Recruitment and Baseline Characteristics of Participants in the "Sanadak" Trial: A Self-Help App for Syrian Refugees with Post-traumatic Stress

Self-compassion and association with distress, depression, and anxiety among displaced Syrians: A population-based study

Displaced communities are at increased risk of poor mental health with limited resources for treatment. Self-compassion moderates the impacts of stressors on mental health in high-income country general population samples, but its impact has not been described among people who have experienced displacement and associated trauma. The aim of this study was to characterize the associations between self-compassion, mental health, and resilience in a sample of displaced Syrian adults living in Jordan. This is a cross-sectional study using four validated survey tools measuring self-compassion, resilience, mental health, and traumatic exposure. Syrian adults who presented to four different community organizations serving refugees within Amman, Jordan were invited to participate. A total of 272 displaced Syrians were included in the final analysis. A majority of those surveyed were positive for emotional distress (84.6%), depression (85.7%), and anxiety (76.5%). In univariate analysis there was a significant lower risk of emotional distress, depression, and anxiety, with both higher resilience and self-compassion. However, in the multivariate model only self-compassion remained significantly associated with less emotional distress, depression, and anxiety, independent of resilience and other covariates. Female gender, poor financial stability, and high levels of traumatic exposure were also identified as persistent predictors of mental health morbidity. The findings of this study suggest that self-compassion is associated with less distress, depression, and anxiety in displaced individuals; suggesting it might be protective against poor mental health. Self-compassion is a modifiable factor that can be utilized as a tool by healthcare professionals and communities caring for refugees to promote positive mental health outcomes.

Efficacy of technology-based mental health interventions in minimizing mental health symptoms among in immigrants, asylum seekers or refugees; systematic review

Digital health technologies may offer an alternate approach to augmenting the established mental health care delivery systems for migrants and promoting their mental well-being. This review aims to provide a broad examination of literature, to determine the impact of technology-based interventions on outcomes of immigrants and refugees experiencing mental health symptoms associated with pre-and postmigration stress (depression, anxiety, psychological stress, PTSD). We searched five electronic databases (PubMed, Embase, PsycINFO, Web of Science, and the ACM digital library). We included studies that looked at the effectiveness of any technologybased intervention (internet or phone-based, telepsychiatry, telemedicine, digital technology, videoconferencing, or tele video). We limited our search to articles written in English and published up until January 2202. Two reviewers independently extracted article data and evaluated the quality of studies using the Cochrane risk-of-bias criteria and ROBINS-I risk of bias evaluation tool. We found scant evidence that the use of digital interventions, such as mobile-based therapies, video conferencing, and digital platforms, is associated with a statistically significant reduction in depressive and anxious symptoms among immigrants and refugees. In the included trials, no evidence of a substantial decrease in PTSD symptoms was found following the use of a self-help mobile app. Our systematic review revealed intriguing but limited evidence that digital psychological therapies can reduce depression in immigrants and refugees. Future study with a randomized experimental design is required to examine the effectiveness of digital treatments in lowering the impacts of mental health outcomes among immigrants.

Mental health outcomes in Syrian refugees: A systematic review

BACKGROUND

Syria is the main country of origin for refugees in the world. The prevalence of mental disorders in this population is high, but there is a lack of more comprehensive data on mental health issues in this population.

AIM

This study aims to review the literature for mental health outcomes in Syrian refugees.

METHODS

We performed a systematic quantitative literature review of original observational studies indexed on the MEDLINE via PubMed, Embase, Web of Science, PsycINFO, LILACS, and SciELO databases with quantitative data reporting mental health outcomes in Syrian refugees. A descriptive analysis was conducted, and the quality of the included studies was assessed using an adaptation from The National Institutes of Health (NIH) quality assessment tool for observational studies. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were followed.

RESULTS

A total of 64 studies were included. The majority were published between 2019 and 2020, and focused on the prevalence of post-traumatic stress disorder (PTSD), depression, and anxiety, with a wide range of variations. Other outcomes were difficulties in the post-migration period and promotive factors for mental health, such as resilience, positive coping strategies, and psychosocial well-being.

CONCLUSIONS

High prevalence rates of mental disorders were observed, as well as risk factors for their occurrence. Studies showed a very high variability of prevalence rates and heterogeneity in methodologies. There is a need for research focusing on other determinants and specific necessities for mental health, especially in the post-resettlement period.

