Occurrence and predictors of lifetime suicidality and suicidal ideation in autistic adults

LAY ABSTRACT

Over the past few years, more and more research is showing that many autistic people are at an increased risk for suicide. In this study, we asked participants from the Netherlands Autism Register, which is longitudinal register including individuals with autism, about their possible experiences with thoughts and feelings about suicide. Specifically, we looked at whether these thoughts and feelings in their lifetime and in the past month were related to various factors (such as their age, gender, and having psychiatric disorder diagnoses). We found that 80% of the participants had experienced thoughts about or even attempted to take their own life at least once throughout their lifetime. Furthermore, in a subgroup of participants, we found that the presence of a psychiatric disorder diagnosis, feelings of loneliness, and a higher number of autistic traits were associated with experiencing suicidal thoughts and feelings in their lifetime. For those who experienced these suicidal thoughts in the past month, we found that having (multiple) psychiatric disorder diagnoses and a higher number of autistic traits were related to more severe and frequent thoughts about suicide in the past month. Our findings show that additional factors in autistic individuals should be considered when assessing the suicide risk, and it brings us one step closer to understanding why suicide is more common for autistic people.

Remote mental health care interventions during the COVID-19 pandemic: An umbrella review

Mitigating the COVID-19 related disruptions in mental health care services is crucial in a time of increased mental health disorders. Numerous reviews have been conducted on the process of implementing technology-based mental health care during the pandemic. The research question of this umbrella review was to examine what the impact of COVID-19 was on access and delivery of mental health services and how mental health services have changed during the pandemic. A systematic search for systematic reviews and meta-analyses was conducted up to August 12, 2022, and 38 systematic reviews were identified. Main disruptions during COVID-19 were reduced access to outpatient mental health care and reduced admissions and earlier discharge from inpatient care. In response, synchronous telemental health tools such as videoconferencing were used to provide remote care similar to pre-COVID care, and to a lesser extent asynchronous virtual mental health tools such as apps. Implementation of synchronous tools were facilitated by time-efficiency and flexibility during the pandemic but there was a lack of accessibility for specific vulnerable populations. Main barriers among practitioners and patients to use digital mental health tools were poor technological literacy, particularly when preexisting inequalities existed, and beliefs about reduced therapeutic alliance particularly in case of severe mental disorders. Absence of organizational support for technological implementation of digital mental health interventions due to inadequate IT infrastructure, lack of funding, as well as lack of privacy and safety, challenged implementation during COVID-19. Reviews were of low to moderate quality, covered heterogeneously designed primary studies and lacked findings of implementation in low- and middle-income countries. These gaps in the evidence were particularly prevalent in studies conducted early in the pandemic. This umbrella review shows that during the COVID-19 pandemic, practitioners and mental health care institutions mainly used synchronous telemental health tools, and to a lesser degree asynchronous tools to enable continued access to mental health care for patients. Numerous barriers to these tools were identified, and call for further improvements. In addition, more high quality research into comparative effectiveness and working mechanisms may improve scalability of mental health care in general and in future infectious disease outbreaks.

Anxiety and depression symptoms during the COVID-19 pandemic in European countries and Australia

Background

Studies on mental health changes during the COVID-19 pandemic report no change or increasing prevalence of mental health problems in general, but less is known on changes in potentially disadvantaged groups over time. We investigated changes in anxiety and depression symptoms during the first year of the pandemic in France, Germany, Italy, the Netherlands, Spain, Sweden, and Australia by prior mental disorders and migration status.

Methods

Overall, 4,674 adults answered a web-based survey in May-June 2020 and were followed by three repeated surveys up to February 2021 in these countries. Information on socio-demographic, living conditions, psychosocial factors, diagnosis of mental disorders before, depression and anxiety symptoms during the pandemic and migration status (being a resident or not) was collected. Weighted general estimation equations modelling was used to investigate the association between prior mental disorders, migration status, and symptoms over time.

Results

Most participants were <40 years old (48%), women (78%), and highly educated (62%) with some variations across countries. The baseline prevalence of depressive and anxiety symptoms ranged between 19%-45% and 13%-35% respectively. In most countries, prevalence remained unchanged throughout the pandemic and was higher among people with prior mental disorder than without even after adjustment for socioeconomic, psychosocial, living and health factors. We observed interactions between previous mental disorders and symptoms of anxiety or depression over time in Germany (p = 0.01) and in Spain (p = 0.04). No prevalence difference was noted by migration status.

