Screening for major depression and posttraumatic stress disorder among asylum seekers: adapting a standardized instrument to the social and cultural context

Mental Health Screening Approaches for Resettling Refugees and Asylum Seekers: A Scoping Review

Refugees and asylum seekers often face delayed mental health diagnoses, treatment, and care. COVID-19 has exacerbated these issues. Delays in diagnosis and care can reduce the impact of resettlement services and may lead to poor long-term outcomes. This scoping review aims to characterize studies that report on mental health screening for resettling refugees and asylum seekers pre-departure and post-arrival to a resettlement state. We systematically searched six bibliographic databases for articles published between 1995 and 2020 and conducted a grey literature search. We included publications that evaluated early mental health screening approaches for refugees of all ages. Our search identified 25,862 citations and 70 met the full eligibility criteria. We included 45 publications that described mental health screening programs, 25 screening tool validation studies, and we characterized 85 mental health screening tools. Two grey literature reports described pre-departure mental health screening. Among the included publications, three reported on two programs for women, 11 reported on programs for children and adolescents, and four reported on approaches for survivors of torture. Programs most frequently screened for overall mental health, PTSD, and depression. Important considerations that emerged from the literature include cultural and psychological safety to prevent re-traumatization and digital tools to offer more private and accessible self-assessments.

Social factors ameliorate psychiatric disorders in community-based asylum seekers independent of visa status

The impact of industrialised host nations' deterrent immigration policies on the mental health of forced migrants has not been well characterised. The present study investigated the impact of Australia's refugee determination process (RDP) on psychiatric morbidity in community-based asylum-seekers (AS) and refugees. Psychiatric morbidity was predicted to be greater in AS than refugees, and to persist or increase as a function of time in the RDP. The effect on mental health of demographic and socio-political factors such as health cover and work rights were also investigated. Psychiatric morbidity was measured prospectively on five mental health indices at baseline (T1, n=131) and an average of 15.7 months later (T2, n=56). Psychiatric morbidity in AS significantly decreased between time points such that it was no longer greater than that of refugees at T2. Caseness of PTSD and demoralisation reduced in AS who gained protection; however, those who maintained asylum-seeker status at T2 also had a significant reduction in PTS and depression symptom severity. Reduced PTS and demoralisation symptoms were associated with securing work rights and health cover. Living in the community with work rights and access to health cover significantly improves psychiatric symptoms in forced migrants irrespective of their protection status.

A cross-sectional survey of the mental health needs of refugees and asylum seekers attending a refugee health clinic: a study protocol for using research to inform local service delivery

BACKGROUND

Refugees and asylum seekers have high rates of risk factors for mental disorders. In recent years, Australia has experienced a rapid increase in asylum seeker arrivals, creating new challenges for services in areas with high settlement numbers. This paper describes the design, including analytic framework, of a project set in a refugee health service in the state of Victoria, Australia, as part of their response to meeting the mental health needs of their burgeoning local population of refugees and asylum seekers. In order to assist service planning, the primary aim of this study is to determine: 1) an overall estimate of the prevalence of psychiatric disorders; 2) the specific prevalence of post-traumatic stress disorder 3) the perceived need and unmet need for mental health treatment. The secondary aim of the study is to establish matched risk ratios based on an Australian-born matched comparison group from the 2007 National Survey of Mental Health and Well-Being.

METHODS/DESIGN

A cross-sectional survey is used to estimate the prevalence of psychiatric disorders in refugees and asylum seekers attending a local refugee health service. Measures include the Kessler Psychological Distress Scale-10, the Post-Traumatic Stress Disorder-8, the General-practice User's Perceived-need Inventory together with service utilisation questions from the National Survey of Mental Health and Well-Being. Data collected from refugees and asylum seekers (n = 130) is matched to existing data from Australian-born residents drawn from the 2007 National Survey of Mental Health and Well-Being (n = 520) to produce estimates of the risk ratio.

DISCUSSION

The paper describes a prototype for what is possible within regular services seeking to plan for and deliver high quality mental health care to refugees and asylum seekers. A novel project output will be the development and dissemination of an epidemiological methodology to reliably compare mental health status in a relatively small target sample with a matched comparator group.

Interpersonal psychotherapy versus treatment as usual for PTSD and depression among Sichuan earthquake survivors: a randomized clinical trial

Background

Without effective treatment, PTSD and depression can cause persistent disability in disaster-affected populations.

Methods

Our objective was to test the efficacy of Interpersonal Psychotherapy (IPT) delivered by trained local personnel compared with treatment as usual (TAU) for Posttraumatic Stress Disorder (PTSD) and Major Depressive Disorder (MDD) among adults affected by the Sichuan 2008 earthquake. A small randomized controlled trial of IPT + TAU versus TAU alone was delivered by local mental health personnel in Shifang, China. Between July 2011 and January 2012, 49 adults ≥ 18 years with PTSD, MDD or both were enrolled and randomized to 12 weekly sessions of IPT + TAU (27) or TAU (22) alone x 12 weeks. IPT was then offered to the TAU group. Unblinded follow up assessments were conducted at three and six months. IPT was a 12 session, weekly one hour treatment delivered by local personnel who were trained and supervised in IPT. TAU was continuation of prescribed psychotropic medication (if applicable) and crisis counseling, as needed.

Main Outcome(s) and Measures (s): Clinician Administered PTSD Scale (CAPS) PTSD diagnosis; Structured Clinical Interview for DSM-IV (SCID) for MDD diagnosis. Secondary measures included PTSD/depression symptoms, interpersonal conflict/anger, social support, self-efficacy and functioning.

