Psychological therapies for the treatment of mental disorders in low- and middle-income countries affected by humanitarian crises

Fostering engagement using a wearable for self-tracking assisted psychotherapy with refugees diagnosed with complex PTSD: a feasibility pilot study

Background

To address the unique challenges faced by refugees diagnosed with complex post-traumatic stress disorder (CPTSD), psychotherapy needs to be personalized. The integration of self-tracking instruments into therapy offers a promising approach to personalizing treatment. This feasibility pilot study develops and explores a preliminary self-tracking assisted treatment concept using a wearable self-tracking instrument called the One Button Tracker (OBT). The OBT is a single-purpose self-tracking instrument, designed to track subjectively experienced phenomena.

Methods

The feasibility pilot study adopted a participatory action research design, involving close collaboration between two therapists, two refugees diagnosed with CPTSD, and a research team. Quantitative data was collected from the OBT and qualitative data consisted of semi-structured post-treatment interviews and session logbooks. Reflexive thematic analysis was used for the interpretation of interview data. Quantitative data was used descriptively.

Results

The integration of OBT into psychotherapy with refugees was found to be feasible, marked by consistent high engagement as seen in the self-tracking data. Five themes were generated from the interview analyses, across two contexts: therapy sessions (navigating between precision and alliance with the OBT, and data usefulness in therapy) and daily life (paradox of awareness, OBT as a sign of treatment, and following the Doctor's orders).

Conclusion

This feasibility pilot study illustrates the feasibility and therapeutic potential for integrating the OBT into psychotherapy for refugees with CPTSD to enhance engagement and personalization. The findings emphasize the necessity of an adaptive, personalized approach, vigilance regarding potential risks, and consideration of cultural factors. Further research is needed to refine this novel therapeutic approach.

Integrated programs for common mental illnesses within primary care and community settings in Latin America: a scoping review of components and implementation strategies

Integrated programs for common mental illnesses are evidence-informed practices yet to be routinely implemented in Latin America. It synthesizes the literature on integrated programs for common mental illnesses (anxiety, depression, and posttraumatic stress disorder) in Latin American primary care and community settings. It maps program components (the 'what') to the collaborative care model core components and implementation strategies (the 'how') to the Expert Recommendations for Implementing Change (ERIC) taxonomy. Results from 18 programs across six countries (Belize, Brazil, Chile, Colombia, Mexico, Peru) show wide heterogeneity in component and strategy combinations. Overall, provider-level components and strategies were more common than family- or community-level ones. 'Team-based care' was the most commonly reported component, and 'family/user engagement' the least. The most common implementation strategy was 'supporting clinicians,' while 'changing infrastructure' was the least. Programs commonly addressed depression and only four followed experimental designs. We found limited evidence on the potential mechanisms of integrated program components and strategies.

Post-traumatic stress disorder-induced behavioral modulation by the medial septum-medial habenula neural pathway

Post-traumatic stress disorder (PTSD) is characterized by anxiety, excessive fear, distress, and weakness as symptoms of a psychiatric disorder. However, the mechanism associated with its symptoms such as anxiety-like behaviors is not well understood. It is aimed to investigate the underlying mechanisms of the medial septum (MS)-medial habenula (MHb) neural circuit modulating the anxiety-like behaviors of PTSD mice through in vivo fiber photometry recording, optogenetics, behavioral testing by open-field and elevated plus maze, fluorescent gold retrograde tracer technology, and viral tracer technology. In the mouse PTSD model induced by compound stress consisting of single-prolonged stress combined with electrical foot shock, the average peak value of the Ca2 + signals in both the MHb and MS glutamatergic neurons significantly increased. The anterograde and retrograde tracer markers were used to indicate the possible connection between MS and MHb via glutamatergic neural pathway. After the optogenetic manipulation of the MS-MHb pathway in mice with PTSD, if the MS-MHb glutamatergic pathway was inhibited, anxiety was relieved based on changes in the various indices of behavioral experiments in mice with PTSD. Moreover, the heart rate of mice decreased. In conclusion, both glutamatergic neurons located in MS and MHb can be engaged in the development of PTSD anxiety-like behavior, and the MS-MHb can be related to the regulation of PTSD anxiety-like behavior and cardiac function through the glutamatergic neural pathway.

War exposure, daily stressors, and mental health 15 years on: implications of an ecological framework for addressing the mental health of conflict-affected populations

AIMS

Fifteen years ago, we published an article in Social Science and Medicine seeking to resolve the contentious debate between advocates of two very different frameworks for understanding and addressing the mental health needs of conflict-affected populations. The two approaches, which we labelled trauma-focused and psychosocial, reflect deeply held beliefs about the causes and nature of distress in war-affected communities. Drawing on the burgeoning literature on armed conflict and mental health, the reports of mental health and psychosocial support (MHPSS) staff in the field, and on research on the psychology and psychophysiology of stress, we proposed an integrative model that drew on the strengths of both frameworks and underscored their essential complementarity. Our model includes two primary pathways by which armed conflict impacts mental health: directly, through exposure to war-related violence and loss, and indirectly, through the harsh conditions of everyday life caused or exacerbated by armed conflict. The mediated model we proposed draws attention to the effects of stressors both past (prior exposure to war-related violence and loss) and present (ongoing conflict, daily stressors), at all levels of the social ecology; for that reason, we have termed it an ecological model for understanding the mental health needs of conflict-affected populations.

METHODS

In the ensuing 15 years, the model has been rigorously tested in diverse populations and has found robust support. In this paper, we first summarize the development and key tenets of the model and briefly review recent empirical support for it. We then discuss the implications of an ecological framework for interventions aimed at strengthening mental health in conflict-affected populations.

RESULTS

We present preliminary evidence suggesting there has been a gradual shift towards more ecological (i.e., multilevel, multimodal) programming in MHPSS interventions, along the lines suggested by our model as well as other conceptually related frameworks, particularly public health.

CONCLUSIONS

We reflect on several gaps in the model, most notably the absence of adverse childhood experiences. We suggest the importance of examining early adversity as both a direct influence on mental health and as a potential moderator of the impact of potentially traumatic war-related experiences of violence and loss.

A Scoping Review of Factors Associated with HIV Acquisition in the Context of Humanitarian Crises

Humanitarian crises-natural or human-made events that can threaten communities' health, safety, security, and well-being-may affect the HIV epidemic dynamics. Common aspects of humanitarian crises such as poverty, powerlessness, disruptions to the health systems, and social instability can contribute to a person's vulnerability to HIV infection through increased risk behaviors and limited access to health services. Guided by the Joanna Briggs Institute methodology for scoping reviews and the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping Reviews (PRISMA-ScR) reporting guidelines, we conducted a scoping review of literature published in English between January 1990 and March 2022 to characterize the global evidence of modifiable and non-modifiable factors for HIV acquisition in the context of humanitarian crises. We systematically searched, screened, and synthesized literature from MEDLINE, Embase, Global Health (all accessed via Ovid), and Scopus, and also grey literature through websites of humanitarian agencies and relevant non-government organizations, the International AIDS Society's abstract databases, and Google Scholar. We considered studies presenting empirical data on HIV prevalence, incidence, or risk factors in humanitarian crises-affected populations, including refugees, asylum seekers, and internally displaced persons. Forty-nine studies met the inclusion criteria. The majority of studies were quantitative (n = 43, 87.8%) and cross-sectional (n = 37, 75.5%) in design. Most were single-country studies (n = 43, 87.8%) and conducted in Sub-Saharan Africa (n = 31, 63.3%). We identified 5 non-modifiable factors for HIV acquisition (i.e., age, gender, location, place of birth or origin, and ethnicity) and 60 modifiable factors that we further classified into five categories, namely 18 policy and structural, 9 sociocultural, 11 health and mental health, 16 sexual practice, and 6 humanitarian crisis-related traumatic event factors. Within the modifiable categories, factors that were most often investigated were education level, marital status, sexually transmitted infection diagnosis, condom use, and experience of rape or sexual trauma, respectively. Informed by the findings, we applied the social-ecological model to map the identified multidimensional factors associated with HIV acquisition at the levels of individual, social and sexual networks, community, public policy, and the context of humanitarian crises. The current review provides a comprehensive, global analysis of the available evidence on HIV prevalence, incidence, and risk factors in humanitarian crises and implications for potential programs and research. Future research is warranted to further understand the directionality of the non-modifiable and modifiable factors affecting HIV acquisition, and the multilevel barriers and facilitators to the uptake of HIV prevention strategies in the context of humanitarian crises. Such research can generate actionable evidence to inform the development of ethical, trauma-informed, and culturally appropriate HIV prevention interventions in humanitarian settings.

Combining a guided self-help and brief alcohol intervention to improve mental health and reduce substance use among refugee men in Uganda: a cluster-randomized feasibility trial

Evidence on the effectiveness and implementation of mental health and psychosocial support (MHPSS) interventions for men in humanitarian settings is limited. Moreover, engagement and retention of men in such interventions has been challenging. Adaptations may therefore be required to improve the appropriateness and acceptability of these interventions for men. This study conducted formative research and examined the feasibility of combining an MHPSS intervention, Self-Help Plus, with a brief intervention to reduce harmful alcohol use among refugee men in Uganda. We conducted a cluster randomized feasibility trial comparing the combined alcohol intervention and Self-Help Plus, Self-Help Plus alone and enhanced usual care. Participants were 168 South Sudanese refugee men in Rhino Settlement who reported moderate or high levels of psychological distress. Session attendance was adequate: all sessions had at least 69% of participants present. Participant outcome measures, including symptoms of psychological distress, functional impairment, self-defined problems, depressive symptoms, post-traumatic stress symptoms, overall substance use risk, substance specific risk (alcohol, cannabis, stimulants and sedatives) and well-being, were sensitive to change. A combined approach to addressing mental health and alcohol use appears feasible among men in refugee settings, but further research is needed to examine the effectiveness of combined interventions among men.

Intervention impact on quality of life in Ukrainians with post-traumatic stress disorder

BACKGROUND

The World Health Organization (WHO) estimates the prevalence of Post-Traumatic Stress Disorder (PTSD) among the population of Ukraine at approximately 25%. Almost half of the population, or 57%, is at risk of developing PTSD.

