Providing mental healthcare to immigrants: current challenges and new strategies

Association of depression and self-reported health status by birthplace and citizenship status: Results from the 2010-2018 National Health Interview Survey

BACKGROUND

Self-reported health (SRH) is an important indicator of mental health outcomes. More information, however, is needed on whether this association varies by birthplace (defined as US-born or non-US-born) and citizenship status (i.e., non-US-born citizen, non-US citizen, and US-born citizen).

METHODS

We examined the associations between SRH and depression among non-US-born US citizens, non-US citizens, and US-born citizens aged 18 years and older using weighted cross-sectional data from the 2010-2018 National Health Interview Survey (n = 139,884). Logistic regression models were used to assess the association between depression and SRH by citizenship status, adjusting for covariates.

RESULTS

US-born citizens reported the highest prevalence of depression (40.3 %), and non-US-born citizens reported the highest prevalence of poor/fair SRH (14.5 %). Individuals with fair/poor SRH had a significantly increased likelihood of depression relative to those with good/very good/excellent for non-US-born US citizens (Adjusted Odds Ratio [AOR] = 2.42, 95 % Confidence Interval [95 % CI] = 2.04-2.88), non-US citizens (AOR = 2.80, 95 % CI = 2.31-3.40), and US-born citizens (AOR = 2.31, CI = 2.18-2.45).

LIMITATIONS

The study is cross-sectional, reducing the strength of determining causal relationships. Also, there is a possible response bias due to the self-reported nature of the data.

CONCLUSIONS

Our study indicates that fair/poor SRH is significantly associated with an increased likelihood of depression regardless of an individual citizenship status. Additionally, immigrants with fair/poor SRH had higher increased odds of depression. Therefore, mental healthcare interventions tailored for immigrants can reduce mental health problems and disparities among immigrants.

Cultural concepts of distress among Albanian young adults living in Switzerland - a qualitative study

Objectives

Existing research recognizes the critical role that social, sociodemographic, and acculturative processes play in increasing vulnerability for experiencing psychological distress among second-generation migrants. However, to date, far too little attention has been given to the study of psychological distress in this social group. The main objective of this study is to examine cultural identities, as well as expressions and causes of psychological distress among second-generation Albanian-speaking migrants in Switzerland.

Methods

Semi-structured qualitative interviews were conducted with 13 Albanian-speaking participants between 19 and 35 years of age using the interview of the Barts Explanatory Model Inventory. Data were analyzed by qualitative content analysis using MAXQDA-2018 software.

Findings

Study participants showed bicultural identities, which caused value conflicts and a feeling of being "caught" between Swiss and Albanian culture. Some participants experienced the fear of disappointing their parents. Others find it difficult to deal with conflicting norms and values. Parentification was another important cause within their cultural concept of distress. At the same time, (implicit) social support, i.e., spending time with the family and the community, was an important coping mechanism.

Conclusion

Second-generation immigrants are exposed to specific risk factors for psychological distress. A better understanding of these risk factors and their coping mechanisms is essential for providing them with meaningful support services, both in prevention and psychotherapy.

Classification of traumatic life events and substance use among persons admitted to inpatient psychiatry in Ontario, Canada

BACKGROUND

Trauma is commonly overlooked or undiagnosed in clinical care settings. Undetected trauma has been associated with elevated substance use highlighting the need to prioritize identifying individuals with undetected trauma through common characteristics.

OBJECTIVE

The purpose of this study is to identify classifications of traumatic life experiences and substance use among persons admitted to inpatient psychiatry in Ontario and to identify covariates associated with classification membership.

STUDY DESIGN

A population-based retrospective cohort study was conducted using interRAI Mental Health (MH) assessment data. Individuals were included who experienced traumatic life events (N = 10,125), in Ontario, Canada between January 1, 2015, to December 31, 2019.

RESULTS

Eight latent classes were identified that ranged from low (i.e., Class 1: Interpersonal Issues, Without Substance use) to high (i.e., Class 8: Widespread Trauma, Alcohol & Cannabis Addiction) complexity patterns of traumatic life events and substance use indicators. Classifications with similar trauma profiles were differentiated by patterns of substance use. For example, individuals in Class 2: Safety & Relationship Issues, Without Substance use and Class 3: Safety & Relationship Issues, Alcohol & Cannabis both had many estimates centered around the experience of victimization (e.g., victim of sexual assault, victim of physical assault, victim of emotional abuse). Multinomial logistic regression models highlighted additional factors associated with classifications such as homelessness, where those who were homeless were 2.09-4.02 times more likely to be in Class 6: Widespread Trauma & Substance Addiction.

INTERPRETATION

Trauma exposures are complex and varied among persons in inpatient psychiatry and can be further differentiated by substance use patterns. These findings provide a population-based estimate of the trauma experiences of persons in inpatient settings in Ontario, Canada. Findings demonstrate the importance of using comprehensive assessment to support clinical decision making in relation to trauma and substance.

Strategies for improving access to primary care services for homeless immigrants in England: a Delphi study

AIM

The aim of the study was to identify the most prioritized strategies in improving access to primary care services (PCS) for homeless immigrants.

BACKGROUND

The issue of improving access to PCS for homeless immigrants is a complex and multifaceted one, and yet there is limited research on the strategies aimed at improving these services. Hence, the need for more studies that directly engage homeless immigrants and service providers in understanding their barriers to accessing PCS and their preferences for improving access to these services.

METHODS

The study used a two round Delphi method to elicit the views of stakeholders. The Delphi process utilized a web-based questionnaire. The stakeholders included healthcare providers and voluntary sector providers. The first round had a total of 58 items belonging to 14 categories. The second round comprised a total of 25 items belonging to 12 categories which were preselected based on participants' ranking of their importance in the first round. Participants were required to rank the relative importance of all the items on a 5-point Likert scale. Data were analysed using the STATA-15 software package.

FINDINGS

A total of 12 stakeholders participated in both rounds of the Delphi survey. The top three strategies encompassed fighting against discrimination and prejudice, improving and promoting mental health services, and empowering homeless immigrants. These evidence-based strategies hold the potential to support the implementation of healthcare interventions aimed at improving access to PCS and healthcare outcomes for homeless immigrants. However, it is crucial to conduct further research that includes homeless immigrants in the Delphi study to gain insights into the strategies that are most important to them in enhancing access to PCS, as they are the primary target users. Such research will contribute to the development of comprehensive and effective interventions tailored to the specific needs of homeless.

Uses of Andersen health services utilization framework to determine healthcare utilization for mental health among migrants-a scoping review

Background

Migration is a worldwide occurrence that carries significant implications for healthcare systems, and it entails challenges to mental healthcare. The Andersen Behavioral Model is widely used by researchers to determine healthcare service utilization among many populations, including migrants. Our study aimed to explore the ways of using the Andersen Health System Utilization Framework in the literature to discover the utilization of mental healthcare by migrants.

