Mental health care for adult refugees in high-income countries

Why Chaplaincy at Asylum Centers is a Good Idea: A Care Ethics Perspective on Spiritual Care for Refugees

This article argues in favor of introducing chaplaincy care at asylum centers and develops three arguments for doing so. First, chaplaincy is one way to protect the right to health of refugees and to improve their spiritual well-being. The positive contribution of chaplaincy services to mental health care is increasingly recognized, especially in the domain of PTSD. Second, chaplaincy services support asylum seekers in exercising their freedom of religion while entrusted to state care. Chaplains can create a safe space for asylum seekers to reflect on their spiritual and religious needs, orientation and belonging. Third, chaplains are well positioned to help asylum seekers in rebuilding their life-sustaining web, while at the same time promoting a climate of inclusion and respect in and outside the asylum center.

Relationship between working conditions and mental health of migrants and refugees/asylum seekers vs. natives in Europe: a systematic review

OBJECTIVE

Migrants and refugees/asylum seekers make up a significant proportion of the European workforce. They often suffer from poor working conditions, which might impact mental health. The main objective of this systematic review was to summarize and analyze existing research on working conditions of migrants and refugees/asylum seekers in European host countries and compare them to those of natives. Furthermore, the relationship between working conditions and mental health of migrants/refugees/asylum seekers and natives will be compared.

METHODS

Three electronic databases (PubMed/MEDLINE, PsycInfo and CINAHL) were systematically searched for eligible articles using quantitative study designs written in English, German, French, Italian, Polish, Spanish or Turkish and published from January 1, 2016 to October 27, 2022. Primary health outcomes were diagnosed psychiatric and psychological disorders, suicide (attempts), psychiatric and psychological symptoms, and perceived distress. Secondary health outcomes were more general concepts of mental health such as well-being, life satisfaction and quality of life. Screening, data extraction and the methodological quality assessment of primary studies by using the Newcastle-Ottawa Scale were done independently by two reviewers. The results of the primary studies were summarized descriptively. Migrants and refugees/asylum seekers were compared with natives in terms of the association between working conditions and mental health.

RESULTS

Migrants and refugees often face disadvantages at work concerning organizational (low-skilled work, overqualification, fixed-term contracts, shift work, lower reward levels) and social conditions (discrimination experiences) in contrast to natives. Most unfavorable working conditions are associated with worse mental health for migrants as well as for natives.

CONCLUSIONS

Even if the results are to be taken with caution, it is necessary to control and improve the working conditions of migrants and refugees/asylum seekers and adapt them to those of the native population to maintain their mental health and thus their labor force.

"Putting words to their feelings"- civic communicators' perceptions and experiences of an in-depth course on mental health for newly settled refugee migrants in Sweden

BACKGROUND

Newly settled refugee migrants face psychological stressors stemming from pre-, during- and post-migration experiences. In Sweden, mental health promotion is part of the health module in the civic orientation classes for newly settled refugee migrants. Training courses are offered to civic communicators and workshop leaders to facilitate communication about mental health; however, the training is seldom evaluated. In the current study, we aim to explore civic communicators' perceptions and experiences of an in-depth mental health training course in relation to observed needs among newly settled refugee migrants.

METHOD

We interviewed ten civic communicators that had partaken in the in-depth training course on mental health. All respondents had prior migratory experience and worked as civic communicators in their native languages. The interviews were semi-structured and data were analyzed using thematic analysis.

RESULTS

Three themes were identified: (1) Intertwined mental health needs related to migration, (2) Multi-layered barriers to addressing mental health, and (3) Becoming aware of the mental health journey. One overarching theme was arrived at through synthesizing the three themes 'Acquired new tools to lead reflective conversations about mental health and well-being'.

