A WHO digital intervention to address depression among young Chinese adults: a type 1 effectiveness-implementation randomized controlled trial

Common mental disorders among young people are rising globally. Current university-based interventions are inadequate to address the need for evidence-based interventions. We investigated the effectiveness and implementation of Step-by-Step (SbS), a WHO digital intervention to address depression, among Chinese university students with depressive symptoms. In this paper, we report a type 1 hybrid effectiveness-implementation randomized controlled trial conducted between September 2021 and September 2022. The control condition was enhanced treatment as usual (ETAU, psychoeducation). The primary outcome was improvement in depression symptoms. Secondary outcomes were improvements in psychological well-being, anxiety symptoms, and self-identified psychosocial problems. Effectiveness of the intervention was evaluated using generalized linear mixed models. Implementation outcomes were evaluated by thematic analysis of participant interviews. A total of 371 participants were enrolled to two treatment conditions in a 1:1 ratio. SbS resulted in a greater reduction in depressive symptoms at posttreatment (p = 0.004, Hedges' g = 0.35), but no significant difference between SbS and ETAU was observed at three-month follow-up (p = 0.179, Hedges' g = 0.16). The treatment effect was larger among those who adhered to the treatment (Hedges' gs = 0.59 and 0.30). Subjective well-being also improved for SbS at both time points (Hedges' gs = 0.31 and 0.30). In addition, SbS resulted in more improvement in anxiety symptoms at posttreatment (p = 0.029, Hedges' g = 0.26), but not at three-month follow-up (p = 0.265, Hedges' g = 0.13). The qualitative results demonstrated that the intervention was well-implemented as a self-help mental health service, with minimal support from peer supporters. In conclusion, Step-by-Step, a digital intervention developed by WHO, was effective in reducing depressive symptoms in the short term and improving psychological well-being in a longer term. The sustained effect on depression needs further investigation. Improving uptake and engagement in the program is needed for its scale-up implementation as a university-based mental health service for Chinese young adults. Trial registration: ChiCTR2100050214.

Internet-based transdiagnostic treatment for emotional disorders in Arabic- and Farsi-speaking refugees: study protocol of a randomized controlled trial

BACKGROUND

Refugee populations have an increased risk for mental disorders, such as depression, anxiety, and posttraumatic stress disorders. Comorbidity is common. At the same time, refugees face multiple barriers to accessing mental health treatment. Only a minority of them receive adequate help. The planned trial evaluates a low-threshold, transdiagnostic Internet-based treatment. The trial aims at establishing its efficacy and cost-effectiveness compared with no treatment.

METHODS

N = 131 treatment-seeking Arabic- or Farsi-speaking patients, meeting diagnostic criteria for a depressive, anxiety, and/or posttraumatic stress disorder will be randomized to either the intervention or the waitlist control group. The intervention group receives an Internet-based treatment with weekly written guidance provided by Arabic- or Farsi-speaking professionals. The treatment is based on the Common Elements Treatment Approach (CETA), is tailored to the individual patient, and takes 6-16 weeks. The control group will wait for 3 months and then receive the Internet-based treatment.

DISCUSSION

The planned trial will result in an estimate of the efficacy of a low-threshold and scalable treatment option for the most common mental disorders in refugees.

TRIAL REGISTRATION

German Registry for Clinical Trials DRKS00024154. Registered on February 1, 2021.

Blended-ALMAMAR app for inpatient mental health care for refugees: study protocol for a multicenter implementation study within the I-REACH consortium (Internet based REfugee mentAl healtH Care)

BACKGROUND

Refugees are at high risk for developing mental illnesses. Due to language and cultural barriers, there is need for specifically adapted therapeutic procedures for refugees in inpatient mental health care settings. Internet-based applications in refugee mother tongues have the potential to improve the outcomes of mental health care for this vulnerable population. The key research question of the present implementation study is whether the newly developed "blended ALMAMAR" app for Arabic and Farsi speaking refugees in Germany is used and accepted by patients and professionals in routine inpatient mental health care (blended care).

METHODS

We present the design of an observational, prospective multicenter implementation study in eight psychiatric hospitals. We plan to recruit 100 Farsi or Arabic speaking refugees receiving in-patient treatment due to depression, anxiety disorder, posttraumatic stress disorder or substance use disorders. These patients will get access to the "blended ALMAMAR" app during their inpatient stay in a blended-care approach. We will assess the usage (e.g., duration and frequency of use of the app) as well as subjective acceptability and usability of the intervention. To identify sociodemographic and clinical factors associated with "blended ALMAMAR" usage, we will also perform clinical and questionnaire assessments.

DISCUSSION

The newly developed "blended ALMAMAR" app may help to close communication gaps for the hard-to reach and vulnerable group of refugees in inpatient mental health care. It is the first blended-care intervention that addresses severely mentally ill refugees in an inpatient psychiatric setting in Germany.

TRIAL REGISTRATION

The trial was registered in the German Clinical Trials Register on November 11, 2021 (DRKS00025972) and adapted on November 14, 2023.

Understanding the protective effect of social support on depression symptomatology from a longitudinal network perspective

BACKGROUND

Higher social support protects people from developing mental disorders. Limited evidence is available on the mechanism through which social support plays this protective role.

OBJECTIVE

To investigate the stress-buffering process of social support on depressive symptoms using a novel longitudinal dynamic symptom network approach.

METHODS

A total of 4242 adult participants who completed the first two waves (from May to October 2020) of the International Covid Mental Health Survey were included in the study. Cross-lagged panel network modelling was used to estimate a longitudinal network of self-reported social support, loneliness and depressive symptoms. Standardised regression coefficients from regularised cross-lagged regressions were estimated as edge weights of the network.

FINDINGS

The results support a unidirectional protective effect of social support on key depressive symptoms, partly mediated through loneliness: A higher number of close confidants and accessible practical help was associated with decreased anhedonia (weight=-0.033) and negative self-appraisal symptoms (weight=-0.038). Support from others was also negatively associated with loneliness, which in turn associated with decreased depressed mood (weight=0.086) and negative self-appraisal (weight=0.077). We identified a greater number of direct relationships from social support to depressive symptoms among men compared with women. Also, the edge weights from social support to depression were generally stronger in the men's network.

CONCLUSIONS

Reductions in negative self-appraisal might function as a bridge between social support and other depressive symptoms, and, thus, it may have amplified the protective effect of social support. Men appear to benefit more from social support than women.

CLINICAL IMPLICATIONS

Building community-based support networks to deliver practical support, and loneliness reduction components are critical for depression prevention interventions after stressful experiences.

