Experiences with treating immigrants: a qualitative study in mental health services across 16 European countries

Usability of technological tools to overcome language barriers in health care: a scoping review protocol

INTRODUCTION

In many healthcare contexts globally, where the languages of care providers and patients do not match, miscommunication or non-communication can lead to inaccurate diagnoses and subpar treatment outcomes. In order to bridge these language barriers, a range of informal practices are used, such as family members or staff acting as interpreters, 'receptive multilingualism' or machine translation. The development and use of technological tools are increasing, but factors such as translation quality for complex health-related texts vary widely between languages. The objective of this scoping review is to (1) identify and describe the technological tools used in direct patient-provider communication to overcome a language barrier in a healthcare setting, (2) identify how the usability of these tools was evaluated and (3) assess the usability of the technological tools.

METHODS AND ANALYSIS

The scoping review will follow the Joanna Briggs Institute methodology. A search strategy using variations of the keywords 'technological tools', 'language barrier' and 'healthcare' will be applied in the following databases and research platforms: PubMed, PsycArticle, Scopus, EBSCOhost, ProQuest and Web of Science. All literature where individuals use a technological tool to overcome a language barrier in a healthcare context will be included and exported into the screening assistant software Rayyan. The search will be limited to articles written in German or English. Two independent reviewers will screen the articles, and all relevant extracted data will be presented in a descriptive summary.

ETHICS AND DISSEMINATION

This scoping review does not require ethical approval, as the study's methodology consists of collecting data from publicly available sources. The findings will be disseminated through publication in an open-access, peer-reviewed journal and presentations at scientific conferences. The scoping review results will also guide future research in a multinational project investigating multilingualism in providing (mental) healthcare to migrants.

Communication in refugee and migrant mental healthcare: A systematic rapid review on the needs, barriers and strategies of seekers and providers of mental health services

BACKGROUND

Migrants and refugees may not access mental health services due to linguistic and cultural discordance between them and health and social care professionals (HSCPs). The aim of this review is to identify the communication needs and barriers experienced by third-country nationals (TCNs), their carers, and HSCPs, as well as the strategies they use and their preferences when accessing/providing mental health services and language barriers are present.

METHODS

We undertook a rapid systematic review of the literature (01/01/2011 - 09/03/2022) on seeking and/or providing mental health services in linguistically discordant settings. Quality appraisal was performed, data was extracted, and evidence was reviewed and synthesised qualitatively.

RESULTS

58/5,650 papers met the inclusion criteria. Both TCNs (and their carers) and HSCPs experience difficulties when seeking or providing mental health services and language barriers are present. TCNs and HSCPs prefer linguistically and culturally concordant provision of mental health services but professional interpreters are often required. However, their use is not always preferred, nor is it without problems.

CONCLUSIONS

Language barriers impede TCNs' access to mental health services. Improving language support options and cultural competency in mental health services is crucial to ensure that individuals from diverse linguistic and cultural backgrounds can access and/or provide high-quality mental health services.

The effect of a low-level psychological intervention (PM+) on post-migration living difficulties - Results from two studies in Switzerland and in the Netherlands

AIMS OF THE STUDY

After arriving in host countries, most refugees are confronted with numerous post-migration stressors (e.g., separation from family, discrimination, and employment difficulties). Post-migration living difficulties (PMLDs) significantly contribute to the development and persistence of mental disorders. Effective treatment approaches focusing on reducing post-migration stress are urgently needed. The aim of the present study was to examine the effect of a brief psychological intervention, Problem Management Plus (PM+), on PMLDs among Syrian refugees in two European countries.

METHODS

We merged data from two single-blind feasibility trials with Syrian refugees experiencing elevated levels of psychological distress and impaired functioning in Switzerland (N = 59) and the Netherlands (N = 60). Participants were randomised to receive either five sessions of PM+ or an enhanced care-as-usual control condition. PMLDs were assessed at baseline and 3 months after the intervention. To estimate treatment effect on PMLD, linear mixed model analysis was performed.

RESULTS

Three months after the intervention, participants in the PM+ condition reported significantly fewer PMLDs compared to the control condition. Further analyses at item-level showed that interpersonal and family related PMLDs, such as "worries about family back home" significantly improved over time in the PM+ condition.

CONCLUSIONS

This exploratory study suggests that brief psychological interventions have the potential to reduce PMLDs in refugees and asylum seekers. The reduction of post-migration stress in turn may subsequently lead to an overall reduction in psychological distress.

CLINICAL TRIAL NUMBERS

BASEC Nr. 2017-0117 (Swiss trial) and NL61361.029.17, 7 September 2017 (Dutch trial).

Refugees and asylum seekers who have experienced trauma: Thematic synthesis of therapeutic boundary considerations

OBJECTIVE

Therapeutic boundaries are limits to appropriate behaviours within a therapist-client relationship (e.g. related to accepting gifts, self-disclosures, therapist neutrality and advocacy). Therapeutic boundary considerations are fundamental in the care of refugees and asylum seekers. Research on the experiences of therapists navigating such boundaries is sparse and warrants further exploration. The aim of this qualitative systematic review was to thematically synthesise literature regarding therapists' (psychologists, psychotherapists, counsellors) experiences of implementing flexible therapeutic boundaries with refugee and asylum seeker clients and determine how such applications have been helpful for therapeutic interventions.

METHOD

Six databases were searched. Following full-text screening, 21 papers were included in the analysis. Boundary theory underpinned the analysis.

RESULTS

Three major themes were developed: (i) Changes to Therapeutic Practice & Therapeutic Intervention, (ii) Re-Conceptualisation of Therapy as 'Clinical Political' and Re-Conceptualisation of Therapist Identity and (iii) Careful Monitoring of Personal Boundaries-Not becoming 'Hardened' or 'Haunted'. Papers described how, when used in a reflective, considerate way, flexible therapeutic boundaries can strengthen the therapist-client alliance and positively impact therapeutic interventions. Many therapists acknowledged making conscious efforts to re-conceptualise therapeutic work with refugee and asylum seeker clients from advocacy standpoints. However, systemic constraints, and lack of guidance, made this difficult to navigate and contributed to therapist burn-out.

CONCLUSIONS

Boundary considerations manifested as interpersonal, structural and cultural changes to practice. These have implications for clinical practice and developing guidelines on boundary practices with refugees and asylum seekers. Future research should explore promoting therapist well-being and training needs for therapists supporting this population.

A balancing act: how interpreters affect the therapeutic alliance in psychotherapy with trauma-affected refugees-a qualitative study with therapists

Objective

The therapeutic alliance (TA) has the highest predictive value concerning the success of psychotherapy. The presented study aimed to explore how the presence of an interpreter affects the TA when working with trauma-affected refugees.

Method

Semi-structured interviews were conducted with seven psychologists working in an outpatient clinic specialized in mental health care for migrant and refugee patients with trauma-related mental health problems in Denmark. Interviews were transcribed verbatim and analyzed using a structuring content analysis approach.

Results

TA has been described as a dynamic therapist-interpreter-patient alliance triangle consisting of three distinct but highly intertwined and mutually influential dyadic alliances. Specific factors affecting the quality of the TA were identified, e.g., interpreter being emotionally attuned yet not overly involved; interpreter being barely visible yet present as a human being. Characteristics of trauma-affected refugee patients affecting the TA formation were also identified, e.g., a high level of personal distrust, different understandings of mental disorders and psychotherapy, stigmatization, perceptions of authorities.

Conclusion

The presence of interpreters was perceived ambivalently and the formation of a good TA seems to be a balancing act. Based on the findings, recommendations for forming and maintaining a good TA in interpreter-mediated psychotherapy are provided.

Germans' awareness of refugees' information barriers regarding health care access: a cross-sectional study

BACKGROUND

In light of their experiences on the refuge and upon their arrival in the receiving society, refugees may have differentiated needs regarding health care. However, negative attitudes of the members of the receiving society and a lack of information pose as barriers for refugees when trying to access health care services. In that sense, it is largely unknown, which antecedents positively affect Germans' perception of information barriers that refugees face. Based on an extended version of the Empathy-Attitude-Action model, this study examined selected predictors of problem awareness in the form of perceived information barriers that refugees face, emphasizing the role of positive intercultural contact experiences.