CONCLUSION

The in-depth mental health training course led to the attainment of new knowledge and new tools enabling civic communicators to lead reflective conversations about mental health and well-being with newly settled refugee migrants. Mental health needs were related to pre- and post-migration experiences. Barriers to talking about mental health included stigma and a lack of arenas to promote the mental health of refugee migrants. Increasing knowledge among civic communicators can facilitate the promotion of mental self-help capacity and resilience among newly settled refugee migrants.

Forcibly displaced persons and mental health: A survey of the experiences of Europe-wide psychiatry trainees during their training

Many European countries have seen increasing refugee populations and asylum applications over the past decade. Forcibly displaced persons (FDPs) are known to be at higher risk of developing mental disorders and are in need of specific care. Thus, specific training for mental health professionals is recommended by international health organizations. The aim of this exploratory study was to assess the experience of clinical work with FDPs among psychiatric trainees in Europe and Central Asia as well as their interest and specific training received on this topic. An online questionnaire was designed by the Psychiatry Across Borders working group of the European Federation of Psychiatric Trainees (EFPT) and was distributed via email through local networks among European trainees from 47 countries between March 2017 and April 2019. Answers of 342 psychiatric trainees from 15 countries were included in the survey analysis. A majority of trainees (71%) had had contact with FDPs in the last year of their clinical work. Although three-quarters expressed a strong interest in the mental health of FDPs, only 35% felt confident in assessing and treating them. Specific training was provided to 25% of trainees; of this subset, only a quarter felt this training prepared them adequately. Skills training on transcultural competencies, post-traumatic stress disorder, and trauma management was regarded as essential to caring for refugees with confidence. Although psychiatric trainees are motivated to improve their skills in treating FDPs, a lack of adequate specific training has been identified. The development of practical skills training is essential. International online training courses could help meet this pressing need.

From struggle to hope: A gender-sensitive investigation on Nigerian male and female asylum seekers' experiences

The study presents a qualitative and culturally-sensitive investigation of the lived experiences of the forced migration of six Nigerian asylum seekers, three men and three women, hosted in Italy. Through a focus on gender identity issues, the study aimed to explore possible gender differences between participants and define their specific needs, requirements and characteristics. Overall, the gender-focused perspective through which we explored participants' subjective experiences has enriched our understanding of their unique life stories, shedding light on the psychic dimensions as well as on the social and cultural inscriptions of their gender identity and providing insights on the different ways in which Nigerian women and men made sense of their experiences of displacement, migration, violence and trauma.

What mental illness means in different cultures: Perceptions of mental health among refugees from various countries of origin

Introduction: Mental illness remains a significant issue in refugees worldwide. Internationally, there continues to be stigma surrounding mental health, mental illness, and mental health treatment. Cultural stigma is just one of many barriers to mental healthcare for refugees. Perceptions of mental health are culture-specific and continue to play a role in refugees. Purpose: The purpose of this review study is to make distinctions between the perceptions of mental health of refugees based on country of origin because knowing these cultural differences has the potential to improve refugee mental healthcare. This knowledge could contribute to treatment approaches and help break some of the barriers to mental healthcare for refugees. Methodology: An extensive literature review of relevant articles published between 2000-2021 was performed using the databases APA PsycInfo, Global Health, MEDLINE via Ovid, CINAHL Plus with Full Text, and Google Scholar. The following search terms, in addition to other related and relevant terms, were used: “mental health, refugees, mental health barriers, perceptions of mental illness, country of origin.” Results: There were both numerous similarities and differences between the perceptions of mental health among refugees from different cultures. There were similarities in terms of mental health stigma, with certain cultures thinking of mental health/illness as taboo, as shameful, or associating it with evil spirits. A few of the cultures studied had similar ideas about the causes of mental illness, believing it was due to traumatic events or possession by evil spirits. The refugee groups had some common treatment options, including informal conversation, religious-based ideas, and community-level solutions. Some differences between refugees from different cultures involved certain symptoms associated with mental health, including physical symptoms, and differing degrees of religiosity. Discussion: Based on studies reviewed about the perceptions of mental health of various refugee cultures, many recommendations are proposed to improve refugee mental healthcare. Suggestions include focusing on cultural competency and community-level solutions, in addition to implementing mobile health clinics and telehealth. Conclusions: This review discusses the perceptions of mental health, mental illness, and mental health treatment of refugees from numerous countries of origin. It is unique in its inclusion of different groups of refugees. Culture seems to play a significant role in the perceptions encountered. Keeping culture in mind, several recommendations are made to improve refugee mental healthcare, such as more integrative treatment methods and telehealth.  