Conclusions

Depression and anxiety symptoms were worse among individuals with prior mental disorders than without, but there was no clear trend of mental health worsening in the observed groups during the first year of the pandemic. Still, monitoring mental health should be continued in the long-term, with special focus on vulnerable groups.

Key messages

• Depression and anxiety symptoms were higher in individuals with prior mental disorders during the first year of the pandemic in an international sample of six European countries and Australia.

• There were no clear trends of mental health worsening in any of the observed groups in neither of the countries between May-June 2020 and February 2021.

Scalable psychological interventions for Syrian refugees: Preliminary results of a randomized controlled trial on the peer-refugee delivered Problem Management Plus (PM+) intervention in the Netherlands

Introduction

In the past decade, millions of Syrians have sought refuge in neighboring countries and Europe. Refugees are at increased risk for the development of common mental disorders (CMD), such as depression and posttraumatic stress disorder (PTSD), but only a small percentage access mental health services. Problem Management Plus (PM+) is a brief, scalable intervention targeting symptoms of CMDs that can be delivered by non-specialist helpers in communities affected by adversity, such as refugees.

Objectives

The aim of this randomized controlled trial (RCT) is to evaluate the effectiveness of PM+ among Syrian refugees in the Netherlands.

Methods

Adult Syrian refugees and other Arabic-speaking refugees of 18 years and older with self-reported psychological distress (K10 >15) and functional impairment (WHODAS 2.0 >16) are included. Participants are randomized into PM+ or care as usual. Follow-up assessments are conducted at one-week, three-month and twelve-month follow-ups. Clinical outcomes are symptoms of depression/anxiety (HSCL-25), PTSD (PCL-5), and functional impairment (WHODAS 2.0).

Results

By November 2021 [recruitment ends by December 2021], 214 participants were screened for eligibility and 184 participants were included. Participants are M=36.5yrs old (range 18-69yrs), and 73 participants are female (39.7%). We will present preliminary results for the effects of PM+ on depression, anxiety, PTSD, and functional impairment at one-week follow-up, as well as barriers and facilitators for implementing PM+ in a European country.

Conclusions

After positive evaluation of peer-refugee delivered PM+, the Arabic manual and training materials will be made available through WHO to encourage scaling-up.

Disclosure

No significant relationships.

A systematic review and meta-analysis of the diagnostic accuracy of self-report screening instruments for common mental disorders in Arabic-speaking adults

Introduction

Self-report questionnaires to screen for symptoms of common mental disorders (CMDs) are commonly used as inexpensive, easy-to-administer tools in research and clinical practice. However, their validity to detect the presence of any CMD across cultures and languages is unclear. Psychometrically sound and brief case-finding instruments are vital for the identification of individuals with mental health needs. With the increasing number of Arabic-speaking refugees in Europe, we aim to evaluate the diagnostic accuracy of Arabic-language screening instruments.

Objectives

The aim of this systematic review/meta-analysis is to synthesize the diagnostic accuracy of self-report questionnaires to detect depression, anxiety and posttraumatic stress disorder (PTSD) in Arabic-speaking populations.

Methods

Five databases were searched (inception-January 2021) (PROSPERO: CRD42018070645) for studies on the diagnostic accuracy of brief questionnaires in Arabic-speaking populations, with a clinical interview as reference standard. Data on sensitivity/specificity were extracted/calculated. Multi-threshold meta-analyses were performed (R diagmeta package). Study quality was assessed using QUADAS-2.

Results

We included 32 studies (N=4042 participants) reporting on questionnaires targeting depression/anxiety (14 questionnaires), distress (2 questionnaires), and PTSD (1 questionnaire). Optimal thresholds were identified for the Edinburgh Postnatal Depression Scale (EPDS; cut-off 11, sensitivity 76.9%, specificity 85.1%), Hospital Anxiety and Depression Scale (HADS) anxiety subscale (cut-off 7, sensitivity 81.9%, specificity 87.6%), depression subscale (cut-off 6, sensitivity 73.0%, specificity 88.6%), and Self-Reporting Questionnaire (SRQ-20; cut-off 8, sensitivity 86.0%, specificity 83.9%).

