Course of Mental Health in Refugees-A One Year Panel Survey

Trends and determinants of mental illness in humanitarian migrants resettled in Australia: Analysis of longitudinal data

Given the frequent exposure of humanitarian migrants to traumatic or stressful circumstances, there exists a potential predisposition to mental illness. Our objective was to pinpoint the trends and determinants of mental illness among humanitarian migrants resettled in Australia. This study considered five waves of longitudinal data involving humanitarian migrants resettled in Australia. Post-traumatic stress disorder (PTSD) and psychological distress were assessed using PTSD-8 and Kessler-6 screening tools. Through a Generalised Linear Mixed model (GLMM), variables displaying a 95% CI that excluded the value of 1.0 for the odds ratio were identified as associated factors for both PTSD and elevated psychological distress. The selection of multivariable covariates was guided by causal loop diagrams and least absolute shrinkage and selection operators methods. At baseline, there were 2399 humanitarian migrants with 1881 retained and at the fifth yearly wave; the response rate was 78.4%. PTSD prevalence decreased from 33.3% (95% CI: 31.4-35.3) at baseline to 28.3% (95% CI: 26.2-30.5) at year 5. Elevated psychological distress persisted across all waves: 17.1% (95% CI: 15.5-18.6) at baseline and 17.1% (95% CI: 15.3-18.9) at year 5. Across the five waves, 34.0% of humanitarian migrants met screening criteria for mental illness, either PTSD or elevated psychological distress. In the multivariate model, factors associated with PTSD were loneliness (AOR 1.5, 95% CI: 1.3-1.8), discrimination (AOR 1.6: 1.2-2.1), temporary housing contract (AOR 3.7: 2.1-6.7), financial hardship (AOR 2.2:1.4-3.6) and chronic health conditions (AOR 1.3: 1.1-1.5), whereas the associated factors for elevated psychological distress were loneliness (AOR 1.8: 1.5-2.2), discrimination (AOR 1.7: 1.3-2.2) and short-term lease housing (AOR 1.6: 1.0-1.7). The prevalence, persistence and consequential burden of mental illness within this demographic underscore the urgent need for targeted social and healthcare policies. These policies should aim to mitigate modifiable risk factors, thereby alleviating the significant impact of mental health challenges on this population.

Challenges in substance use treatment as perceived by professionals and Arabic-speaking refugees in Germany

BACKGROUND

Substance use (SU) and substance use disorders (SUDs) have been recently documented among forcibly displaced populations as a coping mechanism to migration and postmigration stressors. Although the literature exploring substance use among refugees has grown recently, little is known about SU among Arabic-speaking refugees and, more specifically, on the challenges and experiences in regards to SU treatment. This study investigates this topic from the perspectives of Arabic-speaking refugees and professionals in Germany.

METHODS

Design and participants To expand our knowledge on this topic, a qualitative approach was employed by conducting in-depth and semi-structured interviews among 26 participants (13 refugees and 13 professionals) in Germany during 2020-2021. Purposive sampling was used to recruit Arabic-speaking refugees in two rehabilitation centers in Berlin. Data and analysis Interviews were conducted with 26 participants of which 13 were refugees and 13 professionals. Refugees were interviewed individually in the rehabilitation centers, they ranged from 21 to 52 years of age, and their average time in Germany was 6.3 years. An open-ended survey was conducted among the professionals via the SoSci-survey platform, and they ranged from 22 to 66 years of age, with an average of 5 to 9 years of work experience. Data were analyzed using thematic analysis.

RESULTS

Three themes resulted from the thematic analysis: (1) The treatment is facilitated by institutional and emotional support; (2) The affected refugees struggle with complex contextual barriers to access SUD treatment; and (3) Individual and community preventive strategies are needed.

CONCLUSIONS

This study provides insight into the support and challenges of accessing effective SU treatment and prevention among Arabic-speaking refugees in Germany. Collaborative efforts by the community, professionals, and policymakers are needed to facilitate access to effective treatment and implement culturally and linguistically sensitive approaches for the treatment and prevention of SU among refugees.

