Enhancing educational and vocational recovery in adolescents and young adults with early psychosis through Supported Employment and Education (SEEearly): study protocol for a multicenter randomized controlled trial

BACKGROUND

Psychotic disorders often develop a chronic course with devastating consequences for individuals, families, and societies. Early intervention programs for people in the first 5 years after the initial psychotic episode (early psychosis) can significantly improve the outcome and are therefore strongly recommended in national and international guidelines. However, most early intervention programs still focus on improving symptoms and relapse prevention, rather than targeting educational and vocational recovery. The aim of the present study is to explore the effects of Supported Employment and Education (SEE) following the Individual Placement and Support (IPS) model in people with early psychosis.

METHODS

The SEEearly trial compares treatment as usual (TAU) plus SEE to TAU alone in outpatient psychiatric settings. The study is a six-site, two-arm, single-blinded, superiority randomized controlled trial (RCT). Participants are randomly assigned (1:1) to the intervention or control group. Aiming to recruit 184 participants, with an assumed drop-out rate of 22%, we will be able to detect a 24% difference in the main outcome of employment/education with 90% power. We make assessments at baseline and at 6- and 12-month follow-ups. Outcome data on employment/education, medication, and current psychiatric treatment is obtained monthly through phone based short assessments. The primary outcome is steady participation for at least 50% of the 12-month follow-up in competitive employment and/or mainstream education. Secondary employment outcomes capture length of employment/education, time to first employment/education, monthly wages/educational attainment, and social return on investment (SROI). Secondary non-employment outcomes include subjective quality of life, psychopathology, substance use, relapse, hospitalization, and functional impairment. To be eligible, participants must be between 16 and 35 years, fulfill diagnostic criteria for early psychosis, and be interested in competitive employment and/or mainstream education.

DISCUSSION

In SEEearly, we hypothesize that participants with psychosis, who receive TAU plus SEE, present with better primary and secondary outcomes than participants, who receive TAU alone. Positive results of this study will justify SEE as an evidence-based strategy for clinical routine treatment in people with early psychosis.

TRIAL REGISTRATION

SEEearly was registered nationally and internationally in the German Clinical Trials Register (DRKS; identifier: DRKS00029660) on October 14, 2022.

Psychiatric presentations and admissions during the first wave of Covid-19 compared to 2019 in a psychiatric emergency department in Berlin, Germany: a retrospective chart review

BACKGROUND

Most studies agree that the Covid-19 pandemic and the subsequent lockdown had a negative impact on mental health. On the other hand, international studies have shown that psychiatric emergency departments (pED) experienced a decrease in presentations and admissions.

METHODS

Retrospective chart review of all pED presentations and admissions during the first wave of Covid-19 pandemic in Germany (Covid-19 period: 3/2/20 to 05/24/20) in a psychiatric hospital in Berlin compared to 1 year earlier (pre-Covid-19 period). Descriptive statistics and logistic regression were performed.

RESULTS

We observed no statistical significant changes in overall pED presentations and overall hospital admissions during the Covid-19 period compared to the pre-Covid-19 period (813 vs. 894, - 9.1%, p = 0.064 and (363 vs. 437, - 16.9%, p = 0.080 respectively). In the subgroup analysis, less patients with depressive disorders (p = 0.035) and with personality disorders (p = 0.002) presented to the pED, a larger number of presentations with schizophrenia was observed (p = 0.020). In the Covid-19 period, less patients with substance use disorder and paranoid schizophrenia were admitted to the hospital via the pED than in the pre-Covid-19 period (p = 0.035 and p = 0.006, respectively). Bed capacity was reduced in the Covid-19 period by - 32.8% (p <  0.001). Presentations in police custody were 13.7% (p = 0.029) higher during the Covid-19 compared to pre-Covid-19 period, with higher rates in female presentations (p = 0.008) and suicide attempts (p = 0.012) and less hospital admissions (p = 0.048). Logistic regression analyses revealed that positive predictors for pED presentation during Covid-19 period were police custody (p <  0.001), being redirected from another hospital (p <  0.001), suicide attempt (p = 0.038), suicidal thoughts (p = 0.004), presentation with paranoid schizophrenia (p = 0.001) and bipolar and manic disorders (p = 0.004), negative predictors were hospital admission (p <  0.001), depressive disorders (p = 0.021) and personality disorders (p <  0.001).

CONCLUSIONS

A larger number of presentations in police custody during the Covid-19 period may represent untreated medical needs. This was seen predominantly in female patients, suggesting this subgroup might have suffered particularly under lockdown measures. Patients with paranoid schizophrenia were the only subgroup, which increased in absolute numbers, also suggesting a particular lockdown effect. Reduced bed capacity due to infection curbing measures is suggestive to have played an important role in augmenting the threshold for hospital admissions.

