Effectiveness of a brief group behavioral intervention for common mental disorders in Syrian refugees in Jordan: A randomized controlled trial

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.

Psychological and social interventions for the promotion of mental health in people living in low- and middle-income countries affected by humanitarian crises

BACKGROUND

Because of wars, conflicts, persecutions, human rights violations, and humanitarian crises, about 84 million people are forcibly displaced around the world; the great majority of them live in low- and middle-income countries (LMICs). People living in humanitarian settings are affected by a constellation of stressors that threaten their mental health. Psychosocial interventions for people affected by humanitarian crises may be helpful to promote positive aspects of mental health, such as mental well-being, psychosocial functioning, coping, and quality of life. Previous reviews have focused on treatment and mixed promotion and prevention interventions. In this review, we focused on promotion of positive aspects of mental health.

OBJECTIVES

To assess the effects of psychosocial interventions aimed at promoting mental health versus control conditions (no intervention, intervention as usual, or waiting list) in people living in LMICs affected by humanitarian crises.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, and seven other databases to January 2023. We also searched the World Health Organization's (WHO) International Clinical Trials Registry Platform and ClinicalTrials.gov to identify unpublished or ongoing studies, and checked the reference lists of relevant studies and reviews.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing psychosocial interventions versus control conditions (no intervention, intervention as usual, or waiting list) to promote positive aspects of mental health in adults and children living in LMICs affected by humanitarian crises. We excluded studies that enrolled participants based on a positive diagnosis of mental disorder (or based on a proxy of scoring above a cut-off score on a screening measure).

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were mental well-being, functioning, quality of life, resilience, coping, hope, and prosocial behaviour. The secondary outcome was acceptability, defined as the number of participants who dropped out of the trial for any reason. We used GRADE to assess the certainty of evidence for the outcomes of mental well-being, functioning, and prosocial behaviour.

MAIN RESULTS

We included 13 RCTs with 7917 participants. Nine RCTs were conducted on children/adolescents, and four on adults. All included interventions were delivered to groups of participants, mainly by paraprofessionals. Paraprofessional is defined as an individual who is not a mental or behavioural health service professional, but works at the first stage of contact with people who are seeking mental health care. Four RCTs were carried out in Lebanon; two in India; and single RCTs in the Democratic Republic of the Congo, Jordan, Haiti, Bosnia and Herzegovina, the occupied Palestinian Territories (oPT), Nepal, and Tanzania. The mean study duration was 18 weeks (minimum 10, maximum 32 weeks). Trials were generally funded by grants from academic institutions or non-governmental organisations. For children and adolescents, there was no clear difference between psychosocial interventions and control conditions in improving mental well-being and prosocial behaviour at study endpoint (mental well-being: standardised mean difference (SMD) 0.06, 95% confidence interval (CI) -0.17 to 0.29; 3 RCTs, 3378 participants; very low-certainty evidence; prosocial behaviour: SMD -0.25, 95% CI -0.60 to 0.10; 5 RCTs, 1633 participants; low-certainty evidence), or at medium-term follow-up (mental well-being: mean difference (MD) -0.70, 95% CI -2.39 to 0.99; 1 RCT, 258 participants; prosocial behaviour: SMD -0.48, 95% CI -1.80 to 0.83; 2 RCT, 483 participants; both very low-certainty evidence). Interventions may improve functioning (MD -2.18, 95% CI -3.86 to -0.50; 1 RCT, 183 participants), with sustained effects at follow-up (MD -3.33, 95% CI -5.03 to -1.63; 1 RCT, 183 participants), but evidence is very uncertain as the data came from one RCT (both very low-certainty evidence). Psychosocial interventions may improve mental well-being slightly in adults at study endpoint (SMD -0.29, 95% CI -0.44 to -0.14; 3 RCTs, 674 participants; low-certainty evidence), but they may have little to no effect at follow-up, as the evidence is uncertain and future RCTs might either confirm or disprove this finding. No RCTs measured the outcomes of functioning and prosocial behaviour in adults.