[The Konstanz model project for refugees with mental disorders : Coordinated psychotherapeutic treatment involving trained peer support (KOBEG)]

Refugees with mental disorders are confronted with access barriers to the psychiatric and psychotherapeutic care system. In order to counter these barriers, a model project to support the health care and integration of mentally distressed refugees was established in the district of Konstanz (coordinated psychotherapeutic treatment involving trained peer support; KOBEG) and evaluated in an initial 3‑year model phase. A coordination center refers the patients to local certified psychotherapists. Language and culturally sensitive trained mentors (peers) support and accompany the refugees during the therapy. The utilization of the refered therapy and the experiences of the participating therapists serve as indicators for the effectiveness of the peer-supported therapy referral. The effectiveness of therapeutic measures and support by trained peers was evaluated on the basis of the psychological symptom burden (symptom checklist 27) and functional impairment (work and social adjustment scale) before and after an average of 10 months of project participation. The study focuses on the refugees (use of services and mental distress) and the psychotherapists (reported experiences). Initial results showed an above-average stress level among the refugees at the time of the initial interview, a high participation rate and a low drop-out rate. The follow-up survey showed significant improvements in terms of psychological symptom burden as well as functional impairments. The (qualitative) survey among psychotherapists underlines the effectiveness of KOBEG, 93% of the therapists intend to continue working with refugees within the framework of the project.

[Determinants of asylum seekers' health and medical care in Germany]

Asylum seekers in Germany are exposed to a variety of health-related stressors, while their access to medical care is impaired. This review explains some of the determinants that structure this situation, for example by elaborating on how the Asylum Seekers' Benefits Act (ASBA), billing via treatment vouchers, and accommodation in refugee shelters affect asylum seekers' health and healthcare utilization. Hereby, it becomes clear that the exclusion of asylum seekers from the welfare system is detrimental to their health, is expensive, and raises ethical and legal questions. In particular, the huge discretionary scope of the social welfare offices in the assumption of costs as well as the different models for billing medical services for asylum seekers are potentially unjust and lead to a plurality of care, which lacks legal and ethical justification.The second part of the article shows that asylum seekers generally suffer from the same health problems as people with statutory health insurance-with the exception of mental illnesses, which are substantially more common among asylum seekers, but are often undiagnosed and frequently inadequately treated.This leads to three practical conclusions: (1) asylum seekers should be integrated into statutory health insurance, (2) from a public health point of view, accommodation in refugee shelters should be avoided in favor of decentralized accommodation, and (3) to ensure diversity-sensitive care for all patients, the healthcare system must make adjustments to its structures and practices.

Associations between postmigration living situation and symptoms of common mental disorders in adult refugees in Europe: updating systematic review from 2015 onwards

BACKGROUND

Refugees and asylum seekers have a high prevalence of psychiatric disorders such as post-traumatic stress disorder (PTSD), anxiety, and depression. The postmigration context inheres different risk and protective factors for mental health of refugees and asylum seekers in host countries. We conducted a systematic review to update knowledge on the association between characteristics of the postmigration living situation (PMLS) and mental health outcomes in Europe since 2015.

METHODS

We searched in five databases according to the PRISMA statement. From a total of 5,579 relevant studies published in 2015-22, 3,839 were included for title and abstract screening, and 70 full texts screened for eligibility. Out of these, 19 studies on refugees and asylum seekers conducted in European countries after 2014 were included in this systematic review. The quality of studies was assessed by using the Mixed Methods Appraisal Tool (MMAT) - version 2018. We performed a narrative synthesis using the four layers of the social determinants of health framework.

RESULTS

A wide range of risk and protective factors for mental health in the PMLS were identified as exposure measures, which included individual factors (e.g., language skills), social and community networks (e.g., family concerns, loneliness and social support, discrimination), living and working conditions (e.g., legal status, duration of residence, unemployment and financial hardship, housing) as well as general socio-economic, cultural and environmental factors (e.g., social status, acculturation). We found postmigration stressors are positively associated with symptoms of depression, anxiety, and PTSD, albeit not consistently so. Especially, the general socio-economic, cultural and environmental factors showed weak associations with mental health.

CONCLUSIONS

Heterogenous study characteristics likely explain the inconsistent associations between characteristics of the PMLS and mental health outcomes. However, broken down in its component layers, most risk and protective factors of the PMLS were significantly associated with symptoms of mental disorders showing the same direction of association across the included studies, while the association between some stressors or resources of the PMLS and mental health turns out to be less homogeneous than expected. Characteristics of the PMLS contribute to the high prevalence of mental diseases of refugees and asylum seekers. Disadvantages in general socio-economic conditions, living and working conditions, in access to social and community networks need to be redressed, in addition to better access to health care.