METHODS

This longitudinal study included an assessment of QoL dynamics among 109 Ukrainian civilians with PTSD, before and after receiving complex treatment during the Russian-Ukrainian conflict. Clinical, anamnesis, socio-demographic, psychological, and statistical methods were employed. To assess quality of life, we used the Ukrainian versions of the 36-item survey (SF-36) and European Quality Assessment Questionnaire in 5 Regions (EQ-5D-5L) questionnaires.

RESULTS

On the 30th day after the complex treatment, the following parameters showed significant improvement compared to the 1st day: physical functioning (48 vs 5), general perception of health (56 vs 52), and synthetic index associated with physical health (34 vs 29). On the 90th day, there was additional improvement in body pain, vitality, and mental health compared to the 30th day. By the 180th day, the score in general health reached statistical significance at 76. According to items characterizing mental health, it was possible to achieve reliable improvement in overall mental health 100, p = 0.0049 only on the 180th day of the study.

CONCLUSIONS

Normalization of mental health indicators in patients with PTSD occurs more slowly than physical indicators. Therefore, it requires long-term active monitoring of this category of patients during the post-rehabilitation period. In particular, special attention should be paid to psychological aspects even when somatic recovery has been achieved.

In-person vs mobile app facilitated life skills education to improve the mental health of internally displaced persons in Nigeria: protocol for the RESETTLE-IDPs cluster randomized hybrid type 2 effectiveness-implementation trial

BACKGROUND

Internally displaced persons (IDPs) in Nigeria face a high burden of mental health disorders, with limited access to evidence-based, culturally relevant interventions. Life skills education (LSE) is a promising approach to promote mental health and psychosocial well-being in humanitarian settings. This study aims to evaluate the effectiveness and implementation of a culturally adapted LSE program delivered through in-person and mobile platforms among IDPs in Northern Nigeria.

METHODS

This cluster-randomized hybrid type 2 effectiveness-implementation trial will be conducted in 20 IDP camps or host communities in Maiduguri, Nigeria. Sites will be randomly assigned to receive a 12-week LSE program delivered either through in-person peer support groups or WhatsApp-facilitated mobile groups. The study will recruit 500 participants aged 13 years and older. Intervention effectiveness outcomes include the primary outcome of change in post-traumatic stress disorder (PTSD) symptoms assessed using the PCL-5 scale, and secondary outcomes of depression, anxiety, well-being, and life skills acquisition. Implementation outcomes will be assessed using the Acceptability of Intervention Measure (AIM), Intervention Appropriateness Measure (IAM), and Feasibility of Intervention Measure (FIM). Both sets of outcomes will be compared between the in-person and mobile delivery groups. Quantitative data will be analyzed using mixed-effects linear regression models, while qualitative data will be examined through reflexive thematic analysis. The study will be guided by the Reach-Effectiveness-Adoption-Implementation-Maintenance (RE-AIM) framework.

DISCUSSION

The RESETTLE-IDPs study addresses key gaps in the evidence base on mental health interventions for conflict-affected populations. It focuses on underserved IDP populations, evaluates the comparative effectiveness of in-person and mobile-delivered LSE, and incorporates implementation science frameworks to assess contextual factors influencing adoption, fidelity, and sustainability. The study employs a community-based participatory approach to enhance cultural relevance, acceptability, and ownership. Findings will inform the development and scale-up of evidence-based, sustainable mental health interventions for IDPs in Nigeria and other humanitarian contexts.

TRIAL SPONSOR

Dalhousie University, 6299 South St, Halifax, NS B3H 4R2, Canada.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT06412679  Registered 15 May 2024.

Tipping the scales for global mental health: A summary of the Presidential Panel at the 39th Annual Meeting of the International Society for Traumatic Stress Studies

In the past decade, there has been an increasing focus within scientific research on how to assist people affected by the negative consequences of trauma and crises around the globe. As many countries struggle with a lack of resources to deliver mental health interventions, scalable strategies have been developed to help more people in need. These scalable strategies were the theme of the 39th annual meeting of the International Society for Traumatic Stress Studies (ISTSS). The presidential panel, chaired by Marit Sijbrandij during her ISTSS presidency, brought together a group of experts in the field of scalable interventions: Kenneth Carswell, Syed Usman Hamdani, Judy Bass, and Eirini Karyotaki. The panel highlighted the current state of the evidence on scalable interventions for adults and children and outlined important next steps for research and implementation. These recommendations include further improving the availability of, and evidence for, scalable interventions through increased training and sustained funding; conducting more studies in underrepresented samples, such as children and adolescents; and promoting open access availability of research findings worldwide. In this paper, we provide an overview of the topics discussed in the panel as well as the key takeaways.

Interventions targeting social determinants of mental disorders and the Sustainable Development Goals: a systematic review of reviews

Globally, mental disorders account for almost 20% of disease burden and there is growing evidence that mental disorders are socially determined. Tackling the United Nations Sustainable Development Goals (UN SDGs), which address social determinants of mental disorders, may be an effective way to reduce the global burden of mental disorders. We conducted a systematic review of reviews to examine the evidence base for interventions that map onto the UN SDGs and seek to improve mental health through targeting known social determinants of mental disorders. We included 101 reviews in the final review, covering demographic, economic, environmental events, neighborhood, and sociocultural domains. This review presents interventions with the strongest evidence base for the prevention of mental disorders and highlights synergies where addressing the UN SDGs can be beneficial for mental health.

Comparing the effectiveness of narrative therapy and EMDR-GTEP protocols in the treatment of post-traumatic stress in children exposed to humanitarian crises

Background

The mental health of children living in humanitarian crisis situations is a major issue. Post-traumatic stress disorder (PTSD) causes great psychological suffering and has negative consequences on children's development. The aim of the study was to analyze retrospective data collected in a mental health and psychosocial support program for children in the Central African Republic, and to compare results of two trauma-focused treatment interventions: the narrative protocol Action contre la Faim (ACF)/KONO; and the EMDR-based Group Trauma Episode Protocol (G-TEP). Both protocols are proposed in a group setting and led by paraprofessionals.

Methods

In the program, 884 children attended a psychoeducation session and after that, 661 children (290 for ACF/KONO and 371 for G-TEP) benefited from all treatment sessions. PTSD was measured by the Children's Revised Impact of Event Scale (CRIES-8). General distress was measured by the Child Psychosocial Distress Screener (CPDS). Data were collected before and after treatment, and measured 5 months after the end of treatment for 185 children.

Results

Participants in the ACF/KONO group show a significant reduction on CRIES-8 (t = 44.8; p < 0.001, effect size = 2.63) and CPDS (t = 38.2; p < 0.001, effect size = 2.24). Participants to the G-TEP protocol show a significant effect with reduced scores on the CRIES-8 (t = 49.2; p < 0.001, effect size = 2.55) and CPDS (t = 57.2; p < 0.001, effect size = 2.97). A Student's t-test comparing the ACF/KONO and G-TEP groups shows no significant difference between the two types of treatment between pre- and post-treatment CRIES-8 scores (t = 1.744; p = 0.514, effect size = 0.040) and CPDS scores (t = 1.688; p = 0.092, effect size = 0.323). An analysis of the follow-up data for the 185 children shows that the effects of both protocols are maintained over time with mean scores after treatment and follow-up below the clinical cut-off for both CPDS (<8) and CRIES-8 (<17).

Conclusions

Both protocols have been shown to be effective in reducing traumatic symptoms in children exposed to conflict; they can be conducted by paraprofessionals and used in humanitarian crisis situations.

Psychological and social interventions for the promotion of mental health in people living in low- and middle-income countries affected by humanitarian crises

BACKGROUND

Because of wars, conflicts, persecutions, human rights violations, and humanitarian crises, about 84 million people are forcibly displaced around the world; the great majority of them live in low- and middle-income countries (LMICs). People living in humanitarian settings are affected by a constellation of stressors that threaten their mental health. Psychosocial interventions for people affected by humanitarian crises may be helpful to promote positive aspects of mental health, such as mental well-being, psychosocial functioning, coping, and quality of life. Previous reviews have focused on treatment and mixed promotion and prevention interventions. In this review, we focused on promotion of positive aspects of mental health.

OBJECTIVES

To assess the effects of psychosocial interventions aimed at promoting mental health versus control conditions (no intervention, intervention as usual, or waiting list) in people living in LMICs affected by humanitarian crises.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, and seven other databases to January 2023. We also searched the World Health Organization's (WHO) International Clinical Trials Registry Platform and ClinicalTrials.gov to identify unpublished or ongoing studies, and checked the reference lists of relevant studies and reviews.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing psychosocial interventions versus control conditions (no intervention, intervention as usual, or waiting list) to promote positive aspects of mental health in adults and children living in LMICs affected by humanitarian crises. We excluded studies that enrolled participants based on a positive diagnosis of mental disorder (or based on a proxy of scoring above a cut-off score on a screening measure).

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were mental well-being, functioning, quality of life, resilience, coping, hope, and prosocial behaviour. The secondary outcome was acceptability, defined as the number of participants who dropped out of the trial for any reason. We used GRADE to assess the certainty of evidence for the outcomes of mental well-being, functioning, and prosocial behaviour.

