therapy, Eye Movement Desensitisation and Reprocessing (EMDR), carried out online by trained forcibly displaced Syrian women therapists for forcibly displaced Syrian women who require treatment for post-traumatic stress disorder (PTSD).

Methods

83 forcibly displaced Syrian women, living in Türkiye or inside Syria, with diagnosable PTSD, were offered up to 12 sessions of online EMDR over a period of 3 months. This was delivered by forcibly displaced Syrian women therapists who were trained in EMDR. Data were gathered, using Arabic versions, on PTSD symptoms using the Impact of Events Scale Revised, depression symptoms using the Patient Health Questionnaire-9 and anxiety symptoms using the Generalised Anxiety Disorder Assessment-7 at baseline, mid-point, and end of therapy.

Results

PTSD scores, depression scores and anxiety scores all significantly reduced over the course of treatment, with lower scores at midpoint than baseline and lower scores at end of treatment than at midpoint. Only one participant (1%) exceeded the cutoff point for PTSD, and 13 (16%) exceeded the cutoff points for anxiety and depression at the end of treatment.

Conclusion

In this pilot study up to 12 sessions of online EMDR were associated with reductions in PTSD, anxiety and depression symptoms in Syrian women affected by the Syrian conflict. The training of forcibly displaced Syrian mental health professionals to deliver online therapy is a relatively low cost, scalable, sustainable solution to ensure that those who are affected by the conflict can access specialised support. Further research is needed using a control group to confirm that the observed effects are due to EMDR treatment, as is research with post-treatment follow-up to ascertain that benefits are maintained.

Feasibility, acceptability and preliminary effectiveness of a community-based group psychosocial support model for conflict survivors in Colombia: An assessment of in-person and remote intervention modalities during the COVID-19 pandemic

Background

Community-based psychosocial support (CB-PSS) interventions utilizing task sharing and varied (in-person, remote) modalities are essential strategies to meet mental health needs, including during the COVID-19 pandemic. However, knowledge gaps remain regarding feasibility and effectiveness.

Methods

This study assesses feasibility, acceptability and preliminary effectiveness of a CB-PSS intervention for conflict-affected adults in Colombia through parallel randomized controlled trials, one delivered in-person (n = 165) and the other remotely (n = 103), implemented during the COVID-19 pandemic and national protests. Interventions were facilitated by nonspecialist community members and consisted of eight problem-solving and expressive group sessions.

Findings

Attendance was moderate and fidelity was high in both modalities. Participants in both modalities reported high levels of satisfaction, with in-person participants reporting increased comfort expressing emotions and more positive experiences with research protocols. Symptoms of depression, anxiety and posttraumatic stress disorder improved among in-person participants, but there were no significant changes for remote participants in comparison to waitlist controls.

Implications

This CB-PSS intervention appears feasible and acceptable in both in-person and remote modalities and associated with reduction in some forms of distress when conducted in-person but not when conducted remotely. Methodological limitations and potential explanations and areas for future research are discussed, drawing from related studies.

Comparing Mediators and Moderators of Mental Health Outcomes from the Implementation of Group Problem Management Plus (PM+) among Venezuelan Refugees and Migrants and Colombian Returnees in Northern Colombia

Colombia hosts the largest number of refugees and migrants fleeing the humanitarian emergency in Venezuela, many of whom experience high levels of displacement-related trauma and adversity. Yet, Colombian mental health services do not meet the needs of this population. Scalable, task-sharing interventions, such as Group Problem Management Plus (Group PM+), have the potential to bridge this gap by utilizing lay workers to provide the intervention. However, the current literature lacks a comprehensive understanding of how and for whom Group PM+ is most effective. This mixed methods study utilized data from a randomized effectiveness-implementation trial to examine the mediators and moderators of Group PM+ on mental health outcomes. One hundred twenty-eight migrant and refugee women in northern Colombia participated in Group PM+ delivered by trained community members. Patterns in moderation effects showed that participants in more stable, less marginalized positions improved the most. Results from linear regression models showed that Group PM+-related skill acquisition was not a significant mediator of the association between session attendance and mental health outcomes. Participants and facilitators reported additional possible mediators and community-level moderators that warrant future research. Further studies are needed to examine mediators and moderators contributing to the effectiveness of task-shared, scalable, psychological interventions in diverse contexts.

A scoping review of the literature on the application and usefulness of the Problem Management Plus (PM+) intervention around the world

BACKGROUND

Given the high rates of common mental disorders and limited resources, task-shifting psychosocial interventions are needed to provide adequate care. One such intervention developed by the World Health Organization is Problem Management Plus (PM+).

AIMS

This review maps the evidence regarding the extent of application and usefulness of the PM+ intervention, i.e. adaptability, feasibility, effectiveness and scalability, since it was introduced in 2016.

METHOD

We conducted a scoping review of seven literature databases and grey literature from January 2015 to February 2024, to identify peer-reviewed and grey literature on PM+ around the world.

RESULTS

Out of 6739 potential records, 42 met the inclusion criteria. About 60% of the included studies were from low- and middle-income countries. Findings from pilot/feasibility trials demonstrated that PM+ is feasible, acceptable and safe. Results from definitive randomised controlled trials at short-term follow-up also suggested that PM+ is effective, with overall moderate-to-large effect sizes, in improving symptoms of common mental health problems. Although PM+ was more effective in reducing symptoms of common mental disorders, it was found to be costlier compared to usual care in the only study that evaluated its cost-effectiveness.

CONCLUSIONS

Our findings indicate that PM+, in its individual and group formats, can be adapted and effectively delivered by trained helpers to target a wide range of common mental health concerns. More effectiveness and implementation evidence is required to understand the long-term impact of PM+, its cost-effectiveness and scalability, and moderators of treatment outcomes such as gender and delivery formats.

Long-term benefits to psychological health and well-being after ceremonial use of Ayahuasca in Middle Eastern and North African immigrants and refugees

Background

Refugees and immigrants can experience complex stressors from the process of immigration that can have lasting and severe long-term mental health consequences. Experiences after ayahuasca ingestion are shown to produce positive effects on psychological wellbeing and mental health, including anecdotal reports of improved symptoms of trauma and related disorders. However, data on the longitudinal health impact of naturalistic ayahuasca use in Middle Eastern and North African (MENA) immigrant and refugee populations is limited.

Aims

The current longitudinal online survey study was conducted to gather prospective data on ceremonial ayahuasca use in a group (N = 15) of primarily female MENA immigrants and refugees and to provide further insight into the patterns and outcomes surrounding that use. The study sought to assess self-reported changes in physical and mental health, well-being, and psychological functioning, examine relationships between aspects of individual mindset (e.g., psychedelic preparedness) prior to ayahuasca use and observed outcomes during (e.g., subjective drug effects) and afterwards (i.e., persisting effects), characterize risks and negative experiences, and describe trauma exposure and personal history.

Results/Outcomes

Our findings revealed ceremonial use of ayahuasca is associated with significant improvements in mental health, well-being, and psychological functioning, including reductions in depression, anxiety, and shame, and increases in cognitive reappraisal and self-compassion. Most participants reported no lasting adverse effects and experienced notable positive behavioral changes persisting months after ingestion.

Conclusion/Interpretation

While preliminary, results suggest naturalistic ayahuasca use might hold therapeutic potential for MENA populations exposed to trauma prior to and during the process of migration.