Methods

This scoping review was based on Arksey and O'Malley's framework. A comprehensive search was performed across five electronic databases.

Results

A total of 12 articles from January 1992 to July 2023 identified various versions of the Andersen Behavioral Model to provide an overview of mental health services utilization among migrants. The analysis identified four significant trends in the literature. First, there is a predominant focus on individual characteristics over contextual factors. Second, researchers tend to integrate multiple versions of the Andersen Behavioral Model, and the most is the version from 1995. Third, additional factors specific to migrant populations are incorporated into the model, but the categorization is sometimes unclear. Finally, the majority of studies have used a quantitative approach and are based in North America, suggesting a focus on the significance of mental health in migrant communities in that context.

Conclusion

In summary, our scoping review calls for further research using the Andersen Behavioral Model to study mental healthcare utilization among migrants. Notable findings include the adaptation of the model to migrant populations, a focus on individual characteristics, a need for more diverse research methods, and the proposal of a new conceptual model to guide research and policy development in this field.

Mental health among people with a migration background in Belgium over the past 20 years: how has the situation evolved?

BACKGROUND

Poor mental health is highly stigmatized and stereotyped, even more when it comes to migrant and ethnic minority groups (MEM). Belgium, which has a long history of immigration, is a good case study for analysing how the prevalence of mental illness (MI) has evolved over time and how such evolution had differed between MEM. This paper seeks to explore the prevalence of MI and potential inequalities among MEM compared to native Belgians between 1997 and 2018, shedding light on this important issue.

METHODS

The data set is composed of the six cross-sectional waves of the Belgian Health Interview Survey from 1997 to 2018. The 12-item General Health Questionnaire was used to assess the average level of mental health and the prevalence of MI (score ≥ 4) among five major MEM groups in Belgium (Belgian, Moroccan, Turkish, European migrants, and non-European migrants). Multivariate logistic and linear regression models were used to assess the likelihood of having a MI in the different MEM groups and survey years. The minimal clinically important difference (MID) was also calculated for the severity of MI.

RESULTS

After controlling for socioeconomic status, the average marginal effect indicated a decrease in mental health among Moroccans and Turks in Belgium between 1997 and 2018, compared to Belgians. This result was confirmed by the Chi²-test, which showed that Turkish (χ²=17.75, p < 0.001) and Moroccans respondents (χ²=4.19, p < 0.04) had a higher overall level of mental distress than Belgians. Furthermore, in 2018, even after adjusting for age, sex and education level, having a mother born in a non-EU country increased the risk of mental illness.

CONCLUSIONS

Mental health inequalities between migrant and ethnic groups are on the rise in Belgium. To address this issue, particular attention should be given to the Moroccan and Turkish background populations. Specific interventions and policies must be implemented to prevent the increase of psychological distress among migrants and ethnic minorities, on the one hand, and ensure that high-quality mental health care is accessible to all, regardless of ethnicity, on the other hand. Additionally, we recommend that future research on ethnic mental healthcare includes better data collection on the country of birth of respondents and their parents.

Promoting Psychosocial Well-Being and Empowerment of Immigrant Women: A Systematic Review of Interventions

This systematic review (SLR), based on the PRISMA 2020 guidelines, aims to present a current overview of interventions aimed at promoting the psychosocial well-being and/or empowerment (PWE) of immigrant women in order to guide future projects. Data collection was performed in the SCOPUS and Web of Science databases, with studies published between 2012 and 20 March 2023 in English, Portuguese, and Spanish. Inclusion and exclusion criteria were based on the PICO guidelines: (P) immigrant women, (I) interventions to improve PWE, (C) comparison between the initial and final phases, and (O) evaluated results for PWE. Risk of bias was assessed, and most of the studies met more than 80% of the JBI bias criteria and had moderate quality on GRADE. Thirteen studies with 585 participants were included, mostly non-randomized, non-equivalent, and with an experimental-control group design. The main components of interventions were health education/psychoeducation, counseling, cognitive restructuring, and expressive therapies. A descriptive synthesis of qualitative and quantitative data was made to evaluate the results of the interventions in PWE. In the experimental studies, results assessed improvements mainly in mood and depression levels, and stress reduction. Empowerment components were less covered. Experimental groups performed better in almost all variables in the comparison with control groups. The strongest interventions were psychoeducation and cognitive restructuring techniques. The main limitations of the studies were the lack of quality of several studies, sample size and representativeness, language, and the possibility of response bias. Even taking this into account, this article makes an original contribution by advocating for evidence-based practice and offering significant implications for health professionals, policy makers, and researchers that work with the integrative health of immigrant women. This SLR is registered in PROPESRO Registration: CRD42023399683. PS is a research fellow of the Foundation for Science and Technology (FCT) of Portugal.

Unintentional Discrimination Against Patients with a Migration Background by General Practitioners in Mental Health Management: An Experimental Study

Populations with a migration background have a higher prevalence of mental health problems than their native counterparts. They are also more likely to have unmet medical needs and are less frequently referred to mental health services. One potential explanation for this is that physicians, such as general practitioners (GPs), may unintentionally discriminate against migrant patients, particularly when they lack humanization. To date, no experimental study has investigated this hypothesis. This paper assesses the influence of humanization on GPs' discriminatory decisions regarding migrant patients with depression. A balanced 2 × 2 factorial experiment was carried out with Belgian GPs (N = 797) who received video-vignettes depicting either a native patient or a migrant patient with depression. Half of the respondents were exposed to a text that humanized the patient by providing more details about the patient's life story. Decisions related to diagnosis, treatment and referral were collected, as well as the time spent on each video and text, and were analysed using ANOVA. Migrant patients' symptoms were judged to be less severe than those of native patients (F = 7.71, p < 0.05). For almost all treatments, the decision was less favourable for the migrant patient. Humanization had little effect on medical decisions. We observed that GPs spent significantly more time on the vignette with the humanization intervention, especially for the migrant patients. The results indicate that ethnic differences in the management of depression persist in primary care. Humanization, however, does not mitigate those differences in medical decisions.

The duration of untreated psychosis among U.S. Latinxs and social and clinical correlates

Purpose

This study (a) documents the duration of untreated psychosis (DUP) and (b) examines both social and clinical correlates of DUP in a sample of U.S. Latinxs with first-episode psychosis (FEP).