Conclusions

We present optimal thresholds that can be used by clinicians and researchers for the EPDS, HADS and SRQ-20. More research on Arabic-language questionnaires, especially those targeting PTSD, is needed.

Disclosure

No significant relationships.

The prevalence of common mental disorders among Syrian refugees resettled in The Netherlands

Introduction

Refugees are at elevated risk of developing common mental disorders (CMD) as they may have been exposed to stressors and traumatic experiences before, during and after their movement. However, prevalence rates of CMDs among refugees reported across studies vary strongly.

Objectives

To examine the prevalence of CMDs (PTSD, anxiety, depression and somatic disorder) among Syrian refugees in the Netherlands, and the diagnostic accuracy of self-reporting questionnaires in Arabic.

Methods

A sample of N=1339 adult Syrian refugees was randomly selected from the Dutch national population registry. Participants were approached in December 2020-March 2021 to complete questionnaires on symptoms of PTSD (PCL-5), anxiety/depression (HSCL-25), and somatic disorder (SSS-8). After the survey, a sub-sample was invited for a clinical interview using the Structured Clinical Interview for DSM-5 (SCID-5) to enquire about the presence or absence of PTSD, anxiety, depression or somatic disorder.

Results

In total, 407 participants (53.6% female, M age=34.2yrs, SD=14.1) completed the survey. The majority (65.9%) arrived in the Netherlands in 2015-2017. Using a cut-off of PCL-5 ³33, 75 participants (18.4%) reported probable PTSD. Using a cut-off of ³1.83 on the HSCL-25 depression subscale and ³1.75 on the anxiety subscale, 153 participants (37.6%) reported depression and 135 (33.2%) reported anxiety, and using a cut-off of ³12.0 on the SSS-8, 121 (29.8%) reported somatic complaints. A sub-sample of 214 participants (52.6%) were followed-up with the SCID-5. Psychometric properties will be presented.

Conclusions

Syrian refugees in the Netherlands are at high risk for the development of a CMD. Implications, strengths and limitations of the study will be discussed.

Disclosure

No significant relationships.

Group problem management plus (PM+) to decrease psychological distress among Syrian refugees in Turkey: a pilot randomised controlled trial

BACKGROUND

Syrian refugees resettled in Turkey show a high prevalence of symptoms of mental disorders. Problem Management Plus (PM+) is an effective psychological intervention delivered by non-specialist health care providers which has shown to decrease psychological distress among people exposed to adversity. In this single-blind pilot randomised controlled trial, we examined the methodological trial procedures of Group PM+ (gPM+) among Syrian refugees with psychological distress in Istanbul, Turkey, and assessed feasibility, acceptability, perceived impact and the potential cost-effectiveness of the intervention.

METHODS

Refugees with psychological distress (Kessler Psychological Distress Scale, K10 > 15) and impaired psychosocial functioning (World Health Organization Disability Assessment Schedule, WHODAS 2.0 > 16) were recruited from the community and randomised to either gPM+ and enhanced care as usual (E-CAU) (n = 24) or E-CAU only (n = 22). gPM+ comprised of five weekly group sessions with eight to ten participants per group. Acceptability and feasibility of the intervention were assessed through semi-structured interviews. The primary outcome at 3-month follow-up was symptoms of depression and anxiety (Hopkins Symptoms Checklist-25). Psychosocial functioning (WHODAS 2.0), symptoms of posttraumatic stress disorder and self-identified problems (Psychological Outcomes Profiles, PSYCHLOPS) were included as secondary outcomes. A modified version of the Client Service Receipt Inventory was used to document changes in the costs of health service utilisation as well as productivity losses.

RESULTS

There were no barriers experienced in recruiting study participants and in randomising them into the respective study arms. Retention in gPM+ was high (75%). Qualitative analyses of the interviews with the participants showed that Syrian refugees had a positive view on the content, implementation and format of gPM+. No adverse events were reported during the implementation. The study was not powered to detect an effect. No significant difference between gPM+ and E-CAU group on primary and secondary outcome measures, or in economic impacts were found.

CONCLUSIONS

gPM+ delivered by non-specialist peer providers seemed to be an acceptable, feasible and safe intervention for Syrian refugees in Turkey with elevated levels of psychological distress. This pilot RCT sets the stage for a fully powered RCT.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier NCT03567083 ; date: 25/06/2018.

