Somatic distress among Syrian refugees in Istanbul, Turkey: A cross-sectional study

Mental healthcare access among resettled Syrian refugees in Leipzig, Germany

Our aim was to examine mental health needs and access to mental healthcare services among Syrian refugees in the city of Leipzig, Germany. We conducted a cross-sectional survey with Syrian refugee adults in Leipzig, Germany in 2021/2022. Outcomes included PTSD (PCL-5), depression (PHQ-9), anxiety (GAD-7) and somatic symptom (SSS-8). Descriptive, regression and effect modification analyses assessed associations between selected predictor variables and mental health service access. The sampling strategy means findings are applicable only to Syrian refugees in Leipzig. Of the 513 respondents, 18.3% had moderate/severe anxiety symptoms, 28.7% had moderate/severe depression symptoms, and 25.3% had PTSD symptoms. A total of 52.8% reported past year mental health problems, and 48.9% of those participants sought care for these problems. The most common reasons for not accessing mental healthcare services were wanting to handle the problem themselves and uncertainty about where to access services. Adjusted Poisson regression models (n = 259) found significant associations between current mental health symptoms and mental healthcare service access (RR: 1.47, 95% CI: 1.02-2.15, p = 0.041) but significance levels were not reached between somatization and trust in physicians with mental healthcare service access. Syrian refugees in Leipzig likely experience high unmet mental health needs. Community-based interventions for refugee mental health and de-stigmatization activities are needed to address these unmet needs in Leipzig.

Weathering within war: Somatic health complaints among Vietnamese older adults exposed to bombing and violence as adolescents in the American war

OBJECTIVE

People living in war may experience deteriorating health via weathering (wear and tear) from long-term exposures to psychosocial and environmental stressors. Weathering embodied in somatic health complaints may illuminate the effects of war on health.

METHODS

We investigate whether wartime stress exposures occurring during adolescence and early adulthood affect weathering in late adulthood via linear regression with data from the Vietnamese Health and Aging Study (VHAS). VHAS is a cross-sectional study wherein investigators surveyed 2447 adults aged 60+ in four districts of northern and central Vietnam in 2018. These same individuals ranged in age from seven to 52 in 1965, with most having been in adolescence or early adulthood at the peak of the American war in Vietnam (1965-1975). The sample used for this study (n = 2254) were participants in the first VHAS wave in 2018.

RESULTS

We find older Vietnamese adults exposed to higher-intensity provincial bombing suffer more numerous somatic health complaints (unstandardized β = 0.005, SE = 0.001, p = 0.001). Additionally, greater health complaints emerge among older adults whose most intense bombing exposures were at younger ages of adolescence (< age 15) as compared to those whose peak exposures were in older ages (19-25) (unstandardized β = 0.62 95%, SE = 0.19, p = 0.01).

CONCLUSION

Our findings suggest that age of exposure to armed conflict is a critical determinant of weathering across the life course.

An online tiered screening procedure to identify mental health problems among refugees

BACKGROUND

Many refugees suffer from mental health problems due to stressful and traumatic events before, during, and after migration. However, refugees are facing a wide variety of barriers, limiting their access to mental health care. Internet-based tools, available in several languages, could be one way to increase the availability of mental health services for refugees. The present study aimed to develop and test a screening tool to screen for clinically relevant symptoms of psychiatric disorders common among refugees (i.e. Depression, Anxiety, Post-traumatic stress disorder, and Insomnia). We, designed, translated, and adapted an internet-based tiered screening procedure suitable for use with the largest refugee populations residing in Sweden. The tool aims to accurately identify symptoms of mental distress (Tier 1), differentiate between symptoms of specific psychiatric disorders (Tier 2), and assess symptom severity (Tier 3). We tested the overall efficiency of using a tiered screening procedure.

METHODS

Seven hundred fifty-seven refugees residing in Sweden, speaking any of the languages Arabic, Dari, Farsi, English, or Swedish, completed an online questionnaire following a three-tiered procedure with screening instruments for each tier. In this study, the Tier 3 scales were used as reference standards for clinically relevant symptoms, to evaluate screening efficiency in terms of accuracy and reduction of item burden in previous tiers.

RESULTS

The results show that the tiered procedure could reduce the item burden while maintaining high accuracy, with up to 86% correctly assessed symptoms and few false negatives with moderate symptoms and above (at most 9%), and very few with severe symptoms (at most 1.3%).