Methods

Data were collected for a longitudinal study evaluating a community education campaign to help primarily Spanish-speaking Latinxs recognize psychotic symptoms and reduce the DUP, or the delay to first prescribed antipsychotic medication after the onset of psychotic symptoms. Social and clinical variables were assessed at first treatment presentation. A sequential hierarchical regression was conducted using √DUP to identify independent predictors of the DUP. A structural equation model was used to explore the association between DUP predictors, DUP, and clinical and social correlates.

Results

In a sample of 122 Latinxs with FEP, the median DUP was 39 weeks (M = 137.78, SD = 220.31; IQR = 160.39-5.57). For the full sample, being an immigrant and having self-reported relatively poor English-speaking proficiency and self-reported strong Spanish-speaking proficiency were related to a longer delay to first prescribed medication after psychosis onset. For the immigrant subgroup, being older at the time of migration was related to a longer delay. Self-reported English-speaking proficiency emerged as an independent predictor of the DUP. Although the DUP was not related to symptomatology, it was associated with poorer social functioning. Low self-reported English-speaking ability is associated with poorer social functioning via the DUP.

Conclusion

Latinxs with limited English language skills are especially at high risk for experiencing prolonged delays to care and poor social functioning. Intervention efforts to reduce the delay in Latinx communities should pay particular attention to this subgroup.

A call for nurses and interdisciplinary collaborators to urgently respond to the health and well-being needs of refugees across the world

The COVID-19 pandemic is compounding the distress of millions of refugees (made up of displaced persons, forced migrants, refugees and asylum seekers) throughout the world. This discursive paper pitches a challenge for the global nursing profession, within the multidisciplinary context, to consider its collective agency in responding to the health and well-being needs of a priority portion of the global population. Nursing leaders are encouraged to renew their commitment to the International Council of Nurses' Code of Ethics and consider the role of their profession in assisting global refugees, because the extent of present need has become an escalating major global humanitarian crisis. The nursing profession comprises half the world's healthcare workforce. The World Health Organization considers that nurses play a fundamental role in ensuring access to universal healthcare as a basic human right, addressing the global need for health promotion care, disease prevention and primary and community healthcare (International Council of Nurses, The ICN code of ethics for nurses; 2012). It is a human right to seek asylum from persecution, and in doing so, people should not be subjected to cruel, inhumane or degrading treatment or circumstances. Nurses are increasingly interested in fostering a healthy and adaptive environment in which people can thrive, despite personal, political, emotional, physical or social adversity. Nursing care is indispensable for the easement of human distress and for the promotion of comfort and coping. Nurses have an essential role in advocating for policies that will enhance immigrants' access to health/mental health services and address barriers irrespective of migrant/refugee/asylum seeker status. These are challenging times as the world responds to the pandemic crisis, and nurses are called to rise to global and local leadership roles and join with other health and social care colleagues in addressing the universal human health, social and political crisis of our time. The global nursing collective must come to terms with the need to initiate additional compelling ways to improve and integrate health and social care processes so that nursing care, mental health and social care augment a holistic achievement of appropriate care for refugees.

Recovery Capital among Migrants and Ethnic Minorities in Recovery from Problem Substance Use: An Analysis of Lived Experiences

Migrants and ethnic minorities (MEM) are known to be disadvantaged concerning risk factors for problem substance use and resources to initiate and sustain recovery (i.e., recovery capital). Yet, the voices of MEM are largely overlooked in recovery literature. This study explores recovery capital through 34 semi-structured interviews with a diverse sample of MEM in recovery in two ethnically diverse cities in Belgium. A Qualitative Content Analysis using recovery capital theory allowed us to identify various recovery resources on a personal, social, and community level. While physical and human recovery resources play a central role in participants' narratives, personal recovery capital is closely intertwined with meaningful social networks (i.e., social recovery capital) and recovery-supportive environments that maximize opportunities for building culturally sensitive recovery capital (i.e., community recovery capital). Though MEM-specific elements such as culture, migration background, stigma, and structural inequalities play a significant role in the recovery resources of MEM, the largely "universal" nature of recovery capital became clear. The narratives disclose a distinction between "essential" and "acquired" recovery capital, as well as the duality of some recovery resources. The need for developing recovery-oriented systems of care that are culturally responsive, diminish structural inequalities, and facilitate building recovery capital that is sensitive to the needs of MEM is emphasized.

Immigrant Communities and COVID-19: Strengthening the Public Health Response

The COVID-19 pandemic has exposed the many broken fragments of US health care and social service systems, reinforcing extant health and socioeconomic inequities faced by structurally marginalized immigrant communities. Throughout the pandemic, even during the most critical period of rising cases in different epicenters, immigrants continued to work in high-risk-exposure environments while simultaneously having less access to health care and economic relief and facing discrimination. We describe systemic factors that have adversely affected low-income immigrants, including limiting their work opportunities to essential jobs, living in substandard housing conditions that do not allow for social distancing or space to safely isolate from others in the household, and policies that discourage access to public resources that are available to them or that make resources completely inaccessible. We demonstrate that the current public health infrastructure has not improved health care access or linkages to necessary services, treatments, or culturally competent health care providers, and we provide suggestions for how the Public Health 3.0 framework could advance this. We recommend the following strategies to improve the Public Health 3.0 public health infrastructure and mitigate widening disparities: (1) address the social determinants of health, (2) broaden engagement with stakeholders across multiple sectors, and (3) develop appropriate tools and technologies. (Am J Public Health. 2021;111(S3):S224-S231. https://doi.org/10.2105/AJPH.2021.306433).

Parity and Psychosocial Risk Factors Increase the Risk of Depression During Pregnancy Among Recent Immigrant Women in Canada

Prior investigations have examined risk factors associated to postpartum depression in immigrant women, but depression during pregnancy has received less attention. This study describes the prevalence and early determinants of antenatal depression among recent (≤ 5 years) and long-term immigrants (> 5 years), compared to Canadian-born women. 503 women completed standardized self-report questionnaires measuring sociodemographics and psychosocial factors. Multivariate logistic regressions identified first trimester risk factors for depression in each immigrant group. The prevalence of depressive symptoms was highest for recent immigrant (25.3-30.8%) compared to long-term immigrant (16.9-19.2%) and Canadian-born women (11.7-13.8%). Among recent immigrants, multiparity, higher stress and pregnancy-specific anxiety in early pregnancy increased the risk of antenatal depression. Among long-term immigrants, stress in the first trimester was significantly associated with antenatal depressive symptoms. Knowledge of modifiable risk factors (pregnancy-specific anxiety and stress) may help improve antenatal screening and inform the development of tailored interventions to meet the mental health needs of immigrant women during the perinatal period.