MAIN RESULTS

We included 13 RCTs with 7917 participants. Nine RCTs were conducted on children/adolescents, and four on adults. All included interventions were delivered to groups of participants, mainly by paraprofessionals. Paraprofessional is defined as an individual who is not a mental or behavioural health service professional, but works at the first stage of contact with people who are seeking mental health care. Four RCTs were carried out in Lebanon; two in India; and single RCTs in the Democratic Republic of the Congo, Jordan, Haiti, Bosnia and Herzegovina, the occupied Palestinian Territories (oPT), Nepal, and Tanzania. The mean study duration was 18 weeks (minimum 10, maximum 32 weeks). Trials were generally funded by grants from academic institutions or non-governmental organisations. For children and adolescents, there was no clear difference between psychosocial interventions and control conditions in improving mental well-being and prosocial behaviour at study endpoint (mental well-being: standardised mean difference (SMD) 0.06, 95% confidence interval (CI) -0.17 to 0.29; 3 RCTs, 3378 participants; very low-certainty evidence; prosocial behaviour: SMD -0.25, 95% CI -0.60 to 0.10; 5 RCTs, 1633 participants; low-certainty evidence), or at medium-term follow-up (mental well-being: mean difference (MD) -0.70, 95% CI -2.39 to 0.99; 1 RCT, 258 participants; prosocial behaviour: SMD -0.48, 95% CI -1.80 to 0.83; 2 RCT, 483 participants; both very low-certainty evidence). Interventions may improve functioning (MD -2.18, 95% CI -3.86 to -0.50; 1 RCT, 183 participants), with sustained effects at follow-up (MD -3.33, 95% CI -5.03 to -1.63; 1 RCT, 183 participants), but evidence is very uncertain as the data came from one RCT (both very low-certainty evidence). Psychosocial interventions may improve mental well-being slightly in adults at study endpoint (SMD -0.29, 95% CI -0.44 to -0.14; 3 RCTs, 674 participants; low-certainty evidence), but they may have little to no effect at follow-up, as the evidence is uncertain and future RCTs might either confirm or disprove this finding. No RCTs measured the outcomes of functioning and prosocial behaviour in adults.

AUTHORS' CONCLUSIONS

To date, there is scant and inconclusive randomised evidence on the potential benefits of psychological and social interventions to promote mental health in people living in LMICs affected by humanitarian crises. Confidence in the findings is hampered by the scarcity of studies included in the review, the small number of participants analysed, the risk of bias in the studies, and the substantial level of heterogeneity. Evidence on the efficacy of interventions on positive mental health outcomes is too scant to determine firm practice and policy implications. This review has identified a large gap between what is known and what still needs to be addressed in the research area of mental health promotion in humanitarian settings.

A Study on the Psychological Experience and Influential Factors of Pregnant Women Who Decided Elective Caesarean Section After Public Health Emergencies - A Cross-Sectional Survey

Background

The COVID-19 pandemic used to be a major public health emergency which affected people worldwide, and it affected individuals' body, mood, work and lifestyle to some extent. The pregnant woman affected by the unstable hormone will be more sensitive than normal ones. Long-term depression and anxiety could feedback on their body and lead to a host of pregnancy complications. Because pregnant women who choose cesarean section are awake during the perioperative period, to ensure safety, the degree of cooperation about psychology and behavior is relatively high, so we should know the psychological state of such a group of people.

Objective

This study aims to explore psychological experience and influential factors of pregnant women who decided elective caesarean section after the COVID-19 pandemic.

Methods

This is a cross-sectional study carried out in a hospital in Shanghai, according to the inclusion and exclusion criteria, we selected pregnant women who selected elective cesarean section as the study objects, all participants provided informed consent and completed questionnaires, including sociodemographic questionnaire, Generalized Anxiety Disorder scale (GAD-7) and General Well-Being Schedule (GWBS). Software SPSS 23.0 was used to analyze and explore the influencing factors.

Results

Eligible 595 questionnaires were included in the study, the mean score of GAD-7 was 4.855 ± 3.254 and 90.699 ± 13.807 of GWBS. Generalized linear regression analysis revealed several factors that were statistically significant with the two scales, including birthplace, average monthly income, number of abortion and pregnancy complication (p < 0.01).

Conclusion

The COVID-19 infection status and symptoms around infection have no statistical difference in anxiety level and general well-being after they experience the COVID-19 pandemic. However, through this study, we found some influencing factors that worth further exploration. In the future, we will expand the sample size to explore the different situation of multi-center, and we hope provide psychological nursing interventions based on existing results to offer a better delivery experience.

Primary-level and community worker interventions for the prevention of mental disorders and the promotion of well-being in low- and middle-income countries

BACKGROUND

There is a significant research gap in the field of universal, selective, and indicated prevention interventions for mental health promotion and the prevention of mental disorders. Barriers to closing the research gap include scarcity of skilled human resources, large inequities in resource distribution and utilization, and stigma.

OBJECTIVES

To assess the effectiveness of delivery by primary workers of interventions for the promotion of mental health and universal prevention, and for the selective and indicated prevention of mental disorders or symptoms of mental illness in low- and middle-income countries (LMICs). To examine the impact of intervention delivery by primary workers on resource use and costs.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL, Global Index Medicus, PsycInfo, WHO ICTRP, and ClinicalTrials.gov from inception to 29 November 2021.

SELECTION CRITERIA

Randomized controlled trials (RCTs) of primary-level and/or community health worker interventions for promoting mental health and/or preventing mental disorders versus any control conditions in adults and children in LMICs.

DATA COLLECTION AND ANALYSIS

Standardized mean differences (SMD) or mean differences (MD) were used for continuous outcomes, and risk ratios (RR) for dichotomous data, using a random-effects model. We analyzed data at 0 to 1, 1 to 6, and 7 to 24 months post-intervention. For SMDs, 0.20 to 0.49 represented small, 0.50 to 0.79 moderate, and ≥ 0.80 large clinical effects. We evaluated the risk of bias (RoB) using Cochrane RoB2.

MAIN RESULTS

Description of studies We identified 113 studies with 32,992 participants (97 RCTs, 19,570 participants in meta-analyses) for inclusion. Nineteen RCTs were conducted in low-income countries, 27 in low-middle-income countries, 2 in middle-income countries, 58 in upper-middle-income countries and 7 in mixed settings. Eighty-three RCTs included adults and 30 RCTs included children. Cadres of primary-level workers employed primary care health workers (38 studies), community workers (71 studies), both (2 studies), and not reported (2 studies). Interventions were universal prevention/promotion in 22 studies, selective in 36, and indicated prevention in 55 RCTs. Risk of bias The most common concerns over risk of bias were performance bias, attrition bias, and reporting bias. Intervention effects 'Probably', 'may', or 'uncertain' indicates 'moderate-', 'low-', or 'very low-'certainty evidence. *Certainty of the evidence (using GRADE) was assessed at 0 to 1 month post-intervention as specified in the review protocol. In the abstract, we did not report results for outcomes for which evidence was missing or very uncertain. Adults Promotion/universal prevention, compared to usual care: - probably slightly reduced anxiety symptoms (MD -0.14, 95% confidence interval (CI) -0.27 to -0.01; 1 trial, 158 participants) - may slightly reduce distress/PTSD symptoms (SMD -0.24, 95% CI -0.41 to -0.08; 4 trials, 722 participants) Selective prevention, compared to usual care: - probably slightly reduced depressive symptoms (SMD -0.69, 95% CI -1.08 to -0.30; 4 trials, 223 participants) Indicated prevention, compared to usual care: - may reduce adverse events (1 trial, 547 participants) - probably slightly reduced functional impairment (SMD -0.12, 95% CI -0.39 to -0.15; 4 trials, 663 participants) Children Promotion/universal prevention, compared to usual care: - may improve the quality of life (SMD -0.25, 95% CI -0.39 to -0.11; 2 trials, 803 participants) - may reduce adverse events (1 trial, 694 participants) - may slightly reduce depressive symptoms (MD -3.04, 95% CI -6 to -0.08; 1 trial, 160 participants) - may slightly reduce anxiety symptoms (MD -2.27, 95% CI -3.13 to -1.41; 1 trial, 183 participants) Selective prevention, compared to usual care: - probably slightly reduced depressive symptoms (SMD 0, 95% CI -0.16 to -0.15; 2 trials, 638 participants) - may slightly reduce anxiety symptoms (MD 4.50, 95% CI -12.05 to 21.05; 1 trial, 28 participants) - probably slightly reduced distress/PTSD symptoms (MD -2.14, 95% CI -3.77 to -0.51; 1 trial, 159 participants) Indicated prevention, compared to usual care: - decreased slightly functional impairment (SMD -0.29, 95% CI -0.47 to -0.10; 2 trials, 448 participants) - decreased slightly depressive symptoms (SMD -0.18, 95% CI -0.32 to -0.04; 4 trials, 771 participants) - may slightly reduce distress/PTSD symptoms (SMD 0.24, 95% CI -1.28 to 1.76; 2 trials, 448 participants).

AUTHORS' CONCLUSIONS

The evidence indicated that prevention interventions delivered through primary workers - a form of task-shifting - may improve mental health outcomes. Certainty in the evidence was influenced by the risk of bias and by substantial levels of heterogeneity. A supportive network of infrastructure and research would enhance and reinforce this delivery modality across LMICs.

Using energy psychology to remediate emotional wounds rooted in childhood trauma: preliminary clinical guidelines

Adverse childhood experiences (ACEs) are potentially traumatic events that occur in childhood, such as violence, abuse, severe neglect, or mental health problems in caregivers. The negative physical and mental health consequences of severe or multiple ACEs provide a major challenge for the health care community. Psychotherapies that utilize a mind-body approach in treating ACE-related conditions are seen by their proponents as having advantages for bringing healing and restoration compared with talk, introspective, interpersonal, and exposure therapies that do not intervene at the body level, as famously encapsulated by Bessel van der Kolk's observation that "the body keeps the score." A mind-body approach whose use has been rapidly increasing in clinical settings as well as on a self-help basis is called "energy psychology." Energy psychology combines conventional therapeutic techniques such as cognitive restructuring and psychological exposure with the stimulation of acupuncture points (acupoints) by tapping on them. A review of the development, efficacy, and plausible mechanisms of energy psychology is presented, and several strengths are enumerated, such as how integrating acupoint tapping into conventional exposure methods enhances the speed and power of outcomes. The impact of energy psychology protocols on the three brain networks most centrally involved with ACEs is also examined. Finally, recommendations are offered for using an energy psychology approach at each stage of therapy with individuals who have endured severe or multiple ACES, from establishing a therapeutic alliance to assessment to treatment to follow-up.

Effects of a Contextual Adaptation of the Unified Protocol in Multiple Emotional Disorders in Individuals Exposed to Armed Conflict in Colombia: A Randomized Clinical Trial

Importance

A transdiagnostic treatment, the Unified Protocol, is as effective as single diagnostic protocols in comorbid emotional disorders in clinical populations. However, its effects on posttraumatic stress disorder and other emotional disorders in individuals living in war and armed conflict contexts have not been studied.