METHODS

A sample of members of the receiving society, here: Germans (N = 910) completed a cross-sectional online survey with validated self-report measures. From the perspective of Germans, assessments covered positive intercultural contact, attitudes on refugees' rights, the recognition of refugees' socio-emotional support needs as a form of cognitive empathy, and the perception of refugees' information barriers when accessing health care. We conducted structural equation modeling to examine hypothesized latent associations and specified three different models with unidirectional paths between the study variables, each allowing another direct path from intercultural contact to the variables. We determined the best model using the chi-square-difference test and tested for indirect effects along the paths through bias-corrected bootstrapping.

RESULTS

Our results show consistency with the Empathy-Attitude-Action model. We found Germans' cognitive empathy toward refugees to be associated with more positive attitudes and a greater awareness of refugees' information barriers. We further found more positive intercultural contact to be associated with greater cognitive empathy toward refugees and with more positive attitudes. While these contact experiences showed a slightly direct negative effect on Germans' perception of refugees' information barriers to accessing health care, the indirect effects via cognitive empathy and positive attitudes were positive.

CONCLUSION

Previous positive intercultural contact may be directly and indirectly linked to greater awareness for refugees, helping Germans as the receiving community (1) to become more empathetic toward refugees, (2) to improve their attitudes toward refugees' rights and to (3) raise consciousness for information barriers that refugees face when trying to access health care services.

Ethnic minority experiences of mental health services in the Netherlands: an exploratory study

Objective

Despite considerable spending on mental health in the Netherlands, access to mental health remains suboptimal, particularly for migrants and ethnic minorities. Addressing the growing mental health service needs requires an understanding of the experiences of all stakeholders, specifically minority populations. In this exploratory study, we sought to understand the perspectives and experience of mental health services by migrants and their provider. An exploratory qualitative study was conducted with 10 participants, five of whom were mental health service providers and the other five were clients who had utilized or currently utilized MHS in the Netherlands.

Results

We identified three themes that explained the experiences of clients and providers of MHS in the Netherlands (i) Perceptions of mental health service utilization (ii) Mismatch between providers (iii) Availability of services. The most significant factor that influenced participants experience was a service provider of a different cultural background. Minority populations accessing mental health services have multiple needs, including an expressed need for cultural understanding. Their experiences of mental health services could be improved for minority populations by addressing the diversity of health providers.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13104-022-06159-0.

Beliefs About Causes and Cures of Prolonged Grief Disorder Among Arab and Sub-Saharan African Refugees

Background

Many refugees have experienced the death of a loved one under traumatic circumstances. Accordingly, the prevalence of Prolonged Grief Disorder (PGD) among refugees is high. Culture-specific symptoms of PGD have been described previously, but beliefs about causes and cures of PGD among refugees remain unknown. We therefore aimed at identifying illness beliefs and treatment expectations regarding PGD among refugees.

Method

We focused on refugees from Arab countries (n = 14) and from Sub-Sahara Africa (n = 9) and applied qualitative and quantitative methods. In a semi-structured interview, participants first answered questions about assumed causes and potential cures for prototypical PGD symptoms according to ICD-11 that were presented in a vignette as representatives of their own culture. In the quantitative part, they completed the Cause Subscale of the Illness Perception Questionnaire (IPQ-R) that included additional culture-specific items. Interviews were analyzed with Qualitative Content Analysis.

Results

In both groups of refugees, PGD symptoms were predominantly attributed to a close relationship to the deceased, lack of social support, personal vulnerabilities, and circumstances of the death. Participants also named a number of flight-related causes (e.g., inability to perform or participate in rituals, feeling isolated in the host country). None of the participants attributed PGD symptoms to supernatural causes. Descriptive analyses of responses on the IPQ-R indicated that participants predominantly attributed PGD symptoms to psychological causes. Participants believed that PGD can be cured and predominantly mentioned social and religious support. Psychological help was only mentioned by a minority of participants. In both groups, participants emphasized that a therapist must be familiar with the patient's culture and rituals. Participants also mentioned stigma associated with seeking psychological help.

Conclusion

Results suggest specific beliefs of refugees regarding causes and cures of PGD as well as similarities with Western conceptualizations. A culture-sensitive approach to the treatment of PGD in refugees that can include knowledge of culture-specific rituals and incorporating religious beliefs as well as decreasing stigma and increasing mental health literacy seem important. The study is limited by its focus on only two groups of refugees and its small sample size.

To cross or not to cross: Clinical boundary considerations with persons who are refugees

Recent studies suggest that culturally divergent explanatory models of illness and treatment practices, differing physician-patient goals and expectations, and mistrust and misunderstandings between refugee patients and health care professionals are associated with lower health care utilization and outcomes among refugees in Western host countries. In our experience working as psychiatrists with persons who are refugees, we have found that attention to the processes that define and redefine boundary relationships has important implications for therapeutic care, as well as for training residents and others in culturally-responsive care. This article examines the manner and micro-processes by which boundaries are established, maintained, or altered between medical provider and person who is a refugee as a key pathway in the development of working relationships that are culturally sensitive. We work from an expanded concept of boundaries in psychiatry, viewing boundaries as a way of describing interactions that play important and even critical roles in advancing, impeding, and redefining significant aspects of the therapeutic relationship between practitioner and patient. The quality of the interactions occurring minute by minute within treatment sessions provides the foundation from which relationships are defined, parameters of openness or closure of communication are conveyed, and the power structure is laid out. We offer Martin Buber's formulation of the I-Thou relationship as the philosophical grounding of flexible, culturally sensitive boundary behaviors. At its best, boundaries of mutual engagement that are respectful and cognizant of a patient's individuality and cultural history and values are conveyed to the refugee patient.

Health professionals' experiences of and attitudes towards mental healthcare for migrants and refugees in Europe: A qualitative systematic review

Migrants living in Europe constitute over half of the world's international migrants and are at higher risk of poor mental health than non-migrants, yet also face more barriers in accessing and engaging with services. Furthermore, the quality of care received is shaped by the experiences and attitudes of health professionals. The aim of this review was to identify professionals' attitudes towards migrants receiving mental healthcare and their perceptions of barriers and facilitators to service provision. Four electronic databases were searched, and 23 studies met the inclusion criteria. Using thematic synthesis, we identified three themes: 1) the management of multifaceted and complex challenges associated with the migrant status; 2) professionals' emotional responses to working with migrants; and 3) delivering care in the context of cultural difference. Professionals employed multiple strategies to overcome challenges in providing care yet attitudes towards this patient group were polarized. Professionals described mental health issues as being inseparable from material and social disadvantage, highlighting a need for effective collaboration between health services and voluntary organizations, and partnerships with migrant communities. Specialist supervision, reflective practice, increased training for professionals, and the adoption of a person-centered approach are also needed to overcome the current challenges in meeting migrants' needs. The challenges experienced by health professionals in attempting to meet migrant needs reflect frustrations in being part of a system with insufficient resources and without universal access to care that effectively stigmatizes the migrant status.

Albanian Migrants in Cyclades: Contact with Mental Health Services and Implications for Practice

The purpose of this study was to examine the potential differences between Albanian migrants and Greeks in the islands of Paros and Antiparos with regard to seeking help from the local public mental health service, namely the Mobile Mental Health Unit of NE Cyclades Islands (EPAPSY-NGO). The study’s instruments include the Global Assessment of Functioning (GAF) and a questionnaire for recording psychosocial profile data and information concerning contact with the services. The results showed that significantly less Albanian migrants contacted the mental health services in the past in comparison to Greeks. When using the service, the Albanians were more likely to see a psychiatrist in the Unit, rather than a psychologist-psychotherapist, and they more often received prescriptions for medication. There was a significantly higher dropout rate among Albanian migrants. This study highlights the different aspects of access and use of mental health services among Albanian migrants compared with native residents. Further research should focus on the factors related to early dropouts and difficulties accessing mental health services in rural areas, in order to develop more focused and effective interventions and improve the quality of care provided.