Health Profile of Precarious Migrants Attending the Médecins Du Monde's Health and Social Care Centres in France: a Cross-Sectional Study

Objective: The present study aimed to compare the precarious migrants' health problems managed in Médecins du Monde's health and social care centres (CASO) with those of patients attending general practice in France. Methods: We compared the most frequent health problems managed in the 19 CASO in metropolitan France with those of a national sample of usual general practice consultations, after standardisation for age and sex. Results: Precarious migrants had fewer health problems managed per consultation than other patients (mean: 1.31 vs. 2.16), and these corresponded less frequently to chronic conditions (21.3% vs. 46.8%). The overrepresented health problems among CASO consultations were mainly headache (1.11% vs. 0.45%), viral hepatitis (1.05% vs. 0.20%), type 1 diabetes (1.01% vs. 0.50%) and teeth/gum disease (1.01% vs. 0.23%). Their underrepresented health problems were mainly lipid disorder (0.39% vs. 8.20%), depressive disorder (1.36% vs. 5.28%) and hypothyroidism (0.50% vs. 3.08%). Prevention issues were nominal in precarious migrants (0.16%). Conclusion: Both chronic somatic and mental conditions of precarious migrants are presumably underdiagnosed. Their screening should be improved in primary care.

Health Professionals' Experiences with Treatment Engagement Among Immigrants with Co-occurring Substance Use- and Mental Health Disorders in Norway

Immigrants face barriers in seeking and accessing mental health and addiction services. Health professionals are crucial in providing and promoting healthcare and it is important to understand their experiences in order to enhance the access of mental healthcare. The aim of this paper is to explore and describe health professionals' experiences with treatment engagement among immigrants with co-occurring substance use disorders (SUD) and mental health disorders (MHD) in Norwegian mental health and addiction services. Within a collaborative approach, 3 focus group interviews were conducted with health professionals, who had provided various mental health and addiction care services to immigrants with co-occurring SUD and MHD. The focus group interviews were transcribed verbatim and analyzed using systematic text condensation. The analysis resulted in 5 main categories: (1) difficulties due to language barriers, (2) difficulties due to lack of culturally competent services, (3) difficulties due to social factors, (4) being curious and flexible improves the user-provider relationship, and (5) increasing access to mental health and addiction services. This study provides an enhanced understanding of how health professionals' experienced treatment engagement among immigrants with co-occurring SUD and MHD in the Norwegian context. Implications of the findings for clinical practice and future research are discussed.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Experiences of psychotherapists working with refugees in Germany: a qualitative study

BACKGROUND

Despite a high burden of mental health problems among refugees, there is limited knowledge about effective mental health care provision for this group. Although substantial efforts in understanding the complexity of cross-cultural psychotherapy - which in the context of this study we use to refer to therapy with client and therapist of different cultural backgrounds - have been made, there remains a dearth of research exploring barriers for effective cross-cultural psychotherapy. This study aimed at narrowing this gap in knowledge by exploring major challenges encountered by psychotherapists in cross-cultural psychotherapy and strategies which have proven useful in overcoming such challenges.

METHODS

We employed a qualitative study design, conducting semi-structured in-depth interviews with 10 purposely selected psychotherapists working with refugees in Germany. Respondents were from varying theoretical background and had varying levels of experience. Data were analyzed using a thematic approach, following a mix of deductive and inductive coding.

RESULTS

Respondents reported three main challenges in their cross-cultural practice: different or unrealistic expectations of clients towards what psychotherapy would offer them; challenges grounded in different illness explanatory models; and communication challenges. In dealing with these challenges, respondents recommended psychoeducation to overcome issues related to problematic expectations towards psychotherapy; "imagining the real", identifying "counter magic" and other client-appropriate resources to deal with issues related to clients' foreign illness attributions; and translators in dealing with communication barriers, though the latter not univocally.

CONCLUSIONS

Results show that psychotherapy with refugees can be very successful, at least from the psychotherapist perspective, but also poses significant challenges. Our findings underline the importance of developing, testing, and institutionalizing structured and structural approaches to training psychotherapists in cross-cultural therapy at scale, to accommodate the rising mental health care need of refugees as a client group.

Harnessing Microbes for Sustainable Development: Food Fermentation as a Tool for Improving the Nutritional Quality of Alternative Protein Sources

In order to support the multiple levels of sustainable development, the nutritional quality of plant-based protein sources needs to be improved by food technological means. Microbial fermentation is an ancient food technology, utilizing dynamic populations of microorganisms and possessing a high potential to modify chemical composition and cell structures of plants and thus to remove undesirable compounds and to increase bioavailability of nutrients. In addition, fermentation can be used to improve food safety. In this review, the effects of fermentation on the protein digestibility and micronutrient availability in plant-derived raw materials are surveyed. The main focus is on the most important legume, cereal, and pseudocereal species (Cicer arietinum, Phaseolus vulgaris, Vicia faba, Lupinus angustifolius, Pisum sativum, Glycine max; Avena sativa, Secale cereale, Triticum aestivum, Triticum durum, Sorghum bicolor; and Chenopodium quinoa, respectively) of the agrifood sector. Furthermore, the current knowledge regarding the in vivo health effects of fermented foods is examined, and the critical points of fermentation technology from the health and food safety point of view are discussed.

Reframing resilience: Strengthening continuity of patient care to improve the mental health of immigrants and refugees

Refugee and immigrant populations experience many pre- and post-migration risk factors and stressors that can negatively impact their mental health. This qualitative study aimed to explore the system-level issues that affect the access to, as well as quality and outcomes of mental health care for immigrants and refugees, with a particular focus on challenges in the continuity of patient care. A multidisciplinary group of health providers, including nurses, identified six themes including (i) perceived access to care; (ii) coordination amongst health care providers; (iii) patient connections with community organizations; (iv) coordinated care planning; (v) organizational protocols, policies and procedures and (vi) systemic and health care training needs. Although patient resilience is seen as a pivotal way for vulnerable populations to cope with hardship, there is a clear need for creating a resilient health care system that is able to anticipate and adapt to adverse situations. The findings from this study have implications for nurses, who are uniquely positioned to advocate for public health policy that improves the continuity of health care by creating systemic resilience.