Effects of a Self-Guided Transdiagnostic Smartphone App on Patient Empowerment and Mental Health: Randomized Controlled Trial

BACKGROUND

Mental disorders impact both individuals and health systems. Symptoms and syndromes often remain undetected and untreated, resulting in chronification. Besides limited health care resources, within-person barriers such as the lack of trust in professionals, the fear of stigmatization, or the desire to cope with problems without professional help contribute to the treatment gap. Self-guided mental health apps may support treatment seeking by reducing within-person barriers and facilitating mental health literacy. Digital mental health interventions may also improve mental health related self-management skills and contribute to symptom reduction and the improvement of quality of life.

OBJECTIVE

This study aims to investigate the effects of a self-guided transdiagnostic app for mental health on help seeking, reduced stigma, mental health literacy, self-management skills, mental health symptoms, and quality of life using a randomized controlled design.

METHODS

Overall, 1045 participants (recruited via open, blinded, and web-based recruitment) with mild to moderate depression or anxiety-, sleep-, eating-, or somatization-related psychopathology were randomized to receive either access to a self-guided transdiagnostic mental health app (MindDoc) in addition to care as usual or care as usual only. The core features of the app were regular self-monitoring, automated feedback, and psychological courses and exercises. The coprimary outcomes were mental health literacy, mental health-related patient empowerment and self-management skills (MHPSS), attitudes toward help seeking, and actual mental health service use. The secondary outcomes were psychopathological symptom burden and quality of life. Data were collected at baseline and 8 weeks and 6 months after randomization. Treatment effects were investigated using analyses of covariance, including baseline variables as predictors and applying multiple imputation.

RESULTS

We found small but robust between-group effects for MHPSS (Cohen d=0.29), symptoms burden (Cohen d=0.28), and quality of life (Cohen d=0.19) 8 weeks after randomization. The effects on MHPSS were maintained at follow-up. Follow-up assessments also showed robust effects on mental health literacy and preliminary evidence for the improvement of help seeking. Predictors of attrition were lower age and higher personality dysfunction. Among the non-attritors, predictors for deterioration were less outpatient treatment and higher initial symptom severity.

CONCLUSIONS

A self-guided transdiagnostic mental health app can contribute to lasting improvements in patient empowerment. Symptoms of common mental disorders and quality of life improved faster in the intervention group than in the control group. Therefore, such interventions may support individuals with symptoms of 1 or more internalizing disorders, develop health-centered coping skills, prevent chronification, and accelerate symptom improvement. Although the effects for individual users are small and predictors of attrition and deterioration need to be investigated further, the potential public health impact of a self-guided intervention can be large, given its high scalability.

TRIAL REGISTRATION

German Clinical Trials Register DRKS00022531; https://drks.de/search/de/trial/DRKS00022531.

Mental health across two years of the COVID-19 pandemic: a 5-wave longitudinal study in Germany

The COVID-19 pandemic has been negatively associated with mental health. However, little is known about the temporal dynamics of mental health in the longer term of the pandemic. We aimed to investigate symptom levels and changes of depression, anxiety, posttraumatic stress, and loneliness spanning two years of the pandemic; and to examine associated risk factors. This five-wave, longitudinal online study from May 2020 to April 2022 included 636 adults (Mage = 39.5 years, SD = 16.11; 84.1% female) from the German general population who completed the international COVID-19 Mental Health Survey. Symptoms of anxiety (Generalized Anxiety Disorder-7; GAD-7), depression (Patient Health Questionnaire-9; PHQ-9), posttraumatic stress (PTSD Checklist for DSM-5; PCL-5), and loneliness ("Do you feel lonely?") were assessed using mixed-effects models. Associations with anxiety and depressive symptoms were examined with having children, student status, financial worries, contamination fear, and loneliness. PHQ-9, GAD-7, PCL-5, and loneliness scores overall decreased throughout the two-year period of the pandemic but exhibited an increase during two national lockdowns. Controlled for significant associations with female gender and younger age, increased PHQ-9 and GAD-7 scores were associated with contamination fear, financial worries, and loneliness. No associations were found with having children and student status. Symptoms of depression, anxiety, posttraumatic stress, and loneliness decreased over time but varied along with the dynamics of the pandemic. Longitudinal monitoring of mental health in vulnerable subgroups is required, especially those of younger age, females, and the financially insecure.

Correction: Effects of a WHO-guided digital health intervention for depression in Syrian refugees in Lebanon: A randomized controlled trial

[This corrects the article DOI: 10.1371/journal.pmed.1004025.].

Peer-provided psychological intervention for Syrian refugees: results of a randomised controlled trial on the effectiveness of Problem Management Plus

BACKGROUND

The mental health burden among refugees in high-income countries (HICs) is high, whereas access to mental healthcare can be limited.

OBJECTIVE

To examine the effectiveness of a peer-provided psychological intervention (Problem Management Plus; PM+) in reducing symptoms of common mental disorders (CMDs) among Syrian refugees in the Netherlands.

METHODS

We conducted a single-blind, randomised controlled trial among adult Syrian refugees recruited in March 2019-December 2021 (No. NTR7552). Individuals with psychological distress (Kessler Psychological Distress Scale (K10) >15) and functional impairment (WHO Disability Assessment Schedule (WHODAS 2.0) >16) were allocated to PM+ in addition to care as usual (PM+/CAU) or CAU only. Participants were reassessed at 1-week and 3-month follow-up. Primary outcome was depression/anxiety combined (Hopkins Symptom Checklist; HSCL-25) at 3-month follow-up. Secondary outcomes included depression (HSCL-25), anxiety (HSCL-25), post-traumatic stress disorder (PTSD) symptoms (PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition; PCL-5), impairment (WHODAS 2.0) and self-identified problems (PSYCHLOPS; Psychological Outcomes Profiles). Primary analysis was intention-to-treat.

FINDINGS

Participants (n=206; mean age=37 years, 62% men) were randomised into PM+/CAU (n=103) or CAU (n=103). At 3-month follow-up, PM+/CAU had greater reductions on depression/anxiety relative to CAU (mean difference -0.25; 95% CI -0.385 to -0.122; p=0.0001, Cohen's d=0.41). PM+/CAU also showed greater reductions on depression (p=0.0002, Cohen's d=0.42), anxiety (p=0.001, Cohen's d=0.27), PTSD symptoms (p=0.0005, Cohen's d=0.39) and self-identified problems (p=0.03, Cohen's d=0.26), but not on impairment (p=0.084, Cohen's d=0.21).

CONCLUSIONS

PM+ effectively reduces symptoms of CMDs among Syrian refugees. A strength was high retention at follow-up. Generalisability is limited by predominantly including refugees with a resident permit.

CLINICAL IMPLICATIONS

Peer-provided psychological interventions should be considered for scale-up in HICs.