[The application of virtual reality in the treatment of mental disorders]

BACKGROUND

Virtual reality (VR) enables immersion in an interactive digital world with realistic experiences, that can be applied for controlled and personalized interventions. This review summarizes the current research on VR in the treatment of mental disorders.

METHODS

Selective literature search in PubMed and Google Scholar.

RESULTS

An increasing number of publications report the therapeutic application of VR for the treatment of mental disorders. Most VR applications are based on established therapy approaches, such as exposure therapy. According to meta-analytic data, virtual exposure therapy (VRET) for specific phobia and agoraphobia with panic disorder is as effective as traditional in vivo exposure therapy. VRET for the treatment of social phobia is significantly more effective than waitlist and placebo control groups with, however, currently inconsistent metanalytic results when compared to in vivo exposure therapy. VRET for the treatment of posttraumatic stress disorder (PTSD) is similar in effectiveness compared to active psychotherapy. For psychosis, positive results have been reported for the VR-based treatment of auditory verbal hallucinations. For patients with a substance use disorder, VR can induce craving, with still unverified diagnostic and therapeutic relevance.

CONCLUSIONS

VRET can broaden the psychotherapy options for anxiety disorders. Encouraging results of VR-based treatments for psychosis and PTSD indicate the need for further research concerning its effectiveness and safety. In the field of substance use disorders, evaluation of clinical-orientated VR applications is needed.

Multiple Discrimination and Its Consequences for the Mental Health of Ethnic Minorities

Discrimination is a violation of human rights. The Universal Declaration of Human Rights proclaims in Art. 1 the equality of all human beings without distinction as to race, colour, sex, sexual orientation, religion, age or health. International law assigns three main characteristics to discrimination: disadvantageous treatment, based on unlawful grounds, and lack of reasonable and objective justification. Thus, it must be based on an unlawful characteristic: Ethnicity, religion, national or social origin, language, physical appearance, descent, gender, sexual orientation, age or disability. A growing body of literature has recognized health disparities and has investigated the relationship between discrimination and poor health outcomes. Ethnic minority groups across the world face social and psychological challenges linked to their minority status, often involving discrimination. Furthermore, cumulative exposure to racial discrimination has incremental negative long-term effects on the mental health of ethnic minority people.Studies that examine exposure to discrimination only at one point in time may underestimate the contribution of racism to poor health. Lower patient-centered care was associated with higher perceptions of discrimination, despite experiences of continuous discrimination or discrimination experienced as different types. Further, dissatisfaction with care was associated with discrimination, particularly when experienced in various forms. These findings reinforce a need for patient-provider communication that is inclusive and eliminates perceptions of discrimination and bias, increases patient-centeredness, and improves overall clinical care. Additionally, these results stress the need for more research investigating the relationship between discrimination and outcomes in patients, as perceived discrimination manifests as a significant barrier to effective disease management.

Disclosure

No significant relationships.

Transcultural Aspect of Mental Health Care

Culture is not simply the aggregate of individual traits but a more or less coherent system of shared meanings, institutions and practices (i.e. beliefs, attitudes and values). It is a repository of meaningful symbols that structure experience both implicitly and through explicit models. Culture shapes how and what psychiatric symptoms are expressed, influences the meanings that are given to symptoms and impacts the interaction between the patient and the health care system. Explanatory models are the ways in which individuals in different cultures see the core reasons of their suffering. The DSM-5 cultural formulation interview is developed to be used as clinical instrument and valuable tool. It is evident that phenomena such as the increasing migratory flows and the globalisation of prevailing social criteria referred to the economy, trade, religion and the perception and the attribution of the causes of disease have determined a shift in the world cultural balance that have direct repercussions on World Mental Health. More specifically, it needs to be seen how the transcultural differences in the personality configurations and psychological operations can be correlated with the cross-cultural differences in psychopathology to arrive at an understanding of these. Furthermore, understanding the central role of culture of mental health and illness must, therefore, be central to any vision of the future of psychiatry. In this presentation transcultural aspects of mental health care in psychiatry will be highlighted and discussed.

The Impact of Violence and Abuse on Mental Health of Women – Current Data

Violence against women is widely recognised as a violation of human rights and a public health problem. The most common forms of violence against women are domestic abuse and sexual violence, and victimisation is associated with an increased risk of mental disorders. It is reported that a three times increase in the likelihood of depressive disorders, a four times increase in the likelihood of anxiety disorders, and a seven times increase in the likelihood of post-traumatic disorder (PTSD) for women who have experienced domestic violence and abuse. Significant associations between intimate partner violence and symptoms of psychosis, substance misuse, and eating disorders have also been reported. Furthermore, systematic reviews of predominantly cross-sectional studies report consistent relationships between being a victim of domestic violence and abuse and having mental disorders across the diagnostic spectrum for men and women, but since women are more likely to be victims, the population attributable fractions are higher for women. In this presentation, the focus will also be on clinical guidance on the role of mental health professionals in identifying violence against women and responding appropriately, poor identification persists and can lead to non-engagement with services and poor response to treatment. After a literature review, we will present and discuss current data from parental consultation and a survey on violence during the Covid-19 pandemic in Berlin.