Which psychotherapy is effective in panic disorder? Findings and reflections from a systematic network meta-analysis

Introduction

Panic disorder is among the most prevalent anxiety diseases. Although psychotherapy is recommended as first-line treatment for panic disorder, little is known about the relative efficacy of different types of psychotherapies.

Objectives

To evaluate the effectiveness and acceptability of different types of psychotherapies for adults suffering from panic disorder, with or without agoraphobia.

Methods

We are conducting a systematic network meta-analysis of randomized controlled trials examining panic disorder. A comprehensive search was performed to identify relevant studies. The primary efficacy outcome is anxiety symptoms at study endpoint. The primary acceptability outcome is all-cause trial discontinuation at endpoint. Pairwise and network meta-analysis will be conducted. We are considering any kind of psychotherapy delivered by any therapist, as long as they were trained to deliver the therapy, or as self-help.

Results

To date we have identified 126 panic disorder and agoraphobia trials. The publication time span ranges from 1968 to 2020. We are now extracting data to provide an overview of the included study characteristics. The statistical analysis will be conducted between December 2020 and January 2021, and its results presented for the first time at the forthcoming 2021 EPA congress.

Conclusions

126 trials on psychotherapy for panic disorders in adults are available. Because of this huge body of knowledge, it is important that the results of these studies are summarized using network meta-analytic techniques. The findings of this study will guide future research as knowledge gaps will be easily identified. Moreover, policymakers will have the opportunity to use this summarized knowledge to inform evidence-based decision making.

Disclosure

No significant relationships.

Problem Management Plus (PM+) for Syrian refugees in the Netherlands

Background

Refugees are at considerable risk to develop common mental disorders and related somatic health symptoms. In order to meet the mental health needs of individuals affected by crisis worldwide, the World Health Organization has developed a set of transdiagnostic low-intensity psychological interventions. These interventions, including Problem Management Plus (PM+) and its variants, are delivered by trained non-professional counsellors under supervision of local clinicians. The EU H2020 STRENGTHS project evaluates the effectiveness of these interventions across refugee settings in Europe and the Middle East. This presentation will present the results of a pilot randomized controlled trial (RCT) on individual PM+ in the Netherlands.

Methods

Syrian refugees (N = 60) with elevated levels of psychological distress (10 item-Kessler Psychological Distress Scale >15) and impaired daily functioning (WHO Disability Assessment Schedule 2.0 >16) were randomized into PM + (N=30)) or care-as-usual control (CAU; N = 30). The main outcomes were symptoms of depression and anxiety at 3 months. Secondary outcomes were functioning, symptoms of posttraumatic stress disorder, service utilisation and health costs.

Results

At 3 months follow-up, the PM+ group had significantly lower scores than control for depression (d=.52?) and anxiety (d=.48), symptoms of posttraumatic stress disorder (d=.66, p = .006?), functional impairment (d=.73, p = .009) and self-identified problems (d=.81, p = .005). PM+ potentially may be cost effective with an ICER of €5,047, (95% CI €0, €19773) per additional recovery achieved.

Conclusions

PM+ delivered by non-specialist peer-refugee helpers has the potential be effective in reducing depression, anxiety, improving functioning, and reducing health costs. Larger RCTs on the effects of PM+ are currently conducted within the EU STRENGTHS project.

Labour market marginalisation in young refugees with and without common mental disorders

Background

This study explored how inequality in labour market marginalisation (LMM) between refugees and their peers developed during early adulthood in Denmark and Sweden (DK/SE), and the role of common mental disorders (CMD) in these trends.

Methods

Using registry data, all refugees living in DK/SE in 2009-2012 who were born 1986-1993 and who immigrated as children (aged 0-17) were included (N = 13,390/45,687) and 1:5 matched on age, sex and municipality size to individuals born in DK/SE with at least one parent also born in DK/SE (N = 69,650/227,287). Information on psychiatric care (hospital and medicine) during 2009-2011 indicated CMD, while LMM was measured during 2012-2015 using income-based indicators. Probabilities of LMM were standardized by multiplying the estimated parameters of linear probability models in SE (adjusted for age, sex, municipality size, age of arrival, origin country, and accompanying family) onto the mean of the covariates in DK.