A qualitative evaluation of the use of Problem Management Plus (PM+) among Arabic-speaking migrants with psychological distress in France - The APEX study

ABSTRACTBackground: Feasibility studies with non-French speaking migrants in France are needed to inform appropriate adaptation of psychosocial intervention procedures.Objective: To test the WHO Problem Management Plus (PM+) intervention protocol for Arabic-speaking migrants in the Paris metropolitan region.Methods: Between 2019 and 2021 we recruited participants from three accommodation centres receiving asylum seekers or migrants experiencing social and economic difficulties. Participants experiencing psychological distress underwent five PM + sessions with trained helpers. Feasibility was evaluated through 15 interviews with 8 participants, 4 helpers, and 3 study supervisors. Interview topics covered PM + implementation in general and for each component. We also sought to understand problems with delivery and gathered suggestions for improvement. Data were analysed thematically using a deductive approach.Results: We found implementation of PM + to be feasible, with predominantly positive reactions from participants, helpers and study staff. All intervention components were considered beneficial, with breathing exercises considered easy to implement and often sustained. Selection of problems and strategies to address them were described as challenging to execute. Psychosocial support from and rapport with helpers and the use of the native language were considered key strengths of the programme. However, we observed the need for complementary or higher intensity psychological support in some cases. Findings also highlighted the importance of addressing distress among non-specialist helpers delivering PM + . Finally, local guidance to social resources were suggested to be added in the protocol.Conclusion: PM + was well-liked and feasible, with cultural adjustments and increased access to community resources for migrants needed.

Mental healthcare access among resettled Syrian refugees in Leipzig, Germany

Our aim was to examine mental health needs and access to mental healthcare services among Syrian refugees in the city of Leipzig, Germany. We conducted a cross-sectional survey with Syrian refugee adults in Leipzig, Germany in 2021/2022. Outcomes included PTSD (PCL-5), depression (PHQ-9), anxiety (GAD-7) and somatic symptom (SSS-8). Descriptive, regression and effect modification analyses assessed associations between selected predictor variables and mental health service access. The sampling strategy means findings are applicable only to Syrian refugees in Leipzig. Of the 513 respondents, 18.3% had moderate/severe anxiety symptoms, 28.7% had moderate/severe depression symptoms, and 25.3% had PTSD symptoms. A total of 52.8% reported past year mental health problems, and 48.9% of those participants sought care for these problems. The most common reasons for not accessing mental healthcare services were wanting to handle the problem themselves and uncertainty about where to access services. Adjusted Poisson regression models (n = 259) found significant associations between current mental health symptoms and mental healthcare service access (RR: 1.47, 95% CI: 1.02-2.15, p = 0.041) but significance levels were not reached between somatization and trust in physicians with mental healthcare service access. Syrian refugees in Leipzig likely experience high unmet mental health needs. Community-based interventions for refugee mental health and de-stigmatization activities are needed to address these unmet needs in Leipzig.

The associations of hair cortisol and DHEA with posttraumatic stress disorder symptoms in refugees

BACKGROUND

Exposure to traumatic events, ongoing adversity, and posttraumatic stress disorder (PTSD) are associated with altered activity of the hypothalamic-pituitary-adrenal (HPA) axis, but findings are mixed. This may be explained in part by heterogeneity in PTSD symptom profiles.

AIM

The aim of this study was to investigate the complex relationships between the number of traumatic events and post-displacement stressors, individual symptoms of PTSD, and HPA-axis hormones cortisol and dehydroepiandrosterone (DHEA) in refugees.

METHODS

Adult (18+ years) Syrian refugees with increased levels of distress participating in a randomized controlled trial completed baseline measures to assess traumatic events (trauma checklist), post-displacement stressors (Post-Migration Living Difficulties checklist), symptoms of PTSD (PTSD Checklist for DSM-5; PCL-5), and provided a hair sample for additional stress hormone analyses. We used R-packages qgraph and bootnet to perform network analysis on the number of traumatic events and post-displacement stressors, individual symptoms of PTSD, and HPA-axis hormones cortisol and DHEA. The final network model was corrected for depression severity.

RESULTS

115 (53% male, M age = 36.9, SD = 12.7) of 206 participants provided a hair sample. A higher number of traumatic events was directly associated with three symptoms of the PTSD cluster arousal and reactivity, i.e., sleep disturbance, hypervigilance and physiological reactivity, and with three other PTSD symptoms, namely flashbacks, avoidance of reminders, and self-destructive behavior. A higher number of post-displacement stressors was associated with four symptoms of the PTSD cluster cognition and mood, i.e., trauma-related amnesia, negative beliefs, blaming of self/others, and detachment, as well as with intrusive thoughts, sleep disturbance, hypervigilance, and exaggerated startle response. The number of traumatic events and post-displacement stressors were not associated with cortisol or DHEA. Cortisol was positively associated with two symptoms of the PTSD cluster cognition and mood, i.e., negative beliefs and negative trauma-related emotions, and negatively associated with avoidance of reminders. DHEA was positively associated with restricted affect and with three symptoms of the PTSD symptom cluster arousal and reactivity, i.e., irritability/anger, sleep disturbance, and self-destructive behavior, and negatively associated with avoidance of thoughts.

CONCLUSIONS

This study demonstrated that exposure to traumatic events and post-displacement stressors is not related to cortisol and DHEA, but that cortisol and DHEA are differentially related to individual symptoms of PTSD. While lower levels of both cortisol and DHEA were associated with increased avoidance, higher levels of cortisol were mostly associated with symptoms of the PTSD cluster cognition and mood and higher levels of DHEA were mostly associated with symptoms of the PTSD cluster arousal and reactivity. These findings contribute to explaining the variability of findings in the literature on HPA-axis activity in PTSD.

ETHICS

The study was approved by the Research Ethics Review Committee at VU Medical Center, the Netherlands (Protocol ID: NL61361.029.17, 7 September 2017) and prospectively registered online (https://www.trialregister.nl/trial/6665).

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.

Barriers To Accessing Mental Health Services Among Syrian Refugees: A Mixed-Method Study

OBJECTIVE

Although Syrian refugees have high rates of mental health problems due to war trauma, little is known on their degree of need for and contact with mental health services. Using a population sample of Syrian refugees living in Ankara, we assessed the perceived need for and contact with mental health services, as well as the barriers to access these services.

METHOD

This was a cross-sectional mixed-method study of 420 Syrian refugees living in Ankara city center, using face to face interviews administered at the respondents' home by trained, Arabic-speaking interviewers. PTSD and depression were assessed using Harvard Trauma Questionnaire and Beck Depression Inventory, respectively.

RESULTS

Of all the refugees in our sample, 14,8% (N=62) stated that they felt the need for mental healthcare since arriving in Turkey. The actual number contacting any mental health service was very low (1,4%, N=6). The most important barriers to accessing mental health services were reported by the respondents to be language problems and lack of information on available mental health services. Service providers and policymakers also reported similar topics as the most important barriers: low awareness about mental health problems, daily living difficulties, and language and cultural barriers. Multivariate analyses revealed that presence of medical or mental disorders and female gender predicted the perceived need for contacting services.

CONCLUSION

Our results show that, although refugees report high rates of mental health problems, the perceived need for and actual contact with services are very low. To address this treatment gap, and to provide adequate care for refugees with mental health problems, common barriers (language and awareness) should be identified and dealt with.

Blended-ALMAMAR app for inpatient mental health care for refugees: study protocol for a multicenter implementation study within the I-REACH consortium (Internet based REfugee mentAl healtH Care)

BACKGROUND

Refugees are at high risk for developing mental illnesses. Due to language and cultural barriers, there is need for specifically adapted therapeutic procedures for refugees in inpatient mental health care settings. Internet-based applications in refugee mother tongues have the potential to improve the outcomes of mental health care for this vulnerable population. The key research question of the present implementation study is whether the newly developed "blended ALMAMAR" app for Arabic and Farsi speaking refugees in Germany is used and accepted by patients and professionals in routine inpatient mental health care (blended care).