Future Anxiety Among Young People Affected by War and Armed Conflict: Indicators for Social Work Practice

Strengthening the evidence base for professional social work intervention that contributes to providing psychosocial support to international students affected by war and conflict is a major priority as this vulnerable group of youth increases. Therefore, this study aimed to determine the level of future anxiety among international students coming from areas experiencing war and conflict. This study used the descriptive correlative approach, where the future anxiety scale was applied to a sample of 287 international students affected by war and conflicts. Findings showed that there are statistically significant differences between males and females (in favor of females) in the level of the social dimension of future anxiety. The current study results showed a statistically significant relationship between future anxiety and some variables related to war and conflict (living in a war environment - direct and indirect exposure to damage). There are statistically significant differences between those who lived in Yemen at the time of wars and those who did not live (in favor of those who lived in Yemen at the time of wars) in the level of future anxiety. There are also statistically significant differences between those exposed to harm or their family because of the war and those who were not exposed (in favor of those who were exposed) in the level of future anxiety as a whole. The study recommends developing psychosocial support services for this vulnerable group, considering the cultural context to promote women and protect them from discrimination in the services they deserve on an equal basis with men.

STARC-SUD - Adaptation of a Transdiagnostic Intervention for Refugees With Substance Use Disorders

Background

Refugees often suffer from multiple mental health problems, which transdiagnostic interventions can address. STARC (Skills-Training of Affect Regulation - A Culture-sensitive Approach) is a culturally sensitive transdiagnostic group intervention that has been developed for refugees to improve affect regulation. In refugees with substance use disorders (SUD), the consideration of SUD-specific elements might improve the acceptance and effectiveness of such an intervention. We aimed to adapt the STARC program for refugees with SUD in a culturally sensitive way.

Method

The conceptual framework of Heim and Kohrt (2019) was used to culturally sensitively adapt the STARC program to the needs of Syrian refugees with SUD. The results of five focus group discussions with refugees on cultural concepts of SUD and their treatment informed the adaption. An expert group suggested adaptions and decided by consensus on their implementation. Two pilot groups were conducted with the adapted STARC-SUD program. Interviews with the therapists of these pilot groups informed further adaption.

Results

The concepts related to SUD identified in focus groups and therapists' interviews that differed from Western concepts were integrated into the STARC intervention.

Discussion

Further studies should assess the acceptance and effectiveness of the culturally sensitive STARC-SUD program for refugees with SUD.

Predicting and preventing dropout in research, assessment and treatment with refugees

Refugees and asylum seekers are exposed to multiple burdensome experiences and suffer from ongoing post-migration stressors that are known to affect the physical and mental health. In psychological treatment offered to refugees and asylum seekers, dropout is an important challenge. The current practice-oriented review aims to provide for the first time knowledge on the prevalence, prediction and prevention of dropout in psychological treatment for refugees and asylum seekers. Due to the limited empirical evidence for this specific population, we synthesized refugee-specific research but also reviewed the existing evidence on dropout from treatment in general and specifically discuss how the findings can be adapted to refugee populations. The review integrates literature from online databases, grey literature, hand search and expert contacts. Prevalence rates of dropout from psychological treatment in Western samples are reported at about 20%. For refugees and asylum seekers, evidence from single efficacy trials showed considerable variability in dropout rates (0%-64.7%). Further, for refugees and asylum seekers, specific sociodemographic variables, high initial impairment, deviating expectations and perceptions of mental health and psychological treatment, as well as external barriers seem to be important predictors for dropout. To prevent dropout, it is important to develop and promote cultural competencies, adapt the treatment to refugee-specific needs and focus on role induction, preparation for treatment, fostering the therapeutic alliance and strengthening hope. Future specific research on dropout in treatment offered to refugees and asylum seekers is needed.

Equitable substance use treatment for migrants and ethnic minorities: the entwinement of micro and meso barriers and facilitators

In Europe, the prerequisites of equitable substance use treatment (SUT) for migrants and ethnic minorities (MEM) remain understudied. This qualitative study maps barriers and facilitators identified by 14 professionals in Flanders, Belgium. The analysis identified micro and meso level barriers and how they intersect. Whereas barriers to treatment are often attributed to the client (vulnerabilities, language, trust, knowledge) our results demonstrate that they are also rooted in services (lack of expertise, issues with interpreters, diversity policies, waiting list and referral bias). These results emphasize the responsibility of meso and macro policymaking in resolving treatment mismatch problems.

Health Professionals' Experiences with Treatment Engagement Among Immigrants with Co-occurring Substance Use- and Mental Health Disorders in Norway

Immigrants face barriers in seeking and accessing mental health and addiction services. Health professionals are crucial in providing and promoting healthcare and it is important to understand their experiences in order to enhance the access of mental healthcare. The aim of this paper is to explore and describe health professionals' experiences with treatment engagement among immigrants with co-occurring substance use disorders (SUD) and mental health disorders (MHD) in Norwegian mental health and addiction services. Within a collaborative approach, 3 focus group interviews were conducted with health professionals, who had provided various mental health and addiction care services to immigrants with co-occurring SUD and MHD. The focus group interviews were transcribed verbatim and analyzed using systematic text condensation. The analysis resulted in 5 main categories: (1) difficulties due to language barriers, (2) difficulties due to lack of culturally competent services, (3) difficulties due to social factors, (4) being curious and flexible improves the user-provider relationship, and (5) increasing access to mental health and addiction services. This study provides an enhanced understanding of how health professionals' experienced treatment engagement among immigrants with co-occurring SUD and MHD in the Norwegian context. Implications of the findings for clinical practice and future research are discussed.

Primary care consultations on emotional distress - a part of the acculturation process in patients with refugee backgrounds: a grounded theory approach

Background

Considering the global refugee crisis, there is an increasing demand on primary care physicians to be able to adequately assess and address the health care needs of individual refugees, including both the somatic and psychiatric spectra. Meanwhile, intercultural consultations are often described as challenging, and studies exploring physician–patient communication focusing on emotional distress are lacking. Therefore, the aim was to explore physician–patient communication, with focus on cultural aspects of emotional distress in intercultural primary care consultations, using a grounded theory approach, considering both the physician’s and the patient’s perspective.

Methods

The study was set in Region Stockholm, Sweden. In total, 23 individual interviews and 3 focus groups were conducted. Resident physicians in family medicine and patients with refugee backgrounds, originating from Somalia, Syria, Afghanistan and Iraq, were included. Data was analysed using a grounded theory approach.

Results

Over time, primary care patients with refugee backgrounds seemed to adopt a culturally congruent model of emotional distress. Gradual acceptance of psychiatric diagnoses as explanatory models for distress and suffering was noted, which is in line with current tendencies in Sweden. This acculturation might be influenced by the physician. Three possible approaches used by residents in intercultural consultations were identified: “biomedical”, “didactic” and “compensatory”. They all indicated that diagnoses are culturally valid models to explain various forms of distress and may thus contribute to shifting patient perceptions of psychiatric diagnoses.

Conclusions

Physicians working in Swedish primary care may influence patients’ acculturation process by inadvertently shifting their perceptions of psychiatric diagnoses. Residents expressed concerns, rather than confidence, in dealing with these issues. Focusing part of their training on how to address emotional distress in an intercultural context would likely be beneficial for all parties concerned.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-021-01487-9.

A Central Clearing Clinic to Provide Mental Health Services for Refugees in Germany

Objective: To determine migration related distress pattern in refugees and feasibility of a de novo established, central low-threshold outpatient clinic serving more than 80,000 newly arrived refugees in the metropole of Berlin. Methods: In an observational cohort study the relative prevalence of major psychiatric disorders by age, place of living within berlin, language and region of origin were assessed in a refugee cohort from 63 nationalities speaking 36 languages. Findings: Within 18 months, a total of 3,096 cases with a mean age of 29.7 years (11.7) have been referred from all 12 districts and 165 of 182 subdistricts of Berlin to the CCC. 33.7% of the patients were female. The three most frequent diagnoses were unipolar depression (40.4%), posttraumatic stress disorder (24.3%), and adjustment disorder (19.6%). Conclusion: The present data gives insight into the distribution of mental disorders in a large sample of refugees and provides evidence that a CCC is an effective service to quickly and broadly provide psychiatric consultations and thus to overcome classical barriers refugees usually experience in the host communities. In Berlin, Germany, and Europe treatment resources for this population should focus on stress and trauma related disorders.