Results

The risk of LMM was 2-2.5 times higher for refugees across ages 20-29 in DK/SE. The risk tended to decrease in SE but increased in DK for refugees. The increase was accentuated for youth with CMD. However, CMD did not explain the inequality between refugee and majority youth. The increase in DK was driven by birth-cohort differences, while the trend in SE was consistent across birth cohorts.

Conclusions

CMD did not capture the vulnerability that sets refugees apart from their peers. While immigration and integration policy differences between DK and SE increased, the integration outcomes diminished, suggesting the importance of factors other than national level policies.

Key messages

Young refugees in DK/SE were more at risk of labour market marginalization than their majority peers. Healthcare contact for common mental disorders raised levels, but did not reduce inequalities. Labour market marginalisation decreased with age in Sweden but increased for refugees in Denmark, driven by birth cohort difference.

Common mental disorders in young refugees in Sweden: the role of education and duration of residency

Background

Studies investigating risks of common mental disorders (CMDs) in refugee youth are sparse. The current study examined health care use due to CMDs in unaccompanied and accompanied refugee youth and Swedish-born, and the role of education and residency duration.

Methods

This register-based, longitudinal cohort study included 743,671 individuals (whereof 33,501 refugees) between 19-25 years, residing in Sweden in 2009. Refugees were classified as unaccompanied/accompanied. Risk estimates of CMDs, measured as health care and antidepressant treatment, between 2010-2016 were calculated as adjusted hazard ratios (aHR) with 95% confidence intervals (CI). Highest attained education in 2009, and residency duration were examined as potential modifiers.

Results

Compared to Swedish-born youth, refugees had a lower risk of treated major depressive and anxiety disorders (aHR): 0.73 (95% CI 0.68-0.78) and 0.74 (95% CI 0.70-0.79) respectively), but a higher risk for posttraumatic stress disorders (PTSD). Compared to Swedish-born, unaccompanied had an 8-fold elevated risk for PTSD (aHR: 8.40, 95% CI 6.16-11.47) and accompanied refugees had a nearly 3-fold risk of PTSD (aHR: 2.78, 95% CI 2.29-3.37). Rates of PTSD decreased with years spent in Sweden. The risk of CMDs decreased with increasing education.

Conclusions

Young refugees had a lower risk of treated depressive and anxiety disorders, but a higher risk for PTSD. In refugees, the rates of anxiety disorders increased slightly over time, whereas the rates of PTSD decreased. Last, low education was an important predictor for CMDs.

Key messages

Our study highlights the need to specifically focus on stress-related mental disorders in studies on refugees as risk estimates might differ. Moreover, providing scalable low-intensity interventions to address CMDs including posttraumatic stress are an important first step in order to prevent prolonged suffering and persistence of PTSD in refugee youth.

Treating repetitive suicidal intrusions using eye movements: study protocol for a multicenter randomized clinical trial

BACKGROUND

Suicide is a major public health problem, and it remains unclear which processes link suicidal ideation and plans to the act of suicide. Growing evidence shows that the majority of suicidal patients diagnosed with major depression or bipolar disorder report repetitive suicide-related images and thoughts (suicidal intrusions). Various studies showed that vividness of negative as well as positive intrusive images may be reduced by dual task (e.g. eye movements) interventions taxing the working memory. We propose that a dual task intervention may also reduce frequency and intensity of suicidal imagery and may be crucial in preventing the transition from suicidal ideation and planning to actual suicidal behaviour. This study aims a) to evaluate the effectiveness of an Eye Movement Dual Task (EMDT) add-on intervention targeting suicidal imagery in depressed patients, b) to explore the role of potential moderators and mediators in explaining the effect of EMDT, and c) to evaluate the cost-effectiveness of EMDT.

METHODS

We will conduct a multi-center randomized clinical trial (RCT) evaluating the effects of EMDT in combination with usual care (n = 45) compared to usual care alone (n = 45). Participants will fill in multiple online batteries of self-report questionnaires as well as complete a semi-structured interview (Intrusion Interview), and online computer tasks. The primary outcome is the frequency and intrusiveness of suicidal imagery. Furthermore, the vividness, emotionality, and content of the suicidal intrusions are evaluated; secondary outcomes include: suicidal behaviour and suicidal ideation, severity of depression, psychological symptoms, rumination, and hopelessness. Finally, potential moderators and mediators are assessed.