AUTHORS' CONCLUSIONS

To date, there is scant and inconclusive randomised evidence on the potential benefits of psychological and social interventions to promote mental health in people living in LMICs affected by humanitarian crises. Confidence in the findings is hampered by the scarcity of studies included in the review, the small number of participants analysed, the risk of bias in the studies, and the substantial level of heterogeneity. Evidence on the efficacy of interventions on positive mental health outcomes is too scant to determine firm practice and policy implications. This review has identified a large gap between what is known and what still needs to be addressed in the research area of mental health promotion in humanitarian settings.

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.

Effectiveness and cost-effectiveness of a transdiagnostic intervention for alcohol misuse and psychological distress in humanitarian settings: study protocol for a randomised controlled trial in Uganda

BACKGROUND

The war in South Sudan has displaced more than four million people, with Uganda hosting the largest number of South Sudanese refugees. Research in Uganda has shown elevated levels of alcohol misuse and psychological distress among these refugees. The World Health Organization (WHO) has developed a trans-diagnostic scalable psychological intervention called Problem Management Plus (PM +) to reduce psychological distress among populations exposed to adversities. Our study aims to evaluate the effectiveness and cost-effectiveness of the CHANGE intervention, which builds on PM + , to also address alcohol misuse through problem-solving therapy and selected behavioural strategies for dealing with alcohol use disorders. We hypothesise that the CHANGE intervention together with enhanced usual care (EUC) will be superior to EUC alone in increasing the percentage of days abstinent.

METHODS

A parallel-arm individually randomised controlled trial will be conducted in the Rhino Camp and Imvepi settlements in Uganda. Five hundred adult male South Sudanese refugees with (i) elevated levels of alcohol use (between 8 and 20 on the Alcohol Use Disorder Identification Test [AUDIT]); and (ii) psychological distress (> 16 on the Kessler Psychological Distress Scale) will be randomly assigned 1:1 to EUC or CHANGE and EUC. CHANGE will be delivered by lay healthcare providers over 6 weeks. Outcomes will be assessed at 3 and 12 months post-randomisation. The primary outcome is the percentage of days abstinent, measured by the timeline follow-back measure at 3 months. Secondary outcomes include percentage of days abstinent at 12 months and alcohol misuse (measured by the AUDIT), psychological distress (i.e. depression, anxiety, posttraumatic stress disorder), functional disability, perpetration of intimate partner violence, and health economic indicators at 3 and 12 months. A mixed-methods process evaluation will investigate competency, dose, fidelity, feasibility, and acceptability. Primary analyses will be intention-to-treat.

DISCUSSION

CHANGE aims to address alcohol misuse and psychological distress with male refugees in a humanitarian setting. If it is proven to be effective, it can help fill an important under-researched gap in humanitarian service delivery.

TRIAL REGISTRATION

ISRCTN ISRCTN10360385. Registered on 30 January 2023.

Evaluating a stepped care model of psychological support for adults affected by adversity: study protocol for a randomised controlled trial in Jordan

BACKGROUND

The burden of common mental disorders in low and middle-income countries (LMICs) is growing with little known about how to allocate limited resources to reach the greatest number of people undergoing instances of significant psychological distress. We present a study protocol for a multicentre, parallel-group, superiority, randomised controlled trial.

METHODS AND ANALYSIS

Adults with significant psychological distress (K10 score ≥20) will be randomised to receive a stepped care programme involving a self-guided course (Doing What Matters) followed by a more intensive group programme (Problem Management Plus) or the self-guided course alone, both of which will take place in addition to enhanced treatment as usual comprising of a follow-up referral session to available services within the community. We will include 800 participants. An intent-to-treat and completer analysis will explore the impact of the stepped model of care on anxiety and depression symptoms (as measured by the Hopkins Symptom Checklist; HSCL-25) at 24 weeks from baseline. Secondary outcomes include positive psychological well-being, agency, changes in patient-identified problems, quality of life and cost-effectiveness. Linear mixed models will be used to assess the differential impact of the conditions over time. Analyses will focus on the primary outcome (HSCL-25) and secondary outcomes (agency subscale, WHO Well-Being Index, WHO Disability Assessment Schedule V.2.0, EQ-5D, Psychological Outcomes Profiles Scale) for both conditions, with the main outcome time point being the 3-month follow-up, relative to baseline.