Involuntary Admissions and Patient Autonomy - How do they Fit Together

The United Nations Convention on the Rights of Persons with Disabilities Article 12 General Commentary, explicitly states that persons with mental illnesses must always have full exercise of their legal rights in all their aspects. Assistants or support persons must not substitute or have undue influence on the decisions of persons with disabilities, including the expression of their consent. Rationales behind the concept include increased patient autonomy, promotion of coping skills, early help-seeking, avoidance of power struggles, establishment of an asylum function, reduced time spent in inpatient care and prevention of coercive measures. Quantitative data points toward a dramatic reduction of total time spent in inpatient care and of involuntary admissions in patients with previously high inpatient care consumption, whereas qualitative data indicates that the concept increases patient autonomy, responsibility and confidence in daily life. Patient-controlled admission is a promising novel approach to inpatient care in psychiatry. However, available studies are small and quality of evidence is generally low. In this talk an overview of literature review on involuntary admissions and patient autonomy as well as ethical aspects will be given and discussed.

Racism and mental health and the role of mental health professionals

The concept of "race" and consequently of racism is not a recent phenomenon, although it had profound effects on the lives of populations over the last several hundred years. Using slaves and indentured labor from racial groups designated to be "the others," who was seen as inferior and thus did not deserve privileges, and who were often deprived of the right to life and basic needs as well as freedoms. Thus, creation of "the other" on the basis of physical characteristics and dehumanizing them became more prominent. Racism is significantly related to poor health, including mental health. The impact of racism in psychiatric research and clinical practice is not sufficiently investigated. Findings clearly show that the concept of "race" is genetically incorrect. Therefore, the implicit racism that underlies many established "scientific" paradigms need be changed. Furthermore, to overcome the internalized, interpersonal, and institutional racism, the impact of racism on health and on mental health must be an integral part of educational curricula, from undergraduate levels through continuing professional development, clinical work, and research. In awareness of the consequences of racism at all levels (micro, meso, and macro), recommendations for clinicians, policymakers, and researchers are worked out.

Depression in middle-aged and older first generation migrants in Europe: Results from the Survey of Health, Ageing and Retirement in Europe (SHARE)

Objective

To determine the prevalence of depression in migrants aged 50 years or older in comparison to residents without a history of migration in 11 European countries.

Methods and subjects

The Survey of Health, Ageing and Retirement in Europe (SHARE), a cross-national, multidisciplinary, household-based panel survey using nationally representative probability samples (n = 28,517) of 11 European countries of the non-institutionalized population aged 50 years and older. Depression was measured using the EURO-D scale, and odds ratios (OR) were estimated for migration status. Effects of sociodemographic variables, somatic comorbidities, functional impairment, cognitive function, geographic region, and time lived in current country of residence were assessed in multivariate logistic regression analysis.

Results

Adjusting for confounds, the OR for depression in migrants was 1.42 (95% CI, 1.28–1.59). The influence of migration status on the prevalence of depression was significantly greater in Northern (OR, 1.85; 95% CI, 1.39–2.46) and Western Europe (OR, 1.38; 95% CI, 1.22–1.57), compared to Southern Europe (OR, 1.16; 95% CI, 0.79–1.70) (p < 0.05 for the interaction).

Conclusion

We found a higher prevalence of depression in first-generation migrants aged 50 years or older, together with relevant geographical variation. This difference was not due to other known predictors of depression in older age.

Explanatory models of addictive behaviour among native German, Russian-German, and Turkish youth

In Germany, the public system of addiction treatment is used less by migrants with addictive disorders than by their non-migrant counterparts. To date, the literature has focused primarily on language, sociocultural factors, and residence status when discussing access barriers to this part of the health care system. However, little attention has been paid to cultural differences in explanatory models of addictive behaviour. This is surprising when we consider the important role played by popular knowledge in a population's perceptions of and responses to illnesses, including their causes, symptoms, and treatment.

In the present study, we examined explanatory models of addictive behaviour and of mental disorders in 124 native German und Russian-German youth and compared these models to those observed in an earlier study of 144 German and Turkish youth. We employed the free listing technique German and to compile the terms that participating subjects used to describe addictive behaviour. Subsequently, we examined how a subset of our study population assigned these terms to the respective disorders by means of the pile sort method.

Although the explanatory models used by the German and Russian-German youth in our study were surprisingly similar, those employed by Turkish youth did not make any fundamental distinction between illegal and legal drugs (e.g. alcohol and nicotine). German and Russian-German youth regarded eating disorders as “embarrassing” or “disgraceful”, but Turkish youth did not. Unlike our German and Russian-German subjects, the Turkish youth did not classify eating disorders as being addictive in nature. Moreover, medical concepts crucial to a proper understanding of dependence disorders (e.g. the term “physical dependence”) were characterised by almost half of our Turkish subjects as useless in describing addictions.