DISCUSSION

This study generated an accurate screening tool that efficiently identifies clinically relevant symptoms of common psychiatric disorders among refugees. Using an adapted online tiered procedure to screen for multiple mental health issues among refugees has the potential to facilitate screening and increase access to mental health services for refugees. We discuss the utility of the screening tool and the necessity of further evaluation.

Relations between criteria for somatic symptom disorder and quality of life in asylum seekers living in Germany

OBJECTIVE

Asylum seekers often suffer from medically unexplained symptoms that affect their quality of life (QoL). The present study is the first to investigate the extent to which somatic symptoms and the B criteria for the DSM-5 somatic symptom disorder (SSD) are associated with the QoL of asylum seekers living in Germany.

METHODS

In 144 asylum seekers, somatic symptoms (PHQ-15), B criteria for SSD, symptoms of posttraumatic stress (PDS), depressive symptoms (PHQ-9), post-migration living difficulties (PMLD), and QoL (EUROHIS) were assessed cross-sectionally. Multiple regressions in the total sample and in groups of somatic symptom severity (mild/moderate and severe) were conducted to examine the associations between somatic symptoms and B criteria with QoL.

RESULTS

Sleep problems and pain were the most frequently reported somatic symptoms. Sixteen (11%) participants met one B criterion, 24 (17%) met two, and 84 (58%) met all three criteria. QoL correlated negatively with somatic symptoms (r = -0.56, p < .001) and with the existence of at least one B criterion (r = -0.24, p < .001). In the total sample, stronger depressive and somatic symptoms were related to lower QoL (adjusted R² = 0.53) while the B criteria were not. In persons with severe somatic symptom severity, the B criterion behavior was associated with lower QoL.

CONCLUSION

In addition to stronger somatic and depressive symptoms, the psychological B criterion behavior seems to play an important role in the lower QoL of asylum seekers with severe somatic symptoms.

Chronic pain, mental health and functional impairment in adult refugees from Syria resettled in Norway: a cross-sectional study

BACKGROUND

Limited research exists on pain and especially the co-occurrence of pain and mental ill health in general refugee populations. The present study aimed to approximate the prevalence of chronic pain (CP) among adult refugees from Syria resettled in Norway; investigate the association between CP and mental ill health; and explore how CP and mental ill health associate with both perceived general health and functional impairment. Gender as potential effect modifier in these associations was also examined.

METHODS

Cross-sectional, postal survey questionnaire.

INCLUSION CRITERIA

≥ 18 years old; refugee from Syria; and arrived in Norway between 2015 and 2017. Study sample was randomly drawn from full population registries, and n = 902 participated (participation rate ≈10%). CP was measured with 10 items on pain lasting for ≥ 3 consecutive months last year. Symptoms of anxiety, depression and PTSD were measured with the HSCL and HTQ scales, respectively. Ordered and binomial logistic regressions were used in analyses. Gender was tested as effect modifier with Wald test for interaction.

RESULTS

In the sample overall, the proportion of participants who reported severe CP was 43.1%. There was strong evidence that anxiety, depression and PTSD were associated with higher levels of CP. In fully adjusted regression models, including both CP and mental health variables, CP was strongly associated with poor perceived general health whereas mental health showed much weaker associations. The association between mental health (anxiety and PTSD) and functional impairment was highly gender specific, with strong associations in men but not in women. CP was strongly associated with functional impairment with no difference across gender.

CONCLUSION

The study shows a high burden of CP in a general population of adult refugees from Syria with likely substantial adverse consequences for daily functioning. The strong association between CP and mental ill health suggests personnel working with refugees' health should be attuned to their co-occurrence as both problems may need to be addressed for either to be effectively mitigated. A clear mismatch exists between the burden on health caused by pain in general refugee populations and the amount of available evidence to guide mitigating strategies.

TRIAL REGISTRATION

NCT03742128.

Mental health outcomes in Syrian refugees: A systematic review

BACKGROUND

Syria is the main country of origin for refugees in the world. The prevalence of mental disorders in this population is high, but there is a lack of more comprehensive data on mental health issues in this population.

AIM

This study aims to review the literature for mental health outcomes in Syrian refugees.

METHODS

We performed a systematic quantitative literature review of original observational studies indexed on the MEDLINE via PubMed, Embase, Web of Science, PsycINFO, LILACS, and SciELO databases with quantitative data reporting mental health outcomes in Syrian refugees. A descriptive analysis was conducted, and the quality of the included studies was assessed using an adaptation from The National Institutes of Health (NIH) quality assessment tool for observational studies. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were followed.