ETHICS AND DISSEMINATION

This will be the first randomised controlled trial to assess the benefits of a stepped model of care to addressing psychological distress in a LMIC setting. Results will provide important insights for managing limited resources to mental healthcare in these settings and will be accordingly disseminated to service providers and organisations via professional training and meetings, and via publication in relevant journals and conference presentations. We will also present these findings to the Jordanian Ministry of Health, where this institute will guide us on the most appropriate format for communication of findings, including written reports, verbal presentations and/or brochures. Ethical approval was obtained from the University of Jordan School of Nursing Research Ethics Committee (number: PF.22.10).

TRIAL REGISTRATION NUMBER

ACTRN12621000189820p; Australian New Zealand Clinical Trials Registry.

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.

A mixed methods systematic review of mental health self-care strategies for Arabic-speaking refugees and migrants

BACKGROUND

Self-care strategies can improve mental health and wellbeing, however, the evidence on preferred strategies among Arabic-speaking refugees and migrants is unclear. This mixed methods systematic review aimed to identify and synthesise the global research on mental health self-care strategies used by these populations.

METHODS

English and Arabic language studies reporting on positive mental health self-care strategies to address symptoms of posttraumatic stress disorder, generalised anxiety and depression in the target populations were identified by systematically searching eight electronic databases and grey literature. Studies were deemed eligible if they were published from 2000 onwards and included Arabic-speaking migrants, refugees or asylum seekers aged 12 years and above. A narrative synthesis of study characteristics and relevant key findings was undertaken. The review protocol was registered on PROSPERO (registration number CRD42021265456).

RESULTS

Fifty-nine records reporting 57 studies were identified, the majority appearing after 2019. There were 37 intervention studies that incorporated a self-care component and 20 observational studies that reported on self-generated self-care practices. Across both study types, four broad groups of mental health self-care were identified-social, psychological, religious/spiritual, and other (e.g., expressive arts and exercise). Psychological strategies were the most reported self-care practice overall and featured in all intervention studies. Religious/spiritual and social strategies were more common in the observational studies. Intervention studies in diverse settings reported statistical improvements on a range of outcome measures. Observational studies reported a range of individual and community benefits. Linguistic, cultural and religious considerations, inherent in the observational studies, were variably addressed in the individual and group interventions.

CONCLUSION

Overall, study participants experienced self-care as helpful although some encountered challenges in practicing their preferred strategies. Further research on mental health self-care strategies among Arabic-speaking refugees and migrants is needed in Western resettlement countries to guide mental health service delivery and primary healthcare initiatives for new arrivals and in transit countries.

Addressing mental health problems among persons without stable housing in the context of the COVID-19 pandemic: study protocol for a randomised trial. RESPOND - France

BACKGROUND

The COVID-19 pandemic has had an impact on population-wide mental health and well-being. Although people experiencing socioeconomic disadvantage may be especially vulnerable, they experience barriers in accessing mental health care. To overcome these barriers, the World Health Organization (WHO) designed two scalable psychosocial interventions, namely the web-based Doing What Matters in Times of Stress (DWM) and the face-to-face Problem Management Plus (PM+), to help people manage stressful situations. Our study aims to test the effectiveness of a stepped-care program using DWM and PM + among individuals experiencing unstable housing in France - a majority of whom are migrant or have sought asylum.