Objective

To evaluate the efficacy of a cultural and contextual adaptation of the Unified Protocol (CXA-UP) on posttraumatic stress disorder, anxiety, and depression compared to waitlist control in individuals exposed to armed conflict in Colombia.

Design, Setting, and Participants

From April 2017 to March 2020, 200 participants 18 years and older were randomly assigned to the CXA-UP or to a waitlist condition. CXA-UP consisted of 12 to 14 twice-a-week or weekly individual 90-minute face-to-face sessions. Outcomes were assessed at baseline, posttreatment, and 3 months following treatment. Analyses were performed and compared for all randomly allocated participants (intent-to-treat [ITT]) and for participants who completed all sessions and posttreatment measures (per protocol [PP]). The study took place at an outpatient university center and included individuals who were registered in the Colombian Victims Unit meeting DSM-5 diagnostic criteria for posttraumatic stress disorder, anxiety, or depression or were severely impaired by anxiety or depression. Individuals who were receiving psychological therapy, were dependent on alcohol or drugs, were actively suicidal or had attempted suicide in the previous 2 months, had psychosis or bipolar disorder, or were cognitively impaired were excluded.

Intervention

CXA-UP or waitlist.

Main Outcomes and Measures

Primary outcomes were changes in anxiety, depression, and somatic scores on the Patient Health Questionnaire and Posttraumatic Stress Disorder Checklist for DSM-5.

Results

Among the 200 participants (160 women [80.0%]; 40 men [20.0%]; mean [SD] age, 43.1 [11.9] years), 120 were randomized to treatment and 80 to waitlist. Results for primary outcomes in the ITT analysis showed a significant pretreatment-to-posttreatment reduction when comparing treatment and waitlist on the posttraumatic stress disorder checklist for DSM-5 scores (slope [SE], -31.12 [3.00]; P < .001; Cohen d, 0.90; 90% CI, 0.63-1.19), 9-item Patient Health Questionnaire (PHQ-9) (slope [SE],-11.94 [1.30]; P < .001; Cohen d, 0.77; 90% CI, 0.52-1.06), PHQ-anxiety (slope [SE], -6.52 [0.67]; P < .001; Cohen d, 0.82; 90% CI, 0.49-1.15), and PHQ-somatic (slope [SE], -8.31 [0.92]; P < .001; Cohen d, 0.75; 90% CI, 0.47-1.04).

Conclusions and Relevance

In this study, significant reductions and large effect sizes in all measures of different emotional disorders showed efficacy of a single transdiagnostic intervention in individuals exposed to armed conflicts.

Trial Registration

ClinicalTrials.gov Identifier: NCT03127982.

Prevention and promotion effects of Self Help Plus: secondary analysis of cluster randomised controlled trial data among South Sudanese refugee women in Uganda

INTRODUCTION

Evidence-based and scalable prevention and promotion focused mental health and psychosocial support interventions are needed for conflict-affected populations in humanitarian settings. This study retrospectively assessed whether participation in Self Help Plus (SH+) versus enhanced usual care (EUC) resulted in reduced incidence of probable mental disorder and increased positive mental health and well-being post-intervention among South Sudanese refugee women in Uganda.

METHODS

This study used secondary data from treatment-oriented pilot (n=50) and fully-powered cluster randomised controlled trials (cRCT)s (n=694) of SH+ versus EUC. Data from baseline and post-intervention assessments were combined. A composite latent indicator for mental health problems was generated using mental health and well-being measures included in both cRCTs. In order to assess incidence, a binary variable approximating probable mental disorder was created to exclude those with probable mental disorder from the analysis sample and as the primary prevention outcome. The promotive effects of SH+ relative to EUC were examined in the same sample by assessing subjective well-being and psychological flexibility scale scores.

RESULTS

A single factor for mental health problems was identified with all factor loadings >0.30 and acceptable internal consistency (α=0.70). We excluded 161 women who met criteria for probable mental disorder at baseline. Among those with at least moderate psychological distress but without probable mental disorder at baseline and with follow-up data (n=538), the incidence of probable mental disorder at post-intervention was lower among those who participated in SH+ relative to EUC (Risk ratio =0.16, 95% CI: 0.05 to 0.53). Participation in SH+ versus EUC was also associated with increased subjective well-being (β=2.62, 95% CI: 1.63 to 3.60) and psychological flexibility (β=4.55, 95% CI: 2.92 to 6.18) at post-intervention assessment.

CONCLUSIONS

These results support the use and further testing of SH+ as a selective and indicated prevention and promotion focused psychosocial intervention in humanitarian settings.

TRIAL REGISTRATION NUMBER

ISRCTN50148022.

The effect of COVID-19 on the mental health of the people in the Indian subcontinent: A scoping review

Indian subcontinent has high mental heath burden and low resources to cope the mental health challenges. Assessment of impact of COVID-19 pandemic on the mental health would help to prioritize the resource allocations. We aimed to assess the impact of COVID-19 on the mental health of people in the Indian subcontinent. Following the PRISMA 2020 guideline, a scoping review was performed by systematically searching the PubMed, Scopus, and Embase databases to identify original studies that assessed mental health conditions during the COVID-19 pandemic in the Indian subcontinent. In this review, a total of 34 studies conducted between 2020 and 2022 were analyzed. The prevalence of anxiety disorders was found to range widely, from 2.5% in North Indian urban slum to 53% in Bangladesh and 21.7% in Pakistan. Similarly, the prevalence of depression varied widely, with rates ranging from 3.5% in North India to 29.8% in Pakistan. The prevalence of stress-related problems ranged from 18.3% in Pakistan to 59.7% in Bangladesh. Factors such as female gender, married status, healthcare workers, and mental illness were identified as important predictors of anxiety and depressive disorders. The impact of COVID-19 pandemic on mental health in Indian subcontinent varies widely based on study population and methods. Therefore, a cautious interpretation is needed while generalizing the study results.

The impact of pandemic mental cognition on cultural values: an empirical study based on social media

BACKGROUND

COVID-19 has triggered a global public health crisis, and had an impact on economies, societies, and politics around the world. Based on the pathogen prevalence hypothesis suggested that residents of areas with higher infection rates are more likely to be collectivists as compared with those of areas with lower infection rates. Many researchers had studied the direct link between infectious diseases and individualism/collectivism (infectious diseases→ cultural values), but no one has focused on the specific psychological factors between them: (infectious diseases→ cognition of the pandemic→ cultural values). To test and develop the pathogen prevalence hypothesis, we introduced pandemic mental cognition and conducted an empirical study on social media (Chinese Sina Weibo), hoping to explore the psychological reasons behind in cultural value changes in the context of a pandemic.

METHODS

We downloaded all posts from active Sina Weibo users in Dalian during the pandemic period (January 2020 to May 2022) and used dictionary-based approaches to calculate frequency of words from two domains (pandemic mental cognition and collectivism/individualism), respectively. Then we used the multiple log-linear regression analysis method to establish the relationship between pandemic mental cognition and collectivism/individualism.

RESULTS

Among three dimensions of pandemic mental cognition, only the sense of uncertainty had a significant positive relationship with collectivism, and also had a marginal significant positive relationship with individualism. There was a significant positive correlation between the first-order lag term AR(1) and individualism, which means the individualism tendency was mainly affected by its previous level.

CONCLUSIONS

The study found that more collectivist regions are associated with a higher pathogen burden, and recognized the sense of uncertainty as its underlying cause. Results of this study validated and further developed the pathogen stress hypothesis in the context of the COVID-19 pandemic.

War exposure, posttraumatic stress disorder, and complex posttraumatic stress disorder among parents living in Ukraine during the Russian war

BACKGROUND

High rates of posttraumatic stress disorder (PTSD) have been documented in war-affected populations. The prevalence of Complex PTSD (CPTSD) has never been assessed in an active war zone. Here, we provide initial data on war-related experiences, and prevalence rates of ICD-11 PTSD and CPTSD in a large sample of adults in Ukraine during the Russian war. We also examined how war-related stressors, PTSD, and CPTSD were associated with age, sex, and living location in Ukraine.

METHOD

Self-report data were gathered from a nationwide sample of 2004 adult parents of children under 18 from the general population of Ukraine approximately 6 months after Russia's invasion.

RESULTS

All participants were exposed to at least one war-related stressor, and the mean number of exposures was 9.07 (range = 1-26). Additionally, 25.9% (95% CI = 23.9%, 27.8%) met diagnostic requirements for PTSD and 14.6% (95% CI = 12.9%, 16.0%) met requirements for CPTSD. There was evidence of a strong dose-response relationship between war-related stressors and meeting criteria for PTSD and CPTSD. Participants who had the highest exposure to war-related stressors were significantly more likely to meet the requirements for PTSD (OR = 4.20; 95% CI = 2.96-5.95) and CPTSD (OR = 8.12; 95% CI = 5.11-12.91) compared to the least exposed.

CONCLUSIONS

Humanitarian responses to the mental health needs of the Ukrainian population will need to take account of posttraumatic stress reactions. Education in diagnosing and treating PTSD/CPTSD, especially in the situation of a significant lack of human resources and continuing displacement of the population, is necessary.

Efficacy of psychological interventions for PTSD in distinct populations - An evidence map of meta-analyses using the umbrella review methodology

We aimed at mapping the meta-analytic evidence base on the efficacy of psychological treatments for posttraumatic stress disorder (PTSD) in specific populations. We conducted a systematic search until January 2022 in MEDLINE, PsycINFO, PTSDpubs, Web of Science, and the Cochrane Database of Systematic Reviews for meta-analyses of randomized controlled trials. We contrasted all eligible meta-analyses irrespective of overlapping datasets to present a comprehensive overview of the state of research. Reporting quality was assessed using the AMSTAR 2 tool and certainty of evidence was assessed using established umbrella review criteria. Nine meta-analyses with distinct adult populations (51 unique trials) and four with children and adolescents (24 unique trials) were included. Reporting quality of meta-analyses was heterogeneous with risk of bias assessment being rated lowest. The certainty of evidence on the efficacy of psychological interventions for adult populations was thoroughly weak because of small samples and large heterogeneity. In war- and conflict-affected youth, the certainty of evidence was suggestive. Our review highlights the need to improve quality of meta-analyses on treatment efficacy for PTSD. More importantly, however, the findings demonstrate the need for new large-scale trials on the efficacy of treatments for PTSD in distinct populations in order to increase certainty of evidence and to identify potential differences in treatment responses.