Guided digital health intervention for depression in Lebanon: randomised trial

BACKGROUND

Most people with mental disorders in communities exposed to adversity in low-income and middle-income countries (LMICs) do not receive effective care. Digital mental health interventions are scalable when digital access is adequate, and can be safely delivered during the COVID-19 pandemic.

OBJECTIVE

To examine the effects of a new WHO-guided digital mental health intervention, Step-by-Step, supported by a non-specialist helper in Lebanon, in the context of concurring economic, humanitarian and political crises, a large industrial disaster and the COVID-19 pandemic.

METHODS

We conducted a single-blind, two-arm pragmatic randomised trial, comparing guided Step-by-Step with enhanced care as usual (ECAU) among people suffering from depression and impaired functioning. Primary outcomes were depression (Patient Health Questionnaire 9 (PHQ-9)) and impaired functioning (WHO Disability Assessment Schedule-12 (WHODAS)) at post-treatment.

FINDINGS

680 people with depression (PHQ-9>10) and impaired functioning (WHODAS>16) were randomised to Step-by-Step or ECAU. Intention-to-treat analyses showed effects on depression (standardised mean differences, SMD: 0.71; 95% CI: 0.45 to 0.97), impaired functioning (SMD: 0.43; 95% CI: 0.21 to 0.65), post-traumatic stress (SMD: 0.53; 95% CI: 0.27 to 0.79), anxiety (SMD: 0.74; 95% CI: 0.49 to 0.99), subjective well-being (SMD: 0.37; 95% CI: 0.12 to 0.62) and self-identified personal problems (SMD: 0.56; 95% CI 0.29 to 0.83). Significant effects on all outcomes were retained at 3-month follow-up.

CONCLUSIONS

Guided digital mental health interventions can be effective in the treatment of depression in communities exposed to adversities in LMICs, although some uncertainty remains because of high attrition.

CLINICAL IMPLICATIONS

Guided digital mental health interventions should be considered for implementation in LMICs.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov NCT03720769.

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.

Resilience of people with chronic medical conditions during the COVID-19 pandemic: a 1-year longitudinal prospective survey

BACKGROUNDS

Individuals with chronic medical conditions are considered highly exposed to COVID-19 pandemic stress, but emerging evidence is demonstrating that resilience is common even among them. We aimed at identifying sustained resilient outcomes and their predictors in chronically ill people during the first year of the pandemic.

METHODS

This international 4-wave 1-year longitudinal online survey included items on socio-demographic characteristics, economic and living situation, lifestyle and habits, pandemic-related issues, and history of mental disorders. Adherence to and approval of imposed restrictions, trust in governments and in scientific community during the pandemic were also investigated. The following tools were administered: the Patient Health Questionnaire, the Generalized Anxiety Disorder scale, the PTSD Checklist DSM-5, the Oslo Social Support Scale, the Padua Inventory, and the Portrait Values Questionnaire.

RESULTS

One thousand fifty-two individuals reporting a chronic condition out of 8011 total participants from 13 countries were included in the study, and 965 had data available for the final model. The estimated probability of being "sustained-resilient" was 34%. Older male individuals, participants employed before and during the pandemic or with perceived social support were more likely to belong to the sustained-resilience group. Loneliness, a previous mental disorder, high hedonism, fear of COVID-19 contamination, concern for the health of loved ones, and non-approving pandemic restrictions were predictors of not-resilient outcomes in our sample.

CONCLUSIONS

We found similarities and differences from established predictors of resilience and identified some new ones specific to pandemics. Further investigation is warranted and could inform the design of resilience-building interventions in people with chronic diseases.

A protocol for a type 1 effectiveness-implementation randomized controlled trial of the WHO digital mental health intervention Step-by-Step to address depression among Chinese young adults in Macao (SAR), China

BACKGROUND

Among Chinese college students, the burden of depression is considerably high, affecting up to 30 % of the population. Despite this burden, few Chinese students seek mental health treatment. In addition, depression is highly comorbid with other mental health disorders, such as anxiety. Scalable, transdiagnostic, evidence-based interventions are needed for this population.

OBJECTIVE

The study will evaluate the effectiveness of a World Health Organization transdiagnostic digital mental health intervention, Step-by-Step, to reduce depressive and anxiety symptoms and improve well-being compared with enhanced care as usual and its implementation in a Chinese university community.

METHODS

A type 1 effectiveness-implementation two-arm, parallel, randomized controlled trial will be conducted. The two conditions are 1) the 5-session Step-by-Step program with minimal guidance by trained peer-helpers and 2) psychoeducational information on depression and anxiety and referrals to local community services. A total of 334 Chinese university students will be randomized with a 1:1 ratio to either of the two groups. Depression, anxiety, wellbeing, and client defined problems will be assessed at pre-intervention, post-intervention, and 3-month follow-up. Endline qualitative interviews and focus group discussions will be conducted to explore SbS implementation among service users, university staff, and stakeholders. Data will be analysed based on the intent-to-treat principle.

DISCUSSION

Step-by-Step is an innovative approach to address common mental health problems in populations with sufficient digital literacy. It is a promising intervention that can be embedded to scale mental health services within a university setting. It is anticipated that after successful evaluation of the program and its implementation in the type 1 hybrid design RCT study, Step-by-Step can be scaled and maintained as a low-intensity treatment in universities, and potentially extended to other populations within the Chinese community.

TRIAL REGISTRATION

ChiCTR2100050214.

Attentional bias in German Armed Forces veterans with and without posttraumatic stress symptoms - An eye-tracking investigation and group comparison

BACKGROUND AND OBJECTIVES

Most eye tracking based paradigms evidence patterns of sustained attention on threat coupled with low evidence for vigilance to or avoidance of threat in posttraumatic stress symptoms (PTSS). Still, eye tracking data on attention bias is particularly limited for military population. This eye tracking study investigated attentional bias in PTSS in a sample of German Armed Forces veterans.

METHODS

Veterans with deployment-related PTSS (N = 24), veterans with deployment-related traumatization without PTSS (N = 28), and never-deployed healthy veterans (N = 18) were presented with pairs of combat and neutral pictures, pairs of general threat and neutral pictures, and pairs of emotional and neutral faces. Their eye gazes were tracked during a free viewing task. 3 x 3 x 2 mixed general linear model analyses were conducted. Internal consistency of attention bias indicators was calculated for the entire sample and within groups.

RESULTS

Veterans with PTSS dwelled longer on general threat AOIs in contrast to non-exposed controls and shorter on general threat and combat associated neutral AOIs in contrast to both control groups. Veterans with PTSS entered faster to general threat AOIs than non-exposed controls. Veterans with PTSS showed circumscribed higher attention fluctuation in contrast to controls. Internal consistency varied across attention bias indicators.