Does Time Heal Trauma? 18 Month Follow-Up Study of Syrian Refugees' Mental Health in Iraq's Kurdistan Region

The findings of longitudinal studies on traumatized refugees have shown that factors related to premigration, migration, and post-migration experiences determine changes in mental health over time. The primary aim of this follow-up study was to examine the potential change in the prevalence rates of probable PTSD and depression among Syrian refugees in Iraq. An unselected group of N = 92 Syrian adult refugees was recruited from Arbat camps in Sulaymaniyah Governorate in Iraq's Kurdistan Region, and then interviewed at two different time points between July 2017 and January 2019. Locally validated instruments were used to assess traumatic events and mental health symptoms. The primary results showed no significant change in the mean scores of PTSD and depression symptoms from the first measurement to the second measurement over the course of 18 months. On the individual level, no reliable change was found for either PTSD or depression symptoms in more than three-quarters of the participants (78.3% and 77.2%, respectively). New adversities and traumatic events that occurred over the 18 months between the interviews were a significant predictor of increasing trauma-related symptoms. After the flight from conflict settings, trauma-related disorders seem to be chronic for the majority of Syrian refugees. Further longitudinal studies are needed in order to identify specific risk factors that lead to maintaining or worsening mental health symptoms over time, and to explore effective therapeutic intervention methods for this traumatized population.

Parenting-related trauma exposure among parents of children with intellectual and developmental disorders: Development and validation of the Parenting Trauma Checklist

Parents of children with intellectual and developmental disorders (IDDs) often encounter parenting-related traumatic events. Trauma exposure is a risk factor for mental health problems, including posttraumatic stress disorder (PTSD). Little is known regarding the types of traumatic events that parents commonly experience and how to best assess parenting-related trauma exposure. To address this gap, we developed the Parenting Trauma Checklist (PTC) and tested its psychometric properties. The PTC was created based on an extensive literature review and consultation with stakeholders, which led to the creation of a 17-item instrument. Participants (N = 424) were Canadian parents of children with IDDs who completed an online test battery that included the PTC and several questionnaires to assess PTSD symptoms, global mental and physical health, lifetime trauma exposure, and functional impairment, which were included to test the validity of the new instrument. The PTC demonstrated good construct validity. Ninety four percent of the sample reported parenting-related trauma exposure. Parents reported having experienced an average of 5.79 parenting-related traumatic events, with seeing their child undergo a medical procedure the most frequently endorsed event (68.6%). Experiencing more parenting-related traumatic events was positively associated with higher PTSD symptom levels, r = .35, p < .001. The PTC is a promising instrument that can be used to examine parenting-related trauma exposure. The measure can be used as a screening tool to detect parents' risk of traumatic stress disorders, evaluate traumatic experiences, and assess whether trauma-focused treatment is warranted.

Risk and protective factors for posttraumatic stress and posttraumatic growth in parents of children with intellectual and developmental disorders

BACKGROUND

Parents of children with intellectual and developmental disorders often experience potentially traumatic events while caring for their children. Heightened posttraumatic stress (PTS) and posttraumatic growth (PTG) have been found in this population.

OBJECTIVE

We aimed to explore risk and protective factors for their PTS and PTG.

METHOD

A cross-sectional study was conducted with 385 parents (average age M = 43.14 years, SD = 7.40; 95.3% mothers).

RESULTS

Parenting trauma showed an adverse effect on developing PTS (beta = 0.25, p < .01) and a positive role in promoting PTG (beta = 0.16, p < .01). Social support was protective in its correlation with lower levels of PTS (beta = -0.12, p < .01) and higher levels of PTG (beta = 0.22, p < .01). Barriers to care were associated with increased PTS (beta = 0.23, p < .01), but unrelated to PTG (beta = .01, p = .855). Negative parenting showed a significant, but small, correlation with more severe PTS (beta = 0.11, p < .05), and was unrelated to PTG (beta = -0.09, p = .065).

CONCLUSIONS

Our study increases the understanding of posttraumatic reactions in parents, predominantly mothers, of children with IDD and identified parenting-related trauma, social support, and barriers to mental health care as predictive factors of the reactions. More research is needed to confirm and validate the effects of the discussed factors. Although causation can not be inferred, prompt and adequate screening and therapeutic resources should be provided to those mothers who were exposed to multiple stressful caregiving events and had limited healthcare access and less support from their spouses, peers, and caregiving partners.