Influence of Previous Mental State on Psychological Outcomes of Spanish Out-of-Hospital Professionals during the COVID-19 Pandemic

This study aimed to describe factors relating to the psychological distress of healthcare workers (HCWs) in Spanish out-of-hospital emergency medical services (EMS), according to the previous or non-use of psychotropic drugs or psychotherapy. A multicentre, cross-sectional descriptive study was designed. The study population were all physicians, nurses, and emergency medical technicians (EMTs) working in any Spanish out-of-hospital EMS between February and April 2021. The main outcomes were the levels of stress, anxiety, depression, and self-efficacy, assessed by DASS-21 and G-SES. Differences in levels of stress, anxiety, depression, and self-efficacy, according to sex, age, previous use of psychotropic drug or psychotherapy, work experience, professional category, type of work, and modification of working conditions were measured using the Student's t-test for independent samples, one-way ANOVA, Pearson's correlation, or 2-factor analysis of covariance. A total of 1636 HCWs were included, of whom one in three had severe mental disorders because of the pandemic. The interaction of the previous or non-use of psychotropic drugs or psychotherapy with the rest of the factors considered did not modify the levels of stress, anxiety, depression, and self-efficacy. However, HCWs with a history of psychotropic drug or psychotherapy use had a more intense negative emotional response and lower self-efficacy, regardless of their sex, professional category, type of work, or change in the working conditions. These HCWs are considered particularly vulnerable to the development or recurrence of new disorders or other comorbidities; therefore, the implementation of monitoring and follow-up strategies should be a priority.

Reversal of hyperactive higher-order thalamus attenuates defensiveness in a mouse model of PTSD

Posttraumatic stress disorder (PTSD) is a highly prevalent and debilitating psychiatric disease often accompanied by severe defensive behaviors, preventing individuals from integrating into society. However, the neural mechanisms of defensiveness in PTSD remain largely unknown. Here, we identified that the higher-order thalamus, the posteromedial complex of the thalamus (PoM), was overactivated in a mouse model of PTSD, and suppressing PoM activity alleviated excessive defensive behaviors. Moreover, we found that diminished thalamic inhibition derived from the thalamic reticular nucleus was the major cause of thalamic hyperactivity in PTSD mice. Overloaded thalamic innervation to the downstream cortical area, frontal association cortex, drove abnormal defensiveness. Overall, our study revealed that the malfunction of the higher-order thalamus mediates defensive behaviors and highlighted the thalamocortical circuit as a potential target for treating PTSD-related overreactivity symptoms.

The impact of employment programs on common mental disorders: A systematic review

BACKGROUND

While employment programs were not created with the intent to improve common mental disorders (CMDs), they may have a positive impact on the prevalence, incidence, and severity of CMD by reducing poverty and increasing access to economic mobility.

AIM

To examine and synthesize the available quantitative evidence of the impact of employment programs on outcomes of CMD.

METHODS

Embase, Econlit, Global Health, MEDLINE, APA PsychINFO, and Social Policy and Practice were searched for experimental and quasi-experimental studies which investigated the impact of employment programs on primary and secondary outcomes of a CMD. A narrative synthesis according to Popay was conducted. The methodological quality of studies was assessed with the Cochrane Risk of Bias tool and the Newcastle-Ottawa Assessment Scale.

RESULTS

Of the 1,327 studies retrieved, two randomized controlled trials, one retrospective cohort, one pilot study with a non-randomized experimental design, and one randomized field experiment were included in the final review. Employment programs generally included multiple components such as skills-based training, and hands-on placements. Depression and anxiety were the CMDs measured as primary or secondary outcomes within included studies. Findings regarding the impact of employment programs on CMD were mixed with two studies reporting significantly positive effects, two reporting no effects, and one reporting mixed effects. The quality among included studies was good overall with some concerns regarding internal validity.

CONCLUSION

Employment programs may support a decrease in the prevalence, incidence, and severity of CMDs. However, there is high heterogeneity among study effects, designs, and contexts. More research is needed to gain further insight into the nature of this association and the mechanisms of impact. This review highlights the potential for employment programs and other poverty-reduction interventions to be utilized and integrated into the wider care, prevention, and treatment of common-mental disorders.

Adverse childhood experiences and global mental health: avenues to reduce the burden of child and adolescent mental disorders

Mental disorders are one of the largest contributors to the burden of disease globally, this holds also for children and adolescents, especially in low- and middle-income countries. The prevalence and severity of these disorders are influenced by social determinants, including exposure to adversity. When occurring early in life, these latter events are referred to as adverse childhood experiences (ACEs).In this editorial, we provide an overview of the literature on the role of ACEs as social determinants of mental health through the lenses of global mental health. While the relation between ACEs and mental health has been extensively explored, most research was centred in higher income contexts. We argue that findings from the realm of global mental health should be integrated into that of ACEs, e.g. through preventative and responsive psychosocial interventions for children, adolescents and their caregivers. The field of global mental health should also undertake active efforts to better address ACEs in its initiatives, all with the goal of reducing the burden of mental disorders among children and adolescents globally.

A Pilot Randomized Clinical Trial of a Novel, Culturally Adapted, Trauma-Focused Cognitive-Behavioral Intervention for War-Related PTSD in Iraqi Women

Trauma-focused cognitive-behavioral therapy (TF-CBT), broadly, is one of the leading evidence-based treatments for youth with posttraumatic stress disorder (PTSD). Generally, few culturally adapted TF-CBT interventions have been examined among war trauma-affected populations in low- and middle-income countries. Using a randomized clinical trial design, a total of 48 war trauma-exposed women in Iraq, M_age (SD) = 32.91 (5.33), with PTSD were randomly assigned to either TF-CBT or wait-list control (WLC) conditions. The intervention group received 12 individual weekly sessions of a culturally adapted TF-CBT intervention. Significant reductions in PTSD symptom severity were reported by women in the TF-CBT condition from pre- to posttreatment. Women in the TF-CBT condition reported significantly greater reductions in PTSD symptoms compared to WLC at 1-month follow-up. Additionally, levels of depression, anxiety, stress, and use of maladaptive emotion regulation strategies were significantly lower in the TF-CBT condition at posttreatment and 1-month follow-up, compared to the WLC condition. Women in the TF-CBT condition also reported significant improvements in various domains of quality of life at posttreatment and 1-month follow-up. This clinical trial provides preliminary cross-cultural support for the feasibility and efficacy of TF-CBT for the treatment of PTSD symptoms among women in non-Western cultures. Future directions and study limitations are discussed.

Community-Based Interventions for the Treatment and Management of Conflict-Related Trauma in Low-Middle Income, Conflict-Affected Countries: a Realist Review

Where low- and middle-income countries have limited economic resources to provide individualized mental health services to people exposed to conflict, community-based interventions may be more appropriate. We aimed to evaluate community level interventions for improving mental health outcomes in Low- and Middle-income countries (LMIC). A realist review of community-based interventions (CBIs) to improve mental health for people in LMIC following conflict. Five databases (Cochrane, PubMed, PsychINFO, Medline, and CINAHL) and a manual search of individual papers. We found 1318 articles, of which 29 were selected. Out of the 29 primary articles, 19 showed successful results, 4 showed mixed results, 1 showed inconclusive results, and 1 showed unsuccessful results. After analyzing the results, we found 3 mechanisms that may influence the effectiveness of these CBIs: the use of lay community members as intervention deliverers, the application of transdiagnostic approaches, and customized outcome assessment tools. Community-based approaches to improve mental health in LMICs are rare and evidence for their effectiveness is limited. Interventions that have a wide scope, train lay mental health workers, and use contextually adapted outcome assessment tools show promise.

Community-based interventions for improving mental health in refugee children and adolescents in high-income countries

BACKGROUND

An unprecedented number of people around the world are experiencing forced displacement due to natural or man-made events. More than 50% of refugees worldwide are children or adolescents. In addition to the challenges of settling in a new country, many have witnessed or experienced traumatic events. Therefore, refugee children and adolescents are at risk of developing mental health problems such as post-traumatic stress disorder, and require appropriate and effective support within communities.

OBJECTIVES

To assess the effectiveness and acceptability of community-based interventions (RCTs only) in comparison with controls (no treatment, waiting list, alternative treatment) for preventing and treating mental health problems (major depression, anxiety, post-traumatic stress disorder, psychological distress) and improving mental health in refugee children and adolescents in high-income countries.

SEARCH METHODS

Databases searches included the Cochrane Common Mental Disorders Controlled Trials Register (all available years), CENTRAL/CDSR (2021, Issue 2), Ovid MEDLINE, Embase, six other databases, and two trials registries to 21 February 2021. We checked reference lists of included study reports.  SELECTION CRITERIA: Studies of any design were eligible as long as they included child or adolescent refugees and evaluated a community-based mental health intervention in a high-income country. At a second stage, we selected randomised controlled trials.

DATA COLLECTION AND ANALYSIS

For randomised controlled trials, we extracted data relating to the study and participant characteristics, and outcome data relating to the results of the trial. For studies using other evaluation methods, we extracted data relating to the study and participant characteristics. W derived evidence on the efficacy and availability of interventions from the randomised controlled trials only. Data were synthesised narratively.

MAIN RESULTS

We screened 5005 records and sought full-text manuscripts of 62 relevant records. Three randomised controlled trials were included in this review. Key concerns in the risk of bias assessments included a lack of clarity about the randomisation process, potential for bias is outcome measurement, and risk of bias in the selection of results. Primary outcomes There was no evidence of an effect of community-based interventions when compared with a waiting list for symptoms of post-traumatic stress (mean difference (MD) -1.46, 95% confidence interval (CI) -6.78 to 3.86: 1 study; low-certainty evidence), symptoms of depression (MD 0.26, 95% CI -2.15 to 2.67: 1 study; low-certainty evidence), and psychological distress (MD -10.5, 95% CI -47.94 to 26.94; 1 study; very low-certainty evidence).  There were no data on adverse events. Secondary outcomes Three trials reported on short-term changes in child behaviour, using different measures, and found no evidence of an effect of the intervention versus a waiting list (low to very low certainty). None of the trials reported on quality of life or well-being, participation and functioning, or participant satisfaction.