LIMITATIONS

Statistical power was reduced due to recruitment difficulties.

CONCLUSIONS

Evidence is provided for the maintenance hypothesis in PTSS. No robust evidence is provided for hypervigilant behavior in PTSS. Findings on attention bias variability remain unclear, calling for more investigations in this field.

Symptoms of anxiety and depression during the COVID-19 pandemic in six European countries and Australia - Differences by prior mental disorders and migration status

BACKGROUND

Little is known about changes of mental health during the COVID-19 pandemic in potentially disadvantaged groups. We investigated changes in anxiety and depression symptoms during the first year of the pandemic in six European countries and Australia by prior mental disorders and migration status.

METHODS

Overall, 4674 adults answered a web-based survey in May-June 2020 and were followed by three repeated surveys up to February 2021. Information on psychosocial, financial and demographic, living conditions, prior mental disorders, depression and anxiety symptoms during the pandemic and migration status 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%). The baseline prevalence of depressive and anxiety symptoms ranged between 19%-45% and 13%-35%, respectively. In most countries, prevalence rates remained unchanged throughout the pandemic and were higher among people with prior mental disorders than without even after adjustment for several factors. We observed interactions between previous mental disorders and symptoms of anxiety or depression over time in two countries. No difference by migration status was noted.

LIMITATIONS

Convenience sampling limits generalizability. Self-assessed symptoms of depression and anxiety might involve some misclassification.

CONCLUSIONS

Depression and anxiety symptoms were worse among individuals with prior mental disorders than without, but there was no clear trend of worsening mental health in the observed groups during the observed period.

Trauma-related but not PTSD-related increases in hair cortisol concentrations in military personnel

Dysregulated hypothalamic-pituitary-adrenal (HPA) axis functioning has been associated with posttraumatic stress disorder (PTSD). The current literature is inconsistent regarding this association, possibly due to confounding influences. Hair cortisol concentrations (HCC) allow for retrospective assessment of cumulative HPA axis secretion over several weeks and are considered a trait-like marker of HPA axis activity. Three groups of active and former German Armed Forces service members, comprising PTSD patients (n = 19), healthy controls with deployment-related trauma exposure (n = 10), and non-deployed healthy controls (n = 10) provided samples for HCC analysis. We observed significantly higher HCC in the PTSD and the deployed compared to the non-deployed group. HCC was neither significantly correlated with perceived chronic stress, nor with PTSD severity within patients. The results suggest a differential impact of trauma exposure on HPA axis activity and highlight the notion of cumulative, retrospective cortisol secretion as a psychobiological indicator of trauma exposure. TRIAL REGISTRATION: Australian Clinical Trials Registry (ACTRN12616000956404).

Scalable psychological interventions for Syrian refugees in Europe and the Middle East: STRENGTHS study protocol for a prospective individual participant data meta-analysis

INTRODUCTION

The World Health Organization's (WHO) scalable psychological interventions, such as Problem Management Plus (PM+) and Step-by-Step (SbS) are designed to be cost-effective non-specialist delivered interventions to reduce symptoms of common mental disorders, such as anxiety, depression and post-traumatic stress disorder (PTSD). The STRENGTHS consortium aims to evaluate the effectiveness, cost-effectiveness and implementation of the individual format of PM+ and its group version (gPM+), as well as of the digital SbS intervention among Syrian refugees in seven countries in Europe and the Middle East. This is a study protocol for a prospective individual participant data (IPD) meta-analysis to evaluate (1) overall effectiveness and cost-effectiveness and (2) treatment moderators of PM+, gPM+ and SbS with Syrian refugees.

METHODS AND ANALYSIS

Five pilot randomised controlled trials (RCTs) and seven fully powered RCTs conducted within STRENGTHS will be combined into one IPD meta-analytic dataset. The RCTs include Syrian refugees of 18 years and above with elevated psychological distress (Kessler Psychological Distress Scale (K10>15)) and impaired daily functioning (WHO Disability Assessment Schedule 2.0 (WHODAS 2.0>16)). Participants are randomised into the intervention or care as usual control group, and complete follow-up assessments at 1-week, 3-month and 12-month follow-up. Primary outcomes are symptoms of depression and anxiety (25-item Hopkins Symptom Checklist). Secondary outcomes include daily functioning (WHODAS 2.0), PTSD symptoms (PTSD Checklist for DSM-5) and self-identified problems (PSYCHLOPS). We will conduct a one-stage IPD meta-analysis using linear mixed models. Quality of evidence will be assessed using the GRADE approach, and the economic evaluation approach will be assessed using the CHEC-list.

ETHICS AND DISSEMINATION

Local ethical approval has been obtained for each RCT. This IPD meta-analysis does not require ethical approval. The results of this study will be published in international peer-reviewed journals.

Salivary Cortisol and Alpha-Amylase in Posttraumatic Stress Disorder and Their Potential Role in the Evaluation of Cognitive Behavioral Treatment Outcomes

Alterations in HPA-axis and autonomic nervous system activity have been associated with posttraumatic stress disorder (PTSD) development and maintenance and are potentially associated with trauma-focused cognitive behavioral therapy (TF-CBT) outcomes. We examined the role of salivary cortisol (sCort) and alpha-amylase (sAA) in PTSD and TF-CBT outcomes in German Armed Forces service members (N = 100). Participants categorized as PTSD patients (n = 39), previously deployed healthy controls (n = 33), and nondeployed healthy controls (n = 28) provided diurnal profiles of sCort and sAA; PTSD patients provided samples before, immediately after, and 3 months after an internet-based TF-CBT intervention. No group differences emerged regarding total daily sCort and sAA output or daily slopes, ps = .224-.897, fs = 0.05-0.24. Participants with PTSD demonstrated a significantly attenuated sCort awakening response compared to deployed, p = .021, d = 0.59, but not nondeployed controls, p = .918, d = 0.08. Moreover, a significantly steeper sAA awakening response emerged in PTSD patients, p = .034, d = 0.67, and deployed controls, p = .014, d = 0.80, compared to nondeployed controls. From pretreatment to posttreatment (n = 21) and posttreatment to follow-up (n = 14), stable sCort, ps = .282-.628, fs = 0.34-0.49, and sAA concentrations, ps = .068-.758, fs = 0.24-1.13 paralleled a nonsignificant treatment effect. Both PTSD and trauma exposure were associated with alterations in awakening responses, but further investigation is needed to determine whether the observed correspondence remains when PTSD symptoms significantly decline.