Relational Spirituality and Transgenerational Obligations: The Role of Family in Lay Explanatory Models of Post-traumatic Stress Disorder in Male Cameroonian Asylum Seekers and Undocumented Migrants in Europe

Context: Diasporic Cameroonians are increasingly leading a transnational life in which family members are sustained through networks of relations and obligations. However, before arriving in Europe, the vast majority of African migrants who take the Mediterranean route are exposed to trauma and hardship. Moreover, the joint occurrence of forced displacement, trauma, and extended separation from families has a significant impact on mental health. Objectives: This study explores the role of culture-specific conceptualizations of family structures and transnationalism in explanatory models of post-traumatic stress disorder (PTSD) among male Cameroonian asylum-seekers and undocumented migrants in Europe. Methods: An in-depth study of two samples of Cameroonian migrants with a precarious residency status in Europe was conducted. Focus group discussions and interviews were carried out with asylum seekers in Germany (n = 8) and undocumented migrants and failed asylum seekers in France (n = 9). The verbatim transcripts of these interviews served as the data for interpretative phenomenological analyses. Results, Analysis, and Discussion: Family was conceptualized in religious and spiritual terms, and relational spirituality appeared to be a crucial element of family cohesion. Explanatory models of PTSD were mainly based on an intersection of family and spirituality. The disrespect of transgenerational, traditional, and spiritual obligations toward parents and ancestral spirits represented a crucial causal attribution for post-traumatic symptoms. Conclusions: Conceptualizations of post-traumatic stress were based on a collective family and spiritual level instead of an individualized illness-centered perception. The Western psychological and psychiatric perspective on post-traumatic stress might conflict with traditional, religious, and spiritual practices in the context of family conceptualizations of Cameroonian forced migrants with a precarious residency status.

Mental Health and Service Use of Migrants in Contact with the Public Psychiatry System in Paris

BACKGROUND

Migrants, and particularly asylum seekers, are at increased risk of psychiatric disorders in comparison with natives. At the same time, inequalities in access to mental health care are observed.

METHODS

In order to evaluate whether the Parisian public psychiatric system is optimally structured to meet the needs of this population, we examined data on mental health and service use considering three different levels: the global system treatment level, a psychiatric reception center, and mobile teams specializing in access to psychiatric care for asylum seekers.

RESULTS

We found higher treatment rates among migrants than among natives (p < 0.001) but inequalities in pathways to care: more mandatory admissions (OR = 1.36, 95% CI: 1.02-1.80) and fewer specialized consultations (OR = 0.56, 95% CI: 0.38-0.81). We observed a mismatch between increased need and provision of care among migrants without stable housing or seeking asylum.

CONCLUSIONS

Inequalities in the provision of care for migrants are observed in the Parisian public psychiatric system, particularly for those experiencing poor social and economic conditions. There is a need to facilitate access to mental health care and develop more tailored interventions to reduce discontinuity of care.

Experiences of psychotherapists working with refugees in Germany: a qualitative study

BACKGROUND

Despite a high burden of mental health problems among refugees, there is limited knowledge about effective mental health care provision for this group. Although substantial efforts in understanding the complexity of cross-cultural psychotherapy - which in the context of this study we use to refer to therapy with client and therapist of different cultural backgrounds - have been made, there remains a dearth of research exploring barriers for effective cross-cultural psychotherapy. This study aimed at narrowing this gap in knowledge by exploring major challenges encountered by psychotherapists in cross-cultural psychotherapy and strategies which have proven useful in overcoming such challenges.

METHODS

We employed a qualitative study design, conducting semi-structured in-depth interviews with 10 purposely selected psychotherapists working with refugees in Germany. Respondents were from varying theoretical background and had varying levels of experience. Data were analyzed using a thematic approach, following a mix of deductive and inductive coding.

RESULTS

Respondents reported three main challenges in their cross-cultural practice: different or unrealistic expectations of clients towards what psychotherapy would offer them; challenges grounded in different illness explanatory models; and communication challenges. In dealing with these challenges, respondents recommended psychoeducation to overcome issues related to problematic expectations towards psychotherapy; "imagining the real", identifying "counter magic" and other client-appropriate resources to deal with issues related to clients' foreign illness attributions; and translators in dealing with communication barriers, though the latter not univocally.

CONCLUSIONS

Results show that psychotherapy with refugees can be very successful, at least from the psychotherapist perspective, but also poses significant challenges. Our findings underline the importance of developing, testing, and institutionalizing structured and structural approaches to training psychotherapists in cross-cultural therapy at scale, to accommodate the rising mental health care need of refugees as a client group.

Treatment Experiences with Norwegian Health Care among Immigrant Men Living with Co-Occurring Substance Use- and Mental Health Disorders

Immigrants are considered at risk of psychological distress and therefore involvement in substance abuse, due to a variety of pre- and post-migration factors. Further, there is lower treatment engagement, a higher dropout rate, and less frequent hospitalizations among this group compared to the general population. There are few studies on the subjective understanding of co-occurring substance use disorder (SUD) and mental health disorder (MHD) among immigrants in Norway. This qualitative study aims to explore the treatment experiences of immigrant men living with co-occurring SUD and MHD. Within a collaborative approach, individual interviews were conducted with 10 men of immigrant background, living with co-occurring SUD and MHD, who had treatment experiences from the Norwegian mental health and addiction services. Data were analyzed using a systematic text condensation. The analysis yielded 6 categories where participants described their treatment experiences in mental health and addiction services in Norway as: lack of connection, lack of individually tailored treatment, stigma and discrimination preventing access to treatment, health professionals with multi-cultural competence, care during and after treatment, and raising awareness and reducing stigma. A significant finding was the mention by participants of the value of being seen and treated as a “person” rather than their diagnosis, which may increase treatment engagement. They further mentioned aftercare as an important factor to prevent relapse. This study provides an enhanced understanding of how immigrant men living with co-occurring SUD and MHD experienced being treated in Norwegian healthcare settings. These experiences may add to the knowledge required to improve treatment engagement.

Migration and Psychosis: Specificity and Burden on the Mental Health System in Italy

In the last years, there has been a huge migratory flow to Italy. Migration is a risk factor for the development of psychopathology, especially psychosis and posttraumatic stress disorder. We aimed at investigating the burden and characteristics of psychotic features among immigrants in Lombardy, one of the most involved regions. A total of 7819 patients had at least one psychiatric appointment in 2013, 10.3% of them where immigrants. Patients from Africa showed a significant higher rate of psychosis, psychiatric onset, compulsory admissions, and number of professional appointments. Our result can confirm a cultural specificity of psychotic manifestations and their burden on the mental health system.

Assessing Provider Bias in General Practitioners' Assessment and Referral of Depressive Patients with Different Migration Backgrounds: Methodological Insights on the Use of a Video-Vignette Study

Although the prevalence of common mental health conditions such as depression and anxiety, is higher among people with a migration background, these groups are generally underrepresented in all forms of institutionalized mental health care. At the root of this striking discrepancy might be unequal referral by health care practitioners. In this article we describe the development of a quasi-experimental video vignette methodology to assess potential forms of unequal diagnosing, treatment and referral patterns, based on clients' migration background and asylum status. The presented methodology also allows to explore whether potential differences are related to provider bias, i.e. underlying attitudes and expectations held by general practitioners. Potential assets and drawbacks of this methodology are discussed in detail.