These findings show that it is impossible to translate medical or everyday concepts of disease and treatment properly into a different language without considering the connotations and implications of each term as it relates to the respective culture. Terms that are central to Western medical models of disease may otherwise be misunderstood, misinterpreted, or simply rejected.

Mental health care in Berlin

Aim

To provide information on the mental health care system in Berlin, Germany.

Method

Using available data we report on the spectrum of mental health care services provided in Berlin, the number of professionalsworking in these sectors, funding arrangements, pathways into care, and user/carer involvement.

Results

The health care system in Berlin consists of a network of inpatient, outpatient, ancillary, and rehabilitative facilities, all of which are meant to work in a synergistic fashion. However, although the individual treatment options are generally well-planned, there is still a lack of co-ordination between them. Currently, the entire network is threatened by cuts in state funding for ancillary and rehabilitative services, by further reductions in the number of hospital beds, and by insurance company cuts in prescription drug budgets, such as those used for atypical antipsychotics in outpatient care.

Discussion

Despite many similarities with the situation in other European capitals, the system of mental health care in Berlin suffersfrom a variety of problems related to co-ordination and costs that are unique to the German capital.

Study on Female Refugees – A Representative Research Study on Refugee Women in Germany

Introduction

Germany is one of the European countries that receive the highest number of refugees for the last years, with around 468 thousand asylum seekers in the first half of 2016. However, the increase in the speed of short-term procedures regarding refugees may at the same time overlook the risks regarding specific populations. Moreover, women and children constitute the most vulnerable groups during war and conflicts and the worst effects, in terms of physical, mental and social consequences, develop on these groups.

Objectives

To understand deeply the psychosocial situation of female refugees that have arrived in Federal German Republic, to assess their challenges and resources before, during and after the displacement and to propose recommendations for policy changes.

Methods

The study consists of two modules, taking place in five states in Federal German Republic, including Berlin, Mecklenburg-Vorpommern, Bayern, Hessen und Mainz. In the first step, a representative stratified sample of female refugees from Syria, Iraq, Iran, Afghanistan, Somali and Eritrea are recruited. The quantitative study instrument include a socio-demographic question form and HSCL-Hopkins checklist, Harvard Trauma questionnaire, Beck depressions inventory, EUROHIS–QOL and SCL-14. In the second step, a qualitative in-depth analysis of focus group meetings is conducted.

Results and conclusions

There is an urgent need to take action for the mental health problems of refugees. This study constitutes one of the most extensive researches, especially on a subpopulation of refugees that requires specific attention. Challenges faced throughout the protocol and detailed results will be shared as presentation.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Participatory research for developing health promotion campaigns for migrants and host community in Berlin, Germany

Background

During the current refugee crisis, hundreds of refugees left their homes and fled to Europe. The country that received the highest rates of refugees was Germany, which above all presented a challenge to the healthcare system. This study aimed to inform the development of a pilot intervention to improve migrants healthcare access in Berlin, Germany.

Methods

A Metaplan© qualitative technique was applied to ensure the community participation, with three sessions with refugee and asylum seeking women and youth in Arabic, Somali and German languages, and one with professionals. With each group, participants identified issues in migrants’ healthcare, then suggested solutions to address these issues and prioritized these solutions.

Results

The migrants (n = 30) were mainly from Syria (n = 4), Somalia (n = 14) and other African countries, mainly females (17-53 yrs) and youth (16-18yrs). The professionals’ group (n = 13) included an interdisciplinary team of a psychiatric day clinic. All groups prioritized language barriers as a crucial problem and suggested to work with interpreters to facilitate the communication. Professionals are additionally confronted with cultural differences in the treatment of refugees. Somali women prioritized raising the awareness about Female Genital Mutilation in the healthcare system and also in their community. Other suggestions included supervisors for unaccompanied minors, multilingual forms, increased intercultural competence of health care providers and reducing waiting time for an appointment.

Conclusions

Future interventions should focus on intercultural competences for professionals and health-promoting information in the specific sociocultural context of migrant communities. This would include the dissemination of multi-lingual doctors’ brochures, interactive training for health care providers as well as informational workshops for migrants to increase their health literacy and promote health-enhancing behaviors.

[Depressive and somatoform disorders in persons with a Turkish migration background in Germany]

BACKGROUND

Migration is a risk factor for the onset of mental disorders. Epidemiologic studies indicate that there is an increased prevalence of depressive and somatoform disorders in individuals with a Turkish migration background in Germany.

OBJECTIVES

The aim of this review article is to determine the impact of sociocultural factors on depressive and somatoform disorders in individuals with a Turkish migration background in Germany.