AUTHORS' CONCLUSIONS

There is insufficient evidence to determine the efficacy and acceptability of community-based mental health interventions for refugee children and adolescents.

Uses of Energy Psychology Following Catastrophic Events

Energy psychology, as most widely practiced, integrates the manual stimulation of acupuncture points with imaginal exposure, cognitive restructuring, and other evidence-based psychotherapeutic procedures. Efficacy for energy psychology protocols has been established in more than 120 clinical trials, with meta-analyses showing strong effect sizes for PTSD, anxiety, and depression. The approach has been applied in the wake of natural and human-made disasters in more than 30 countries. Four tiers of energy psychology interventions following the establishment of safety, trust, and rapport are described, including (1) immediate relief/stabilization, (2) reducing limbic arousal to trauma-based triggers, (3) overcoming complex psychological difficulties, and (4) promoting optimal functioning. The first tier is most pertinent in psychological first aid immediately following a disaster, with the subsequent tiers progressively being introduced over time with complex stress reactions and chronic disorders. Advantages of adding the stimulation of acupuncture points to a conventional exposure approach are identified, and challenges around cultural sensitivities and unintended effects are discussed. After establishing a framework for introducing energy psychology in disaster relief efforts, reports from a sampling of settings are presented, based on interviews with this paper's author. These include accounts of relief work with survivors of mass shootings, genocide, ethnic warfare, earthquakes, hurricanes, tornadoes, floods, wildfires, and the COVID-19 pandemic. Hundreds of other reports from the field show a pattern of strong outcomes following the use of energy psychology in the days or weeks after a disaster and in the subsequent treatment of trauma-based psychological problems. Many of these accounts corroborate one another in terms of rapid relief and long-term benefits. Finally, examples of more efficient delivery methods utilizing large groups, lay counselors, digital technology, and cultivating community resilience are presented.

Cultural adaptation and validation of the Strategies to end seclusion restraint module of the QualityRights ToolKit

OBJECTIVE

to adapt to the Brazilian culture and validate the module "Strategies to end seclusion restraint" of the QualityRights toolkit of the World Health Organization on mental disorders to train health professionals in Brazil.

METHOD

it is a methodological study divided into three stages. The modules were translated from the original language (English) to the target language (Brazilian Portuguese) in the first stage. In the second, the translation was assessed by a committee of judges with seven experts. In the third stage, the assessment was conducted by mental health professionals (nurses, psychologists, and lawyers), in which seven mental health professionals participated. They assessed the material using the Suitability Assessment of Materials instrument.

RESULTS

in the assessment conducted by the experts (n=7), 8 items assessed obtained 100% approval and the other 6 items obtained lower approvals, with a total approval of 92%. Regarding the assessment by health professionals (n=7), 2 items had a maximum approval of 100% and the other had the approval of 86% each, with a total approval of 88%.

CONCLUSION

based on the results, it is considered that this module is adapted to the Brazilian culture and can be used to train Brazilian health professionals.

Mental health consequences of armed conflicts in adults: an overview

Armed conflicts (AC) in the world are still active and lead to the growth of violence, with a possible impact on mental health (MH).

Strengthening women's empowerment and gender equality in fragile contexts towards peaceful and inclusive societies: A systematic review and meta-analysis

Background

Across the globe, gender disparities still exist with regard to equitable access to resources, participation in decision-making processes, and gender and sexual-based violence. This is particularly true in fragile and conflict-affected settings, where women and girls are affected by both fragility and conflict in unique ways. While women have been acknowledged as key actors in peace processes and post-conflict reconstruction (e.g., through the United Nations Security Council Resolution 1325 and the Women, Peace and Security Agenda) evidence on the effectiveness of gender-specific and gender-transformative interventions to improve women's empowerment in fragile and conflict-affected states and situations (FCAS) remains understudied.

Objectives

The purpose of this review was to synthesize the body of evidence around gender-specific and gender-transformative interventions aimed at improving women's empowerment in fragile and conflict-affected settings with high levels of gender inequality. We also aimed to identify barriers and facilitators that could affect the effectiveness of these interventions and to provide implications for policy, practice and research designs within the field of transitional aid.

Methods

We searched for and screened over 100,000 experimental and quasi-experimental studies focused on FCAS at the individual and community levels. We used standard methodological procedures outlined by the Campbell Collaboration for the data collection and analysis, including quantitative and qualitative analyses, and completed the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) methodology to assess the certainty around each body of evidence.

Results

We identified 104 impact evaluations (75% randomised controlled trials) assessing the effects of 14 different types of interventions in FCAS. About 28% of included studies were assessed as having a high risk of bias (45% among quasi-experimental designs). Interventions supporting women's empowerment and gender equality in FCAS produced positive effects on the outcomes related to the primary focus of the intervention. There are no significant negative effects of any included interventions. However, we observe smaller effects on behavioural outcomes further along the causal chain of empowerment. Qualitative syntheses indicated that gender norms and practices are potential barriers to intervention effectiveness, while working with local powers and institutions can facilitate the uptake and legitimacy of interventions.

Conclusions

We observe gaps of rigorous evidence in certain regions (notably MENA and Latin America) and in interventions specifically targeting women as actors of peacebuilding. Gender norms and practices are important elements to consider in programme design and implementation to maximise potential benefits: focusing on empowerment only might not be enough in the absence of targeting the restrictive gender norms and practices that may undermine intervention effectiveness. Lastly, programme designers and implementation should consider explicitly targeting specific empowerment outcomes, promoting social capital and exchange, and tailoring the intervention components to the desired empowerment-related outcomes.

Case Series: Managing Severe Mental Illness in Disaster Situation: the Croatian Experience After 2020 Earthquake

On the 29th of December 2020, amidst the COVID-19 pandemic, Petrinja in the Croatian Sisak-Moslavina County experienced a strong earthquake, resulting in a severe disruption in mental health service delivery. Specialized care community mental health teams were introduced days within the event with the aim to bridge the gap in psychiatric care that was severely disturbed in the region affected by the earthquake. Through a case series of patients with SMI, we describe how care was quickly deployed and delivered after a natural disaster and during a pandemic resulting in their functional recovery. Community mental health teams have the potential to provide feasible, comprehensive, and accessible mental health services, and their continued implementation in the post-disaster period in Croatia could be beneficial for care management of people with severe mental illness.

A cross-sectional analysis of mental health disorders in a mental health services-seeking population of children, adolescents, and young adults in the context of ongoing violence and displacement in northern Cameroon

BACKGROUND

Displacement and conflict exposure are known risk factors for mental health conditions. Here, we examine the mental health of youth in a conflict-affected region of Cameroon.

METHODS

Participants were recruited from among beneficiaries of a project conducted by Univers Psy and the United Nations Population Fund in Cameroon's Far North region. Community health workers conducted sensitization campaigns, following which they referred adolescents and young adults who self-identified as having mental health concerns to clinical psychologists. We ultimately conducted chart reviews of 948 of these youth. Univariate analyses using chi-squared tests were used to assess the relationships among demographics, displacement status, and mental health. Logistic regressions were then performed to determine the odds of having a psychiatric disorder based on displacement status.

OUTCOME

Sixty-eight percent of evaluated youth met criteria for a psychiatric disorder. Anxiety disorders were most prevalent at 24.3%, followed by trauma- and stressor-related disorders at 17.0%, and mood disorders at 8.0%. Refugees and IDPs had 0.11 (95% CI 0.06, 0.19) and 0.46 (95% CI 0.29, 0.74) odds, respectively, of any diagnosis compared to the host population. Females had 1.71 (95% CI 1.17, 2.50) odds of an anxiety disorder and 2.18 (95% CI 1.16, 4.10) odds of a mood disorder compared to males.

INTERPRETATION

In a youth sample in Cameroon self-identified as having mental health concerns, this study found high rates of psychiatric illness, particularly anxiety disorders. We found a higher prevalence among host population individuals than among displaced individuals and especially in the female population.

Rumination, Posttraumatic Stress Disorder Symptoms, and Posttraumatic Growth Among Wenchuan Earthquake Adult Survivors: A Developmental Perspective

This study examined the long-term effects of the Wenchuan earthquake among adult survivors. Specifically, it explored the role of perceived social support (PSS) in the relationship between rumination and posttraumatic growth (PTG) and posttraumatic stress disorder (PTSD) symptoms. Data were collected from March to July 2020 using a youth survivor sample (n = 476) of the 2008 Wenchuan earthquake. Participants were divided into three groups depending on their age when the quake occurred: 6-11 years (n = 227), 12-15 years (n = 83), 16-19 years (n = 166). The results indicated that long-term PTG and PTSD symptom levels varied by age group. Both intrusive and deliberate ruminations had a significant effect on PTG as well as PTSD symptoms. PSS played a mediating role between rumination and PTG, and the mediation mechanisms varied by age group (developmental stages). Moderated analyses revealed that PSS from significant others significantly buffered the indirect effect of rumination on PTSD symptoms. Our findings demonstrated the universal nature of traumatic events encountered during childhood and adolescence development and underscore the importance of examining the developmental context of PTG in investigations on traumatic experiences and their consequences.

Cultural adaptation and validation of the Strategies to end seclusion restraint module of the QualityRights ToolKit*

Abstract Objective to adapt to the Brazilian culture and validate the module “Strategies to end seclusion restraint” of the QualityRights toolkit of the World Health Organization on mental disorders to train health professionals in Brazil. Method it is a methodological study divided into three stages. The modules were translated from the original language (English) to the target language (Brazilian Portuguese) in the first stage. In the second, the translation was assessed by a committee of judges with seven experts. In the third stage, the assessment was conducted by mental health professionals (nurses, psychologists, and lawyers), in which seven mental health professionals participated. They assessed the material using the Suitability Assessment of Materials instrument. Results in the assessment conducted by the experts (n=7), 8 items assessed obtained 100% approval and the other 6 items obtained lower approvals, with a total approval of 92%. Regarding the assessment by health professionals (n=7), 2 items had a maximum approval of 100% and the other had the approval of 86% each, with a total approval of 88%. Conclusion based on the results, it is considered that this module is adapted to the Brazilian culture and can be used to train Brazilian health professionals.