DISCUSSION

If proven effective, EMDT can be added to regular treatment to reduce the frequency and vividness of suicidal imagery.

TRIAL REGISTRATION

The study has been registered on October 17th, 2018 at the Netherlands Trial Register, part of the Dutch Cochrane Centre ( NTR7563 ).

Evaluating feasibility and acceptability of a group WHO trans-diagnostic intervention for women with common mental disorders in rural Pakistan: a cluster randomised controlled feasibility trial

AIMS

The aim of this feasibility trial was to evaluate the feasibility and acceptability of the locally adapted Group Problem Management Plus (PM+) intervention for women in the conflict affected settings in Swat, Pakistan.

METHODS

This mixed-methods study incorporated a quantitative component consisting of a two arm cluster randomised controlled feasibility trial, and qualitative evaluation of the acceptability of the Group PM+ to a range of stakeholder groups. For the quantitative component, on average from each of the 20 Lady Health Workers (LHWs) catchment area (20 clusters), six women were screened and recruited for the trial with score of >2 on the General Health Questionnaire and score of >16 on the WHO Disability Assessment Schedule. These LHW clusters were randomised on a 1 : 1 allocation ratio using a computer-based software through a simple randomisation method to the Group PM+ intervention or Enhanced Usual Care. The Group PM+ intervention consisted of five weekly sessions of 2 h duration delivered by local non-specialist females under supervision. The primary outcome was individual psychological distress, measured by levels of anxiety and depression on the Hospital Anxiety and Depression Scale at 7th week after baseline. Secondary outcomes include symptoms of depression, post-traumatic stress disorder (PTSD), general psychological profile, levels of functioning and generalised psychological distress. Intervention acceptability was explored through in-depth interviews.

RESULTS

The results show that lay-helpers with no prior mental health experience can be trained to achieve the desired competency to successfully deliver the intervention in community settings under supervision. There was a good intervention uptake, with Group PM+ considered useful by participants, their families and lay-helpers. The outcome evaluation, which was not based on a large enough study to identify statistically significant results, indicated statistically significant improvements in depression, anxiety, general psychological profile and functioning. The PTSD symptoms and depressive disorder scores showed a trend in favour of the intervention.

CONCLUSION

This trial showed robust acceptance in the local settings with delivery by non-specialists under supervision by local trained females. The trial paves the way for further adaptation and exploration of the outcomes through larger-scale implementation and definitive randomised controlled trials in the local settings.

The efficacy of eye movement desensitization and reprocessing for post-traumatic stress disorder and depression among Syrian refugees: results of a randomized controlled trial

BACKGROUND

Previous research indicates a high prevalence of post-traumatic stress disorder (PTSD) and depression among refugees. Eye movement desensitization and reprocessing (EMDR) is an effective treatment for PTSD for victims of natural disasters, car accidents or other traumatic events. The current study examined the effect of EMDR on symptoms of PTSD and depression by comparing the treatment with a wait-list control condition in Syrian refugees.

METHOD

Adult refugees located in Kilis Refugee Camp at the Turkish-Syrian border with a PTSD diagnosis were randomly allocated to either EMDR (n = 37) or wait-list control (n = 33) conditions. All participants were assessed with the Mini-International Neuropsychiatric Interview Plus at pre-intervention, at 1 week after finishing the intervention and at 5 weeks after finishing the intervention. The main outcome measures were the Harvard Trauma Questionnaire (HTQ) and the Impact of Event Scale-Revised. The Beck Depression Inventory and the Hopkins Symptoms Checklist-25 were included as secondary outcome measures. The Trial Registration no. is NCT01847742.

RESULTS

Mixed-model analyses adjusted for the baseline scores indicated a significant effect of group at post-treatment indicating that the EMDR therapy group showed a significantly larger reduction of PTSD symptoms as assessed with the HTQ. Similar findings were found on the other outcome measures. There was no effect of time or group × time interaction on any measure, showing that the difference between the groups at the post-treatment was maintained to the 5-week follow-up.

CONCLUSIONS

EMDR may be effective in reducing PTSD and depression symptoms among Syrian refugees with PTSD located in a refugee camp.