HIGHLIGHTS

Parents of a child with Intellectual and Developmental Disorders with parenting trauma had higher posttraumatic stress (PTS) and posttraumatic growth (PTG).Social support was related to lower PTS and higher PTG.Barriers to care were related to higher PTS but unrelated to PTG.

Sick and Tired-Sociodemographic and Psychosocial Characteristics of Asylum Seekers Awaiting an Appointment for Psychotherapy

Background: An EU directive holds the EU member states responsible for implementing the provision of health care for asylum seekers. However, current literature indicates insufficient care for asylum seekers in the German health system. This article aims to characterize the situation of the client population on the waiting list of a psychosocial center (PSZ). Methods: We conducted a retrospective observational study based on client files in Halle (Saale), Germany. We included 437 adults who were on the PSZ waiting list between 2016 and 2019. Questionnaires that collected information on the clientele at two different times were analyzed. Results: The average waiting time for psychotherapy was 50 weeks. In total, 85.6% of the 188 respondents reported sleep disorders (n = 161), 65.4% of clients reported pain (n = 123) and 54.8% suicide attempts/suicidal thoughts (n = 54). In the 16-week waiting period in which the clients waited for an initial appointment with a psychologist, the residence status deteriorated in 21.3% (n = 40). Conclusion: Improving asylum seekers’ access to the German health system is urgently needed in order to prevent unnecessary suffering in the future and to comply with EU law.

Health of war-affected Karen adults 5 years post-resettlement

BACKGROUND

An estimated 140 000 refugees from Burma have resettled to the USA since 2009, comprising 21% of total resettlement in the USA over the last decade. Our objective was to describe patterns of longitudinal health outcomes in a cohort of Karen refugees resettled in the USA for 5 years, and to translate these findings to a primary healthcare context.

METHODS

The study was a retrospective cohort study focused on the analysis of the first 5 years of electronic health records of a sample of 143 Karen refugees who were initially resettled between May 2011 and May 2013.

RESULTS

Through descriptive, inferential and survival statistics, we described patterns of retention in primary care, biometric trends, condition prevalence and survival probabilities. Highest prevalence health conditions documented at any point in the 5-year period included diagnoses or symptoms associated with pain (52%); gastrointestinal disturbance (41%); metabolic disorder (41%); infectious process (34%); mental health condition (31%) and central nervous system disorder (24%).

CONCLUSIONS

This study is the first retrospective longitudinal analysis of patterns of health in Karen refugees originating from Burma and resettled to the USA. Findings identified in the 5-year, the post-resettlement period provided important clinical insights into the health trajectories of war-affected populations. Burden of illness was high although results did not demonstrate the extent of trauma-associated physical health conditions reported in the literature. Indicators such as significant increases in body mass index (BMI), the overall prevalence of dyslipidaemia and others suggested that the cohort may be exhibiting an early trajectory towards the development of these conditions. Authors summarize potential protective factors experienced by the cohort that promoted aspects of health frequently challenged in forced migration.

A Systematic Review of Factors Affecting Mental Health and Well-Being of Asylum Seekers and Refugees in Germany

Background: Since the onset of the 2015 European refugee crisis, ~4. 46 million people have sought asylum in the European Union, with Germany logging the largest share of all asylum applications. In addition to the severe adversities before and during flight, the process of settling into a new environment involves stressors that affect psychological well-being and mental health. The aim of this systematic review was to examine contextual factors during post-migration that influence the mental health and well-being of asylum seekers and refugees (ASRs) in Germany. Methods: Following PRISMA guidelines, a systematic review was conducted across multiple databases for English and German studies published between 2015 and 2020 with index keywords. Results: From a total of 303 articles, 156 duplicates were removed and, after title review, another 87 were excluded for not meeting the inclusion criteria. After assessing the abstracts of the remaining 60 articles, 39 were excluded. Full texts of 21 articles were assessed for eligibility and after excluding 8 articles, 13 articles were included in the review. The results demonstrate high rates of psychological distress among ASRs in Germany and the significant influence of contextual factors on their mental health and psychological well-being. The risk factors for poor mental health include an uncertain asylum status, living in shared asylum accommodations, separation from the nuclear family, lack of German language skills, integration issues and discrimination, while employment is a protective factor. Conclusion: Asylum seekers and refugees have high prevalence rates of psychological distress directly influenced by contextual factors in Germany. Based on these findings, policy makers are strongly recommended to apply preventive strategies to reduce mental health problems of ASRs in Germany.