MATERIALS AND METHODS

The systematic review is based on 23 studies identified in PubMed and PsycINFO.

RESULTS

Acculturation, perceived discrimination and the socioeconomic status affect the severity of mental disorders, and impair the access to the health care system as well as to psychotherapy. Women with a Turkish migration background represent a particularly vulnerable group in this context.

CONCLUSION

Multiple factors influence the increased prevalence of depressive and somatoform disorders in individuals with a Turkish migration background in Germany. Most of the identified studies suffer from significant methodological restrictions and as such do not allow generalization to the whole population of individuals with a Turkish migration background in Germany. There is a lack of national surveys and a need for longitudinal studies in representative population samples.

[Suicidal tendencies in adolescence : Dysfunctional familiar communication as risk factor]

BACKGROUND

Suicide is one of the four most common causes of death in adolescence worldwide. Although it is well known that suicidal people often have insufficient communication strategies, the importance of family communication for adolescent suicidality has not yet been sufficiently explored.

OBJECTIVE

The aim of this study was to provide a systematic review of family communication as a risk factor for adolescent suicidal tendencies and to develop treatment recommendations.

METHODS

In this study a systematic literature search was conducted in PubMed, Embase, CENTRAL and PsychINFO. The methodological quality of the studies was evaluated and a summary prepared.

RESULT

A total of 195 studies were extracted and screened for their suitability. Of these studies, 7 which examined a total of 13,107 adolescents aged 11-22 years were included in this review and critically evaluated. Of the studies evaluated six found a correlative relationship between dysfunctional parent-child communication and adolescent suicidality. Communication with the mother appears to be more essential.

CONCLUSION

The results of this literature search indicate that functional communication with parents seems to be protective for suicidal adolescents. From this, recommendations can be derived for preventive measures in families with adolescents who are otherwise at increased risk of suicide. Longitudinal study designs are needed to conclusively answer the research question.

Providing Care for Migrants and Refugees

With growing globalisation and an increasing number of people on the move across boundaries, it has become vital that service providers, policy makers and mental health professionals are aware of the different needs of the patients they are responsible. One of the most fundamental barriers for migrants, refugees and asylum seekers in accessing health services are inadequate legal entitlement and, mechanisms for ensuring that they are well known and respected in practice. Access to the healthcare system is impeded by language and cultural communication problems. Qualified language and cultural mediators are not widely available, and moreover, are not regularly asked to attend. This can lead to misunderstandings, misdiagnosis and incorrect treatment, with serious consequences for the afflicted. The language barrier represents one of the main barriers to access to the healthcare system for people who do not speak the local language; indeed, language is the main working tool of psychiatry and psychotherapy, without which successful communication is impossible. Additionally, the lack of health literacy among the staff of institutions, which provide care for refugees and asylum seekers means that there is a lack of knowledge about the main symptoms of common mental health problems among these groups. The healthcare services, which are currently available, are not well prepared for these increasing specific groups. In dealing with ethnic minorities, including asylum seekers and refugees, mental healthcare professionals need to be culturally competent.

In this talk, main models for providing mental health care for migrants and refugees will be presented and discussed.

Disclosure of interest

The author has not supplied his declaration of competing interest.

Ethics in Transcultural Psychiatry

Global migration and the increasing number of minority groups, including immigrants, asylum seekers, refugees and ethnic minorities, mean that increasingly, psychiatrists and patients may come from different cultural backgrounds. Therefore, cultural differences between patients and clinicians have become a matter of growing importance to mental health care as western societies have become increasingly diverse. This talk will attempt to illustrate how attention to these cultural differences enriches the discussion of ethics in mental health care. This talk will also attempt to underline that cultural competence is able to enhance the ethical treatment of mental health of patients from different cultural backgrounds. Consequently, to be culturally competent, a clinician must be sensitive, knowledgeable, and empathetic about cultural differences. Therefore, cultural competence is a concrete, practical expression of bioethics ideals. According to Hoop et al. in 2008, it is a practical, concrete demonstration of the ethical principles of respect for persons, beneficence (doing good), nonmaleficence (not doing harm), and justice (treating people fairly), the cornerstones of ethical codes for the health professions.

In this talk the complex relationship between culture, values, and ethics in mental health care will be analyzed and discussed.

Disclosure of interest

The author declares that he has no competing interest.