METHODS

We present the design of an observational, prospective multicenter implementation study in eight psychiatric hospitals. We plan to recruit 100 Farsi or Arabic speaking refugees receiving in-patient treatment due to depression, anxiety disorder, posttraumatic stress disorder or substance use disorders. These patients will get access to the "blended ALMAMAR" app during their inpatient stay in a blended-care approach. We will assess the usage (e.g., duration and frequency of use of the app) as well as subjective acceptability and usability of the intervention. To identify sociodemographic and clinical factors associated with "blended ALMAMAR" usage, we will also perform clinical and questionnaire assessments.

DISCUSSION

The newly developed "blended ALMAMAR" app may help to close communication gaps for the hard-to reach and vulnerable group of refugees in inpatient mental health care. It is the first blended-care intervention that addresses severely mentally ill refugees in an inpatient psychiatric setting in Germany.

TRIAL REGISTRATION

The trial was registered in the German Clinical Trials Register on November 11, 2021 (DRKS00025972) and adapted on November 14, 2023.

The effect of a low-level psychological intervention (PM+) on post-migration living difficulties - Results from two studies in Switzerland and in the Netherlands

AIMS OF THE STUDY

After arriving in host countries, most refugees are confronted with numerous post-migration stressors (e.g., separation from family, discrimination, and employment difficulties). Post-migration living difficulties (PMLDs) significantly contribute to the development and persistence of mental disorders. Effective treatment approaches focusing on reducing post-migration stress are urgently needed. The aim of the present study was to examine the effect of a brief psychological intervention, Problem Management Plus (PM+), on PMLDs among Syrian refugees in two European countries.

METHODS

We merged data from two single-blind feasibility trials with Syrian refugees experiencing elevated levels of psychological distress and impaired functioning in Switzerland (N = 59) and the Netherlands (N = 60). Participants were randomised to receive either five sessions of PM+ or an enhanced care-as-usual control condition. PMLDs were assessed at baseline and 3 months after the intervention. To estimate treatment effect on PMLD, linear mixed model analysis was performed.

RESULTS

Three months after the intervention, participants in the PM+ condition reported significantly fewer PMLDs compared to the control condition. Further analyses at item-level showed that interpersonal and family related PMLDs, such as "worries about family back home" significantly improved over time in the PM+ condition.

CONCLUSIONS

This exploratory study suggests that brief psychological interventions have the potential to reduce PMLDs in refugees and asylum seekers. The reduction of post-migration stress in turn may subsequently lead to an overall reduction in psychological distress.

CLINICAL TRIAL NUMBERS

BASEC Nr. 2017-0117 (Swiss trial) and NL61361.029.17, 7 September 2017 (Dutch trial).

Evaluation of the Early Adolescent Skills for Emotions (EASE) intervention in Lebanon: A randomized controlled trial

BACKGROUND

There is a need for scalable evidence-based psychological interventions for young adolescents experiencing high levels of psychological distress in humanitarian settings and low- and middle-income countries. Poor mental health during adolescence presents a serious public health concern as it is a known predictor of persistent mental disorders in adulthood. This study evaluates the effectiveness of a new group-based intervention developed by the World Health Organization (Early Adolescent Skills for Emotions; EASE), implemented by non-specialists, to reduce young adolescents' psychological distress among mostly Syrian refugees in Lebanon.

METHODS

We conducted a two-arm, single-blind, individually randomized group treatment trial. Adolescents aged 10 to 14 years who screened positive for psychological distress using the Pediatric Symptom Checklist (PSC) were randomly allocated to EASE or enhanced treatment as usual (ETAU) (1:1.6). ETAU consisted of a single scripted psycho-education home-visit session with the adolescent and their caregivers. EASE consists of seven group sessions with adolescents and three sessions with caregivers. The primary outcome was adolescent-reported psychological distress as measured with the PSC (internalizing, externalizing, and attentional symptoms). Secondary outcomes included depression, posttraumatic stress, well-being, functioning, and caregivers' parenting and distress. All outcomes were assessed at baseline, endline, and 3 months (primary time point) and 12 months follow-up.

RESULTS

Due to the COVID-19 pandemic and other adversities in Lebanon at the time of this research, the study was prematurely terminated, resulting in an under-powered trial sample (n = 198 enrolled compared to n = 445 targeted). We screened 604 children for eligibility. The 198 enrolled adolescents were assigned to EASE (n = 80) and ETAU (n = 118), with retention rates between 76.1 and 88.4% across all timepoints. Intent-to-treat analyses demonstrated no between-group differences on any of the outcome measures between the EASE and ETAU. We did observe a significant improvement on the primary outcome equally in the EASE and ETAU groups (-0.90, 95% CI: -3.6, 1.8; p = .52), - a trend that was sustained at three months follow-up. Sub-group analyses, for those with higher depression symptoms at baseline, showed ETAU outperformed EASE on reducing depression symptoms (difference in mean change = 2.7, 95% CI: 0.1, 5.3; p = .04; d = 0.59) and internalizing problems (difference in mean change 1.0, 95% CI: 0.08, 1.9; p = .03; d = 0.56) .

CONCLUSION

No conclusions can be drawn about the comparative effectiveness of the intervention given that the sample was underpowered as a result of early termination. Both EASE and single session psycho-education home visits resulted in meaningful improvements in reducing psychological distress. We did not identify any indications in the data suggesting that EASE was more effective than a single session family intervention in the context of the COVID-19 pandemic and other crises in Lebanon. Fully powered research is needed to evaluate the effectiveness of EASE.

Medical Care for Newly Arrived Displaced Persons

Medical Care for Displaced PersonsThe United Nations High Commissioner for Refugees reports that more than 100 million people have been forcibly displaced from their homes due to persecution, conflict, violence, and human rights violations. Displacement has profound health impacts. Here, Jain and colleagues review medical care for newly displaced persons.

Primary-level and community worker interventions for the prevention of mental disorders and the promotion of well-being in low- and middle-income countries

BACKGROUND

There is a significant research gap in the field of universal, selective, and indicated prevention interventions for mental health promotion and the prevention of mental disorders. Barriers to closing the research gap include scarcity of skilled human resources, large inequities in resource distribution and utilization, and stigma.

OBJECTIVES

To assess the effectiveness of delivery by primary workers of interventions for the promotion of mental health and universal prevention, and for the selective and indicated prevention of mental disorders or symptoms of mental illness in low- and middle-income countries (LMICs). To examine the impact of intervention delivery by primary workers on resource use and costs.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL, Global Index Medicus, PsycInfo, WHO ICTRP, and ClinicalTrials.gov from inception to 29 November 2021.

SELECTION CRITERIA

Randomized controlled trials (RCTs) of primary-level and/or community health worker interventions for promoting mental health and/or preventing mental disorders versus any control conditions in adults and children in LMICs.

DATA COLLECTION AND ANALYSIS

Standardized mean differences (SMD) or mean differences (MD) were used for continuous outcomes, and risk ratios (RR) for dichotomous data, using a random-effects model. We analyzed data at 0 to 1, 1 to 6, and 7 to 24 months post-intervention. For SMDs, 0.20 to 0.49 represented small, 0.50 to 0.79 moderate, and ≥ 0.80 large clinical effects. We evaluated the risk of bias (RoB) using Cochrane RoB2.