A Feasibility Study of the WHO Digital Mental Health Intervention Step-by-Step to Address Depression Among Chinese Young Adults

Background: Chinese young adults experience barriers to mental health treatment, including the lack of treatment providers and stigma around treatment seeking. Evidence-based digital mental health interventions are promising and scalable alternatives to face-to-face treatment for this population, but lack rigorous evidence to support scale-up in China. Aim: The study was a feasibility study for a large-scale RCT of Step-by-Step, a behavioral activation-based, mental health intervention to address depression and anxiety symptoms in Chinese young adults. It sought to assess feasibility of recruitment and of delivery of Step-by-Step in a University setting, to assess acceptability of the intervention, and to examine potential effectiveness. Method: An uncontrolled, feasibility trial was conducted to assess the feasibility and acceptability of Chinese Step-by-Step for Chinese University students with elevated depressive symptoms (PHQ-9 scores at or above 10) in Macao, China. Data was collected at two different time points (i.e., baseline and 8-weeks after baseline), administered via questionnaires embedded in an interventional mobile application. Participation rate and dropout rate were measured. Depressive and anxiety symptom severity, well-being, and self-defined stress were assessed. Satisfaction with the program was assessed using qualitative interviews. Results: A total of 173 students were screened, 22.0% (n = 38) were eligible, and 63.2% of them (n = 24) started the intervention. The dropout rate by post-test was 45.8%. Results from completers showed that Step-by-Step was potentially effective in reducing depressive and anxiety symptom severity, and self-defined stress. Students were generally satisfied with the program, but also offered suggestions for continued improvement. Qualitative feedback was reported within the RE-AIM framework, covering recruitment, effectiveness, adoption, implementation, and maintenance. Amendments to the program were made according to the feedback (e.g., adding notification for new session, modify the time zone). Conclusion: A minimally guided Step-by-Step protocol and the study procedure were successfully pilot tested for use for Chinese University students. The intervention was acceptable and no adverse events were reported. The results support the potential effectiveness and feasibility of a large-scale evaluation of the program.

Evaluating the Implementation of a Mental Health App for Overseas Filipino Workers in Macao China: A Mixed-Methods Study of Stakeholders' Perspectives

BACKGROUND

Overseas Filipino workers (OFWs) is one of the largest communities of international migrant workers. They face systemic barriers to fulfilling their health needs. The COVID-19 pandemic worsened this condition and provided a context to evaluate the utility of a digital mental health intervention delivered within a stepped-care model to address OFW mental health. Using an implementation science framework, this study aimed to evaluate stakeholders' perspectives on the implementation of Kumusta Kabayan, a mobile phone-based mental health app, for OFWs in Macao.

METHODS

A mixed-methods convergent design was used by conducting two parallel steps, including quantitative and qualitative measures. The quantitative data was collected from Filipino team members and local non-governmental organization (NGO) staff members (N = 12). The qualitative data were gathered from interviews with OFWs in Macao who used the app (N = 25; 80% females, 76% domestic workers).

RESULTS

From the online survey, the staff members of the local partner NGO and the Filipino team members strongly perceived that their organization could adapt Kumusta Kabayan to their program and generally evaluated that Kumusta Kabayan achieved its goal and was received well by OFWs. In the interviews, the OFW app users shared their experiences in using Kumusta Kabayan, which was thematically organized into six aspects of the participants' experience: (1) promotional channel and expectation; (2) when to use the app and in what language; (3) lessons learnt; (4) memorable aspects; (5) key facilitators and barriers; and (6) suggestions.

CONCLUSION

Kumusta Kabayan was well accepted and shows potential to be integrated into the existing support services for OFWs in Macao. This app has the promise of being scaled-up for OFWs in other countries by collaborating with local and overseas stakeholders. Lessons learnt from this evaluation could also be implemented in wider digital mental health services in different settings.

Does app-based unguided self-management improve mental health literacy, patient empowerment and access to care for people with mental health impairments? Study protocol for a randomised controlled trial

INTRODUCTION

Mental disorders pose a huge burden to both individuals and health systems. Symptoms and syndromes often remain undetected and untreated, resulting in comorbidity and chronification. Besides limited resources in healthcare systems, the treatment-gap is-to a large extent-caused by within-person barriers impeding early treatment seeking. These barriers include a lack of trust in professionals, fear of stigmatisation, or the desire to cope with problems without professional help. While unguided self-management interventions are not designed to replace psychotherapy, they may support early symptom assessment and recognition by reducing within-person barriers. Digital self-management solutions may also reduce inequalities in access to care due to external factors such as regional unavailability of services.

METHODS AND ANALYSIS

Approximately 1100 patients suffering from mild to moderate depressive, anxiety, sleep, eating or somatisation-related mental disorders will be randomised to receive either a low-threshold unguided digital self-management tool in the form of a transdiagnostic mental health app or care as usual. The primary outcomes will be mental health literacy, patient empowerment and access to care while secondary outcomes will be symptom distress and quality of life. Additional moderator and predictor variables are negative life events, personality functioning, client satisfaction, mental healthcare service use and application of self-management strategies. Data will be collected at baseline as well as 8 weeks and 6 months after randomisation. Data will be analysed using multiple imputation and analysis of covariance employing the intention-to-treat principle, while sensitivity analyses will be based on different multiple imputation parameters and a per-protocol analysis.

ETHICS AND DISSEMINATION

Approval was obtained from the Ethics Committee of the Faculty of Educational Science and Psychology at the Freie Universität Berlin. The results will be submitted to peer-reviewed specialised journals and presented at national and international conferences.

TRIAL REGISTERATION

The trial has been registered in the DRKS trial register (DRKS00022531);Pre-results.

[Autoptical display of the nasopharyngeal space in cases of suspected SARS-Co2 infection]

This paper deals with a dissection technique in order to display the nasopharyngeal space. It consists of a parafrontal saw cut through the base of the skull at the level of the sella turcica. In this way the ventral part of the nasopharyngeal space can be separated from the cervical spine and the posterior base of the skull within an anatomically preformed border region. Apart from a comprehensive overview of the nasopharyngeal space, this technique also enables samples to be correctly taken. The time required takes approximately 2-3 min, the external appearance of the deceased is not affected and the preparation of the body is not complicated.