RESULTS

A total of 64 studies were included. The majority were published between 2019 and 2020, and focused on the prevalence of post-traumatic stress disorder (PTSD), depression, and anxiety, with a wide range of variations. Other outcomes were difficulties in the post-migration period and promotive factors for mental health, such as resilience, positive coping strategies, and psychosocial well-being.

CONCLUSIONS

High prevalence rates of mental disorders were observed, as well as risk factors for their occurrence. Studies showed a very high variability of prevalence rates and heterogeneity in methodologies. There is a need for research focusing on other determinants and specific necessities for mental health, especially in the post-resettlement period.

Addressing Mental Health Concerns in Refugees and Displaced Populations: Is Enough Being Done?

There are over 82.4 million forcibly displaced people worldwide, about a quarter of whom are resettling as refugees. In the wake of the global refugee crisis spurred by conflict, religious and political persecution, human rights violations, and climate disasters, a mental health has crisis followed. Not only does trauma experienced in home countries and as part of forced migration affect mental health, so too do post-migration traumatic events, discrimination, lack of access to quality and affordable healthcare and housing, and acculturation. To address mental health concerns in refugees and displaced populations, collective action is needed not only from health care providers but also from mental health researchers, funders, journals, resettlement agencies, government entities, and humanitarian organizations. The present review highlights the work of numerous scholars and organizations with the goal of understanding the mental health concerns of forcibly displaced persons within and across ecological systems. The present review seeks to bring attention to the experiences of forcibly displaced persons, summarize the growing body of research understanding the acute and chronic effects of forced displacement and possible interventions, and give a call to action for all members of the global community at every level to engage in joint efforts to improve mental health in refugees and displaced persons. Notably, there is a need for more interventions at the familial and community level that serve not only as treatment but also as prevention. Smartphone-based interventions, mind-body modalities, and interventions delivered by lay and non-clinician community members hold promise. Numerous strides could be made in refugee mental health and treatment when funding agencies include these goals in their research priorities. Despite the challenges they have faced, persons who resettle as refugees are incredibly resilient and deserve to be afforded every right, opportunity, dignity, and respect.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION

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

Vulnerabilities of Syrian refugee children in Turkey and actions taken for prevention and management in terms of health and wellbeing

BACKGROUND

The Syrian crisis, which started in March 2011, has resulted in the displacement of 6.3 million refugees predominantly to neighboring countries in addition to the internal displacement of 6.2 million people. Turkey is the country hosting the largest number of refugees in the world with 3.6 million Syrian refugees 46 % of which are under 18 years old.

OBJECTIVE

The purpose of this article is to conduct a narrative review and analyze the vulnerabilities of refugee children in Turkey from the lens of the Sustainable Development Goals (SDG), more specifically SDG Goal 3: Good Health and Wellbeing, with a specific focus on Syrian refugee children. Moreover, this article explores the actions taken to prevent and mitigate issues that arise from these vulnerabilities.

METHOD

This narrative review article collected data from various primary and secondary sources on the Turkish refugee framework including national and international legislation, governmental and non-governmental data and reports, and scientific papers.

RESULTS

Syrian refugee children in Turkey are facing a variety of risks in terms of their health and wellbeing including communicable and non-communicable diseases, post-traumatic stress disorder, depression, family violence, child labor, and child marriage. The measures taken for prevention and response by governmental and non-governmental entities are multilateral and aim to address issues from multiple perspectives including medical, psychosocial, child protection, and legal.

CONCLUSIONS

The interventions and restructuring of the health system in Turkey contribute to the SDG number 3 for refugee children. The existence of a legal system which enables refugee access to health, protection, and other social services is key to achieve this goal. However, the existing system could be improved especially through solidifying the legal basis and centralizing the implementation for child and refugee protection. The engagement of all stakeholders to improve the health and wellbeing of refugee children remains vital.

Somatic distress among Syrian refugees with residence permission in Germany: analysis of a cross-sectional register-based study

BACKGROUND

Previous studies have already proven high rates of common mental disorders in Syrian refugees. Nevertheless, little is known about the patterns of somatic distress among this refugee population. For this reason, we aimed to examine the prevalence, co-occurrence, and risk factors of somatic distress among Syrian refugees in Germany.