MAIN RESULTS

Description of studies We identified 113 studies with 32,992 participants (97 RCTs, 19,570 participants in meta-analyses) for inclusion. Nineteen RCTs were conducted in low-income countries, 27 in low-middle-income countries, 2 in middle-income countries, 58 in upper-middle-income countries and 7 in mixed settings. Eighty-three RCTs included adults and 30 RCTs included children. Cadres of primary-level workers employed primary care health workers (38 studies), community workers (71 studies), both (2 studies), and not reported (2 studies). Interventions were universal prevention/promotion in 22 studies, selective in 36, and indicated prevention in 55 RCTs. Risk of bias The most common concerns over risk of bias were performance bias, attrition bias, and reporting bias. Intervention effects 'Probably', 'may', or 'uncertain' indicates 'moderate-', 'low-', or 'very low-'certainty evidence. *Certainty of the evidence (using GRADE) was assessed at 0 to 1 month post-intervention as specified in the review protocol. In the abstract, we did not report results for outcomes for which evidence was missing or very uncertain. Adults Promotion/universal prevention, compared to usual care: - probably slightly reduced anxiety symptoms (MD -0.14, 95% confidence interval (CI) -0.27 to -0.01; 1 trial, 158 participants) - may slightly reduce distress/PTSD symptoms (SMD -0.24, 95% CI -0.41 to -0.08; 4 trials, 722 participants) Selective prevention, compared to usual care: - probably slightly reduced depressive symptoms (SMD -0.69, 95% CI -1.08 to -0.30; 4 trials, 223 participants) Indicated prevention, compared to usual care: - may reduce adverse events (1 trial, 547 participants) - probably slightly reduced functional impairment (SMD -0.12, 95% CI -0.39 to -0.15; 4 trials, 663 participants) Children Promotion/universal prevention, compared to usual care: - may improve the quality of life (SMD -0.25, 95% CI -0.39 to -0.11; 2 trials, 803 participants) - may reduce adverse events (1 trial, 694 participants) - may slightly reduce depressive symptoms (MD -3.04, 95% CI -6 to -0.08; 1 trial, 160 participants) - may slightly reduce anxiety symptoms (MD -2.27, 95% CI -3.13 to -1.41; 1 trial, 183 participants) Selective prevention, compared to usual care: - probably slightly reduced depressive symptoms (SMD 0, 95% CI -0.16 to -0.15; 2 trials, 638 participants) - may slightly reduce anxiety symptoms (MD 4.50, 95% CI -12.05 to 21.05; 1 trial, 28 participants) - probably slightly reduced distress/PTSD symptoms (MD -2.14, 95% CI -3.77 to -0.51; 1 trial, 159 participants) Indicated prevention, compared to usual care: - decreased slightly functional impairment (SMD -0.29, 95% CI -0.47 to -0.10; 2 trials, 448 participants) - decreased slightly depressive symptoms (SMD -0.18, 95% CI -0.32 to -0.04; 4 trials, 771 participants) - may slightly reduce distress/PTSD symptoms (SMD 0.24, 95% CI -1.28 to 1.76; 2 trials, 448 participants).

AUTHORS' CONCLUSIONS

The evidence indicated that prevention interventions delivered through primary workers - a form of task-shifting - may improve mental health outcomes. Certainty in the evidence was influenced by the risk of bias and by substantial levels of heterogeneity. A supportive network of infrastructure and research would enhance and reinforce this delivery modality across LMICs.

Interventions addressing family violence and mental illness or substance use in low- and middle-income countries: A systematic review

Most family violence research has been conducted in high-income countries, although family violence rates are higher in low- and middle-income countries (LMICs), and outcomes more severe. Given the strong associations of family violence with substance use and mental illness, the aim of this systematic review was to examine interventions that targeted familial violence and at least one other condition of substance use or mental illness to determine effective treatments in LMICs. We conducted a systematic review of interventions that addressed family violence and mental illness or substance use. A committee of three researchers independently screened titles and abstracts and conducted full-text eligibility assessments. Two researchers conducted a risk of bias assessment. Data were extracted using a structured spreadsheet and narratively synthesized. Our search identified 29 articles produced from 19 studies conducted in 13 LMICs. Most (n = 15) studies randomized to study condition. Lack of blinding was the most common threat. The external validity of studies was generally poor. Fourteen studies had a primary intervention target of family violence, mental health, substance use, economic improvement, or HIV. None of the studies showed improvements in all intervention areas. Child maltreatment was less likely to be addressed than intimate partner violence (IPV). Targeted interventions for substance and mental health mostly improved primary outcomes, although they were less effective in reducing IPV. Evidence-based treatments must be rigorously evaluated before innovations in implementation can occur. Interventions overwhelmingly addressed IPV victimization and should consider how to work with couples and include men and children.

Rational Drug and Antibiotic Use Status, E-Health Literacy in Syrian Immigrants and Related Factors: A Cross-Sectional Study

Rational drug use is a pivotal concept linked with morbidity and mortality. Immigration plays a significant role as a determinant affecting individuals' health-related attitudes, behaviors, and the pursuit of health services. Within this context, the study was initiated to assess the factors influencing health literacy and rational drug use among Syrian immigrants in Istanbul. A cross-sectional study was undertaken on 542 Syrian adults utilizing a three-part questionnaire encompassing sociodemographics, rational drug use, and the e-health literacy scale (eHEALS). With an average age of 39.19 ± 13.10 years, a majority of participants believed medications should solely be doctor-prescribed (97%) and opposed keeping antibiotics at home (93.7%). Yet, 62.5% thought excessive herbal medicine use was harmless. The mean eHEALS score stood at 20.57 ± 7.26, and factors like age, marital status, income, and duration of stay in Turkey influenced e-health literacy. Associations were seen between low e-health literacy and being female, being older, having a lower education level, and regular medication use. Syrian immigrants displayed proper knowledge concerning antibiotics yet exhibited gaps in their understanding of general drug usage, treatment adherence, and herbal medicines. Approximately 80.3% had limited health literacy, pointing to the need for targeted interventions for enhanced health and societal assimilation.

World Health Organization's low-intensity psychosocial interventions: a systematic review and meta-analysis of the effects of Problem Management Plus and Step-by-Step

Many societies have been recently exposed to humanitarian and health emergencies, which have resulted in a large number of people experiencing significant distress and being at risk to develop mental disorders such as depression, anxiety and post-traumatic stress disorder. The World Health Organization has released a series of scalable psychosocial interventions for people impaired by distress in communities exposed to adversities. Prominent among these is a low-intensity transdiagnostic psychosocial intervention, Problem Management Plus (PM+), and its digital adaptation Step-by-Step (SbS). This systematic review is the first to summarize the available evidence on the effects of PM+ and SbS. Up to March 8, 2023, five databases were searched for randomized controlled trials examining the effects of PM+ or SbS on distress indicators (i.e., general distress; anxiety, depressive or post-traumatic stress disorder symptoms; functional impairment, self-identified problems) and positive mental health outcomes (i.e., well-being, quality of life, social support/relationships). We performed random-effects multilevel meta-analyses on standardized mean differences (SMDs) at post-intervention and short-term follow-up assessments. Our search yielded 23 eligible studies, including 5,298 participants. We found a small to medium favorable effect on distress indicators (SMD=-0.45, 95% CI: -0.56 to -0.34) and a small beneficial effect on positive mental health outcomes (SMD=0.31, 95% CI: 0.14-0.47), which both remained significant at follow-up assessment and were robust in sensitivity analyses. However, our analyses pointed to substantial between-study heterogeneity, which was only partially explained by moderators, and the certainty of evidence was very low across all outcomes. These results provide evidence for the effectiveness of PM+ and SbS in reducing distress indicators and promoting positive mental health in populations exposed to adversities, but a larger high-quality evidence base is needed, as well as research on participant-level moderators of the effects of these interventions, their suitability for stepped-care programs, and their cost-effectiveness.