Associations between oxytocin and vasopressin concentrations, traumatic event exposure and posttraumatic stress disorder symptoms: group comparisons, correlations, and courses during an internet-based cognitive-behavioural treatment

Background: Posttraumatic stress disorder (PTSD) is characterized by impairments in extinction learning and social behaviour, which are targeted by trauma-focused cognitive behavioural treatment (TF-CBT). The biological underpinnings of TF-CBT can be better understood by adding biomarkers to the clinical evaluation of interventions. Due to their involvement in social functioning and fear processing, oxytocin and arginine vasopressin might be informative biomarkers for TF-CBT, but to date, this has never been tested. Objective: To differentiate the impact of traumatic event exposure and PTSD symptoms on blood oxytocin and vasopressin concentrations. Further, to describe courses of PTSD symptoms, oxytocin and vasopressin during an internet-based TF-CBT and explore interactions between these parameters. Method: We compared oxytocin and vasopressin between three groups of active and former male service members of the German Armed Forces (n = 100): PTSD patients (n = 39), deployed healthy controls who experienced a deployment-related traumatic event (n = 33) and non-deployed healthy controls who never experienced a traumatic event (n = 28). PTSD patients underwent a 5-week internet-based TF-CBT. We correlated PTSD symptoms with oxytocin and vasopressin before treatment onset. Further, we analysed courses of PTSD symptoms, oxytocin and vasopressin from pre- to post-treatment and 3 months follow-up, as well as interactions between the three parameters. Results: Oxytocin and vasopressin did not differ between the groups and were unrelated to PTSD symptoms. PTSD symptoms were highly stable over time, whereas the endocrine parameters were not, and they also did not change in mean. Oxytocin and vasopressin were not associated with PTSD symptoms longitudinally. Conclusions: Mainly due to their insufficient intraindividual stability, single measurements of endogenous oxytocin and vasopressin concentrations are not informative biomarkers for TF-CBT. We discuss how the stability of these biomarkers might be increased and how they could be better related to the specific impairments targeted by TF-CBT.

Step-by-step: Feasibility randomised controlled trial of a mobile-based intervention for depression among populations affected by adversity in Lebanon

BACKGROUND

E-mental health interventions may help to bridge the mental health treatment gap. Evidence on their effectiveness is compelling in high-income countries. Not enough evidence has been generated on their use with communities affected by adversity in low- and middle-income countries. The World Health Organization (WHO), the National Mental Health Programme (NMMP) at Ministry of Public Health (MoPH) in Lebanon and other partners have adapted a WHO intervention called Step-by-Step for use with Lebanese and displaced people living in Lebanon. Step-by-Step is a minimally guided, internet-based intervention for adults with depression. In this study, a feasibility randomised controlled trial (RCT) and a qualitative process evaluation were conducted to explore the feasibility and the acceptability of the research methods, and the intervention, in preparation for two fully powered trials to assess the effectiveness and cost-effectiveness of Step-by-Step in Lebanon.

METHOD

Participants were recruited through social media. Inclusion criteria were: being able to understand and speak Arabic or English; access to an internet connected device; aged over 18; living in Lebanon; scores above cut-off on the Patient Health Questionnaire and the WHO Disability Assessment Schedule 2.0. Participants were randomly assigned to the intervention or enhanced care as usual. They completed post-assessments eight weeks after baseline, and follow-up assessments another three months later. Primary outcomes were depression and level of functioning, secondary outcomes were anxiety, post-traumatic stress, and well-being. Qualitative interviews were conducted to evaluate the feasibility and acceptability of the research procedures and the intervention.

RESULTS

A total of N = 138 participants, including 33 Syrians, were recruited and randomised into two equal groups. The dropout rate was higher in the control group (73% post- and 82% follow-up assessment) than in the intervention group (63% post- and 72% follow-up assessment). The intervention was perceived as relevant, acceptable and beneficial to those who completed it. Suggestions were made to further adapt the content and to make the intervention more engaging. Statistical analyses were conducted despite the small sample size. Complete cases analysis showed a statistically significant symptom reduction in depression, anxiety, disability, and post-traumatic stress, and statistically significant improvement in well-being and functioning. Intention-to-treat analysis revealed non-significant effects.

CONCLUSION

The research design, methods and procedures are feasible and acceptable in the context of Lebanon and can be applied in the RCTs. Preliminary findings suggest that Step-by-Step may be effective in reducing symptoms of depression and anxiety and improving functioning and well-being.

Evaluating the Effectiveness of an E-Mental Health Intervention for People Living in Lebanon: Protocol for Two Randomized Controlled Trials

Background

The lack of availability of evidence-based services for people exposed to adversity globally has led to the development of psychological interventions with features that will likely make them more scalable. The evidence for the efficacy of e-mental health from high-income countries is compelling, and the use of these interventions could be a way to increase the coverage of evidence-based psychological interventions in low- and middle-income countries. Step-by-Step is a brief (5-session) intervention proposed by the World Health Organization as an innovative approach to reducing the suffering and disability associated with depression.

Objective

This study aims to evaluate the effectiveness and cost-effectiveness of a locally adapted version of Step-by-Step with Syrian nationals (trial 1) and Lebanese nationals and other populations residing in Lebanon (trial 2).

Methods

This Step-by-Step trial involves 2 parallel, two-armed, randomized controlled trials comparing the e-intervention Step-by-Step to enhanced care as usual in participants with depressive symptoms and impaired functioning. The randomized controlled trials are designed and powered to detect effectiveness in 2 populations: Syrians in Lebanon (n=568) and other people residing in Lebanon (n=568; Lebanese nationals and other populations resident in Lebanon). The primary outcomes are depressive symptomatology (measured with the Patient Health Questionnaire-9) and functioning (measured with the World Health Organization Disability Assessment Scale 2.0). Secondary outcomes include anxiety symptoms, posttraumatic stress disorder symptoms, personalized measures of psychosocial problems, subjective well-being, and economic effectiveness. Participants are mainly recruited through online advertising. Additional outreach methods will be used if required, for example through dissemination of information through partner agencies and organizations. They can access the intervention on a computer, tablet, and mobile phone through a hybrid app. Step-by-Step has 5 sessions, and users are guided by trained nonspecialist “e-helpers” providing phone-based or message-based support for around 15 minutes a week.

Results

The trials were funded in 2018. The study protocol was last verified June 20, 2019 (WHO ERC.0002797) and registered with ClinicalTrials.gov (NCT03720769). The trials started recruitment as of December 9, 2019, and all data collection was completed in December 2020.

Conclusions

The Step-by-Step trials will provide evidence about the effectiveness of an e-mental health intervention in Lebanon. If the intervention proves to be effective, this will inform future scale-up of this and similar interventions in Lebanon and in other settings across the world.

Trial Registration

ClinicalTrials.gov NCT03720769; https://clinicaltrials.gov/ct2/show/NCT03720769

International Registered Report Identifier (IRRID)

DERR1-10.2196/21585

Screening accuracy of a 14-day smartphone ambulatory assessment of depression symptoms and mood dynamics in a general population sample: Comparison with the PHQ-9 depression screening

Introduction

Major depression affects over 300 million people worldwide, but cases are often detected late or remain undetected. This increases the risk of symptom deterioration and chronification. Consequently, there is a high demand for low threshold but clinically sound approaches to depression detection. Recent studies show a great willingness among users of mobile health apps to assess daily depression symptoms. In this pilot study, we present a provisional validation of the depression screening app Moodpath. The app offers a 14-day ambulatory assessment (AA) of depression symptoms based on the ICD-10 criteria as well as ecologically momentary mood ratings that allow the study of short-term mood dynamics.