[Obsessive-Compulsive Symptoms in a Sample of Patients with Chronic Schizophrenia Under Clozapine Treatment]

Background: There is a high prevalence of obsessive-compulsive symptoms (OCS) in patients with schizophrenia. Antipsychotic treatment, especially duration and type of substance, is suspected to increase or even cause OCS. Methods: We examined in a naturalistic cross-sectional study the severity of OCS (Obsessive-Compulsive Inventory - Revised) and the incidence of obsessive-compulsive disorder (OCD) according to ICD-10 criteria in 70 patients with schizophrenia. 26 patients were treated with clozapine and 44 patients were treated with another second-generation antipsychotic (SGA). After group matching, the two groups did not differ significantly in age, gender, duration of illness, treatment duration with the current antipsychotic substance and chlorpromazine-equivalent dosage. Results: Patients treated with Clozapine showed a significantly higher rate of OCD (χ² = 7.304, p = 0.007) and a significantly higher severity of OCS (t = 2.216, p = 0.037) compared to patients treated with another SGA. For the whole sample, duration of treatment with the current antipsychotic medication correlated significantly (p = 0.033, r = 0.323) with the severity of OCS, controlled for duration of illness. However, there was no significant correlation between severity of OCS and duration of illness, controlled for duration of treatment with the current antipsychotic substance. Discussion: Our data suggest an interrelation between the development of OCS or OCD and antipsychotic treatment, especially clozapine. Thereby, duration of treatment is correlated with the severity of OCS, irrespective of the duration of illness.

EPA Guidance Mental Health Care of Migrants

Migration is an increasingly commonplace phenomenon for a number of reasons. People migrate from rural to urban areas or across borders for reasons including economic, educational or political. There is increasing recent research evidence from many countries in Europe that indicates that migrants are more prone to certain psychiatric disorders. Because of their experiences of migration and settling down in the new countries, they may also have special needs such as lack of linguistic abilities which must be taken into account using a number of strategies at individual, local and national policy levels. In this guidance document, we briefly present the evidence and propose that specific measures must be taken to improve and manage psychiatric disorders experienced by migrants and their descendants. This improvement requires involvement at the highest level in governments. This is a guidance document and not a systematic review.

Social characteristics of psychological distress in disadvantaged areas of Berlin

PURPOSE

Living in disadvantaged urban areas is associated with poor mental health. The purpose of this study was to assess which social characteristics were associated with psychological distress within a disadvantaged, multi-ethnic neighbourhood of Berlin.

METHODS

The study was conducted in an area of Berlin with the highest rates of unemployment and highest density of migrants. A total of 143 participants aged 18-57 years were included from a random sample. The social characteristics educational level, employment status, marital status, living alone, per-capita income and background of migration were collected. Psychological distress was assessed using the General Health Questionnaire GHQ-28; scores ≥ 5 indicated psychological distress corresponding to psychiatric caseness.

RESULTS

Psychological distress was found in 40.6% (n = 58) of the sample. Psychological distress was associated with younger age (OR = 0.95, 95% CI = 0.92-0.98, p = .004), female gender (OR = 3.51, 95% CI = 1.55-7.92, p = .003) and living alone (OR = 3.88, 95% CI = 1.58-9.52, p = .003), but not with background of migration, low educational level or with unemployment.

CONCLUSIONS

Young age and female gender may predispose for psychological distress in disadvantaged areas. Living alone could be a social indicator of poor mental health within disadvantaged urban areas. The directionality of the association is unclear.

BACKGROUND

of migration, low income and educational level do not seem to be associated with poor mental health within those areas.

[Suicide Rates and Suicide Prevention in Women of Turkish Origin in Berlin]

Suicidality in female Turkish immigrants is higher as compared to that of native-born women of the same age. The analysis of the national mortality registry in Germany reported a 2-fold suicide risk in the target group compared to German women of the same age. A population-based multi-modal intervention project was conducted. Suicidal crisis were analysed in focus groups and guided the development of the intervention module. The intervention consisted of a public awareness campaign, a telephone hotline, and the training of key persons. All parts of the intervention were subsequently evaluated. Suicide attempts of the target group that were presented at all emergency units in Berlin were registered. In a population-based interview survey the aim was to elicit central sociodemographic and psychosocial variables that may influence distress and help-seeking behaviour in women of Turkish origin.

Socio-economic status and emotional distress of female Turkish immigrants and native German women living in Berlin

BACKGROUND

Many immigrants face more economic strains and hardship than non-immigrants. Income inequality and an increasing social gap between immigrants and non-immigrants in Europe warrant further studies on the impact of socioeconomic factors on health in immigrant groups. The purpose of this study was to examine the association of socioeconomic status (SES) and emotional distress in women of Turkish descent and in women of German descent.

METHODS AND SUBJECTS

A total of 405 women of German or Turkish descent residing in Berlin were interviewed. Emotional distress was assessed by the General Health Questionnaire-28 (GHQ-28), and SES was examined by level of education, employment status, and income. The associations of emotional distress and SES were estimated in multivariate linear regression analyses.

RESULTS

Unemployment was associated with increased levels of emotional distress in all women, with the highest level of distress in the group of unemployed Turkish women. The overall SES level was related to a greater level of emotional distress in Turkish women, but not in German women (-3.2, 95%CI -5.9 - -.5; p=.020 vs. -.8, 95%CI -2.7 - 1.2; p=.431). Further stratified analyses by relationship status revealed that the association of SES and emotional distress only remained significant among single women.