A summary of the 38th Annual International Society for Traumatic Stress Studies Presidential Panel: How the traumatic stress community can assist individuals affected by the war in Ukraine

As the premier global traumatic stress society, the International Society for Traumatic Stress Studies (ISTSS) has an important role to play in educating and raising awareness about the consequences of traumatic events, such as the war in Ukraine. On November 12, 2022, during its 38th annual meeting, the ISTSS hosted an invited Presidential Panel, chaired by Ananda Amstadter during her term as ISTSS President, that brought together trauma experts Peter Ventevogel, Marit Sijbrandij, Vitalii Klymchuck, Iryna Frankova, and Angela Nickerson to highlight how traumatic stress professionals can assist individuals affected by the war in Ukraine. The present paper summarizes the key points from the panel and discusses future challenges anticipated for people affected by the war.

Identifying psychosocial problems, needs, and coping mechanisms of adolescent Syrian refugees in Jordan

Background

Refugees who have fled war zones are at a heightened risk of psychosocial problems that can impact their ability to function in day-to-day life and place a significant burden on the family structure. This study aimed to assess the psychosocial problems and needs and coping mechanisms of Adolescent Syrian refugees in Jordan.

Methods

Between October and December 2018, we conducted a qualitative study using semi-structured interviews with a sample of key and individual informants. Our sample included 20 primary healthcare professionals, 20 schoolteachers, 20 Syrian parents, and 20 adolescents aged 12-17 years. All interviews were transcribed verbatim, and we utilized thematic analysis to group, categorize, and analyze the original Arabic language transcripts. To ensure thorough analysis, we adopted a bottom-up inductive approach that covered the six-phase iterative process proposed by Braun and Clarke.

Results

The main psychosocial problems encountered by Syrian adolescents included stress, depression, loneliness, lack of a sense of security, isolation, aggressiveness, fear of war, and family disintegration. Almost all schoolteachers reported that they observed that Jordanian adolescents are more settled, self-confident, and financially stable relative to their Syrian peers. The Jordanian government and community were praised for their support, including education, recreational centers, health services, and awareness campaigns. Going to school, praying and reading the Holy Quran, listening to music, and talking to friends and engaging with them were reported as the main coping mechanisms. The majority of respondents said that more services are still needed for adolescents, including more places for entertainment, psychosocial support and psychological counseling, medical care, job creation, and providing health insurance.

Conclusion

Syrian refugees are aware of the psychological aspects of their situation, but they are not always able to access clinic-based humanitarian assistance for mental health and psychosocial support. Stakeholders must interact with refugees to learn about their needs and develop services that are appropriate for their culture.

Scaling-up problem management plus for refugees in Switzerland - a qualitative study

BACKGROUND

Refugees are at an increased risk of developing symptoms of mental disorders but face various structural and socio-cultural barriers to accessing mental health care. The SPIRIT project (Scaling-up Psychological Interventions in Refugees In SwiTzerland) seeks to promote the resilience of refugees and improve their access to mental health care. For this purpose, Problem Management Plus (PM+), an evidence-based low-intensity psychological intervention delivered by trained non-specialist "helpers", is being scaled-up in Switzerland.

OBJECTIVE

To identify factors influencing the process of the large-scale implementation of PM + for refugees in Switzerland and to develop recommendations to guide the implementation process.

METHODS

22 semi-structured interviews were conducted with key informants (Syrian refugees who previously participated in PM+, PM + helpers, health professionals working with refugees and decision-makers from the migration, integration, social, and health sectors). The data were analyzed using thematic analysis, combining an inductive and deductive approach.

RESULTS

The data revealed three major themes, which might have an impact for the longer-term implementation of PM + in Switzerland. First, preconditions for successful integration in the health system prior to scaling-up such as sustainable funding or the introduction of a stepped care approach. Second, the requirements for the PM + intervention supporting scale-up such as quality control during PM + delivery, PM + modality, time and setting when PM + is offered or the views on task sharing. Third, the perceived benefits of scaling-up PM + in Switzerland.

CONCLUSIONS

Our results have shown that PM + must be scaled-up within a stepped care approach, including a functioning triage system and sustainable funding. Rather than selecting one modality or setting, it seemed preferable to offer a variety of formats and settings to achieve maximum reach and benefits. A successful scale-up of PM + in Switzerland might have various benefits. Communicating them to policy-makers and health providers, might enhance their acceptability of the intervention and their willingness to adopt PM + in regulatory structure and promote it.

Scaling up task-sharing psychological interventions for refugees in Jordan: a qualitative study on the potential barriers and facilitators

Training nonspecialists in providing evidence-based psychological interventions (i.e. task-sharing) can effectively increase community access to psychological support. However, task-sharing interventions for this purpose are rarely used at scale. The aim of this study was to examine the factors influencing the potential for scaling up (i.e. scalability) of a task-sharing psychological intervention called Problem Management Plus (PM+) for Syrian refugees in Jordan. Semi-structured individual (n = 17) and group interviews (n = 20) were conducted with stakeholders knowledgeable about PM+ and the mental health system for Syrian refugees in Jordan. Using 'system innovation perspective', this study conceptualized the context as landscape developments, and systemic considerations were divided into culture (shared ways of thinking) and structure (ways of organizing). Political momentum was identified as a landscape trend likely facilitating scaling up, while predicted reductions in financial aid was regarded as a constraint. In terms of culture, the medicalized approach to mental health, stigma and gender were reported barriers for scaling up PM+. Using non-stigmatizing language and offering different modalities, childcare options and sessions outside of working hours were suggestions to reduce stigma, accommodate individual preferences and increase the demand for PM+. In relation to structure, the feasibility of scaling up PM+ largely depends on the ability to overcome legal barriers, limitations in human and financial resources and organizational challenges. We recommend sustainable funding to be made available for staff, training, supervision, infrastructure, coordination, expansion and evaluation of 'actual' scaling up of PM+. Future research may examine the local feasibility of various funding, training and supervision models. Lessons learned from actual scaling up of PM+ and similar task-sharing approaches need to be widely shared.

Making an economic argument for investment in global mental health: The case of conflict-affected refugees and displaced people

Mental health expenditure accounts for just 2.1% of total domestic governmental health expenditure per capita. There is an economic, as well as moral, imperative to invest more in mental health given the long-term adverse impacts of mental disorders. This paper focuses on how economic evidence can be used to support the case for action on global mental health, focusing on refugees and people displaced due to conflict. Refugees present almost unique challenges as some policy makers may be reluctant to divert scarce resources away from the domestic population to these population groups. A rapid systematic scoping review was also undertaken to identify economic evaluations of mental health-related interventions for refugees and displaced people and to look at how this evidence base can be strengthened. Only 11 economic evaluations focused on the mental health of refugees, asylum seekers and other displaced people were identified. All but two of these intervention studies potentially could be cost-effective, but only five studies reported cost per quality-adjusted life year gained, a metric allowing the economic case for investment in refugee mental health to be compared with any other health-focused intervention. There is a need for more consistent collection of data on quality of life and the longer-term impacts of intervention. The perspective adopted in economic evaluations may also need broadening to include intersectoral benefits beyond health, as well as identifying complementary benefits to host communities. More use can be also made of modelling, drawing on existing evidence on the effectiveness and resource requirements of interventions delivered in comparable settings to expand the current evidence base. The budgetary impact of any proposed strategy should be considered; modelling could also be used to look at how implementation might be adapted to contain costs and take account of local contextual factors.