Can Circumstances Be Softened? Self-Efficacy, Post-Migratory Stressors, and Mental Health among Refugees

Post-migratory stressors (PS) are a risk factor for mental health problems among resettled refugees. There is a need to identify factors which can reduce this burden. Self-efficacy (SE) is associated with refugees' mental health. The current study examined whether SE can protect this group from the impact of PS on mental wellbeing. Higher levels of PS were expected to be associated with higher levels of mental health problems. In addition, we expected this linkage to be moderated by lower SE. Questionnaires were administered to a non-clinical refugee sample (N = 114, 46% female, average age 35 SD = 10.42 years) with various backgrounds. The following questionnaires were used: the Self-Reporting Questionnaire-20 (SRQ-20) to assess mental health problems, the General Self-Efficacy Scale (SGES) to measure SE, and an adapted version of the Post-Migration Living Difficulties Checklist (PMLD) to measure PS. Bivariate correlations and multiple linear regression analysis were performed. No significant contribution was found for SE or the interaction of SE and daily stressors, above and beyond the significant contribution of daily stressors to mental health problems. The findings reinforce that PS affects mental health and suggest that SE had a limited impact on mental health in this non-clinical sample of refugees.

Distress and Resilience in Resettled Refugees of War: Implications for Screening

There is little work published about predictors of specific trajectory types of distress in refugees of war during early resettlement in a host country. Data about distress (Refugee Health Screener—15 (RHS-15)) and possible predictors of distress were collected at the domestic medical examination (T1) within 90 days of arrival and the civil surgeon examination (T2) 11–16 months after T1 for refugee groups from three countries (COU). Descriptive, correlative, analyses of variance, and regression techniques were used to determine trajectory type and their predictors. A higher percentage (7.3%) were distressed at T2 than at T1. By group, the Bhutanese became more distressed, the Burmese became less distressed, and Iraqi’s continued to have high distress. A regression model showed gender, loss, post-migration stress, and self-efficacy to be significant predictors of trajectory type (R² = 0.46). When the T1 RHS-15 score was added to the model, observed variance increased (R² = 0.53) and T1 RHS score accounted for the majority of variance (r = 0.64, p < 0.001), with post-migration stress accounting for markedly less (β = 0.19, p = 0.03). Loss and self-efficacy became less significant. Loss was, however, a strong predictor of delayed and chronic distress trajectory type. These data suggest that screening for distress should occur at least twice during resettlement to detect those with initial distress and those with delayed distress. Screening should be coupled with identifying other social determinants of health and a comprehensive assessment to determine the need for intervention for secondary prevention (i.e., reducing delayed distress) and treatment (reducing chronic distress).

Online narrative exposure therapy for parents of children with neurodevelopmental disabilities suffering from posttraumatic stress symptoms - study protocol of a randomized controlled trial

BACKGROUND

Parents of children with intellectual and neurodevelopmental disorders (IDD) often experience traumatic events in the care of their children. This leads to comparatively high numbers of mental health problems such as posttraumatic stress disorder (PTSD) in those parents. Intervention approaches for parents of children with IDD are scarce and many parents remain without support.

OBJECTIVE

This study aims to test the feasibility and efficacy of online Narrative Exposure Therapy (eNET) with parents of children with IDD.

METHODS

The study follows a randomized waitlist-control design. eNET is an exposure-based PTSD intervention and includes 8-12 90-minute sessions. All sessions will be conducted via video calls with trained paraprofessionals. We aim to include 50 parents, approximately 25 in the immediate intervention group and 25 in the waitlist group. Waitlist participants will receive the same intervention after a three-month wait period. All participants need to either fulfill full or subclinical PTSD symptoms according to DSM-5. Feasibility and efficacy of the intervention will be measured with pre, post, and 2 and 6 months follow-up surveys focusing on PTSD symptoms. Secondary outcomes include other health-related outcomes such as physical symptoms, depression symptoms, anxiety symptoms and functionality.