Adaptación cultural y validación del módulo Strategies to end seclusion restraint del ToolKit QualityRights*

Resumen Objetivo adaptar a la cultura brasileña y validar el módulo “Strategies to end seclusion restraint del ‘toolkit QualityRights’” de la Organización Mundial de la Salud sobre trastornos mentales para la capacitación de profesionales de la salud en Brasil. Método se trata de un estudio metodológico, dividido en tres etapas. En la primera, fue realizada la traducción de los módulos de la lengua original (inglés) a la lengua objetivo (portugués brasileño). En la segunda, fue realizada la evaluación de la traducción por un comité de jueces compuesto de siete especialistas. En la tercera etapa, fue realizada la evaluación por profesionales de la salud mental (enfermeros, psicólogos y abogados), de la cual participaron siete profesionales de la salud mental. Ellos evaluaron el material por medio del instrumento Suitability Assessment of Materials. Resultados en la evaluación realizada por los especialistas (n=7), 8 ítems evaluados obtuvieron 100% de aprobación y los otros 6 ítems aprobaciones menores, obteniéndose una aprobación total del 92%. En cuanto a la evaluación realizada por los profesionales de la salud (n=7), 2 ítems tuvieron aprobación máxima del 100% y los demás tuvieron aprobación del 86% cada uno, obteniéndose aprobación total del 88%. Conclusión con base en los resultados, se considera que este módulo está adaptado a la cultura brasileña, pudiendo ser utilizado para la capacitación de profesionales de la salud brasileños.

Mental Health Problems among COVID-19 Frontline Healthcare Workers and the Other Country-Level Epidemics: The Case of Mexico

COVID-19 frontline healthcare workers (FHCW) are struggling to cope with challenges that threaten their wellbeing. We examine the frequency and predictors of the most frequent mental health problems (MHP) among FHCW during the first COVID-19 peak in Mexico, one of the most severely affected countries in terms of FHCW’s COVID-19 mortality. A cross-sectional survey was conducted between May 8 and August 18, 2020. A total of 47.5% of the sample (n = 2218) were FHCW. The most frequent MHP were insomnia, depression, posttraumatic stress symptoms, and health anxiety/somatization (whole sample: 45.7, 37.4, 33.9, and 21.3%; FHCW: 52.4, 43.4, 40.3 and 26.1, respectively). As compared to during the initial COVID-19 phase, depression and health anxiety/somatization symptoms as well as experiences of grieving due to COVID-19, personal COVID-19 status, and having relatives and close friends with COVID-19 were more frequent during the COVID-19 peak. Obesity, domestic violence, personal COVID-19 status, and grieving because of COVID-19 were included in regression models for main FHCW’s MHP during the COVID-19 peak. In conclusion, measures to decrease other country-level epidemics contributing to the likelihood of COVID-19 complications (obesity) and MHP (domestic violence) as well as FHCW´s probability of COVID-19 infection could safeguard not only their physical but also mental health.

Women's experience of pregnancy and birth during the COVID-19 pandemic: a qualitative study

Background

The COVID-19 pandemic has changed how maternity care services are provided worldwide. To contain the virus, many providers reduced the number of face-to-face visits for women. In addition, partner attendance was prohibited in many circumstances to protect staff, and other service users, from potential infection.

Aims

To explore women’s experience of pregnancy and birth in the Republic of Ireland during the COVID-19 pandemic.

Methods

A qualitative study with 14 women was conducted using a grounded theory approach. Data were collected between April and July 2020, and in-depth interviews were conducted either in pregnancy or in the first 12 weeks after the birth.

Results

Six categories emerged: loss of normality, navigating “new” maternity care systems, partners as bystanders, balancing information, uncertainty, and unexpected benefits of pregnancy during the pandemic. While benefits were reported (working from home and additional time spent with partners during the “fourth trimester”), in general, the themes were of increased anxiety and uncertainty.

Conclusion

The pandemic caused additional anxiety for pregnant women. This was exacerbated by uncertainty about the effects of COVID-19 on pregnancy and unclear messaging about restrictions. More interactive and personalized communication is required to support women to cope with uncertainty during a pandemic. The birth partner plays an important role as an advocate for women and excluding them from pregnancy care caused additional anxiety for pregnant women. Containment strategies for a pandemic should be developed with this in mind, to view the family as a unit rather than the woman in isolation.

In(s) and out(s) of adolescent depression - Trajectories of development and recovery

While the role of biological markers in understanding major depressive disorder (MDD) in adults have been studied extensively, less has been done to identify the biomarkers of MDD development and recovery in adolescence. With the majority of mental health disorders starting in adolescence, identifying biomarkers of transition and recovery from MDD early in life is critical for developing effective prevention strategies. Considering most of the child and adolescent populations come from low-and-middle-income countries (LMICs), it is vital to focus on adolescent populations in these settings. With most studies coming from high-income countries (HICs), evidence suggests that elevated morning cortisol levels including cortisol awakening response (CAR), increased peripheral inflammation and brain abnormalities such as cortico-limbic dysregulation or blunted activity in reward related regions in response to positive information are associated with MDD and being at-risk for MDD development in adolescence. We also find that some of the biological mechanisms of recovery from MDD, mainly normalisation in the cortico-limbic dysregulation, are reported following psychological therapy, suggesting shared pathways leading to MDD vulnerability and recovery. Although, only a few studies include adolescent populations. Understanding molecular mechanisms through which psychological interventions are effective, as well as molecular markers of transition to depression in individuals at-risk, are important to inform effective prevention and intervention strategies.

Moving beyond a 'one-size-fits-all' rationale in global mental health: prospects of a precision psychology paradigm

Research on the effectiveness of mental health and psychosocial support interventions for common mental disorders in global mental health provides controversial results. These results are based on mean values for different groups, often without due consideration of individual-level characteristics and contextual factors. Against this background, and based on the recent development of a precision theoretical framework in clinical psychology, which is calling for a renewed perspective on the development and implementation of trial designs, we propose to develop a precision psychology paradigm in global mental health, with emphasis not only on individual clinical and socio-demographic data, but also on the social determinants of mental health. A precision psychology paradigm would require a coordinated action of academics, stakeholders and humanitarian workers in planning a global mental health research agenda, including the design of trials aimed at reliably approximate prediction of intervention response at individual level.

Cultural adaptation of a scalable psychological intervention for Burundian refugee adolescents in Tanzania: a qualitative study

Background

There is an urgent need for evidence-based, scalable, psychological interventions to improve the mental health of adolescents affected by adversity in low-resource settings. Early Adolescents Skills for Emotions (EASE) was developed by the WHO as a brief, transdiagnostic, group intervention for early adolescents exhibiting internalising problems, delivered by trained and supervised lay providers. This study describes the cultural adaptation of EASE for Burundian adolescents living in Mtendeli refugee camps in Tanzania.

Methods

A phased approach to adaptation of the EASE intervention and its implementation, was adopted and comprised of: (1) a desk review to synthesize existing research on mental health issues in conflict-affected Burundian communities, (2) a rapid qualitative assessment involving free listing and key informant interviews with multiple stakeholders, (3) cognitive interviews with end users, and (4) a two-part adaptation workshop involving the implementing partner staff, members of the refugee community and mental health experts. We applied the Bernal framework to systematically document and track adaptations across eight dimensions of the intervention.

Results

Problems associated with worry, stress, sadness, shame and fear were identified as amongst the most critical mental health concerns, alongside a range of experiences of different forms of violence (such as gender-based violence, violence when fleeing from their homes) and associated problems. Problems associated with violence that included past experiences of fleeing as well as ongoing problems of gender-based violence in the camp. The most significant adaptations that were required included providing options for low literacy of participants, safety planning to address the high prevalence of sexual violence, simplification of strategies for the benefit of the end users and of lay facilitators, and implementation changes to consider involvement of refugee incentive workers. A majority of changes were across dimensions of language, people, metaphors, content, methods and context, while there were fewer changes regarding the goals and concepts of EASE.

Conclusions

The approach to adaptation of a psychological intervention suggested both minor and major required changes. Adaptations based on the findings of this study are anticipated to enhance relevance and acceptability of the EASE intervention and its delivery for camp-residing Burundian refugees in Tanzania.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13031-021-00391-4.

PROTOCOL: Strengthening women's empowerment and gender equality in fragile contexts towards peaceful and inclusive societies: A systematic review and meta-analysis

This review builds on 3ie's (international initiative for impact evaluation) evidence gap map (EGM) of the impact evaluation and systematic review (SR) evidence base of interventions aiming to promote peaceful and inclusive societies in fragile contexts. The EGM identified a cluster of studies evaluating gender equality-focused behaviour change communication programmes and raised interest in investigating the evidence base for understanding the role of women more broadly as agents of change in developing peaceful and inclusive societies. Building on the cluster of evidence identified in the EGM, our review will increase generalisability of findings from single studies and focus on interventions across a broad range of geographical locations, settings and populations, types of implementations and outcomes. We will also address (when possible) the identified gaps in literature regarding metaanalysis in conflict-affected contexts. As such, we propose the following objectives: (1) The primary objective of this review is to identify, assess and synthesise evidence on the effect of gender specific and gender transformative interventions within the context of the four pillars of United Nations Security Council Resolution (UNSCR) 1325 on women's empowerment and gender equality in Fragile and Conflict Affected States/Situations (FCAS). The SR will facilitate the use of evidence in informing policy and practice decisions within the field of transition aid, particularly as it relates to gender focused programming. (2) Our second objective is to assess how these interventions contribute to inclusive and sustainable peace in conflict affected situations. We will compare the effectiveness of these different types of interventions through the lenses of their ecological level, types of impact on women's empowerment, local context of gender inequality and conflict. To achieve these objectives we aim to answer the following questions: (1) What are the impacts of gender transformative and specific interventions on women's empowerment and gender equality in FCAS? (2) What are the effects of these interventions on sustainable peace? (3) To what extent do effects vary by population group, ecological level and types of interventions? (4) What are contextual barriers to and facilitators of intervention effectiveness?