Successes and failures in treatment of substance abuse: Treatment system perspectives and lessons from the European continent

Objective:

The article offers an inventory of controversial basic issues related to treatment responses and their sociocultural political context, highlighting policy failures and successes, with a focus on Europe. As a reference point for this assessment, serves a conceptual framework of an “ideal type of treatment system”, which is built upon the following normative assumptions: the objective of harm minimisation or preventing substance-use-related consequences, evidence-based decision making, securing equity and accessibility also from a user perspective as well as efficiency in terms of the diversity and choice of treatment options.

Method:

Five major issues of addiction treatment systems, as identified and exemplified by an expert survey among 14 countries conducted in 2014, served as a reference for discussing fundamental gaps between an assumed ideal type of treatment system and the treatment response in practice: (1) Resistance to change, consensus building and innovation, (2) Political influence and target group bias beyond evidence, (3) Assumptions about rationality and universal evidence, (4) Myths of addiction and ethical deficits and (5) The treatment gap and user perspectives.

Results/conclusions:

Recommendations relevant for politicians, system planners, and clinicians are formulated for each of the five issues, specifically focusing on embeddedness of treatment systems in macro-societal conditions, the abstinence paradigm and outcome diversity, ethnocentric biases of the “evidence credo”, learning from self-change as the major road to recovery, and questioning implicit conceptions of the “addict as a human being”. Furthermore, it is concluded that theories regarding the diffusion of innovation and knowledge exchange can inform future research.

Lived experiences: a focus group pilot study within the MentALLY project of mental healthcare among European users

BACKGROUND

Mental healthcare is an important component in societies' response to mental health problems. Although the World Health Organization highlights availability, accessibility, acceptability and quality of healthcare as important cornerstones, many Europeans lack access to mental healthcare of high quality. Qualitative studies exploring mental healthcare from the perspective of people with lived experiences would add to previous research and knowledge by enabling in-depth understanding of mental healthcare users, which may be of significance for the development of mental healthcare. Therefore, the aim of the current study was to describe experiences of mental healthcare among adult Europeans with mental health problems.

METHOD

In total, 50 participants with experiences of various mental health problems were recruited for separate focus group interviews in each country. They had experiences from both the private and public sectors, and with in- and outpatient mental healthcare. The focus group interviews (N = 7) were audio recorded, transcribed verbatim and analysed through thematic analysis. The analysis yielded five themes and 13 subthemes.

RESULTS

The theme Seeking and trying to find help contained three subthemes describing personal thresholds for seeking professional help, not knowing where to get help, and the importance of receiving help promptly. The theme Awaiting assessment and treatment contained two subthemes including feelings of being prioritized or not and feelings of being abandoned during the often-lengthy referral process. The theme Treatment: a plan with individual parts contained three subthemes consisting of demands for tailored treatment plans in combination with medications and human resources and agreement on treatment. The theme Continuous and respectful care relationship contained two subthemes describing the importance of continuous care relationships characterised by empathy and respect. The theme Suggestions for improvements contained three subthemes highlighting an urge to facilitate care contacts and to increase awareness of mental health problems and a wish to be seen as an individual with potential.

CONCLUSION

Facilitating contacts with mental healthcare, a steady contact during the referral process, tailored treatment and empathy and respect are important aspects in efforts to improve mental healthcare. Recommendations included development of collaborative practices between stakeholders in order to increase general societal awareness of mental health problems.

Disclosure in Undocumented Families and School Mental Health Clinics

The following describes the case of Miguel and a missed diagnosis in an undocumented minor. Miguel Estrada (all names changed to protect identity) was a 10-year-old boy of Central American origin initially seen at age 8 years in our university outpatient child psychiatry clinic. During the initial evaluation with a native Spanish-speaking provider, his mother, Mrs. Estrada, reported behavioral problems beginning at age 5 with diagnoses of attention-deficit/hyperactivity disorder and intellectual disability; a trauma history was denied. Over the subsequent 2 years, Miguel continued treatment in our outpatient service and later transitioned to our school-based clinic. At the intake visit, Mrs. Estrada explained (with the assistance of his school paraprofessional educator and translator) that they crossed the United States/Mexico border illegally when Miguel was 5 years old. Miguel's behavioral problems began when Immigration and Customs Enforcement officials separated him from his parents, his father was deported, and he was exposed to harsh conditions. During his parents' detention, he was transitioned to five failed foster placements with escalating behavioral problems that eventually led to a 3-month psychiatric residential stay. During the initial visit to the school psychiatric clinic a trauma history was again denied by Miguel and his mother. Ten months into treatment in the school-based psychiatric clinic, Miguel reported hearing a male voice and a motorbike throughout the day, and the diagnosis of a psychotic disorder was entertained. Upon questioning, Mrs. Estrada disclosed that a shooting occurred in their country of origin and prompted their flight to the United States; she stated, "He hears the voice of the men who came on motorbikes and shot at the family home." She explained that Miguel was in the home at the time of the incident and the target was his father. Reexperiencing surfaced with the Marjorie Stoneman Douglas High School massacre on February 14, 2018; Miguel no longer felt safe at school and was fearful of being shot. Chronic posttraumatic stress disorder was diagnosed, and treatment with a selective serotonin reuptake inhibitor and trauma-focused cognitive-behavioral therapy was recommended. Mrs. Estrada preferred trauma-focused cognitive-behavioral therapy; however, the school's clinicians were not trained in this treatment modality and were unable to provide regular psychotherapy sessions. Six months later Miguel continued to report attenuated symptoms of posttraumatic stress disorder.

European Psychiatric Association (EPA) guidance on quality assurance in mental healthcare

Purpose:

To advance the quality of mental healthcare in Europe by developing guidance on implementing quality assurance.

Methods:

We performed a systematic literature search on quality assurance in mental healthcare and the 522 retrieved documents were evaluated by two independent reviewers (B.J. and J.Z.). Based on these evaluations, evidence tables were generated. As it was found that these did not cover all areas of mental healthcare, supplementary hand searches were performed for selected additional areas. Based on these findings, fifteen graded recommendations were developed and consented by the authors. Review by the EPA Guidance Committee and EPA Board led to two additional recommendations (on immigrant mental healthcare and parity of mental and physical healthcare funding).

Results:

Although quality assurance (measures to keep a certain degree of quality), quality control and monitoring (applying quality indicators to the current degree of quality), and quality management (coordinated measures and activities with regard to quality) are conceptually distinct, in practice they are frequently used as if identical and hardly separable. There is a dearth of controlled trials addressing ways to optimize quality assurance in mental healthcare. Altogether, seventeen recommendations were developed addressing a range of aspects of quality assurance in mental healthcare, which appear usable across Europe. These were divided into recommendations about structures, processes and outcomes. Each recommendation was assigned to a hierarchical level of analysis (macro-, meso- and micro-level).

Discussion:

There was a lack of evidence retrievable by a systematic literature search about quality assurance of mental healthcare. Therefore, only after further topics and search had been added it was possible to develop recommendations with mostly medium evidence levels.

Conclusion:

Evidence-based graded recommendations for quality assurance in mental healthcare were developed which should next be implemented and evaluated for feasibility and validity in some European countries. Due to the small evidence base identified corresponding to the practical obscurity of the concept and methods, a European research initiative is called for by the stakeholders represented in this Guidance to improve the educational, methodological and empirical basis for a future broad implementation of measures for quality assurance in European mental healthcare.

EPA guidance on cultural competence training

The stress of migration as well as social factors and changes related to the receiving society may lead to the manifestation of psychiatric disorders in vulnerable individuals after migration. The diversity of cultures, ethnicities, races and reasons for migration poses a challenge for those seeking to understand how illness is experienced by immigrants whose backgrounds differ significantly from their clinicians. Cultural competence represents good clinical practice and can be defined as such that a clinician regards each patient in the context of the patient's own culture as well as from the perspective of the clinician's cultural values and prejudices. The EPA Guidance on cultural competence training outlines some of the key issues related to cultural competence and how to deal with these. It points out that cultural competence represents a comprehensive response to the mental health care needs of immigrant patients and requires knowledge, skills and attitudes which can improve the effectiveness of psychiatric treatment. To reach these aims, both individual and organizational competence are needed, as well as teaching competence in terms of educational leadership. The WPA Guidance on Mental Health and Mental Health Care for Migrants and the EPA Guidance on Mental Health Care for Migrants list a series of recommendations for policy makers, service providers and clinicians; these are aimed at improving mental health care for immigrants. The authors of this paper would like to underline these recommendations and, focusing on cultural competency and training, believe that they will be of positive value.