METHODS

This study analyzes the second measurement point (N = 116) of a prospective register-based survey among 200 adult Syrian refugees with residence permission in Germany. The survey consisted of information on sociodemographic and migration-specific characteristics, health care utilization, traumatic life events, acculturative stress (Barcelona Immigration Stress Scale (BISS); subscales: perceived discrimination, intercultural contact stress, homesickness, and general psychosocial stress), and self-reported outcomes of somatic distress (Patient Health Questionnaire (PHQ-15)), depression (PHQ-9), generalized anxiety disorder (GAD-7), and post-traumatic symptoms (Essen Trauma Inventory (ETI)).

RESULTS

Almost half of the respondents (49.1%) were identified as being at risk of somatic distress (PHQ-15 score ≥ 6), and even 24.1% being bothered by moderate-to-severe levels of somatic distress (PHQ-15 score ≥ 10). The most robust associations with somatic distress were found for female gender, the amount of health care utilization, multiple trauma exposures, general psychosocial stress, and self-reported depression and anxiety symptoms. High comorbidities with somatic distress were shown for all of the common mental disorders studied.

CONCLUSIONS

The presented study reveals a significant risk of somatic distress among this displaced population and highlights implications for policy and health care providers.

Self-help plus for refugees and asylum seekers; study protocol for a series of individual participant data meta-analyses

BACKGROUND

Refugees and asylum seekers face various stressors due to displacement and are especially vulnerable to common mental disorders. To effectively manage psychological distress in this population, innovative interventions are required. The World Health Organization (WHO) Self-Help Plus (SH+) intervention has shown promising outcomes in reducing symptoms of common mental disorders among refugees and asylum seekers. However, individual participant differences in response to SH+ remain largely unknown. The Individual Participant Data (IPD) meta-analysis synthesizes raw datasets of trials to provide cutting-edge evidence of outcomes that cannot be examined by conventional meta-analytic approaches.

OBJECTIVES

This protocol outlines the methods of a series of IPD meta-analyses aimed at examining the effects and potential moderators of SH+ in (a) reducing depressive symptoms at post-intervention and (b) preventing the six-month cumulative incidence of mental disorders in refugees and asylum seekers.

METHOD

RCTs on SH+ have been identified through WHO and all authors have agreed to share the datasets of the trials. The primary outcomes of the IPD meta-analyses are (a) reduction in depressive symptoms at post-intervention, and (b) prevention of six-month cumulative incidence of mental disorders. Secondary outcomes include post-traumatic stress disorder symptoms, well-being, functioning, quality of life, and twelve-month cumulative incidence of mental disorders. One-stage IPD meta-analyses will be performed using mixed-effects linear/logistic regression. Missing data will be handled by multiple imputation.

CONCLUSIONS

These results will enrich current knowledge about the response to SH+ and will facilitate its targeted dissemination. The results of these IPD meta-analyses will be published in peer-reviewed journals.

Post-traumatic growth and its predictors among Syrian refugees in Istanbul: A mental health population survey

AIMS

The negative mental health effects of exposure to trauma are well-documented. However, some individuals are theorized to undergo post-traumatic growth (PTG) after exposure to trauma, potentially experiencing positive psychological change across five domains: appreciation for life, relationships with others, new possibilities in life, personal strength, and spiritual change. PTG is less studied in forcibly displaced populations in low- and middle-income countries. This study aimed to explore levels of PTG and associated factors among Syrian refugee adults living in Istanbul, Turkey.

METHODS

A cross-sectional survey was conducted with 1678 respondents. This study analyzed PTG data from 768 individuals as measured by the Post-Traumatic Growth Inventory (PTGI). Descriptive analysis and univariate and multivariate least squares linear regression modeling were used. Factor analysis and Cronbach's alpha tests assessed the psychometric properties of the PTGI.

RESULTS

The sample exhibited a moderate level of PTG at 55.94 (SD=22.91, range 0-105). Factor analysis of PTGI revealed only four factors instead of five, and the PTGI yielded high internal reliability (Cronbach's α=0.90). PTG and post-traumatic stress disorder (PTSD) had a curvilinear relationship, with the highest PTG levels experienced by those with moderate PTSD levels. Five other variables were significantly associated with PTG: older age, less education, somatic distress, and history of an overnight stay at a health facility for mental health care were associated with lower PTG, while more years of education were associated with higher PTG.

CONCLUSIONS

This study identified the role of the sociodemographic and psychological determinants that influence post-traumatic growth among Syrian refugees in Istanbul. These findings could be used to inform future research and programs seeking to understand PTG in refugees.