Materials and methods

N = 113 Moodpath users were selected through consecutive sampling and filled out the Patient Health Questionnaire (PHQ-9) after completing 14 days of AA with 3 question blocks (morning, midday, and evening) per day. The psychometric properties (sensitivity, specificity, accuracy) of the ambulatory Moodpath screening were assessed based on the retrospective PHQ-9 screening result. In addition, several indicators of mood dynamics (e.g. average, inertia, instability), were calculated and investigated for their individual and incremental predictive value using regression models.

Results

We found a strong linear relationship between the PHQ-9 score and the AA Moodpath depression score (r = .76, p < .001). The app-based screening demonstrated a high sensitivity (.879) and acceptable specificity (.745). Different indicators of mood dynamics covered substantial amounts of PHQ-9 variance, depending on the number of days with mood data that were included in the analyses.

Discussion

AA and PHQ-9 shared a large proportion of variance but may not measure exactly the same construct. This may be due to the differences in the underlying diagnostic systems or due to differences in momentary and retrospective assessments. Further validation through structured clinical interviews is indicated. The results suggest that ambulatory assessed mood indicators are a promising addition to multimodal depression screening tools. Improving app-based AA screenings requires adapted screening algorithms and corresponding methods for the analysis of dynamic processes over time.

A digital mental health intervention to reduce depressive symptoms among overseas Filipino workers: protocol for a pilot hybrid type 1 effectiveness-implementation randomized controlled trial

Background

The current pilot randomized controlled trial (RCT) protocol will comprehensively describe the implementation of a culturally adapted Filipino version of the World Health Organization Step-by-Step (SbS-F) program, unguided online psychological intervention for people with depression based on behavioral activation, among overseas Filipino workers (OFWs) in Macao (Special Administrative Region). The main objective of this pilot study is to explore the preliminary effectiveness of the SbS-F program to decrease participant-reported depressive symptoms compared to enhanced care as usual (ECAU); and the secondary objectives are to explore the preliminary effectiveness of the SbS-F to decrease participant-reported anxiety symptoms and improve wellbeing, and to evaluate the potential for SbS-F implementation in real-world settings.

Methods

This trial will follow an effectiveness-implementation hybrid type 1 trial design and utilize the Reach, Efficacy/Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework to accelerate the translation of clinical research into more effective implementation strategies and policies. Participants will be randomized 1:1 to control and treatment groups. Control group participants will receive ECAU that consists of brief depression psychoeducation and referral to local community partners. Treatment group participants will receive a 5-session of digital intervention through a mobile phone application. The primary outcome (depression) and psychological secondary outcomes (anxiety symptoms and wellbeing) will be measured using validated instruments. To evaluate study implementation, an embedded mixed-methods design will be used to collect data from various stakeholders. Data then will be analyzed using intention to treat principle and reported following the Consolidated Standards of Reporting Trials (CONSORT) guideline.

Discussion

This study will provide important new knowledge about the preliminary effectiveness of SbS-F, a mobile application, as a digital mental health intervention and its scalability. If SbS-F shows positive results among OFWs in Macao, it has strong potential to be used by OFWs in other countries that may also experience depression and difficulty accessing mental health services.

Trial registration

Prospective registration, Chinese Clinical Trial Registry (ChiCTR2000034959) on 26/07/2020.

Cultural adaptation of Hap-pas-Hapi, an internet and mobile-based intervention for the treatment of psychological distress among Albanian migrants in Switzerland and Germany

BACKGROUND

Internet- and mobile-based mental health interventions have the potential to narrow the treatment gap in ethnic groups. Little evidence exists on the cultural adaptation of such interventions. Cultural adaptation of evidence-based interventions distinguishes between surface and deep structure adaptation. Surface refers to matching materials (e.g., illustrations, language) or methods of treatment delivery to the target population, whereas deep structure adaptation considers cultural concepts of distress (CCD). So far, CCD have only been considered to a limited extent in cultural adaptation of psychological interventions, and there is a lack of well documented adaptation procedures.

AIMS

With a cross-disciplinary and mixed-method approach, following a new conceptual framework for cultural adaptation of scalable psychological interventions, this study aimed to develop both surface and deep structure adaptations of an internet- and mobile-based intervention called Hap-pas-Hapi for the treatment of psychological distress among Albanian migrants in Switzerland and Germany.

METHODS

A qualitative ethnopsychological study was conducted to examine the target group's CCD. Focus group discussions, an online survey, and individual key informant interviews were utilised to evaluate the original intervention, adaptation drafts and the final adapted intervention. A reporting system was developed to support the decision-making process and to report all adaptations in a transparent and replicable way.

RESULTS

The ongoing involvement of target population key informants provided valuable feedback for the development of a more person-centred intervention, which might enhance treatment acceptance, motivation and adherence.

DISCUSSION

This study provides empirical and theory-based considerations and suggestions for future implementation that may foster acceptability and effectiveness of culturally adapted evidence-based interventions.

Evaluation of an internet-based intervention for service members of the German armed forces with deployment-related posttraumatic stress symptoms

BACKGROUND

The present study was designed to evaluate the efficacy of a therapist-guided internet-based cognitive-behavioral therapy (iCBT) intervention for service members of the German Armed Forces with posttraumatic stress disorder (PTSD). The iCBT was adapted from Interapy, a trauma-focused evidence-based treatment based on prolonged exposure and cognitive restructuring. It lasted for 5 weeks and included 10 writing assignments (twice a week). The program included a reminder function if assignments were overdue, but no multimedia elements. Therapeutic written feedback was provided asynchronously within one working day.

METHODS

Male active and former military service members were recruited from the German Armed Forces. Diagnoses were assessed with the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) and the Mini-International Neuropsychiatric Interview. Psychopathology was assessed at pre-treatment, post-treatment, and 3-month follow-up. Severity of PTSD was the primary outcome and anxiety was the secondary outcome. Participants were randomly allocated to a treatment group that received iCBT immediately or to a waitlist group that received iCBT after 6 weeks. Due to the overall small sample size (n = 37), the two groups were collapsed for the statistical analyses. Change during the intervention period was investigated using latent-change score models.

RESULTS

Improvements in the CAPS-5 were small and not statistically significant. For anxiety, small significant improvements were observed from pre- to follow-up assessment. The dropout rate was 32.3%.