CONCLUSION

The impact of socioeconomic hardship appears to be complicated by social roles and expectations related to these. Further in-depth study of the complex nature of the interaction of social roles and socioeconomic position in female Turkish immigrants in Germany is needed to better understand differing risk patterns for emotional distress.

The influence of stigma on depression, overall psychological distress, and somatization among female Turkish migrants

BACKGROUND

Even though some studies suggest that in Mediterranean and non-western cultures more somatic and less psychological symptoms are reported, this so-called 'somatization' hypothesis has been challenged. Reviews show that somatic symptoms are a core component of depressive episodes regardless of cultural background. The expression of symptoms might be related to the psychosocial, social and cultural context surrounding the patient rather than 'ethnicity' or related constructs. Also, stigma associated with mental disorders can affect patients'symptom presentation.

METHODS

The interrelationships of perceived stigmatization (Explanatory Model Interview Catalogue - Stigma Scale), depression (Beck Depression Index II), overall psychological distress (Symptom Checklist-90-R), and somatic symptoms (The screening for SOMATOFORM SYMPTOMS II) was assessed in a sample of female patients with Turkish descent with a diagnosis of depression (N=63).

RESULTS

Depression, overall psychological distress, and somatic symptoms were positively and significantly related. Stigma was positively related to depression and overall psychological distress. There was no significant relationship between stigma and somatic symptoms, neither among the severely depressed group (N=39), nor among the less depressed group (N=24).

CONCLUSION

The positive relationships between stigma, depression, and overall psychological distress indicate that patients who are more depressed and who have higher levels of overall psychological distress experience their condition as more stigmatizing. Since somatic symptoms and stigma were not related (neither positively, nor negatively), it appears that depressive symptoms and other symptoms of psychological distress affect concerns about stigmatizing attitudes in a way that somatic symptoms do not. This result challenges common assumption of the 'somatization'hypothesis, i.e. that depression is 'somatized'because of concern about stigmatizing attitudes.

Mental health of Turkish women in Germany: resilience and risk factors

BACKGROUND

The purpose of the present study was to examine the protective and risk factors of mental distress among Turkish women living in Germany.

METHOD

105 Turkish immigrant women living in Berlin were investigated with measures of extraversion/neuroticism (NEO-FFI), general self-efficacy (GSE), social support (BSSS), social strain (F-SOZU) and mental distress (GHQ-28). Interrelations between psychosocial variables were assessed using simple Pearson correlations.

RESULTS

In all subjects, social strain (Pearson's r=.26(**), p=.008) and neuroticism (r=.34(**), p<.001) were positively associated with mental distress. In contrast, perceived self-efficacy (r=-.38(**), p<.001) and extraversion (r=-.36(**), p<.001) were negatively associated with mental distress.

CONCLUSION

Protective factors such as extraversion and self-efficacy seem to have a buffering effect on the process of migration. However, in addition to neuroticism, social strain seems to be positively associated with mental distress.

DTNBP1 (dysbindin) gene variants: in vivo evidence for effects on hippocampal glutamate status

INTRODUCTION

In linkage and association studies the DTNBP1 gene has been identified as a major susceptibility gene for schizophrenia. Reduced expression of DTNBP1 was found in the hippocampus and prefrontal cortex in post mortem brains of schizophrenic patients. In vitro and animal models provide evidence that the DTNBP1 gene product dysbindin modulates the activity of the neurotransmitter glutamate in hippocampal neurons and is crucial for cell functioning and synaptogenesis. This study is the first to investigate the effects of genetic variants of DTNBP1 on the status of the glutamate system as well as neuronal integrity (N-acetylaspartate, NAA) in the hippocampus and a cortical region, the anterior cingulate cortex (ACC), in humans.

METHODS

In 79 healthy subjects, the association of single nucleotide polymorphisms (SNPs) rs760665 and rs909706 with absolute concentrations of glutamate and NAA in the left hippocampus and the ACC were investigated, using proton magnetic resonance spectroscopy (MRS) at 3 Tesla and a well established quantification procedure.

RESULTS

Hippocampal glutamate concentration was significantly affected by genotype of rs760665 (F=4.406, df=2,p=0.016) and rs909706 (F=3.171,df=2,p=0.048). For the concentration of NAA, a weak association with rs760665 was observed in the contrast analysis. None of the metabolites measured in the ACC showed a significant connection with either genotype.

CONCLUSION

The results support a role of DTNBP1 gene variants in the glutamate neurotransmission system in the human brain at least in the hippocampus. This is compatible to growing evidence of a crucial role of glutamate in the pathobiology of schizophrenia. In addition, the weak association between DTNBP1 genotype and NAA is in line with a regulatory influence of dysbindin on synaptogenesis and neuronal survival.