Understanding Mental Health Status of Syrian Refugee and Jordanian Women: Novel Insights from a Comparative Study

(1) Background: War and displacement are well-known predictors of negative mental health outcomes among affected populations. This is especially relevant for refugees of war, particularly women, who often repress their mental health needs due to family responsibilities, social stigma, and/or cultural pressures. In this study, we compared the mental health status of urban Syrian refugee women (n = 139) with local Jordanian women (n = 160). (2) Methods: Psychometrically validated Afghan Symptom Checklist (ASC), Perceived Stress Scale (PSS), and Self-Report Questionnaire (SRQ) examined psychological distress, perceived stress, and mental health, respectively. (3) Results: According to independent t-tests, Syrian refugee women scored higher than Jordanian women on the ASC [mean score (SD): 60.79 (16.67) vs. 53.71 (17.80), p < 0.001], PSS [mean score (SD): 31.59 (8.45) vs. 26.94 (7.37), p < 0.001], and SRQ [mean score (SD): 11.82 (4.30) vs. 10.21 (4.72), p = 0.002]. Interestingly, both Syrian refugee and Jordanian women scored higher than the clinical cutoff in the SRQ. Regression analyses indicated that more educated women were less likely to score high on the SRQ (β = -0.143, p = 0.019), particularly in the anxiety and somatic symptoms subscale (β = -0.133, p = 0.021), and were less likely to exhibit symptoms of ruminative sadness (β = -0.138, p = 0.027). Employed women were more likely to exhibit high coping ability than unemployed women (β = 0.144, p = 0.012). (4) Conclusions: Syrian refugee women scored higher than Jordanian women in all used mental health scales. Access to mental health services and enhancing educational opportunities would help mitigate perceived stress and may enhance stress-coping abilities.

Interventions to enhance psychological resilience in forcibly displaced children: a systematic review

BACKGROUND

Children represent nearly 40% of forcibly displaced populations and are subject to stressors that affect well-being. Little is known about the effects of interventions to enhance psychological resilience in these children, outside clinical settings.

METHODS

We conducted a systematic review, following Cochrane methods. Eligible studies tested resilience-enhancing interventions outside clinical settings in forcibly displaced children/adolescents. We included longitudinal quantitative studies with comparator conditions irrespective of geographical scope or language. We searched articles published between January 2010 and April 2020 in PubMed, Embase, Cochrane Library, Web of Science, PsycINFO and the WHO's Global Index Medicus. To standardise effect sizes across the different reported outcomes, we transformed reported mean differences to standardised mean differences using Hedge's g statistic with associated 95% CI. We pooled data for meta-analysis where appropriate. We used Cochrane tools to assess study risk of bias and used Grading of Recommendations Assessment, Development and Evaluation to determine evidence quality for meta-analysed outcomes.

RESULTS

Searches yielded 4829 results. Twenty-three studies met inclusion criteria. Studies reported 18 outcomes measured by 48 different scales; only 1 study explicitly measured resilience. Eight studies were randomised controlled trials; the rest were non-randomised pre-post studies. Interventions were diverse and typically implemented in group settings. Studies reported significant improvement in outcomes pertinent to behavioural problems, coping mechanisms and general well-being but not to caregiver support or psychiatric symptoms. In meta-analysis, resilience was improved (g_av=0.194, 95% CI 0.018 to 0.369), but anxiety symptoms and quality of life were not (g_av=-0.326, 95% CI -0.782 to 0.131 and g_av=0.325, 95% CI -0.027 to 0.678, respectively). Risk of bias varied. Quality of evidence for most graded outcomes was very low.

CONCLUSIONS

The multiplicity of study designs, intervention types, outcomes and measures incumbered quantifying intervention effectiveness. Future resilience research in this population should use rigorous methods and follow reporting guidelines.

PROSPERO REGISTRATION NUMBER

CRD42020177069.

Peer-provided psychological intervention for Syrian refugees: results of a randomised controlled trial on the effectiveness of Problem Management Plus

BACKGROUND

The mental health burden among refugees in high-income countries (HICs) is high, whereas access to mental healthcare can be limited.

OBJECTIVE

To examine the effectiveness of a peer-provided psychological intervention (Problem Management Plus; PM+) in reducing symptoms of common mental disorders (CMDs) among Syrian refugees in the Netherlands.

METHODS

We conducted a single-blind, randomised controlled trial among adult Syrian refugees recruited in March 2019-December 2021 (No. NTR7552). Individuals with psychological distress (Kessler Psychological Distress Scale (K10) >15) and functional impairment (WHO Disability Assessment Schedule (WHODAS 2.0) >16) were allocated to PM+ in addition to care as usual (PM+/CAU) or CAU only. Participants were reassessed at 1-week and 3-month follow-up. Primary outcome was depression/anxiety combined (Hopkins Symptom Checklist; HSCL-25) at 3-month follow-up. Secondary outcomes included depression (HSCL-25), anxiety (HSCL-25), post-traumatic stress disorder (PTSD) symptoms (PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition; PCL-5), impairment (WHODAS 2.0) and self-identified problems (PSYCHLOPS; Psychological Outcomes Profiles). Primary analysis was intention-to-treat.

FINDINGS

Participants (n=206; mean age=37 years, 62% men) were randomised into PM+/CAU (n=103) or CAU (n=103). At 3-month follow-up, PM+/CAU had greater reductions on depression/anxiety relative to CAU (mean difference -0.25; 95% CI -0.385 to -0.122; p=0.0001, Cohen's d=0.41). PM+/CAU also showed greater reductions on depression (p=0.0002, Cohen's d=0.42), anxiety (p=0.001, Cohen's d=0.27), PTSD symptoms (p=0.0005, Cohen's d=0.39) and self-identified problems (p=0.03, Cohen's d=0.26), but not on impairment (p=0.084, Cohen's d=0.21).

CONCLUSIONS

PM+ effectively reduces symptoms of CMDs among Syrian refugees. A strength was high retention at follow-up. Generalisability is limited by predominantly including refugees with a resident permit.

CLINICAL IMPLICATIONS

Peer-provided psychological interventions should be considered for scale-up in HICs.

Twelve-month follow-up of a randomised clinical trial of a brief group psychological intervention for common mental disorders in Syrian refugees in Jordan

AIMS

There is increasing evidence that brief psychological interventions delivered by lay providers can reduce common mental disorders in the short-term. This study evaluates the longer-term impact of a brief, lay provider delivered group psychological intervention (Group Problem Management Plus; gPM+) on the mental health of refugees and their children's mental health.

METHODS

This single-blind, parallel, controlled trial randomised 410 adult Syrians in Azraq Refugee Camp in Jordan who screened positive for distress and impaired functioning to either five sessions of gPM+ or enhanced usual care (EUC). Primary outcomes were scores on the Hopkins Symptom Checklist-25 (HSCL-25; depression and anxiety scales) assessed at baseline, 6 weeks, 3 months and 12 months Secondary outcomes included disability, posttraumatic stress, personally identified problems, prolonged grief, prodromal psychotic symptoms, parenting behaviour and children's mental health.

RESULTS

Between 15 October 2019 and 2 March 2020, 204 participants were assigned to gPM + and 206 to EUC, and 307 (74.9%) were retained at 12 months. Intent-to-treat analyses indicated that although participants in gPM + had greater reductions in depression at 3 months, at 12 months there were no significant differences between treatment arms on depression (mean difference -0.9, 95% CI -3.2 to 1.3; p = 0.39) or anxiety (mean difference -1.7, 95% CI -4.8 to -1.3; p = 0.06). There were no significant differences between conditions for secondary outcomes except that participants in gPM + had greater increases in positive parenting.