CONCLUSIONS

The low treatment utilization and the high dropout rate are in line with previous findings on treatment of service members. The interpretation of the current null results for the efficacy of iCBT is limited due to the small sample size, however for military samples effect estimates were also smaller in other recent studies. Our results demonstrate the need to identify factors influencing treatment engagement and efficacy in veterans.

TRIAL REGISTRATION

Australian Clinical Trials Registry ACTRN12616000956404.

Effectiveness of a peer-refugee delivered psychological intervention to reduce psychological distress among adult Syrian refugees in the Netherlands: study protocol

Background: Syrian refugees face multiple hardships and adversities which put them at risk for the development of mental health problems. However, access to adequate mental health care in host countries is limited. The WHO has developed Problem Management Plus (PM+), a brief, scalable psychological intervention, delivered by non-specialist helpers, that addresses common mental disorders in people affected by adversity. This study is part of the STRENGTHS project, that aims to evaluate peer-refugee delivered psychological interventions for Syrian refugees in Europe and the Middle East. Objective: To evaluate the effectiveness and cost-effectiveness of the peer-refugee delivered PM+ intervention among Syrian refugees with elevated levels of psychological distress in the Netherlands. Methods: PM+ will be tested in a randomized controlled trial (RCT) among Arabic-speaking Syrian refugees in the Netherlands aged 18 years and above with self-reported psychological distress (Kessler Psychological Distress Scale; K10 >15) and impaired daily functioning (WHO Disability Assessment Schedule; WHODAS 2.0 >16). Participants (N = 380) will be randomized into care as usual with PM+ (CAU/PM+, n = 190) or CAU only (CAU, n = 190). Baseline, 1-week post-intervention, and 3-month and 12-month follow-up assessments will be conducted. Primary outcomes are symptoms of depression and anxiety. Secondary outcomes are functional impairment, posttraumatic stress disorder symptoms, self-identified problems, anger, health and productivity costs, and hair cortisol concentrations. A process evaluation will be carried out to evaluate treatment dose, protocol fidelity and stakeholder views on barriers and facilitators to implementing PM+. Results and Conclusions: PM+ has proved effectiveness in other populations and settings. After positive evaluation, the adapted manual and training materials for individual PM+ will be made available through the WHO to encourage further replication and scaling up. Trial registration: Trial registration Dutch Trial Registry, NL7552, registered prospectively on March 1, 2019. Medical Ethics Review Committee VU Medical Center Protocol ID 2017.320, 7 September 2017.

User-Centered App Adaptation of a Low-Intensity E-Mental Health Intervention for Syrian Refugees

Introduction: The aim of this study is to describe the initial stages of the iterative and user-centered mobile mental health adaptation process of Step-by-Step (SbS), a modularized and originally web-based e-mental health intervention developed by the World Health Organization (WHO). Given the great need for improving the responsiveness and accessibility of health systems in host countries, the EU-funded STRENGTHS consortium studies the adaptation, implementation and scaling-up of SbS for Syrian refugees in Germany, Sweden and Egypt. Using early prototyping, usability testing and identification of barriers to implementation, the study demonstrates a user-centered process of contextual adaptation to the needs and expectations of Syrian refugees. Materials and Methods: N = 128 adult Syrian refugees residing in Germany, Sweden and Egypt took part in qualitative assessments. Access, usage, and potential barriers regarding information and communication technologies (ICTs) were assessed in free list interviews. Interactive prototypes of the app were presented in key informant interviews and evaluated on usability, user experience and dissemination strategies. Focus groups were conducted to verify the results. The interview protocols were analyzed using inductive and deductive thematic analysis. Results: The use of digital technologies was found to be widespread among Syrian refugees. Technical literacy and problems with accessing the internet were common barriers. The majority of the respondents reacted positively to the presented app prototypes, stressing the potential health impact of the intervention (n = 28; 78%), its flexibility and customizability (n = 19; 53%) as well as the easy learnability of the app (n = 12; 33%). Aesthetic components (n = 12; 33%) and the overall length and pace of the intervention sessions (n = 9; 25%) were criticized in regard to their negative impact on user motivation. Acceptability, credibility, and technical requirements were identified as main barriers to implementation. Discussion: The study provided valuable guidance for adapting the app version of SbS and for mobile mental health adaptation in general. The findings underline the value of contextual adaptation with a focus on usability, user experience, and context specific dissemination strategies. Related factors such as access, acceptability and adherence have major implications for scaling-up digital interventions.

Transgenerational trauma in a post-conflict setting: Effects on offspring PTSS/PTSD and offspring vulnerability in Cambodian families

We assessed transgenerational effects of maternal traumatic exposure, posttraumatic stress symptoms and posttraumatic stress disorder on trauma-related symptoms in Cambodian offspring born after the genocidal Khmer Rouge Regime. We conducted a randomized cross-sectional study. N=378 mothers from 4 provinces of the country and one of each of their grown-up children were interviewed. Lifetime traumatic exposure was determined using a context-adapted event list. Present posttraumatic stress symptoms and a potential posttraumatic stress disorder were assessed using the civilian version of the Posttraumatic Stress Disorder Checklist. We found no indication of transgenerational effects that were directly related to maternal traumatic exposure, posttraumatic stress symptoms or posttraumatic stress disorder. Instead, a gender-specific moderating effect was found. Individual traumatic exposure had a stronger effect on posttraumatic stress symptoms in daughters, the higher the mother's lifetime traumatic exposure. There is evidence of an interaction between lifetime traumatic exposure of mothers and their offspring that can be interpreted as an increased vulnerability to symptoms of posttraumatic stress in daughters. The mechanisms of transgenerational trauma in the Cambodian context require further research, as learning from previous conflicts will be instructive when addressing the pressing humanitarian needs of today's world.

Strengthening mental health care systems for Syrian refugees in Europe and the Middle East: integrating scalable psychological interventions in eight countries

The crisis in Syria has resulted in vast numbers of refugees seeking asylum in Syria's neighbouring countries as well as in Europe. Refugees are at considerable risk of developing common mental disorders, including depression, anxiety, and posttraumatic stress disorder (PTSD). Most refugees do not have access to mental health services for these problems because of multiple barriers in national and refugee specific health systems, including limited availability of mental health professionals. To counter some of challenges arising from limited mental health system capacity the World Health Organization (WHO) has developed a range of scalable psychological interventions aimed at reducing psychological distress and improving functioning in people living in communities affected by adversity. These interventions, including Problem Management Plus (PM+) and its variants, are intended to be delivered through individual or group face-to-face or smartphone formats by lay, non-professional people who have not received specialized mental health training, We provide an evidence-based rationale for the use of the scalable PM+ oriented programmes being adapted for Syrian refugees and provide information on the newly launched STRENGTHS programme for adapting, testing and scaling up of PM+ in various modalities in both neighbouring and European countries hosting Syrian refugees.