METHODS

This is a randomised controlled trial to evaluate the effectiveness and cost effectiveness of a stepped-care program using DWM and PM + among persons with psychological distress and experiencing unstable housing, in comparison to enhanced care as usual (eCAU). Participants (N = 210) will be randomised to two parallel groups: eCAU or eCAU plus the stepped-care program. The main study outcomes are symptoms of depression and anxiety measured using the Patient Health Questionnaire Anxiety and Depression Scale (PHQ-ADS).

DISCUSSION

This randomised controlled trial will contribute to a better understanding of effective community-based scalable strategies that can help address the mental health needs of persons experiencing socioeconomic disadvantage, whose needs are high yet who frequently have limited access to mental health care services.

TRIAL REGISTRATION

this randomised trial has been registered at ClinicalTrials.gov under the number NCT05033210.

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.

Effectiveness of psychosocial interventions for post-traumatic stress disorder in refugees and asylum seekers resettled in low- and middle-income countries: A systematic review and meta-analysis

Refugees and asylum seekers are more prone to posttraumatic stress disorder (PTSD) than the general population. This systematic review aims to determine which psychosocial interventions effectively treat PTSD among refugees and asylum seekers in low- and middle-income countries (LMIC). Relevant papers were retrieved from the bibliographic databases. PTSD symptoms post-intervention was the primary outcome. Ten studies were selected with 1981 participants. In meta-analyses of Randomised control trials (RCTs), psychosocial interventions for PTSD (SMD -0.60, 95% CI -0.96 to -0.23; I2 = 91%; 95% CI 75-100; nine studies, 1789 participants) were shown to be clinically effective. Also, in case of depression (SMD -0.59, 95% CI -0.95 to -0.22; I2 = 84%; 95% CI 50-90; seven studies, 1248 participants). Eye Movement Desensitization and Reprocessing (EMDR) had the greatest effect size among psychosocial therapies for this demographic. However, the number of studies is small, and their methodological rigour is limited, thus future study should concentrate on performing more rigorous trials.

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.

Effectiveness of the caregiver support intervention on child psychosocial wellbeing among Syrian refugees in Lebanon: Mediation and secondary analysis of a Randomized Controlled Trial

BACKGROUND

War and violence have a serious negative impact on the wellbeing and mental health of many children. Caregivers play an important role in mitigating or exacerbating this impact.

OBJECTIVE

This study evaluates the impact of the nine session Caregiver Support Intervention on improving children's wellbeing and examines putative mediators of changes in children's psychosocial wellbeing.

PARTICIPANTS AND SETTING

240 female caregivers were randomly allocated (1:1) to the CSI or a waitlist control comparison condition. The study was implemented in Lebanon, in an area characterized by high levels of poverty and a high number of the Syrian refugees.

METHODS

A parallel group Randomized Controlled Trial reporting on caregiver-reported child-level wellbeing. We used a combination of the Kid- and Kiddy-KINDL (parent version) for index children ages three to 12. Putative mediators of the CSI on children's psychosocial wellbeing included harsh parenting, caregiver psychological distress, caregiver wellbeing. Measurements were conducted at baseline, post-intervention and 3-months follow-up.

RESULTS

We demonstrated a statistically significant change in caregiver reported children's psychosocial wellbeing at post-intervention (Mdiff =4.39, 95 % CI = 1.12, 7.65, p < 0.01, d = 0.28) but not at follow-up (Mdiff = -0.97, 95 % CI = -4.27, 2.32, p > 0.05). The proportion of the total effect of the CSI intervention on child psychosocial wellbeing mediated by caregiver distress, caregiver wellbeing and harsh parenting was 77 %.

CONCLUSION

The CSI holds potential for down-stream short-term effect on improving children's psychosocial wellbeing, beyond the previously reported positive caregiver outcomes. This effect was not sustained three months post intervention. The study confirms caregiver wellbeing and parenting support as dual pathways mediating child psychosocial wellbeing. Prospective trial registration: ISRCTN22321773.

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.