Results

Using an intent-to-treat analysis, 22 IPT + TAU and 19 TAU participants were compared at three months post-baseline. A significantly greater reduction of PTSD and MDD diagnoses was found in the IPT group (51.9%, 30.1%, respectively) versus the TAU group (3.4%, 3.4%, respectively). Despite the small sample, the estimates for time-by-condition analyses of target outcomes (2.37 for PTSD (p = .018) and 1.91 for MDD (p = .056)) indicate the improvement was better in the IPT + TAU condition versus the TAU group. Treatment gains were maintained at 6 months for the IPT group. A similar treatment response was observed in the TAU group upon receipt of IPT.

Conclusions

This initial study shows that IPT is a promising treatment for reducing PTSD and depression, the two major mental health disorders affecting populations surviving natural disaster, using a design that builds local mental health care capacity.

Trial Registration

ClinicalTrials.Gov number, NCT01624935.

Epidemiology of psychiatric morbidity among migrants compared to native born population in Spain: a controlled study

OBJECTIVE

The aim of this paper is to explore the prevalence of psychiatric morbidity in different immigrant groups in Spain. In keeping with prior studies carried out in Europe, it is expected that the immigrant population will have elevated levels of psychopathology, with some variation across immigrant groups.

DESIGN

Multicenter, observational, cross-sectional study.

SETTING

Primary care settings of two Spanish regions.

SAMPLE

N=1.503 immigrants paired with the same number of Spanish controls, adjusted by gender and age.

VARIABLES

Demographic variables, MINI International Neuropsychiatric Interview and Standardized Polyvalent Psychiatric Interview, somatic symptoms section. Student's t tests, ORs and logistic regressions were used to analyze the data.

RESULTS

No differences in psychiatric morbidity were found (native born 30.9%, population vs. immigrants 29.6%, OR=.942, CI=.806-1.100) when comparing immigrants to native born Spaniards. Relative to Spaniards (30.9%), Latin American immigrants had significantly higher levels of psychopathology (36.8%), Sub-Saharan Africans (24.4%) and Asians (16%) had significantly lower levels, and Eastern Europeans (31.4%) and North Africans (26.8%) showed no significant difference.

CONCLUSIONS

The hypotheses were only partially supported. Although overall immigrants did not differ from the native born population, when analyzed by geographic origin, only Latin Americans had higher levels of psychopathology. It is concluded that multiple factors need to be taken into consideration when studying the mental health of immigrants given that different immigrant groups have different levels of psychopathology.

Mental and physical health in Rwanda 14 years after the genocide

PURPOSE

To examine the socio-demographic determinants of post-traumatic stress disorder (PTSD) and its association with major depressive episode and self-perceived physical and mental health in a large random sample of the Rwandan population 14 years after the 1994 genocide.

METHODS

Using the Mini International Neuropsychiatric Interview and Medical Outcomes Study 36-Item Short-Form (SF-36) translated in Kinyarwanda, we interviewed 1,000 adult residents from the five provinces of Rwanda. Socio-demographic data and specific somatic symptoms were also recorded. Data analysis included 962 questionnaires.

RESULTS

Participants were predominantly female (58.9%), aged between 16 and 34 years (53.2%), with a low level of education (79.7% below secondary school). Prevalence of PTSD was estimated to be 26.1%. In multivariable analysis, factors associated with PTSD were being aged between 25 and 34 years, living in extreme poverty, having endured the murder of a close relative in 1994, being widowed or remarried, having lost both parents and living in the South Province. Participants who fulfilled diagnostic criteria for PTSD were significantly more often affected with major depression (68.4 vs. 6.6%, P < 0.001) and substance dependence (7.6 vs. 3.5%, P = 0.013) than respondents without PTSD. They scored significantly lower on all SF-36 subscales. Somatic symptoms such as hiccups, fainting and loss of speech or hearing delineated a specific pattern of post-traumatic stress syndrome.

CONCLUSIONS

PTSD remains a significant public health problem in Rwanda 14 years after the genocide. Facilitating access to appropriate care for all those who need it should be a national priority.

Torture

PURPOSE OF REVIEW

Torture has become a key theme in healthcare and a rising number of publications, especially over the last years, confirm its relevance also in regard to mental health.

RECENT FINDINGS

Torture survivors appear to be a frequent but also underdetected group in clinical and general populations. Exposure to further stressful and traumatic events is common. Sequelae include posttraumatic stress disorder, chronic pain, depressive disorders, and more, but so far insufficiently explored and partly culture-based, reactive symptoms. Symptoms are frequently chronic and can be hard to treat even in cost-intensive treatment settings. Medical ethics are challenged in several situations, including documentation, in speaking up against and reporting of torture, and in the refusal to participate in or condone any form of torture.

SUMMARY

Torture prevention and interdisciplinary rehabilitation of survivors must receive more attention, and healthcare professionals have an obligation to take a substantial role in this effort.

Transcultural validity of a structured diagnostic interview to screen for major depression and posttraumatic stress disorder among refugees

Refugees and asylum seekers have a high risk of developing mental health problems and appropriate screening in people from diverse origins remains a challenge. The aim of this study was to validate a structured diagnostic interview, adapted from the Major Depressive Episode (MDE) and Posttraumatic Stress Disorder (PTSD) sections of the Mini International Neuropsychiatric Interview, to detect these disorders among newly arrived asylum seekers. The adapted questionnaire was administered by nurses in a primary care context and its performance was judged against the expert opinion of a mental health specialist. One hundred one subjects were included in the study (mean age: 30; origin: Africa 58%, Europe: 37%, Asia: 5%). MDE and PTSD were diagnosed among 33% and 30% of them respectively. The questionnaire demonstrated moderate sensitivity (MDE: 79%; PTSD: 69%), but high specificity (MDE: 95%; PTSD: 94%). These characteristics remained stable despite cultural differences and use of interpreters. This instrument could be used for systematic screening of MDE and PTSD in refugees from various origins.