"Hidden" and Diverse Long-Term Impacts of Exposure to War and Violence

Nowadays, the PTSD diagnosis is often a prerequisite for the survivor's access to specialized treatment services and for obtaining legal recognition or financial compensation when exposed to violence. However, some survivors do not meet all necessary criteria for the PTSD diagnosis, particularly not in the long term. Therefore, they run the risk of being misdiagnosed, inadequately helped or undertreated, and may remain legally unrecognized and unprotected. In this article the "hidden" long-term impacts of exposure to war and violence, beyond the PTSD diagnosis, are presented, discussed, and illustrated with case presentations. They include dissociative states, attachment problems, personality changes, guilt, shame, rage, identity issues, moral injury, substances abuse, damaged core beliefs, and bodily sensations linked to stress activation. These phenomena are not persistent, but fluctuate over the survivor's life trajectories. Moreover, the "hidden" impacts are framed within theoretical models for understanding long-term impacts of exposure to violence. The models help us grasp the dynamics of interactions between resilience, psychological damage, context and time. These interactions are non linear, and contingently result in development of psychopathological phenomena when reaching a threshold during a process of accumulating potentially traumatic experiences over a survivors' lifetime. Understanding psychological impacts of exposure to violence as a spectrum of interchangeable phenomena over a lifetime, and learning to recognize the "hidden" manifestations of psychological trauma will help to improve mental and legal assistance to the survivors both on a short and long term.

Psychiatry Trainees' Attitudes, Knowledge, and Training in Addiction Psychiatry-A European Survey

Background: Although psychoactive substance use disorders (PSUDs) are a domain of mental health, addiction psychiatry is only formally recognized as a subspecialty in a few European countries, and there is no standardized training curriculum. Methods: A 76-item questionnaire was developed and disseminated through an online anonymous data-collecting system and hand-to-hand amongst psychiatric trainees from the 47 European countries of the Council of Europe plus Israel and Belarus. Results: 1,049/1,118 psychiatric trainees from 30 European countries completed the questionnaire. Fifty-nine-point nine percent of trainees stated to have training in addictions. Amongst the trainees who described having training in addictions, 43% documented a not well-structured training and 37% an unsatisfactory training, mainly due to poor acquired knowledge. Overall, 97% of trainees stated that addiction represents a core curriculum for their training. Overall, general adult psychiatric trainees reported a better knowledge in addictions, compared to trainees in child and adolescent psychiatry. Conclusion: Despite a growing spread of PSUDs in European countries, addiction psychiatry is a relatively poorly trained field within psychiatry training programs. Further research should investigate reasons for poor training and timings of the educational activities to optimize experiential education training in addiction psychiatry.

The Impact of Mental Illness Stigma on Psychiatric Emergencies

Psychiatric emergencies are severe behavioral changes secondary to worsening mental illness. Such situations present a risk to the patient and other people, so they need immediate therapeutic intervention. They are associated with feelings of fear, anger, prejudice, and even exclusion. The attitudes of professionals and factors related to the workplace culture in health can help to perpetuate stereotypes and interfere with the quality of care. Stigma has undesirable consequences in patients with mental disorders. Certain measures can reduce stigma and provide a more dignified way for patients to recover from the crisis. This article aims to discuss the causes of stigma, ways of dealing with it, and achievements that have been made in psychiatric emergency care settings.

Multiculturalism and Compassion: Responding to Mental Health Needs Among Refugees and Asylum Seekers Comment on "A Crisis of Humanitarianism: Refugees at the Gates of Europe"

As Fotaki (2019) argues, the current political climate in Europe is threatening principles of humanitarianism, particularly among refugees and asylum seekers. This commentary builds on that argument, with a spotlight on mental health and culturally relevant service design. By addressing some of the barriers faced by refugees and asylum seekers in accessing mental healthcare, we can address inequalities and develop compassionate societies.

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Exploring comorbidity between anxiety and depression among migrant Filipino domestic workers: A network approach

BACKGROUND

Depression and anxiety are comorbid. From the network model perspective, comorbidity is due to direct interactions between depression and anxiety symptoms. These interacting symptoms are called bridge symptoms, suppression of which is expected to halt other symptoms. This study investigates the network structure of depression, anxiety, and bridge symptoms in a sample of migrant domestic workers, who are among the most vulnerable and marginalized groups of workers.

METHOD

Data were collected from 1375 Filipino domestic workers in Macao Special Administrative Region, China. Data from a subsample of 355 consisting of participants who met criteria for depression and anxiety were used in analysis. R software was used to estimate the network.

RESULTS

The eight strongest edges were between items from the same disorder. Six were between depression symptoms, like "concentration difficulties" and "psychomotor agitation/retardation," and "psychomotor agitation/retardation" and "thoughts of death." Two were between anxiety symptoms, including "worry too much" and "trouble relaxing." For centrality indices, "fatigue" had highest strength and closeness, and "restlessness" had highest betweenness. Results revealed three bridge symptoms: "fatigue," "depressed mood," and "anhedonia."

LIMITATIONS

The results may not generalize to the entire Filipino population. Further, while the centrality index of strength had adequate stability, it was not highly stable.

CONCLUSIONS

The current study highlighted critical transdiagnostic bridge symptoms as specific candidates for intervention. "Psychomotor agitation/retardation" was identified as key priority due to its association with suicidal ideation. Systemic multilevel interventions at the person-level (e.g., cognitive therapy and behavioral activation), and at the structural and policy-level to alleviate psychosocial stressors, could be applied to address disorder comorbidity in this population.

Young migrant mental health difficulties and suicidal behaviours: an alternative perspective

SummaryThe Saving and Empowering Young Lives in Europe (SEYLE) study brings attention to the special needs of adolescent migrants. Alternative data analyses could lead to improved service delivery and requisite education/training of health and mental health personnel. We advocate earlier identification by using SEYLE data to shape policy about youth suicidal behaviour and ideation in prevention efforts.Declaration of interestNone.

Prevalence of Mental Health Screening and Associated Factors Among Refugees and Other Resettled Populations ≥ 14 Years of Age in Georgia, 2014-2017

Mental health screening (MHS) during the initial health assessment is recommended within 90 days of arrival to the U.S. Yet, MHS prevalence is not well understood. Screening prevalence [prevalence ratio (PR), adjusted prevalence ratio (adjPR)] and factors associated with MHS were assessed among refugees, Special Immigrant Visa holders, parolees, asylees, and victims of human trafficking ≥ 14 years old resettling in Georgia from 2014 to 2017. Of the 2019 individuals included, 55% received a MHS. Screening was more common among older individuals [reference: 13-22 years old; adjPR 23-35 = 1.20 (1.12-1.29), adjPR 36-49 = 1.14 (1.03-1.26), adjPR ≥ 50 = 1.27 (1.15-1.41)] and those without Medicaid [adjPR Medicaid vs. none = 0.75 (0.63-0.89)]. MHS also differed by country of birth. Although MHS has increased within recent years, gaps exist within sub-populations and geographic regions. Efforts should focus on increasing MHS to ensure timely identification of concerns and linkage to services.