CONCLUSIONS

The short-term benefits of a brief, psychological programme delivered by lay providers may not be sustained over longer time periods, and there is a need for sustainable programmes that can prolong benefits gained through gPM + .

Achieving culturally competent mental health care: A mixed-methods study drawing on the perspectives of UK nursing students

PURPOSE

This study aimed to examine the degree of cross-cultural competency among UK mental health student nurses, and the care delivery challenges arising from their internalized cultural assumptions.

DESIGN AND METHODS

This study adopted a mixed-methods design. Participants were final-year nursing students in the United Kingdom.

FINDINGS

The results revealed participants had a moderate level of cultural awareness and competency but highlighted many challenges to providing cross-cultural care arising from the meanings, enablers, and values they attributed to culturally competent mental health care.

PRACTICE IMPLICATIONS

As cultural competency is considered an essential characteristic of effective nursing care, greater attention should be paid to how student nurses assimilate cultural awareness to develop confidence in their day-to-day practice.

Estimated prevalence rates and risk factors for common mental health problems among Syrian and Afghan refugees in Türkiye

BACKGROUND

Türkiye hosts 4 million refugees and asylum seekers, with Syrians and Afghans being among the largest refugee groups in country. There are limited comparative data on the conflict- and displacement-related experiences of these groups and the relation with mental health status.

AIMS

To assess the mental health status of Syrians and Afghans in Türkiye, identify risk factors and explore to what extent differences in mental health conditions are related to potentially traumatic events and post-displacement stressors.

METHOD

Two parallel online survey studies were conducted between April and June 2021 among 798 Syrians and 785 Afghans in Türkiye. Data were collected on sociodemographic characteristics, traumatic events (Harvard Trauma Questionnaire), post-displacement stressors (Post-Migration Living Difficulties Checklist), symptoms of depression and anxiety (Hopkins Symptoms Checklist-25) and post-traumatic stress disorder (PTSD) (Post-Traumatic Stress Disorder Checklist for DSM-5, short form).

RESULTS

For Syrian and Afghan participants respectively, estimated prevalence rates were: 41.1% and 50.3% for depression; 39.6% and 41% for anxiety; and 41.6% and 46.5% for PTSD. In both groups, significant predictors were female gender, exposure to potentially traumatic events, and structural and socioeconomic post-displacement stressors. Additional risk factors were older age for Afghans and higher education for Syrians.

CONCLUSIONS

Self-reported symptoms of common mental health problems are highly prevalent among Syrian and Afghan refugees and associated with a wide range of risk factors. After controlling for conflict- and displacement-related experiences, Afghans reported higher anxiety symptoms than Syrians, which is likely related to their legal status in Türkiye.

Effectiveness and cost-effectiveness for the treatment of depressive symptoms in refugees and asylum seekers: A multi-centred randomized controlled trial

Background

Current evidence points towards a high prevalence of psychological distress in refugee populations, contrasting with a scarcity of resources and amplified by linguistic, institutional, financial, and cultural barriers. The objective of the study is to investigate the overall effectiveness and cost-effectiveness of a Stepped Care and Collaborative Model (SCCM) at reducing depressive symptoms in refugees, compared with the overall routine care practices within Germany's mental healthcare system (treatment-as-usual, TAU).

Methods

A multicentre, clinician-blinded, randomised, controlled trial was conducted across seven university sites in Germany. Asylum seekers and refugees with relevant depressive symptoms with a Patient Health Questionnaires score of ≥ 5 and a Refugee Health Screener score of ≥ 12. Participants were randomly allocated to one of two treatment arms (SCCM or TAU) for an intervention period of three months between April 2018 and March 2020. In the SCCM, participants were allocated to interventions tailored to their symptom severity, including watchful waiting, peer-to-peer- or smartphone intervention, psychological group therapies or mental health expert treatment. The primary endpoint was defined as the change in depressive symptoms (Patient Health Questionnaire-9, PHQ-9) after 12 weeks. The secondary outcome was the change in Montgomery Åsberg Depression Rating Scale (MADRS) from baseline to post-intervention.

Findings

The intention-to-treat sample included 584 participants who were randomized to the SCCM (n= 294) or TAU (n=290). Using a mixed-effects general linear model with time, and the interaction of time by randomisation group as fixed effects and study site as random effect, we found significant effects for time (p < .001) and time by group interaction (p < .05) for intention-to-treat and per-protocol analysis. Estimated marginal means of the PHQ-9 scores after 12 weeks were significantly lower in SCCM than in TAU (for intention-to-treat: PHQ-9 mean difference at T₁ 1.30, 95% CI 1.12 to 1.48, p < .001; Cohen's d=.23; baseline-adjusted PHQ-9 mean difference at T₁ 0.57, 95% CI 0.40 to 0.74, p < .001). Cost-effectiveness and net monetary benefit analyses provided evidence of cost-effectiveness for the primary outcome and quality-adjusted life years. Robustness of results were confirmed by sensitivity analyses.

Interpretation

The SSCM resulted in a more effective and cost-effective reduction of depressive symptoms compared with TAU. Findings suggest a suitable model to provide mental health services in circumstances where resources are limited, particularly in the context of forced migration and pandemics.

Funding

This project is funded by the Innovationsfond and German Ministry of Health [grant number 01VSF16061]. The present trial is registered under Clinical-Trials.gov under the registration number: NCT03109028. https://clinicaltrials.gov/ct2/show/NCT03109028

A Perspective on How User-Centered Design Could Improve the Impact of Self-Applied Psychological Interventions in Low- or Middle-Income Countries in Latin America

Global technological progress has generated alternatives for psychological assistance, both for the evaluation and for the treatment of different emotional disorders. Evidence suggests that Internet-based treatments are effective for the treatment of anxiety and depression disorders. However, in Latin America online treatments are still scarce compared to developed countries and have similar problems as developed countries, such as high dropout rate. One possible solution to help decrease the dropout rate is to design and develop online interventions based on the needs and characteristics of the users. The user-centered design (UCD) is a fundamental concept to develop successful online interventions. The objective of this article is to provide a perspective overview on how UCD could improve the impact of self-applied psychological interventions in low- or middle-income countries in Latin America; however this proposal can also be applied in low- and middle-income countries in other regions of the world. The literature on UCD has demonstrated its efficacy when properly applied in online interventions; however, it is not common to see how this methodology has been applied in research in online interventions, and regarding Latin America, this is even more scarce with a very limited number of articles implementing the principles of UCD.

Psychosocial treatment outcomes of common mental disorders vary widely in persons in low- and middle-income countries affected by humanitarian crises and refugees in high-income countries

This commentary discusses methodological and contextual factors that might account for variations in psychosocial treatment outcomes found in persons in low- and middle-income countries affected by humanitarian crises and refugees. Factors discussed are related to cultural adaptations, content and intensity of treatment, population characteristics and factors related to research design.

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

Background

Afghan refugees often face hardship and traumatic experiences before, during, and after migration and frequently suffer from mental health burdens. Evidence based psychological treatments for refugees mostly focus on symptoms of posttraumatic stress disorder (PTSD), however, refugees often suffer from a variety of general health problems as well as depression and anxiety. We thus aimed to evaluate the effectiveness of a transdiagnostic psychological intervention.

Objective

To investigate the effectiveness of an adapted version of Problem Management Plus (aPM+) delivered by mental health professionals to adult Afghan refugees and asylum seekers.