CONCLUSIONS

The proposed study allows us to test the feasibility and efficacy of eNET in a sample of parents of children with IDD. There are so far no published studies on the evidence of eNET; this study is one of the first randomized controlled trials investigating the feasibility and efficacy of eNET and therefore will have implications on further research and practice.Clinical trial registration: NCT04385927Date and version identifier: 22 July 2021.

Longitudinal investigation of the relationships between trauma exposure, post-migration stress, sleep disturbance, and mental health in Syrian refugees

Background High prevalence of sleep disturbance, which is associated with poor mental health, has been observed among non-treatment seeking refugees. However, no longitudinal research has investigated the chronicity of untreated sleep disturbance and its impact on refugees' mental health.

OBJECTIVE

This longitudinal study investigated associations between mental health (posttraumatic stress disorder, anxiety, depression), sleep symptoms (insomnia severity, pre-sleep arousal), and factors predicting mental health, over a 12-month period.

METHOD

Syrian refugees (N = 69) from a cross-sectional study (Time 1) participated in the current 12-month (Time 2) follow-up study. Participants completed a series of questionnaires examining sleep, trauma exposure, post-migration living difficulties, and mental health at both time points.

RESULTS

When compared to Time 1, participants showed a significant increase in post-migration stress at Time 2. However, there was an improvement in their mental health and levels of sleep disturbance. Half of the participants met criteria for moderate (36%) or severe sleep disturbance (15%) at Time 2. Forty-two per cent of the participants had moderate to severe sleep disturbance at both Time 1 and Time 2. When predicting mental health at 12-month follow-up, only pre-sleep arousal at Time 1 uniquely predicted mental health at Time 2. Mediation analysis indicated that change in pre-sleep arousal (from Time 1 to Time 2) significantly mediated the relationship between change in post-migration stress and change in mental health symptoms.

CONCLUSIONS

This study demonstrated that sleep symptoms have an indirect and long-term impact on mental health among refugees. Understanding modifiable factors, such as sleep, mediating the relationship between trauma exposure and PTSD symptoms is important, as such factors can be targeted in psychological interventions for refugees.

Post-migration Social-Environmental Factors Associated with Mental Health Problems Among Asylum Seekers: A Systematic Review

People seeking asylum are at an increased risk of mental disorder compared to refugees and other migrants. This paper aims to understand the impact of postmigration social-environmental factors to help inform efforts to reduce rates of mental disorder. We conducted a systematic review searching 11 databases, as well as 6 government and nongovernment websites. We asked 5 experts for recommendations, and carried out forwards and backwards citation tracking. From 7004 papers 21 were eligible and had the appropriate data. Narrative synthesis was conducted. 24 Social-environmental factors were identified and categorised into 7 themes: working conditions, social networks, economic class, living conditions, healthcare, community and identity, and the immigration system. Evidence suggests that discrimination and post-migration stress are associated with increased rates of mental disorder. The post-migration environment influences the mental health of people seeking asylum. Discrimination and post-migration stress are key factors, warranting further research and public attention.

The mental health status of asylum seekers in middle- to high-income countries: a synthesis of current global evidence

INTRODUCTION

The last 5 years have witnessed a significant increase in the number of people fleeing their countries of origin and seeking refuge in host countries. By the end of 2018, there were 3.5 million asylum seekers awaiting outcomes on their applications, the majority of whom were hosted by middle- to high-income countries. This review aimed to identify and synthesize current knowledge regarding the mental health status of asylum seekers in middle- to high-income countries.

SOURCES OF DATA

A search was conducted across various databases for research literature published within the last 5 years (2014-2019). The final review and synthesis included 25 articles.

AREAS OF AGREEMENT

Findings highlighted significant differences in the mental health status of asylum seekers compared to those with refugee status and permanent residence.

AREAS OF CONTROVERSY

Guidelines from the World Health Organization and the United Nations High Commissioner for Refugees emphasize the need to understand and address mental health issues. Instead, there have been policy changes in many host countries regarding asylum applications, and the associated effects of these changes have been shown to negatively impact mental health.

GROWING POINTS

The synthesized findings from the present review provide information regarding the current mental health status of asylum seekers hosted by middle- to high-income countries. Areas of intervention and resource allocation were also identified.

AREAS TIMELY FOR DEVELOPING RESEARCH

Future research should consider the impact of large-scale, low-cost interventions to support the mental health of those seeking asylum.