Correlates of expected eMental Health intervention uptake among Filipino domestic workers in China

BACKGROUND

Transnational migrant populations face critical barriers to mental health service utilization that perpetuate mental health disparities globally. Overseas Filipino workers (OFWs) number over 2 million globally and 25% are female domestic workers. Structural barriers prevent equitable access to mental health services for this population. Electronic mental health (eMental Health) intervention is a scalable alternative to face-to-face treatment. The current study sought to identify key correlates of intention to use eMental Health within a community of female Filipino domestic workers living and working in Macao (SAR), China.

METHODS

Respondent-driven sampling implemented at a community field site was used to reach a sample of 1364 female domestic workers. A multivariable adjusted partial proportional-odds (PPO) model was used to assess relevant correlates of intent to use eMental Health.

RESULTS

The majority (62.8%) reported being likely to utilize eMental Health. The adjusted PPO model showed that younger age (18-25, 26-35, 36-45 v. over 55), longer time as an OFW, being likely (v. neutral and unlikely) to seek professional services, willingness to pay for services (v. not), belief that mental health services are a priority (v. low priority), having access to Wi-Fi outside the employer's home (v. not), and higher levels of social support were associated with increased odds of intent to use eMental Health.

CONCLUSIONS

eMental Health is a promising intervention with high potential for uptake among OFWs. The majority of the study population owned a smartphone and were able to connect to the Internet or Wi-Fi. Future work will rigorously evaluate eMental Health programs for use among OFWs.

Assessing trauma in a transcultural context: challenges in mental health care with immigrants and refugees

The growing numbers of refugees and immigrants from conflict-prone areas settling throughout the world bring several challenges for those working in the mental health care system. Immigrants and refugees of all ages arrive with complex and nuanced mental health histories of war, torture, and strenuous migration journeys. Many of the challenges of addressing the health care needs for this growing population of immigrants and refugees are often unfamiliar, and thus practices to address these challenges are not yet routine for care providers and health care organizations. In particular, complex trauma can make mental health assessments difficult for health care organizations or care providers with limited experience and training in transcultural or trauma-informed care. Using a transcultural approach can improve assessment and screening processes, leading to more effective and high-quality care for immigrant and refugee families experiencing mental health disorders.

This paper presents findings from an assessment of current mental health services focusing on current practices and experiences with immigrant and refugee patients and families. The difficulties in developing shared understandings about mental health can hinder the therapeutic process; therefore, it is imperative to ensure an effective assessment right from the beginning, yet there is limited use of existing cultural formulation tools from the DSM-IV or DSM-5. The paper outlines current practices, approaches, challenges, and recommendations shared by mental health care providers and program leaders in addressing the mental health care needs of immigrants and refugees. The results from this study demonstrate that there are many challenges and inconsistencies in providing transcultural, trauma-informed care. Respondents emphasized the need for a thorough yet flexible and adaptive approach that allows for an exploration of differences in cultural interpretations of mental health. Our study concluded that ensuring a mindful, reflexive, transcultural, and trauma-informed health care workforce, and a learning environment to support staff with education, resources, and tools will improve the health care experiences of immigrants and refugees in the mental health care system.

How do mental health practitioners operationalise cultural competency in everyday practice? A qualitative analysis

BACKGROUND

Despite continued policy and research emphasis to deliver culturally competent mental healthcare, there is: (1) limited evidence about what frontline practitioners consider to be culturally competent care and; (2) what helps or hinders them in delivering such care in their everyday practice. The aims of this article are to address these gaps.

METHODS

Qualitative in-depth interviews were conducted with 20 mental health practitioners working with immigrant patients to explore their understandings and experiences of culturally competent care. Interviews were conducted between September 2015 and February 2016 in the state of Victoria, Australia. Data were thematically analysed.

RESULTS

There were common understandings of cultural competence but its operationalisation differed by profession, health setting, locality, and years of experience; urban psychiatrists were more functional in their approach and authoritarian in their communication with patients compared to allied health staff in non-specialist mental health settings, in rural areas, with less years of experience. Different methods of operationalising cultural competence translated into complex ways of building cultural concordance with patients, also influenced by health practitioners' own cultural background and cultural exposures. Limited access to interpreters and organisational apathy remain barriers to promoting cultural competency whereas organisational support, personal motivation, and professional resilience remain critical facilitators to sustaining cultural competency in everyday practice.

CONCLUSION

While there is need for widespread cultural competence teaching to all mental health professionals, this training must be specific to different professional needs, health settings, and localities of practice (rural or urban). Experiential teaching at tertiary level or professional development programs may provide an avenue to improve the status quo but a 'one-size-fits-all' model is unlikely to work.

Mental health care for adult refugees in high-income countries

Approximately one-third of people who have obtained refugee status live in high-income countries. Over recent years, the number of refugees has been increasing, and there are questions on how many of them need mental health care and which type of interventions are beneficial. Meta-analyses showed highly variable rates of mental disorders in adult refugees. This variability is likely to reflect both real differences between groups and contexts, and methodological inconsistencies across studies. Overall prevalence rates after resettlement are similar to those in host populations. Only post-traumatic stress disorder (PTSD) is more prevalent in refugees. In long-term resettled refugees, rates of anxiety and depressive disorders are higher and linked to poor social integration. Research on mental health care for refugees in high-income countries has been extensive, but often of limited methodological quality and with very context-specific findings. The existing evidence suggests several general principles of good practice: promoting social integration, overcoming barriers to care, facilitating engagement with treatment and, when required, providing specific psychological treatments to deal with traumatic memories. With respect to the treatment of defined disorders, only for the treatment of PTSD there has been substantial refugee-specific research. For other diagnostic categories, the same treatment guidelines apply as to other groups. More systematic research is required to explore how precisely the general principles can be specified and implemented for different groups of refugees and in different societal contexts in host countries, and which specific interventions are beneficial and cost-effective. Such interventions may utilise new communication technologies. Of particular importance are long-term studies to identify when mental health interventions are appropriate and to assess outcomes over several years. Such research would benefit from sufficient funding, wide international collaboration and continuous learning over time and across different refugee groups.

Incidence and prevalence of mental disorders among immigrants and native Finns: a register-based study

PURPOSE

Migrants appear to have a higher risk of mental disorders, but findings vary across country settings and migrant groups. We aimed to assess incidence and prevalence of mental disorders among immigrants and Finnish-born controls in a register-based cohort study.

METHODS

A register-based cohort study of 184.806 immigrants and 185.184 Finnish-born controls (1.412.117 person-years) was conducted. Information on mental disorders according to ICD-10 was retrieved from the Hospital Discharge Register, which covers all public health care use.