Methods

We randomly allocated 88 Afghan refugees either to aPM+ in addition to treatment as usual (aPM+/TAU) or TAU alone. APM+ comprises of six weekly 90-minute individual sessions including strategies of stress management, problem solving, behavioural activation, strengthening social support and either anger regulation or increasing self-efficacy. The primary outcome was general health (GHQ-28) post intervention. Secondary outcome measures included distress by PMLD, Complex PTSD symptoms, quality of life, self-identified problems, and integration.

Results

Attrition was high: 42% of the randomized participants did not participate in the post-treatment assessment. A repeated measures per-protocol (completers only) ANCOVA evidenced a significant group × timepoint interaction for GHQ total scores [F(1, 47) =  14.80, p < .001, partial η2 = 0.24]. Post-hoc analyses showed significantly lower symptoms in the aPM+/TAU arm (n = 26) as compared to the TAU arm (n = 25) for the GHQ total scores (dz  = 1.04). Most secondary outcomes significantly improved in the aPM+/TAU arm, but not in the TAU arm.

Conclusion

APM+ was effective in reducing general health problems in Afghan refugees and might be considered as a first-line intervention. High drop-out rate limit the interpretations of our results, where future investigations should focus on possibilities to reduce these rates.Trial registration: Uniform Trial Number identifier: U1111-1226-3285.

HIGHLIGHTS

Refugees' mental health can be strengthened with a brief psychological intervention that also focuses on skills in the context of post-migration stressors.High drop-out rates are a major challenge for future research and delivery of psychological interventions as part of health care systems to refugees and asylum seekers.

Advancing PTSD Diagnosis and the Treatment of Trauma in Humanitarian Emergencies via Mobile Health: Protocol for a Proof-of-Concept Non-Randomized Controlled Trial

BACKGROUND

Decentralized health systems in Low and Middle-Income Countries (LMICs) impacted by humanitarian crises lack resources and a qualified workforce to attend to the overwhelming demand for mental health care in emergencies. Innovative approaches that are safe, cost-effective, and scalable are needed to address the burden of traumatic stress brought by emergencies. High mobile phone ownership rates combined with the precision of neural, cognitive, and biometric measures of trauma and its feasible integration with Artificial Intelligence (AI) makes digital application (app) interventions a promising pathway to promote precision diagnosis and high-impact care.

OBJECTIVE

The aims of this study are to advance methods for the objective diagnosis and treatment of trauma in emergencies across LMICs by examining (i) neural, cognitive, and biometric markers and (ii) the efficacy of the eResilience App, a neuroscience-informed mobile health mental health app intervention, via changes in clinical symptomatology, cognitive performance, and brain activity.

METHODS

Trauma-exposed African refugees residing in Australia were selected for this study. A research software version of the eResilience App with advanced monitoring capabilities was designed for the trial. Participants completed the eResilience App at home during a seven-day period. Clinical, cognitive, and electrophysiological data were collected during baseline and post-test to examine biomarkers of trauma and the efficacy of the proposed digital intervention for the treatment of trauma and its potential outcomes including depression, anxiety, physical symptoms, self-harm, substance misuse, and cognitive impairment. In addition, biofeedback, wellbeing, and subjective stress data points were collected via the app during the treatment week, followed by clinical interviews at 1, 3, 6 and 12-months post-intervention.

RESULTS

Data collection was conducted between 2018 and 2020. A total n=100 participants exposed to war were screened, n= 75 were enrolled and assigned to a trauma-exposed control (n=38) or Posttraumatic Stress Disorder (PTSD) condition (n=37), and n= 70 completed all baseline, treatment, and post-test assessments. A total n=62 of the n=70 who completed the intervention opted to enrol in the 3, 6 and 12-month follow-ups. Data collection is complete, and results are being prepared for publication. If proven efficacious, this proof-of-concept clinical trial will inform fully powered randomized clinical trials in LMICs to further develop AI-powered, app-based diagnostic and prognostic features, and determine the app's cross-cultural efficacy for the treatment of trauma in emergency settings.

CONCLUSIONS

This protocol provides researchers with a comprehensive background of the study rationale, a detailed guideline for replication studies interested in examining the feasibility and the efficacy of the eResilience App across varied demographics, and a robust framework for investigations of low-cost objective diagnostic markers in mental health interventions. Methodological limitations and suggestions are also provided.

CLINICALTRIAL

Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12616001205426. Universal Trial Number (UTN): U1111-1180-0347.

Addressing Mental Health Concerns in Refugees and Displaced Populations: Is Enough Being Done?

There are over 82.4 million forcibly displaced people worldwide, about a quarter of whom are resettling as refugees. In the wake of the global refugee crisis spurred by conflict, religious and political persecution, human rights violations, and climate disasters, a mental health has crisis followed. Not only does trauma experienced in home countries and as part of forced migration affect mental health, so too do post-migration traumatic events, discrimination, lack of access to quality and affordable healthcare and housing, and acculturation. To address mental health concerns in refugees and displaced populations, collective action is needed not only from health care providers but also from mental health researchers, funders, journals, resettlement agencies, government entities, and humanitarian organizations. The present review highlights the work of numerous scholars and organizations with the goal of understanding the mental health concerns of forcibly displaced persons within and across ecological systems. The present review seeks to bring attention to the experiences of forcibly displaced persons, summarize the growing body of research understanding the acute and chronic effects of forced displacement and possible interventions, and give a call to action for all members of the global community at every level to engage in joint efforts to improve mental health in refugees and displaced persons. Notably, there is a need for more interventions at the familial and community level that serve not only as treatment but also as prevention. Smartphone-based interventions, mind-body modalities, and interventions delivered by lay and non-clinician community members hold promise. Numerous strides could be made in refugee mental health and treatment when funding agencies include these goals in their research priorities. Despite the challenges they have faced, persons who resettle as refugees are incredibly resilient and deserve to be afforded every right, opportunity, dignity, and respect.

Evaluating the Implementation of a Mental Health App for Overseas Filipino Workers in Macao China: A Mixed-Methods Study of Stakeholders' Perspectives

Background

Overseas Filipino workers (OFWs) is one of the largest communities of international migrant workers. They face systemic barriers to fulfilling their health needs. The COVID-19 pandemic worsened this condition and provided a context to evaluate the utility of a digital mental health intervention delivered within a stepped-care model to address OFW mental health. Using an implementation science framework, this study aimed to evaluate stakeholders' perspectives on the implementation of Kumusta Kabayan, a mobile phone-based mental health app, for OFWs in Macao.

Methods

A mixed-methods convergent design was used by conducting two parallel steps, including quantitative and qualitative measures. The quantitative data was collected from Filipino team members and local non-governmental organization (NGO) staff members (N = 12). The qualitative data were gathered from interviews with OFWs in Macao who used the app (N = 25; 80% females, 76% domestic workers).

Results

From the online survey, the staff members of the local partner NGO and the Filipino team members strongly perceived that their organization could adapt Kumusta Kabayan to their program and generally evaluated that Kumusta Kabayan achieved its goal and was received well by OFWs. In the interviews, the OFW app users shared their experiences in using Kumusta Kabayan, which was thematically organized into six aspects of the participants' experience: (1) promotional channel and expectation; (2) when to use the app and in what language; (3) lessons learnt; (4) memorable aspects; (5) key facilitators and barriers; and (6) suggestions.

Conclusion

Kumusta Kabayan was well accepted and shows potential to be integrated into the existing support services for OFWs in Macao. This app has the promise of being scaled-up for OFWs in other countries by collaborating with local and overseas stakeholders. Lessons learnt from this evaluation could also be implemented in wider digital mental health services in different settings.

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.