Predictors of psychological distress in Syrian refugees with posttraumatic stress in Germany

Syria has been the main country of citizenship of refugees in Germany since 2013. Syrians face numerous human rights violations in their country that can be accompanied by the experience of potentially traumatic events, loss and displacement. Along the migration process, refugees are exposed to various factors that can have an impact on mental health. The aim of this study is to investigate sociodemographic, war- and flight-related as well as post-migration factors as predictors of posttraumatic stress, depression, somatization and anxiety in Syrian refugees with posttraumatic stress symptoms based in Germany. Data were based on the baseline sample of the "Sanadak" randomized-controlled trial. A total of 133 adult Syrian refugees participated in the study. A questionnaire covered sociodemographic and flight-related questions as well as standardized instruments for symptoms of PTSD (PDS-5), depression (PHQ-9), somatization (PHQ-15), anxiety (GAD-7), generalized self-efficacy (GSE), religiousness (Z-Scale), social support (ESSI) and mental health stigma (SSMIS-SF). Linear regression models were executed to predict mental health outcomes. Sociodemographic predictors (i.e., female sex, higher education) and flight-related predicting factors (i.e., variability of traumatic events) have a negative impact on mental health in Syrian refugees with posttraumatic stress symptoms in Germany. Mental health stigma predicts worse mental health outcomes. Post-migration factors have a major impact on mental health, such as low income, lack of social support, low life satisfaction or a strongly felt connection to Syria. Somatization is an important manifestation of mental distress in Syrian refugees with posttraumatic stress symptoms. Our study showed a range of factors predicting the mental health of Syrian refugees with posttraumatic stress symptoms. Measures to foster mental health could be securing financial security, promoting gender equality and tailored psychosocial programs addressing mental health stigma, loss and social support networks.

[Occupational Participation of Syrian Refugees with Posttraumatic Stress in Germany]

OBJECTIVE

Description of employment situation and search for determinants of employment depending on symptom severity in refugees with posttraumatic stress.

METHODS

Standardized interviews with 133 Syrian refugees (18 to 65 years) living in Germany with posttraumatic stress symptoms and exploratory data analysis.

RESULTS

27.1 % of the participants were employed; including 13.9 % women and 86.1 % men (p = 0.001). Links between mental health and employment can be shown (posttraumatic stress p = 0.039, depressiveness p = 0.020, somatisation p = 0.026). With regard to social support and type of trauma, as well as residence status and duration of residence, there were no differences between refugees with and without employment.

CONCLUSION

The current analysis on the employment situation of a circumscribed group of Syrian refugees focuses on the importance of psychological symptom burden.

Health Care Services Utilization and Health-Related Quality of Life of Syrian Refugees with Post-Traumatic Stress Symptoms in Germany (the Sanadak Trial)

Refugees who have fled from the ongoing civil war in Syria that arrived in Germany often develop post-traumatic stress symptoms (PTSS). The aim of this study was to determine health care services utilization (HCSU), health care costs and health-related quality of life (HrQoL) of Syrian refugees with mild to moderate PTSS without current treatment in Germany. The study was based on the baseline sample of a randomized controlled trial of a self-help app for Syrian refugees with PTSS (n = 133). HCSU and HrQoL based on the EQ-5D-5L and its visual analogue scale (EQ-VAS) were assessed with standardized interviews. Annual health care costs were calculated using extrapolated four-month HCSU and standardized unit costs. Associations between health care costs, HrQoL and PTSS severity were examined using generalized linear models. Overall, 85.0% of the sample utilized health care services within four months. The mean total annual health care costs were EUR 1920 per person. PTSS severity was not associated with health care costs. The EQ-5D-5L index score and the EQ-VAS score was 0.82 and 73.6, respectively. For Syrian refugees with higher PTSS severity, the EQ-5D-5L index score was lower (−0.17; p < 0.001). The HCSU and the resulting health care costs of Syrian refugees with mild to moderate PTSS without current treatment are low and those with a higher PTSS severity had a lower HrQoL.

Exploring how Syrian women manage their health after migration to Germany: results of a qualitative study

BACKGROUND

In the recent years, the number of Syrians living in Germany increased drastically due to the massive displacement caused by the Syrian conflict. Syrian migrant women in Germany are challenged by both the migration process and the changing of social roles. Seeking out healthcare may be hampered by linguistic and cultural barriers, but the new context may offer opportunities for health and well-being (free access to health care, civil/human rights). Little is known about how Syrian women manage their health after their resettlement in Germany.