Forensic psychiatry evaluation in a U. S. immigration detention center in southwest Texas

Immigration and asylum-seeking are issues that have recently. warranted increased attention and significance. In the aftermath of terrorist attacks, people are more wary of asylum seekers who are usually held in detention centers after fleeing persecution and not for criminal or immigration charges. Asylum seekers may raise suspicions due to inconsistent statements and can be held in detention for the duration of the process and/or denied asylum. Inconsistencies may be influenced by psychiatric symptoms, cognitive abilities, the type of past trauma experienced, the questioning style of the interviewer, and are usually unrelated to dishonesty or malingering making psychiatric consult important in many of these evaluations.

Testing the psychometric properties of the Finnish version of the cross-cultural competence instrument of healthcare professionals (CCCHP)

Background

To test the validity of the Finnish version of the Bernhard et al.’s Cross-Cultural Competence instrument of Healthcare Professionals (CCCHP).

Methods

The study sample comprised registered nurses (N = 810) from the Finnish “Competent workforce for the future” -project (COPE). Exploratory factor analyses and structural equation modelling were applied to test structural validity of the CCCHP. Internal consistency of the sub-scales was evaluated using the Cronbach’s alphas. Criterion validity was explored in terms of received education for multicultural work, perceived difficulty of patients, and job satisfaction variables.

Results

The revised version of the instrument including four (motivation/curiosity, attitudes, skills and emotions/empathy) of the five original dimensions provided satisfactory psychometric properties (internal consistency, a good model fit of the data). Of the four remaining competence sub-scales, motivation/curiosity, attitudes and emotions/empathy were associated with the amount of received education for multicultural work, and all with perceived difficulty of patients, and all but attitudes with job satisfaction.

Conclusion

This revised Finnish version of the CCCHP provides a useful tool for studies focusing on the healthcare personnel’s cross-cultural competence in delivering effective and culturally sensitive healthcare services for patients from different cultures.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4105-2) contains supplementary material, which is available to authorized users.

Symptom manifestation and treatment effectiveness, -obstacles and -facilitators in Turkish and Moroccan groups with depression in European countries: A systematic review

BACKGROUND

This study examined the state of the art relevant for clinical practice on symptom manifestation of depression or depression-related idioms of distress, the treatment effectiveness and obstacles and facilitators for therapeutic success in Turkish and Moroccan immigrant populations with depression in Europe.

METHODS

We conducted a systematic search in PsycINFO, MEDLINE, Science Direct, Web of Knowledge, and Cochrane databases (1970- 31 July 2017). Peer-reviewed studies, with adult populations, and an instrument assessing depressive symptoms met inclusion criteria and were evaluated following quality guidelines.

RESULTS

We included 13 studies on symptom manifestation, 6 on treatment effectiveness, and 17 on obstacles and facilitators, published between 2000 and 2017, from Germany, the Netherlands, Austria and Sweden (n Turkish individuals = 11,533; n Moroccan individuals = 5278; n native individuals = 303,212). Both ethnic groups more often reported combined mood and somatic symptoms (and anxiety in the case of Turkish groups) than natives, and had higher levels of symptoms. There was no report on effectiveness of pharmacotherapy and there was weak evidence of the effectiveness of examined psychological treatments for depression in Turkish groups. No treatment has been examined in Moroccan groups. Salient obstacles to therapeutic success were socioeconomic problems, higher level of psychological symptoms at baseline, and negative attitudes towards psychotherapy. Possible facilitators were interventions attuned to social, cultural and individual needs. Results were most representative of first generation, low SES Turkish immigrant patients, and Moroccan-Dutch members of the general populations.

CONCLUSION

Turkish and Moroccan immigrants with depression presented a comorbid symptom profile with more intertwined depressive and somatic complaints. There were indications that the available therapies are insufficient for Turkish groups, but the current evidence is scarce and heterogeneous, and RCTs suffer from methodological limitations.

Prevalence of Mental Health Screening and Associated Factors Among Refugees and Other Resettled Populations ≥ 14 Years of Age in Georgia, 2014-2017

Mental health screening (MHS) during the initial health assessment is recommended within 90 days of arrival to the U.S. Yet, MHS prevalence is not well understood. Screening prevalence [prevalence ratio (PR), adjusted prevalence ratio (adjPR)] and factors associated with MHS were assessed among refugees, Special Immigrant Visa holders, parolees, asylees, and victims of human trafficking ≥ 14 years old resettling in Georgia from 2014 to 2017. Of the 2019 individuals included, 55% received a MHS. Screening was more common among older individuals [reference: 13-22 years old; adjPR 23-35 = 1.20 (1.12-1.29), adjPR 36-49 = 1.14 (1.03-1.26), adjPR ≥ 50 = 1.27 (1.15-1.41)] and those without Medicaid [adjPR Medicaid vs. none = 0.75 (0.63-0.89)]. MHS also differed by country of birth. Although MHS has increased within recent years, gaps exist within sub-populations and geographic regions. Efforts should focus on increasing MHS to ensure timely identification of concerns and linkage to services.

Access and utilization of mental health services for immigrants and refugees: Perspectives of immigrant service providers

Immigrant and refugee populations experience life stressors due to difficult migration journeys and challenges in leaving one country and adapting to another. These life stressors result in adverse mental health outcomes when coupled with a lack of adequate support-enhancing resources. One area of support is access to and use of mental health services to prevent and address mental health concerns. Immigrant service providers in Canada support the integration and overall well-being of newcomers. This study focuses on immigrant service providers' perceptions of access to and use of mental health services for immigrants and refugees in Alberta. A qualitative descriptive design was used to collect and analyse the perspectives of 53 immigrant service providers recruited from nine immigrant serving agencies in Alberta between November 2016 and January 2017. Data were collected using a combination of individual interviews and focus groups, followed by thematic data analysis to identify relevant themes. Barriers to access and use of mental health services include language barriers, cultural interpretations of mental health, stigma around mental illness, and fear of negative repercussions when living with a mental illness. Strategies to improve mental health service delivery include developing community-based services, attending to financial barriers, training immigrant service providers on mental health, enhancing collaboration across sectors in mental health service delivery, and advancing the role of interpreters and cultural brokers. Overall, immigrant service providers present a nuanced view of the complex and inter-related barriers immigrants and refugees experience and identify potential approaches to enhancing mental health service delivery.

Psychiatric nursing care experiences of immigrant patients: A Focused ethnographic study

This study aimed to describe the psychiatric nursing care experiences of immigrant patients. The incidence of mental health problems is higher and the use of mental health services is lower among immigrants, especially refugees, compared with the majority of the population. The study uses a qualitative research approach, with an emphasis on focused ethnography research methods. The participants were immigrant patients (N = 14) residing in adult psychiatric wards of certain hospitals (N = 3) selected for the study. A majority of the participants were refugees or asylum seekers. A total of 21 in-depth interviews were conducted. The experiences of these immigrant patients, both in their home countries and in their country of residence, had had an adverse effect on their mental health, with past traumatic experiences being the most central factor. Their symptoms included depression, anxiety, somatization, and psychosis. The findings show that the categories of factors that helped promote recovery among immigrant patients were nursing, medical treatment, care environment, and the patients' own methods. Based on the findings, a systematic evaluation of traumatic experiences is recommended for immigrants from countries with a history of war and/or political violence. Healthcare providers should also consider the importance of cultural desire in psychiatric nursing for the recovery of patients.