"Of course, you get depression in this situation": Explanatory Models (EMs) among Afghan refugees in camps in Northern Greece

BACKGROUND

Afghan refugees and asylum seekers constitute one of the largest groups that live in camp settings in Greece. While they experience psychological distress, they are facing significant barriers in accessing appropriate mental health care. Explanatory Models (EMs) provide a context-sensitive framework for understanding the differences between health professionals, refugees and NGOs that operate on the field. This study aims at further understanding how Afghan refugees perceive and explain depression and largely psychological distress, and how this influences their choices for coping strategies and help-seeking.

METHODS

This qualitative study included six vignette-based semi-structured focus-group discussions with Afghan refugees and asylum-seekers (total N = 19, 12 female and 7 male) residing largely in camp settings in Northern Greece. The vignette describes a fictional person with symptoms of depression in line with DSM-5 and ICD-10 criteria. The interviews were recorded, transcribed, and analysed through template analysis.

RESULTS

EMs for depression are explained through Pre-migration Traumatic Experiences (PMTE) and Post-migration Living Difficulties (PMLD) relating to camp settings. Female participants identified gender-based and domestic violence as contributing to psychological distress while males highlighted conflict and persecution. Life in the camp with associated inactivity, and uncertainty for the future, was perceived as a significant risk factor for psychological distress among females and males. In terms of coping strategies, females tended to focus on mobilizing collective resources within the camp (e.g. safe space for women facilitating emotional support), while males advocated for self-empowerment and solution-oriented coping. The value of engagement in peer helper-roles was highlighted.

CONCLUSIONS

The results highlight the potential value of community-based psychosocial approaches to support and promote mental health within camp settings. Additionally, they may inform policies and practices regarding access to appropriate mental health care for Afghan refugees. Further research is needed to establish the efficiency of such interventions in this context.

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.

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

Introduction

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

Methods and analysis

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

Discussion

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

Clinical trial registration

ClinicalTrials.gov, identifier: NCT04993534.

Scalable interventions for refugees

Refugees experience a greater rate of common mental disorders relative to most other populations, and there remains a need to address these needs. However, most refugees are hosted in low-and-middle-income countries, where there is a lack of resources and mental health providers who can deliver mainstream mental health services. This situation has led to the emergence of scalable mental health interventions that can deliver evidence-based programs to refugees in need. Many countries hosting refugees have implemented programs that train local lay providers in interventions that can be delivered at scale. This review provides a narrative overview of these scalable interventions and critiques the evidence for their efficacy. It is noted that there are limitations to currently available scalable interventions, and there is a need for greater attention to determining the longer-term benefits of interventions, addressing the mental health needs of refugees who do not respond to these interventions, assisting refugees with more severe psychological disorders, and understanding the specific mechanisms that underpin observed benefits of these interventions.

Positive Minds for Refugees: A Qualitative Study to Inform Intervention Development

Refugees face significantly worse mental health outcomes compared to the general population within their host country; however, few refugee-specific mental health programs exist within the United States. Utilizing Community-based Participatory Research methods, a community-based mental health intervention named Positive Minds for Refugees (PMR) is in development. In this preliminary study, we shared the in-development intervention with refugees (n = 8), holding a series of 3 focus groups to gain feedback on the intervention content and determine acceptability. Findings suggest that the intervention is generally acceptable and relevant to the refugee community. Mental health for refugees is closely linked with their ability to navigate new social, cultural, and physical environments during resettlement; therefore, to address unmet needs, additional content should be added on: American cultural norms, navigating US society, and coping with social isolation and self-care. This study highlights cultural considerations for presenting written intervention content and implementing sessions.

Videoconferencing-delivered psychological intervention for the treatment of COVID-19 related psychological distress in University students: study protocol for a randomised controlled trial in India

BACKGROUND

The mental health impacts of the COVID-19 pandemic have been profound. This paper outlines the study protocol for a trial that tests the efficacy of a brief group-based psychological intervention (Coping with COVID; CWC), relative to Supportive Counselling, to reduce distress associated with COVID-19 in a young adult population in Bangalore, India.