RESULTS

The incidence of any mental disorder was lower among male (adjusted HR 0.82, 95% CI 0.77-0.87) and female (aHR 0.76, 95% CI 0.72-0.81) immigrants, being lowest among Asian and highest among North African and Middle Eastern immigrants. The incidence of bipolar, depressive and alcohol use disorders was lower among immigrants. Incidence of psychotic disorders was lower among female and not higher among male immigrants, compared with native Finns. Incidence of PTSD was higher among male immigrants (aHR 4.88, 95% CI 3.38-7.05).

CONCLUSIONS

The risk of mental disorders varies significantly across migrant groups and disorders and is generally lower among immigrants than native Finns.

Prevalence of and risk factors for mental disorders in refugees

Given the increasing numbers of refugees worldwide, the prevalence of their mental disorders is relevant for public health. Prevalence studies show that, in the first years of resettlement, only post-traumatic stress disorder (PTSD) rates are clearly higher in refugees than in host countries' populations. Five years after resettlement rates of depressive and anxiety disorders are also increased. Exposure to traumatic events before or during migration may explain high rates of PTSD. Evidence suggests that poor social integration and difficulties in accessing care contribute to higher rates of mental disorders in the long-term. Policy and research implications are discussed.

Mental health difficulties and suicidal behaviours among young migrants: multicentre study of European adolescents

BACKGROUND

Migration has been reported to be associated with higher prevalence of mental disorders and suicidal behaviour.

AIMS

To examine the prevalence of emotional and behavioural difficulties, suicidal ideation and suicide attempts among migrant adolescents and their non-migrant peers.

METHOD

A school-based survey was completed by 11 057 European adolescents as part of the Saving and Empowering Young Lives in Europe (SEYLE) study.

RESULTS

A previous suicide attempt was reported by 386 (3.6%) adolescents. Compared with non-migrants, first-generation migrants had an elevated prevalence of suicide attempts (odds ratio (OR) 2.08; 95% CI 1.32-3.26; P=0.001 for European migrants and OR 1.86; 95% CI 1.06-3.27; P=0.031 for non-European migrants) and significantly higher levels of peer difficulties. Highest levels of conduct and hyperactivity problems were found among migrants of non-European origin.

CONCLUSIONS

Appropriate mental health services and school-based supports are required to meet the complex needs of migrant adolescents.

DECLARATION OF INTEREST

None.

COPYRIGHT AND USAGE

© The Royal College of Psychiatrists 2017. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) license.

Risk of eating disorders in immigrant populations

OBJECTIVE

The risk of certain psychiatric disorders is elevated among immigrants. To date, no population studies on immigrant health have addressed eating disorders. We examined whether risk of eating disorders in first- and second-generation immigrants differs from native-born Danes and Swedes.

METHOD

All individuals born 1984-2002 (Danish cohort) and 1989-1999 (Swedish cohort) and residing in the respective country on their 10th birthday were included. They were followed up for the development of eating disorders based on out-patient and in-patient data.

RESULTS

The risks of all eating disorder types were lower among first-generation immigrants compared to the native populations: Incidence-rate ratio (95% confidence interval) was 0.39 (0.29, 0.51) for anorexia nervosa, 0.60 (0.42, 0.83) for bulimia nervosa, and 0.62 (0.47, 0.79) for other eating disorders in Denmark and 0.27 (0.21, 0.34) for anorexia nervosa, 0.30 (0.18, 0.51) for bulimia nervosa, and 0.39 (0.32, 0.47) for other eating disorders in Sweden. Likewise, second-generation immigrants by both parents were at lower risk, whereas those with only one foreign-born parent were not.

CONCLUSION

The decreased risk of eating disorders among immigrants is opposite to what has been observed for other psychiatric disorders, particularly schizophrenia. Possible explanations include buffering sociocultural factors and underdetection in health care.

Findings from a prospective cohort study evaluating the effects of International Health Advisors' work on recently settled migrants' health

Background

Several interventions have been carried out to tackle health inequalities between migrant groups, especially refugees, and native-born European populations. These initiatives are often address language or cultural barriers. One of them is the International Health Advisors (IHA) in Sweden; a peer education intervention aimed at providing health information for recently settled migrants. It is known that social determinants, such as educational level and access to social capital, affect health. Social determinants may also affect how health information is received and transformed into practice. The aims of this study was to a) assess the impact of the IHA on recently settled migrants’ self-reported health status, and received health information; b) determine the moderating role of educational level and social capital; and c) critically discuss the outcomes and suggest implications for health promotion practice.

Methods

The study was designed as a prospective cohort study. A postal questionnaire translated to Arabic was sent to recently settled Iraqi migrants in eight counties in Sweden, in May 2008 and May 2010. Two of the counties were exposed to the intervention, and six were used as references.

Results

The proportion of individuals who reported that they had received information on healthy diet and physical exercise was higher in the intervention group than in the non-intervention group (OR 2.31, 95% CI 1.02–5.22), after adjustments. Low social participation was negatively associated with deteriorated or unchanged health needs (OR 0.47, 95% CI 0.24–0.92). No other statistically significant differences in health outcomes could be observed between the groups. No signs of effect modification on this association by social capital or educational level could be found.

Conclusions

Health information provided by the IHA increased self-reported level of knowledge on healthy diet and physical exercise. The interpretation of the observed negative association between low social participation and deteriorated or unchanged health needs is that participation was limited to one’s own social group, and therefore had limited positive influence on health seeking behaviour. The lack of measurable improvements in health status could be explained by limitations in the study, in the theoretical assumptions underlying the intervention, and in the implementation of the intervention. Further research is needed to understand success factors in health promoting interventions among recently settled migrants better.

How to make carer involvement in mental health inpatient units happen: a focus group study with patients, carers and clinicians

BACKGROUND

Carers are family members or friends who support people with a mental health problem without being paid. Carer involvement in mental health treatment has been consistently supported by research evidence and promoted by policies but its implementation rates are poor. Particularly when patients are treated in inpatient units, carers often report being left without information or being excluded from decisions about treatment. In this study we have explored, along with staff perspectives, views of patients and carers who had a recent experience of inpatient mental health care on how to improve the implementation of carer involvement in inpatient care.

METHODS

Sixteen focus groups were held with carers, patients and clinicians in London, United Kingdom. We included staff working in inpatient units and patients and carers who had experience of inpatient care in the last five years. Data from focus groups were analysed using thematic analysis.

RESULTS

Eighty six participants in total (31 service users, 22 carers and 33 clinicians) attended the focus groups. Participants identified that generally, carer involvement should happen as soon as possible after admission, although this may be challenging in some cases. Carer involvement should include receiving information, participating in decisions about care and discharge and receiving emotional support by staff. When carers are involved, their personal knowledge of the patient's condition should be utilised. Challenges to carer involvement may include problems with identifying carers during a mental health crisis, obtaining valid patient consent, sharing appropriate information, and contacting and engaging carers. Additionally, it was perceived that all the ward staff need to be actively engaged in order to make carer involvement happen and this cannot be left only to specifically trained clinicians.