'Only God can promise healing.': help-seeking intentions and lay beliefs about cures for post-traumatic stress disorder among Sub-Saharan African asylum seekers in Germany

Background: Epidemiological studies have reported high rates of post-traumatic stress disorder (PTSD) among asylum seekers from Sub-Saharan Africa. In order to provide appropriate and culturally sensitive mental health care for this group, further knowledge about treatment preferences might be necessary. Objective: We aimed to provide insights into help-seeking intentions and lay beliefs about cures for PTSD held by asylum seekers from Sub-Saharan Africa living in Germany. Methods: To address this objective, we used a quantitative and qualitative methodological triangulation strategy based on a vignette describing symptoms of PTSD. In the quantitative part of the study, asylum seekers (n = 119), predominantly from Eritrea (n = 41), Somalia (n = 36), and Cameroon (n = 25), and a German comparison sample without a migration background (n = 120) completed the General Help-Seeking Questionnaire (GHSQ). In the qualitative part, asylum seekers (n = 26) reviewed the results of the questionnaire survey within eight focus group discussions sampled from groups of the three main countries of origin. Results: Asylum seekers showed a high intention to seek religious, medical, and psychological treatment for symptoms of PTSD. However, asylum seekers indicated a higher preference to seek help from religious authorities and general practitioners, as well as a lower preference to enlist psychological and traditional help sources than Germans without a migration background. Furthermore, asylum seekers addressed structural and cultural barriers to seeking medical and psychological treatment. Conclusion: To facilitate access to local health care systems for asylum seekers and refugees, it might be crucial to develop public health campaigns in collaboration with religious communities. When treating asylum seekers and refugees from Sub-Saharan Africa, practitioners should explore different religious and cultural frameworks for healing and recovery in order to signal understanding and acceptance of varying cultural contexts.

Upon Rejection: Psychiatric Emergencies of Failed Asylum Seekers

Background: The status of a refugee or asylum seeker is only recognised after legal processes. The uncertainty of these procedures or the rejection itself may severely impact mental well-being. Methods: We surveyed the patterns of psychiatric services used by patients whose applications for asylum had been rejected. In a retrospective investigation of admissions to the University Emergency Department in Bern, Switzerland between 1 March 2012 and 28 February 2017, we studied patients receiving a psychiatric consultation after their applications had been rejected. The primary endpoint was based on the comparison of these individuals with controls who were asylum seekers with pending asylum applications using the Mann-Whitney U test and the chi-square test (χ²) with a significance level of 0.05. Results: Thirty-eight cases were identified. There were more men than women and the mean age was 30.08 ± 9.62 years. Patients predominantly presented as walk-in patients (n = 16, 42.1%), most frequently due to suicidal ideation (n = 16, 42.1%). Stress-related disorders were the most common diagnosis (n = 29, 76.3%) and patients were mainly referred to inpatient treatment (n = 28, 73.7%). Patients with rejected applications were less likely to be living in reception centres than patients with a pending application (χ² = 17.98, p < 0.001). Conclusion: The profile of asylum seekers whose applications had been rejected reflects individuals with high-stress levels, potentially aggravated by the negative asylum decision.

Psychiatric Emergencies of Asylum Seekers; Descriptive Analysis and Comparison with Immigrants of Warranted Residence

Background: The aim of our study was to assess utilization patterns of psychiatric services by asylum seekers. Methods: We included 119 adults who presented themselves at the University Emergency Department between 1 March 2012 and 1 January 2017 for psychiatric consultation. Descriptive data were compared with a control group of non-Swiss individuals with warranted residence permits using Mann-Whitney-U and chi square (χ²) tests. Results: Patients were mainly single, male, residing in reception centers, and presented themselves most frequently due to suicidal ideation. Almost 60% of the patients were assigned to inpatient treatments, with 28 involuntary cases. Compared to the control group, asylum seekers were younger and more often men (p < 0.001 for both). Further, they less often had family in Switzerland (χ² = 9.91, p = 0.007). The proportion of patients coming in as walk-ins was significantly higher in the control group than in asylum seekers (χ² = 37.0, p < 0.001). Asylum seekers were more frequently referred due to suicidal ideation and aggressive behavior than participants in the control group (χ² = 80.07, p < 0.001). Diagnoses for asylum seekers infrequently included mood, as they often reported stress-related disorders (χ² = 19.6, p = 0.021) and they were infrequently released home (χ² = 9.19, p = 0.027). Conclusion: Asylum seekers more frequently demonstrated severe symptoms such as suicidal ideation and aggressive behavior and they were mainly treated as inpatients, potentially due to minimal social resources.

How do mental health practitioners operationalise cultural competency in everyday practice? A qualitative analysis

BACKGROUND

Despite continued policy and research emphasis to deliver culturally competent mental healthcare, there is: (1) limited evidence about what frontline practitioners consider to be culturally competent care and; (2) what helps or hinders them in delivering such care in their everyday practice. The aims of this article are to address these gaps.

METHODS

Qualitative in-depth interviews were conducted with 20 mental health practitioners working with immigrant patients to explore their understandings and experiences of culturally competent care. Interviews were conducted between September 2015 and February 2016 in the state of Victoria, Australia. Data were thematically analysed.

RESULTS

There were common understandings of cultural competence but its operationalisation differed by profession, health setting, locality, and years of experience; urban psychiatrists were more functional in their approach and authoritarian in their communication with patients compared to allied health staff in non-specialist mental health settings, in rural areas, with less years of experience. Different methods of operationalising cultural competence translated into complex ways of building cultural concordance with patients, also influenced by health practitioners' own cultural background and cultural exposures. Limited access to interpreters and organisational apathy remain barriers to promoting cultural competency whereas organisational support, personal motivation, and professional resilience remain critical facilitators to sustaining cultural competency in everyday practice.

CONCLUSION

While there is need for widespread cultural competence teaching to all mental health professionals, this training must be specific to different professional needs, health settings, and localities of practice (rural or urban). Experiential teaching at tertiary level or professional development programs may provide an avenue to improve the status quo but a 'one-size-fits-all' model is unlikely to work.

Mental health care for adult refugees in high-income countries

Approximately one-third of people who have obtained refugee status live in high-income countries. Over recent years, the number of refugees has been increasing, and there are questions on how many of them need mental health care and which type of interventions are beneficial. Meta-analyses showed highly variable rates of mental disorders in adult refugees. This variability is likely to reflect both real differences between groups and contexts, and methodological inconsistencies across studies. Overall prevalence rates after resettlement are similar to those in host populations. Only post-traumatic stress disorder (PTSD) is more prevalent in refugees. In long-term resettled refugees, rates of anxiety and depressive disorders are higher and linked to poor social integration. Research on mental health care for refugees in high-income countries has been extensive, but often of limited methodological quality and with very context-specific findings. The existing evidence suggests several general principles of good practice: promoting social integration, overcoming barriers to care, facilitating engagement with treatment and, when required, providing specific psychological treatments to deal with traumatic memories. With respect to the treatment of defined disorders, only for the treatment of PTSD there has been substantial refugee-specific research. For other diagnostic categories, the same treatment guidelines apply as to other groups. More systematic research is required to explore how precisely the general principles can be specified and implemented for different groups of refugees and in different societal contexts in host countries, and which specific interventions are beneficial and cost-effective. Such interventions may utilise new communication technologies. Of particular importance are long-term studies to identify when mental health interventions are appropriate and to assess outcomes over several years. Such research would benefit from sufficient funding, wide international collaboration and continuous learning over time and across different refugee groups.

Experience of migrant care and needs for cultural competence training among public health workers in Korea

OBJECTIVE

This study explored the experiences of public health workers (PHWs) providing health care for migrants living in Korea and clarified needs for cultural competence training.

DESIGN AND SAMPLE

Twenty-six PHWs from five public health centers in Gwangju city, South Korea, participated in this exploratory qualitative study.

METHODS

Five semi-structured focus group interviews of PHWs were conducted from September to December 2016. A directed content analysis approach was conducted using four categories: perceived characteristics of migrants, interaction between PHWs and migrants, interaction between PHWs and organizations/systems, and cultural competence training needs.