A Naturalistic Evaluation of Group Integrative Adapt Therapy (IAT-G) with Rohingya Refugees During the Emergency Phase of a Mass Humanitarian Crisis in Cox's Bazar, Bangladesh

Background: Studies of scalable psychological interventions in humanitarian setting are usually carried out when the acute emergency has stabilized. We report the first evaluation of an evidence-based group psychological intervention, Group Integrative Adapt Therapy (IAT-G), during the emergency phase of a mass humanitarian crisis amongst Rohingya refugees in Cox's Bazar, Bangladesh. Methods: We did a pragmatic naturalistic evaluation (2018-2020) of a seven-session group intervention with adult Rohingya refugees with elevated symptoms of depression (≥10 on the Patient Health Questionnaire) and/or posttraumatic stress disorder, PTSD, (≥3 on the Posttraumatic Stress Disorder-8), and functional impairment (≥17 on WHO Disability Assessment Schedule or WHODAS-brief). Screening was done across the most densely populated campsites. Blind assessments were completed at baseline, posttreatment, and at 3-month follow-up using culturally adapted measures of depression, anxiety, posttraumatic stress symptoms, complicated bereavement, adaptive stress associated with disrupted psychosocial support systems, functional impairment, and resilience. Findings: 383 persons were screened and of the 144 persons who met inclusion criteria all participated in the group intervention. Compared to baseline scores, IAT-G participants recorded significantly lower mean scores on key outcome indices (mental health symptoms, adaptive stress, and functional impairment) at posttreatment and 3-month follow-up (all pairwise tests significant Ps<.05). From baseline to 3-month follow-up, score changes were greatest for functional impairment (d = 2.24), anxiety (d = 2.15) and depression (d = 1.9), followed by PTSD symptoms (d = 1.17). Interpretation: A group-based intervention designed specifically to reflect the refugee experience and adapted to the language and culture, showed positive outcomes in the context of a pragmatic, naturalistic trial implemented in a mass humanitarian emergency. Funding: United Nations High Commissioner for Refugees; National Health and Medical Research Council Australia.

Effectiveness of Self-Help Plus in Preventing Mental Disorders in Refugees and Asylum Seekers in Western Europe: A Multinational Randomized Controlled Trial

INTRODUCTION

Self-Help Plus (SH+) is a group-based psychological intervention developed by the World Health Organization for managing stress.

OBJECTIVE

To assess the effectiveness of SH+ in preventing mental disorders in refugees and asylum seekers in Western Europe.

METHODS

We conducted a randomized controlled trial in 5 European countries. Refugees and asylum seekers with psychological distress (General Health Questionnaire score ≥3), but without a Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) or ICD/10 diagnosis of mental disorder, as assessed with the Mini International Neuropsychiatric Interview (MINI), were randomized to SH+ or enhanced treatment as usual (ETAU). The primary outcome was the frequency of mental disorders with the MINI at 6 months. Secondary outcomes included the frequency of mental disorders at postintervention, self-identified problems, psychological symptoms, and other outcomes.

RESULTS

Four hundred fifty-nine individuals were randomly assigned to SH+ or ETAU. For the primary outcome, we found no difference in the frequency of mental disorders at 6 months (Cramer V = 0.007, p = 0.90, RR = 0.96; 95% CI 0.52-1.78), while the difference significantly favored SH+ at after the intervention (secondary outcome, measured within 2 weeks from the last session; Cramer V = 0.13, p = 0.01, RR = 0.50; 95% CI 0.29-0.87).

CONCLUSIONS

This is the first randomized indicated prevention study with the aim of preventing the onset of mental disorders in asylum seekers and refugees in Western Europe. As a prevention effect of SH+ was not observed at 6 months, but rather after the intervention only, modalities to maintain its beneficial effect in the long term need to be identified.

COVID-19 and mental health of pregnant women in Ceará, Brazil

OBJECTIVE

To assess the perceptions of pregnant women about COVID-19 and the prevalence of common mental disorders during the implemented social distancing period.

METHODS

This was an observational, cross-sectional study using digital media, of pregnant women exposed to social distancing due to the COVID-19 pandemic, in Fortaleza, Ceará, Northeastern Brazil. Common mental disorders were estimated using the modified Self-Report Questionnaire-20 (SRQ-20) scale, and the feelings towards COVID-19 were assessed using the Fear of COVID-19 scale through telephone calls made in May 2020. COX multivariate regression models were used to verify the associations.

RESULTS

Of the 1,041 pregnant women, 45.7% (95%CI: 42.7–48.8) had common mental disorders (CMD). All items of the Fear of COVID-19 Scale showed a significant association with the prevalence of CMD (p < 0.001). A CMD risk gradient was observed, going from a prevalence ratio of 1.52 (95%CI: 1.13–2.04) in pregnant women with two positive items to 2.70 (95%CI: 2.08–3.51) for those with four positive items. Early gestational age and the lack of prenatal care were also associated with CMD.

CONCLUSIONS

The prevalence of common mental disorders in pregnant women was high during the period of social distancing and was aggravated by negative feelings towards COVID-19.

Design of a Mobile Application and Evaluation of Its Effects on Psychological Parameters of Covid-19 Inpatients: A Protocol for a Randomized Controlled Trial

Background: Panic of the disease and the associated concerns can lower the quality of life and physical performance. As long as the COVID-19 pandemic is ever on the rise, the psychological pandemic of the disease is on the rise, too. The high prevalence of COVID-19 has further increased physicians' work pressure. Patients' needs are not met adequately by physicians. It seems essential to use aids to monitor patients' needs and serve them properly. Thus, in the present research, suggestions are made on how to evaluate patients' physical and psychological conditions during the treatment via a mobile application. Methods and Analysis: The present research is a randomized, two parallel-group, controlled trial. One-hundred-twelve inpatients diagnosed with the coronavirus will be assigned randomly to the control and intervention groups. In the intervention group, a mobile application will be provided to educate patients, establish two-way interactions between patients and care providers and record patients' symptoms. Those in the control group will receive the usual care. The primary outcome is the change to the depression anxiety stress scales-21 (DASS-21) score from the baseline to 2 weeks after discharge from hospital. It will be measured at the baseline, at the time of discharge, and two weeks later. Ethics and Dissemination: The Ethics committee of Mashhad University of Medical Sciences' approval date was 2020-04-19 with IR.MUMS.REC.1399.118 reference code. Thus far, participants' recruitment has not been completed and is scheduled to end in March 2021. The results will be disseminated in a peer-reviewed journal. Trial Registration: IRCT20170922036314N4 (https://www.irct.ir/trial/47383).

Mental health interventions by lay counsellors: a systematic review and meta-analysis

Objective

To investigate the effectiveness of community-based mental health interventions by professionally trained, lay counsellors in low- and middle-income countries.

Methods

We searched PubMed®, Cochrane Central Register of Controlled Trials, PROSPERO and EBSCO databases and professional section publications of the United States National Center for PTSD for randomized controlled trials of mental health interventions by professionally trained, lay counsellors in low- and middle-income countries published between 2000 and 2019. Studies of interventions by professional mental health workers, medical professionals or community health workers were excluded because there are shortages of these personnel in the study countries. Additional data were obtained from study authors. The primary outcomes were measures of post-traumatic stress disorder, depression, anxiety and alcohol use. To estimate effect size, we used a random-effects meta-analysis model.

Findings

We identified 1072 studies, of which 19 (involving 20 trials and 5612 participants in total) met the inclusion criteria. Hedges' g for the aggregate effect size of the interventions by professionally trained, lay counsellors compared with mostly either no intervention or usual care was -0.616 (95% confidence interval: -0.866 to -0.366). This result indicates a significant, medium-sized effect. There was no evidence of publication bias or any other form of bias across the studies and there were no extreme outliers among the study results.

Conclusion

The use of professionally trained, lay counsellors to provide mental health interventions in low- and middle-income countries was associated with significant improvements in mental health symptoms across a range of settings.

Lay-delivered talk therapies for adults affected by humanitarian crises in low- and middle-income countries

BACKGROUND

Published by the World Health Organization (WHO) and United Nations High Commissioner for Refugees (UNHCR) in 2015, the mental health Gap Action Programme Humanitarian Intervention Guide (mhGAP-HIG) recommends brief versions of structured psychological interventions for people experiencing symptoms of common mental disorders (CMDs). mhGAP-HIG acknowledges a growing body of evidence suggesting these interventions can be delivered by lay workers to people affected by humanitarian crises in low- and middle-income countries (LMICs). However, there has not yet been a systematic review and synthesis of this evidence. This paper reports the results of a systematic review of qualitative, quantitative, and mixed-methods studies assessing the implementation and/or effectiveness of talk therapies for CMDs when provided by lay workers in LMICs to adults who have survived or are currently living in humanitarian situations.

METHODS

Seven electronic databases were searched: MEDLINE, Embase, PsycINFO, PsycEXTRA, Global Health, Cochrane Library, and ClinicalTrials.gov . We also hand-searched the contents pages of three academic journals, reference lists of 30 systematic reviews, and online resource directories of two mental health networks. A preliminary list of included studies was circulated to topical experts for review, and all included studies were backward and forward searched. All titles, abstracts, and full-texts were independently double-screened. Quality appraisal and data extraction were carried out by a single reviewer and checked by a second reviewer, using standardised tools. Any disagreements were discussed and referred to a third reviewer as needed.

RESULTS

We identified 23 unique studies and carried out a narrative synthesis of patient and implementation outcome data. Every evaluation of the effectiveness of lay-delivered talk therapies for adults affected by humanitarian crises in LMICs showed some treatment effect for at least one CMD, and often multiple CMDs. Implementation research generally found these interventions to be acceptable, appropriate and feasible to implement, with good fidelity to manualised therapies.

CONCLUSION

Although results are promising, particularly for individually-delivered talk therapies based on cognitive behavioural therapy techniques, there is a high degree of heterogeneity in this literature. We make several recommendations on how to improve the quality and generalisability of research on this topic, to facilitate further evidence synthesis.

TRIAL REGISTRATION

PROSPERO registration number: CRD42017058287 .