The prevalence and risk factors for mental distress among Syrian refugees in Germany: a register-based follow-up study

BACKGROUND

Mental disorders among refugees as well as their risk factors are already well documented in cross-sectional reports. However, longitudinal follow-up designs are widely lacking. Therefore, the aim of this study was to examine the change of the prevalence of mental disorders among Syrian refugees with German residence permission, taking into account their increasing length of stay in Germany, and to uncover the change in their relationship to pre- and post-migration risk factors.

METHODS

This study formed part of a register-based follow-up study with two measurement points in Erlangen (Germany). At the first time of recruitment in 2017, 200 of the 518 Syrian refugees with residence permission living in Erlangen took part. During the second survey timeframe 1.5 years later, in 2019, 108 of the former 200 Syrian refugees participated again and formed the total sample for this follow-up study. The survey instruments included demographics, migration-related variables and symptoms of post-traumatic stress (Essen Trauma Inventory, ETI), depression (Patient Health Questionnaire - PHQ-9) and generalized anxiety disorder (GAD-7).

RESULTS

At the time of the first survey, 26.9% of the participants exceeded the cut-off for a clinically relevant depression diagnosis, 16.7% for an anxiety disorder and 13.9% for a PTSD diagnosis. At the second measurement point, it was 30.6% for depression, 15.7% for an anxiety disorder and 13.0% for PTSD. No significant changes between the measurement points were found for any of the disorders. In multiple linear regression analyses, higher perceived discrimination, a higher number of traumatic experiences and a shorter duration of residence permission were shown to be the most important pre- and post-migration predictors of psychological stress independent of the time of measurement.

CONCLUSIONS

There is strong empirical evidence that the prevalence rates of mental distress among refugees are significantly higher compared to the overall population. However, it has not yet become clear how these prevalence rates change with an increasing length of stay in the host countries. The results of our study indicate that the psychological burden on this refugee population remains consistently high over time, despite partly improved living conditions, and confirm the importance of therapeutic interventions.

Trajectories of posttraumatic stress symptoms during and after Narrative Exposure Therapy (NET) in refugees

BACKGROUND

Trauma-focused therapy approaches are recommended as treatment for posttraumatic stress disorder (PTSD). This includes the treatment of trauma-related suffering in refugee populations. However, there is a lack of knowledge about symptom trajectories in refugees living in volatile conditions. This has led to fear of "retraumatisation" and general skepticism in clinicians concerning the use of exposure therapy.

METHODS

To test the relevance of this concern, we investigated PTSD symptom trajectories and potentially influencing factors during the course of Narrative Exposure Therapy (NET) in a refugee sample living in Germany. Refugees filled out the PTSD Checklist prior to each treatment session and also during follow-up interviews. Therapists continuously documented positive and negative life events as well as the content of the treatment sessions. Additionally, structured clinical interviews were conducted pre-treatment and at follow-up time points.

RESULTS

On average, clients presented with substantial decreases in PTSD symptoms already during and after NET. However, symptom trajectories differed and ranged from fast responders to slow responders to no immediate response during treatment. Importantly, a persistent worsening of symptoms was not observed, also not after exposure to the most distressing events. In contrast, stressful life experiences seemed to aggravate PTSD symptoms.

CONCLUSIONS

Consistent with earlier studies, NET leads to clinically and behaviorally relevant reductions in PTSD symptoms both throughout and following treatment in refugees living in volatile conditions. Concerns about imaginal exposure in refugees were not substantiated. While stressful life events contributed to transient symptom increases, they weren't found to prevent the overall effectiveness of NET.

TRIAL REGISTRATION

NCT02852616.

Structural and socio-cultural barriers to accessing mental healthcare among Syrian refugees and asylum seekers in Switzerland