RESULTS

PHWs perceived that migrants lacked autonomy in health decisions and awareness of health behaviors. PHWs experienced difficulties in communicating and in establishing trusting relationships. They found clients hard to reach and easy to miss, a lack of continuity in health care programs, and inadequate human and material resources. They preferred passive teaching methods to activity-based simulation. PHWs believed essential training should be provided through e-learning to all PHWs, including management.

CONCLUSION

PHWs reported experiencing multiple challenges from a lack of preparedness for culturally competent care and their clients' vulnerability. Development of cultural competence training is suggested through e-learning that reflects the PHWs' experiences and provides systematic support.

Development and evaluation of diversity-oriented competence training for the treatment of depressive disorders

Studies in Europe indicate that some ethnic minorities have higher rates of mental disorders and less favorable treatment outcomes than their counterparts from majority groups. To date, efforts regarding training to reduce disparities have mainly focused on ethnocultural competences of therapists, with less attention paid to other aspects of diversity, such as sex/gender and socioeconomic status. In this study, we aim to determine the effectiveness of a population-specific, diversity-oriented competence training designed to increase therapists' competencies to integrate aspects of diversity features in clinical assessment, diagnosis, and treatment of depressive disorders in Turkish- and Moroccan-Dutch patients. A group of 40 therapists were location-based assigned to either training or a control condition (no training). Self-reported diversity competence, a knowledge test, and therapists' satisfaction with training were used to monitor the training and to measure competence levels at baseline, post-training, and three-month follow-up. Attitude-awareness and knowledge components of the self-reported diversity competence and test-measured knowledge increased in the training condition. Most gains remained stable at follow-up except test-measured knowledge after controlling for percentage of ethnic minority patients in caseload. There were no changes regarding therapists' self-reported skills. Therapists expressed medium-high satisfaction with the training, acknowledging the relevance of diversity competence for their daily practice. Future training must ensure better adjustment to therapists' pre-existing knowledge and be followed by long-term efforts to maintain competence levels and enhance competence transfer within teams.

Characteristics of Successful and Unsuccessful Mental Health Referrals of Refugees

In this community based participatory research study, we explored key characteristics of mental health referrals of refugees using stories of providers collected through an on-line survey. Ten coders sorted 60 stories of successful referrals and 34 stories of unsuccessful referrals into domains using the critical incident technique. Principal components analysis yielded categories of successful referrals that included: active care coordination, establishing trust, proactive resolution of barriers, and culturally responsive care. Unsuccessful referrals were characterized by cultural barriers, lack of care coordination, refusal to see refugees, and system and language barriers. Recommendations for training and policy are discussed.

The relevance of clinical ethnography: reflections on 10 years of a cultural consultation service

BACKGROUND

Training health professionals in culturally sensitive medical interviewing has been widely promoted as a strategy for improving intercultural communication and for helping clinicians to consider patients' social and cultural contexts and improve patient outcomes. Clinical ethnography encourages clinicians to explore the patient's explanatory model of illness, recourse to traditional and alternative healing practices, healthcare expectations and social context, and to use this information to negotiate a mutually acceptable treatment plan. However, while clinical ethnographic interviewing skills can be successfully taught and learned, the "real-world" context of medical practice may impose barriers to such patient-centered interviewing. Creating opportunities for role modeling and critical reflection may help overcome some of these barriers, and contribute to improved intercultural communication in healthcare. We report and reflect on a retrospective analysis of 10 years experience with a "cultural consultation service" (CCS) whose aim is to provide direct support to clinicians who encounter intercultural difficulties and to model the usefulness of clinical ethnographic interviewing for patient care.

METHODS

We analyzed 236 cultural consultation requests in order to identify key patient, provider and consultation characteristics, as well as the cross cultural communication challenges that motivate health care professionals to request a cultural consultation. In addition, we interviewed 51 clinicians about their experience and satisfaction with the CCS.

RESULTS

Requests for cultural consultations tended to involve patient care situations with complex social, cultural and medical issues. All patients had a migration background, two-thirds spoke French less than fluently. In over half the cases, patients had a high degree of social vulnerability, compromising illness management. Effective communication was hindered by language barriers and undetected or underestimated patient/provider differences in health-related knowledge and beliefs. Clinicians were highly satisfied with the CCS, and appreciated both the opportunity to observe how clinical ethnographic interviewing is done and the increased knowledge they gained of their patients' context and perspective.

CONCLUSIONS

A cultural consultation service such as ours can contribute to institutional cultural competence by drawing attention to the challenges of caring for diverse patient populations, identifying the training needs of clinicians and gaps in resource provision, and providing hands-on experience with clinical ethnographic interviewing.

"It's That Route That Makes Us Sick": Exploring Lay Beliefs About Causes of Post-traumatic Stress Disorder Among Sub-saharan African Asylum Seekers in Germany

Many asylum seekers have been confronted with traumatizing events, leading to high prevalence rates of post-traumatic stress disorder (PTSD). Within the diagnostic context, clinicians should take into account patients' culturally shaped presentation of symptoms. Therefore, we sought to provide insights into beliefs about causes of PTSD held by Sub-Saharan African asylum seekers living in Germany. To this aim, we used a quantitative and qualitative methodological triangulation strategy based on a vignette describing symptoms of PTSD. In the first part of the study, asylum seekers (n = 119), predominantly from Eritrea (n = 41), Somalia (n = 36), and Cameroon (n = 25), and a German comparison sample without a migration background (n = 120) completed the Revised Illness Perception Questionnaire (IPQ-R). In the second part, asylum seekers reviewed the results within eight focus group discussions (n = 26), sampled from groups of the three main countries of origin. Descriptive analyses of the first part demonstrated that asylum seekers predominantly attributed PTSD symptoms to psychological and religious causes, and rather disagreed with supernatural causes. In comparison to the German sample without a migration background, asylum seekers attributed symptoms less strongly to terrible experiences, but more strongly to religious and supernatural causes. Within the focus group discussions, six attribution categories of participants' causal beliefs were identified: (a) traumatic life experiences, (b) psychological causes, (c) social causes, (d) post-migration stressors, (e) religious causes, and (f) supernatural causes. Our findings suggest that the current Western understanding of PTSD is as relevant to migrants as to non-migrants in terms of psychological causation, but might differ regarding the religious and supernatural realm. While awareness of culture-specific belief systems of asylum seekers from Sub-Saharan Africa regarding PTSD is important, our findings do underline, at the same time, that cultural differences should not be overstated.

Determinants of Suicidality and of Treatment Modalities in a Community Psychiatry Sample of Asylum Seekers

A high prevalence of mental illness has been reported in asylum seekers. The present cross-sectional study examined suicidal thoughts, treatment modalities (outpatient crisis intervention, inpatient care), and their determinants in asylum seekers (n = 119) and permanent residents (n = 120) attending the same outpatient clinic in Geneva, Switzerland. The most frequent diagnoses were depressive disorders (64.7%) and posttraumatic stress disorder (34.5%) in asylum seekers and psychotic (55.0%) and depressive disorders (33.3%) in permanent residents. The frequency of suicidal thoughts was similar in both groups (>30%). Asylum seekers benefited from outpatient crisis intervention more frequently than residents did (26.9% vs. 5.8%), whereas inpatient care was less frequent (25.2% vs. 44.2%). In asylum seekers, acute suicidal thoughts were associated with increased frequency of outpatient crisis interventions, and, suicidal thoughts, psychosis, or personality disorders were associated with higher rates of hospitalization. Documenting clinical characteristics and service utilization of asylum seekers is a prerequisite to organizing targeted interventions.

Prevalence of and risk factors for mental disorders in refugees

Given the increasing numbers of refugees worldwide, the prevalence of their mental disorders is relevant for public health. Prevalence studies show that, in the first years of resettlement, only post-traumatic stress disorder (PTSD) rates are clearly higher in refugees than in host countries' populations. Five years after resettlement rates of depressive and anxiety disorders are also increased. Exposure to traumatic events before or during migration may explain high rates of PTSD. Evidence suggests that poor social integration and difficulties in accessing care contribute to higher rates of mental disorders in the long-term. Policy and research implications are discussed.