METHODS

In depth interviews in Arabic were conducted with 9 Syrian women who were recruited through purposive sampling (18-55 years, migrated in 2011-2017, different education levels), focusing on capabilities to control one's health and to navigate the German healthcare system, and social/environmental barriers and facilitators to effectively manage their health. Interview transcripts were analysed using qualitative content analysis.

RESULTS

The women reported their health to be impaired by post-migration stressors, such as perceived discrimination, loss of social status and worrying about the future. Many interviewees felt disempowered and incompetent to successfully and actively navigate the German healthcare system, lacking information and not understanding their rights and options under the health insurance plan. The language barrier added to feeling vulnerable. Many women experienced doctors declining to treat them for capacity reasons; when treated, they often did not feel taken seriously or were dissatisfied with the emotional/cultural aspects of care. If possible, Arabic doctors were sought out. Some women, however, described improved resources for health, and appreciated better women's rights as a source of power.

CONCLUSIONS

The lack of information about the structure and offers of the German healthcare system, language and culture specific barriers as well as socio-cultural challenges are undermining the ability of Syrian women to manage their health effectively after their resettlement in Germany. Providing tailored information on the German healthcare system, creating a health-literacy supportive environment, and improving cultural sensitivity in healthcare provision could help Syrian women better utilize medical care offered in Germany.

A Self-Help App for Syrian Refugees With Posttraumatic Stress (Sanadak): Randomized Controlled Trial

Background

Syrian refugees residing in Germany often develop posttraumatic stress as a result of the Syrian civil war, their escape, and postmigration stressors. At the same time, there is a lack of adequate treatment options. The smartphone-based app Sanadak was developed to provide cognitive behavioral therapy–based self-help in the Arabic language for Syrian refugees with posttraumatic stress.

Objective

The aim of this study was to evaluate the effectiveness and cost-effectiveness of the app.

Methods

In a randomized controlled trial, eligible individuals were randomly allocated to the intervention group (IG; app use) or control group (CG; psychoeducational reading material). Data were collected during structured face-to-face interviews at 3 assessments (preintervention/baseline, postintervention/after 4 weeks, follow-up/after 4 months). Using adjusted mixed-effects linear regression models, changes in posttraumatic stress and secondary outcomes were investigated as intention-to-treat (ITT) and per-protocol (PP) analysis. Cost-effectiveness was evaluated based on adjusted mean total costs, quality-adjusted life years (QALYs), and cost-effectiveness acceptability curves using the net benefit approach.

Results

Of 170 screened individuals (aged 18 to 65 years), 133 were eligible and randomized to the IG (n=65) and CG (n=68). Although there was a pre-post reduction in posttraumatic stress, ITT showed no significant differences between the IG and CG after 4 weeks (Posttraumatic Diagnostic Scale for DSM-5, Diff –0.90, 95% CI –0.24 to 0.47; P=.52) and after 4 months (Diff –0.39, 95% CI –3.24 to 2.46; P=.79). The same was true for PP. Regarding secondary outcomes, ITT indicated a treatment effect for self-stigma: after 4 weeks (Self-Stigma of Mental Illness Scale/SSMIS–stereotype agreement: d=0.86, 95% CI 0.46 to 1.25; stereotype application: d=0.60, 95% CI 0.22 to 0.99) and after 4 months (d=0.52, 95% CI 0.12 to 0.92; d=0.50, 95% CI 0.10 to 0.90), the IG showed significantly lower values in self-stigma than the CG. ITT showed no significant group differences in total costs and QALYs. The probability of cost-effectiveness was 81% for a willingness-to-pay of €0 per additional QALY but decreased with increasing willingness-to-pay.

Conclusions

Sanadak was not more effective in reducing mild to moderate posttraumatic stress in Syrian refugees than the control condition nor was it likely to be cost-effective. Therefore, Sanadak is not suitable as a standalone treatment. However, as the app usability was very good, no harms detected, and stigma significantly reduced, Sanadak has potential as a bridging aid within a stepped and collaborative care approach.

Trial Registration

German Clinical Trials Register DRKS00013782; https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00013782

International Registered Report Identifier (IRRID)

RR2-10.1186/s12888-019-2110-y