Background: Due to their experiences of major stressful life events, including post-displacement stressors, refugees and asylum seekers are vulnerable to developing mental health problems. Yet, despite the availability of specialized mental health services in Western European host countries, refugees and asylum seekers display low mental healthcare utilization. Objective: The aim of this study was to explore structural and socio-cultural barriers to accessing mental healthcare among Syrian refugees and asylum seekers in Switzerland. Method: In this qualitative study, key-informant (KI) interviews with Syrian refugees and asylum seekers, Swiss healthcare providers and other stakeholders (e.g. refugee coordinators or leaders) were conducted in the German-speaking part of Switzerland. Participants were recruited using snowball sampling. Interviews were audiotaped and transcribed, and then analysed using thematic analysis, combining deductive and inductive coding. Results: Findings show that Syrian refugees and asylum seekers face multiple structural and socio-cultural barriers, with socio-cultural barriers being perceived as more pronounced. Syrian key informants, healthcare providers, and other stakeholders identified language, gatekeeper-associated problems, lack of resources, lack of awareness, fear of stigma and a mismatch between the local health system and perceived needs of Syrian refugees and asylum seekers as key barriers to accessing care. Conclusions: The results show that for Syrian refugees and asylum seekers in Switzerland several barriers exist. This is in line with previous findings. A possible solution for the current situation might be to increase the agility of the service system in general and to improve the willingness to embrace innovative paths, rather than adapting mental healthcare services regarding single barriers and needs of a new target population.

The symptom representation of posttraumatic stress disorder in a sample of unaccompanied and accompanied refugee minors in Germany: a network analysis

Background: Given the unprecedented number of traumatized refugee minors in Europe and the increased prevalence of mental disorders such as PTSD in this vulnerable population, new methodologies that help us to better understand their symptomatology are crucial. Network analysis might help clinicians to both understand which symptoms might trigger other symptoms, and to identify relevant targets for treatment. However, to date only two studies have applied the network analysis approach to an (adult) refugee population and only three studies examined this approach in children and adolescents. Objective: The aim of this study is to explore the network structure and centrality of DSM-5 PTSD symptoms in a cross-sectional sample of severely traumatized refugee minors. Method: A total of N = 419 (M age = 16.3; 90.7% male) unaccompanied (79.9%) and accompanied (20.1%) refugee minors were recruited in five studies in southern Germany. PTSD symptoms were assessed using the Child and Adolescent Trauma Screen (CATS). The network was estimated using state-of-the-art regularized partial correlation models using the R-package qgraph. Results: The most central symptoms were nightmares, physiological and psychological reactivity, and concentration problems. The strongest connections between symptoms were established for psychological and physiological reactivity, irritability/anger and self-destructive/reckless behaviour, intrusions and nightmares, nightmares and sleep disturbance, and between concentrations problems and sleep disturbance. Conclusion: This study furnishes information relevant to research and the clinical management of PTSD in refugee minors, and also in terms of comparisons with trauma-exposed children and adolescents without a migration background. Re-experiencing symptoms seem to be central in the refugee minor PTSD profile and thus merit special consideration in the diagnostic and treatment evaluation process. Investigating the PTSD network longitudinally and complementing between-subject analyses with within-subject ones might provide further insight into the symptomatology of refugee minors and how to treat them successfully.

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.

Prevalence of Possible Depression and Post-traumatic Stress Disorder among Community Dwelling Adult Refugees and Refugee Applicants in South Korea

BACKGROUND

Because there has been a recent increase in refugee applications in Korea, the mental health of these refugees merits greater study.

METHODS

We surveyed 129 refugees (including those in process of refugee application) and 121 migrant workers living in urban communities, using: the Patient Health Questionnaire-9 for depressive symptoms, the Impact Event Scale-Revised for post-traumatic stress disorder (PTSD) symptoms, and the health questionnaires used in 2016 Korean National Health and Nutrition Examination Survey (KNHANES). The majority of refugee subjects were from sub-Saharan Africa and Middle East. We compared the prevalence of possible depression and possible PTSD between refugees and migrant workers and refugees and age-gender matched samples from the KNHANES 2016.

RESULTS

Frequency of suicidal planning during the last year was higher in the refugee group than Korean nationals, but frequency of suicidal attempt was not. High risk drinking was found in 0.8% of refugees, 6.6% of migrant workers and 27.2% of Korean nationals. Possible depression was present in 42.9% of refugee subjects, 33.3% of migrant workers, and 4.2% of Korean controls. Possible PTSD was present in 38.9% of refugees compared to 12.5% of migrant workers. Only major risk factor for depression among refugees was a traumatic event before entering Korea.

CONCLUSION

Possible depression and PTSD are significantly more prevalent in refugees, compared to both migrant workers and Korean nationals. Prevalence rates are commensurate with refugee studies worldwide. Appropriate early screening and intervention schemes need to be developed for refugees entering Korea.