METHODS

A single-blind, parallel, randomized controlled trial will be carried out via video conferencing in a small group format. Following informed consent, adults that screen positive for levels of psychological distress (Kessler 10 (K-10 score ≥ 20) and have access to a videoconferencing platform will be randomised to an adapted version of CWC (n = 90) or Supportive Counselling (SC) (n = 90). The primary outcome will be reduction in psychological distress including anxiety and depression at 2-months post treatment. Secondary outcomes include worry, positive wellbeing, and stress in relation to COVID-19.

DISCUSSION

This treatment trial will assess whether CWC will result in reduced distress relative to Supportive Counselling in a young adult population in Bangalore, India. This study will yield important insights into the role of nonspecific factors versus the intervention's components in impacting COVID-19 related distress.

TRIAL REGISTRATION

This trial was prospectively registered on the Australian New Zealand Clinical Trials Registry (ACTRN12621001064897).

ETHICS AND DISSEMINATION

Ethics approval has been obtained from the participating institution, CHRIST University in Bangalore. Results of the trial will be submitted for publication in peer reviewed journals and findings presented at scientific conferences and to key service providers and policy makers.

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 + .

Adverse childhood experiences and global mental health: avenues to reduce the burden of child and adolescent mental disorders

Mental disorders are one of the largest contributors to the burden of disease globally, this holds also for children and adolescents, especially in low- and middle-income countries. The prevalence and severity of these disorders are influenced by social determinants, including exposure to adversity. When occurring early in life, these latter events are referred to as adverse childhood experiences (ACEs).In this editorial, we provide an overview of the literature on the role of ACEs as social determinants of mental health through the lenses of global mental health. While the relation between ACEs and mental health has been extensively explored, most research was centred in higher income contexts. We argue that findings from the realm of global mental health should be integrated into that of ACEs, e.g. through preventative and responsive psychosocial interventions for children, adolescents and their caregivers. The field of global mental health should also undertake active efforts to better address ACEs in its initiatives, all with the goal of reducing the burden of mental disorders among children and adolescents globally.

Ten years of tracking mental health in refugee primary health care settings: an updated analysis of data from UNHCR's Health Information System (2009-2018)

BACKGROUND

This study examines mental, neurological, and substance use (MNS) service usage within refugee camp primary health care facilities in low- and middle-income countries (LMICs) by analyzing surveillance data from the United Nations High Commissioner for Refugees Health Information System (HIS). Such information is crucial for efforts to strengthen MNS services in primary health care settings for refugees in LMICs.

METHODS

Data on 744,036 MNS visits were collected from 175 refugee camps across 24 countries between 2009 and 2018. The HIS documented primary health care visits for seven MNS categories: epilepsy/seizures, alcohol/substance use disorders, mental retardation/intellectual disability, psychotic disorders, severe emotional disorders, medically unexplained somatic complaints, and other psychological complaints. Combined data were stratified by 2-year period, country, sex, and age group. These data were then integrated with camp population data to generate MNS service utilization rates, calculated as MNS visits per 1000 persons per month.

RESULTS

MNS service utilization rates remained broadly consistent throughout the 10-year period, with rates across all camps hovering around 2-3 visits per 1000 persons per month. The largest proportion of MNS visits were attributable to epilepsy/seizures (44.4%) and psychotic disorders (21.8%). There were wide variations in MNS service utilization rates and few consistent patterns over time at the country level. Across the 10 years, females had higher MNS service utilization rates than males, and rates were lower among children under five compared to those five and older.

CONCLUSIONS

Despite increased efforts to integrate MNS services into refugee primary health care settings over the past 10 years, there does not appear to be an increase in overall service utilization rates for MNS disorders within these settings. Healthcare service utilization rates are particularly low for common mental disorders such as depression, anxiety, post-traumatic stress disorder, and substance use. This may be related to different health-seeking behaviors for these disorders and because psychological services are often offered outside of formal health settings and consequently do not report to the HIS. Sustained and equitable investment to improve identification and holistic management of MNS disorders in refugee settings should remain a priority.