[New procedures for recognition and differentiation of depression in immigrants. Case report of a patient with Turkish immigrant background]

Depression is a cross-cultural disorder, which displays cultural differences in symptom presentation and prevalence. The guidelines for the assessment of cultural influencing factors for the medical history and therapy and the consideration of stressors associated with the immigration process can help to better understand the socio-cultural background of patients with an immigration background and facilitate the differential diagnosis. Using these strategies, psychiatry and psychotherapy are better prepared to deal with this large heterogeneous population given the fact that one fifth of Germany's population has an immigration background. The transcultural aspects of depression are illustrated with a case report.

[Patients of immigrant origin in inpatient psychiatric facilities. Differences between first and second generation: nationwide questionnaire of the Psychiatry and Migration Working Group of the German Federal Conference of Psychiatric Hospital Directors]

In a representative nationwide survey, the Psychiatry and Migration Working Group of the German Federal Conference of Psychiatric Hospital Directors examined the use of inpatient psychiatric and psychotherapeutic services in Germany by patients of immigrant origin. Questionnaires were sent to a total of 350 general hospital psychiatric clinics throughout Germany and 131 responded by the specified deadline (19 July 2006). In our study, persons of immigrant origin comprised 17% of patients in the responding facilities, which confirmed the results of the pilot study in 2004 of 17.4%. This indicates that the percentage of inpatient psychiatric services used by patients of immigrant origin is almost proportionate to these patients' percentage of the general population (18.6%, Microcensus 2005). In this main study patients of immigrant origin were significantly more likely to receive an ICD-10 F2 diagnosis, and it was precisely patients with this diagnosis who were observed to experience difficulties in communication with caregivers. With reference to the F2 diagnoses there were no noticeable differences between first generation of inpatients with migration history and second generation of inpatients with migration history. There were however more first generation of inpatients with migration history diagnosed with affective disorders whereas more second generation of inpatients with migration history were diagnosed with personality and behavioural disorders. Such differences were not found in the group of patients without immigrant origin. Whilst first generation of inpatients with migration history demonstrated higher educational levels, second generation of inpatients with migration history showed fewer linguistic difficulties.

Cross-Cultural Challenges in the Diagnosis of Depression

For a long time it was assumed that depressive disorders were a classic western problem specific to industrial states. However, the World Bank discovered in a study as early as 1993 that depression in Third World countries was already fifth on the list of illnesses which comprise the largest contribution to the Global Burden of Disease. Affective and behavioural disorders as well as somatic complaints represent the three central categories of symptoms in depression. In western cultures an affective disorder is seen as the main characteristic of a depression, whereas in other cultures different symptoms can be in the foreground. The increase in supraregional communication and cooperation as well as the worldwide increase in immigrant populations demand that cultural aspects are considered in the diagnosis and treatment of depression. Physicians need to consider the cultural background of their patients in order to achieve an optimal therapy. If the sociocultural aspects, which cannot always be fully appreciated, of a culturally sensitive diagnosis are not taken into consideration, this can lead to an artificial prevalence of the disorder by making false diagnoses. In order to minimize these mistakes, the guideline for judging cultural influencing factors should be used to complete the diagnosis.

Not only the development of culturally adequate therapy concepts and institutions, but also the expansion of knowledge about the psychopathology and epidemiolgy of psychic disorders, e. g. of depression in immigrant groups and the examination of their use of treatment facilities, are the goals of cross-cultural psychiatry and psychotherapy.

Mental health, health care utilisation of migrants in Europe

BACKGROUND

Migration during the 1990s has been high and has been characterised by new migrations. Migration has been a key force in the demographic changes of the European population. Due to the different condition of migration in Europe, variables related to mental health of migrants are: motivation for migration, living conditions in the home and in the host country.

AIMS

To give an overview on (i) prevalence of mental disorders; suicide; alcohol and drug abuse; (ii) access to mental health and psychosocial care facilities of migrants in the European region, and (iii) utilisation of health and psychosocial institution of these migrants.

METHODS

Non-system review of the literature concerning mental health disorders of migrants and their access to and their consumption of health care and psychosocial services in Europe.

RESULTS

It is impossible to consider "migrants" as a homogeneous group concerning the risk for mental illness. The literature showed (i) mental health differs between migrant groups, (ii) access to psychosocial care facilities is influenced by the legal frame of the host country; (iii) mental health and consumption of care facilities is shaped by migrants used patterns of help-seeking and by the legal frame of the host country.

CONCLUSION

Data on migrant's mental health is scarce. Longitudinal studies are needed to describe mental health adjusting for life conditions in Europe to identify those factors which imply an increased risk of psychiatric disorders and influence help seeking for psychosocial care. In many European countries migrants fall outside the existing health and social services, particularly asylum seekers and undocumented immigrants.