CONCLUSIONS

These findings identify basic components that all family interventions in inpatient units should have. Further studies are needed to explore how and if purposively designed clinical interventions can improve carer involvement in inpatient treatment and, consequently, patient outcomes.

Migration-Related Stressors and Their Effect on the Severity Level and Symptom Pattern of Depression among Vietnamese in Germany

OBJECTIVES

Vietnamese in Germany represent a scarcely researched and vulnerable group for mental health problems, especially under exposure to migration-related stressors (MRS). This study analyzes the effect of those MRS on the severity level and symptom pattern of depression.

DESIGN

We analyzed the data of 137 depressed Vietnamese patients utilizing Germany's first Vietnamese psychiatric outpatient clinic. Hierarchical linear regression models were applied to investigate how the quantity of MRS influenced (1) the overall severity of self-reported depression symptoms; (2) the cognitive, affective, and somatic BDI-II subscale; and (3) the single BDI-II items of these subscales.

RESULTS

A greater number of MRS were related to a higher severity level of depression in general, as well as to a higher level on the cognitive depression subscale in particular. The BDI-II single items pessimism, past failure, guilt feelings, punishment feelings, and suicidal thoughts were particularly associated with a higher quantity of perceived MRS.

CONCLUSION

Among depressed Vietnamese migrants in Germany, a higher number of reported MRS were associated with higher overall depression severity. Within the domains of depression, particularly the cognitive domain was linked to perceived MRS. The association between MRS and suicidal thoughts is clinically highly relevant.

Financial Barriers to Health Care Among Mexican Americans With Chronic Disease and Depression or Anxiety in El Paso, Texas

PURPOSE

To determine the barriers to health care access by chronic disease and depression/anxiety diagnosis in Mexican Americans living in El Paso, TX.

DESIGN

A secondary analysis was conducted using data for 1,002 Hispanics from El Paso, TX (2009-2010). Logistic regression was conducted for financial barriers by number of chronic conditions and depression/anxiety diagnosis. Interaction models were conducted between number of chronic conditions and depression or anxiety.

RESULTS

Depressed/anxious individuals reported more financial barriers than those with chronic conditions alone. There were significant interactions between number of chronic conditions and depression/anxiety for cost, denied treatment because of an inability to pay, and an inability to pay $25 for health care.

CONCLUSION

Financial barriers should be considered to maintain optimal care for both mental and physical health in this population.

IMPLICATIONS FOR PRACTICE

There should be more focus on the impact of depression or anxiety as financial barriers to compliance.

Adequacy of Mental Health Services for HIV-Positive Patients with Depression: Ontario HIV Treatment Network Cohort Study

Background

Major depression can profoundly impact clinical and quality-of-life outcomes of people living with HIV, and this disease is underdiagnosed and undertreated in many HIV-positive individuals. Here, we describe the prevalence of publicly funded primary and secondary mental health service use and antidepressant use, as well as mental health care for depression in accordance with existing Canadian guidelines for HIV-positive patients with depression in Ontario, Canada.

Methods

We conducted a prospective cohort study linking data from the Ontario HIV Treatment Network Cohort Study with administrative health databases in the province of Ontario, Canada. Current depression was assessed using the Center for Epidemiologic Depression Scale or the Kessler Psychological Distress Scale. Multivariable regressions were used to characterize prevalence outcomes.

Results

Of 990 HIV-positive patients with depression, 493 (50%) patients used mental health services; 182 (18%) used primary services (general practitioners); 176 (18%) used secondary services (psychiatrists); and 135 (14%) used both. Antidepressants were used by 407 (39%) patients. Patients who identified as gay, lesbian, or bisexual, as having low income or educational attainment, or as non-native English speakers or immigrants to Canada were less likely to obtain care. Of 493 patients using mental health services, 250 (51%) received mental health care for depression in accordance with existing Canadian guidelines.

Conclusions

Our results showed gaps in delivering publicly funded mental health services to depressed HIV-positive patients and identified unequal access to these services, particularly among vulnerable groups. More effective mental health policies and better access to mental health services are required to address HIV-positive patient needs and reduce depression’s impact on their lives.

Clinician descriptions of communication strategies to improve treatment engagement by racial/ethnic minorities in mental health services: A systematic review

OBJECTIVE

To describe studies on clinician communication and the engagement of racial/ethnic minority patients in mental health treatment.

METHODS

Authors conducted electronic searches of published and grey literature databases from inception to November 2014, forward citation analyses, and backward bibliographic sampling of included articles. Included studies reported original data on clinician communication strategies to improve minority treatment engagement, defined as initiating, participating, and continuing services.

RESULTS

Twenty-three studies met inclusion criteria. Low treatment initiation and high treatment discontinuation were related to patient views that the mental health system did not address their understandings of illness, care or stigma. Treatment participation was based more on clinician language use, communication style, and discussions of patient-clinician differences.

CONCLUSION

Clinicians may improve treatment initiation and continuation by incorporating patient views of illness into treatment and targeting stigma. Clinicians may improve treatment participation by using simple language, tailoring communication to patient preferences, discussing differences, and demonstrating positive affect.

PRACTICE IMPLICATIONS

Lack of knowledge about the mental health system and somatic symptoms may delay treatment initiation. Discussions of clinician backgrounds, power, and communication style may improve treatment participation. Treatment continuation may improve if clinicians tailor communication and treatment plans congruent with patient expectations.

Psychenet.de: Development and process evaluation of an e-mental health portal

BACKGROUND

E-mental health interventions can have a positive impact on patient-reported and clinical outcomes. The purpose of this project was to develop a user-centered e-mental health portal.

METHODS

The development of the portal www.psychenet.de included mixed-methods techniques for needs assessment to identify user-relevant content. Furthermore, user-centered design techniques were applied by utilizing individual usability testing with cognitive task analysis. First, a basic version of the portal was created and introduced to the public by means of a media campaign. After the development of module-specific content, exposure and use of the portal was investigated as part of a process evaluation.

RESULTS

Relevant content identified by needs assessment covered both, overarching and diagnosis-specific topics. Results of the process evaluation showed a highly accessed website. During the first 18 months, 119,423 visits were tracked. The portal was predominantly accessed by Google searches (73.9%), while 17.6% of visits were related to direct traffic.

DISCUSSION

Serving as a complement to face-to-face consultations, www.psychenet.de attempts to inform about mental disorders, and engage patients in the course of their treatment. Results of the process evaluation confirm the high relevance and potential of the portal and can be used for further improvements and extensions in the future.