Migrating Populations and Health: Risk Factors for Cardiovascular Disease and Metabolic Syndrome

PURPOSE OF REVIEW

To summarize results of recent studies of migrants in Europe and North America and ongoing efforts to adapt strategies to provide them with inclusive sensitive health care.

RECENT FINDINGS

Major predisposing factors for developing hypertension, obesity, diabetes, and the metabolic syndrome in migrating populations and refugees were identified. Susceptibility to the metabolic syndrome is predominantly due to environmental factors and psychological stress. Acculturation also contributes to the emergence of cardiovascular (CV) risk factors in first-generation adult immigrants. Increased risk for later development of hypertension and dyslipidemia has also been detected in adolescent immigrants. Targets for public health efforts were based on data that show important differences in CV risk factors and prevalence of the metabolic syndrome among ethnic immigrant groups. Studies in young adults focused on lifestyle and dietary behaviors and perceptions about weight and body image, while the focus for older adults was end-of-life issues. Two important themes have emerged: barriers to health care, with a focus on cultural and language barriers, and violence and its impact on immigrants' mental health.

Mental health professionals' perspective on a brief transdiagnostic psychological intervention for Afghan asylum seekers and refugees

Background

While many elaborated treatment protocols focus on post-traumatic stress symptoms, a large number of refugees suffer from a range of mental health problems. Thus, brief and transdiagnostic psychological interventions may be helpful first interventions for help-seeking refugees and asylum seekers in a stepped-care approach. Critically, there is limited research on how transdiagnostic interventions are received in general practice in non-specialized mental healthcare settings in high-income countries, where often only mental health professionals (MHPs) are legally allowed to treat people with mental disorders. MHPs may thus deliver such interventions, but their perspective towards them has not yet been investigated.

Objective

We aimed to investigate MHPs' perception of the usability of adapted Problem Management Plus (aPM+), a brief transdiagnostic psychological intervention for refugees, which we adapted to address distress caused by post-migration living difficulties (PMLDs).

Method

Employing an e-learning tool, we introduced the aPM+ intervention to 59 MHPs and assessed their perspective towards the intervention. We then used an inductive approach to analyse their perspective towards the intervention with open-ended questions.

Results

Altogether, 59 MHPs enrolled in the webinar and 29 provided feedback on the intervention. MHPs had a positive view on the intervention but emphasized the importance of situation-specific adaptations to the structure of the manual. The most favoured specific strategies were 'managing stress/slow-breathing', the 'tree of capabilities', and the 'riding the anger' exercise. The last two were additionally developed to reduce distress caused by PMLDs by either enhancing self-efficacy or reducing anger regulation difficulties.

Conclusions

An adaptation to aPM+ regarding more flexibility of the manual may enhance the likelihood of MHPs implementing the intervention in their daily practice. Strategies addressing coping with PMLDs could be particularly helpful.Trial registration: German Clinical Trials Register identifier: DRKS00016538.

HIGHLIGHTS

Mental health professionals had a positive view on a brief transdiagnostic psychological intervention for refugees but emphasized the importance of situation-specific adaptations to the structure of the manual.Low -intensity interventions may be useful not only in low- and middle-income countries but also in high-income countries as part of a stepped-care approach, even if distributed by MHPs instead of trained laypersons.

Barriers and facilitators to access mental health services among refugee women in high-income countries: a systematic review

BACKGROUND

Based on the Global Trends report from the United Nations High Commissioner for Refugee, in high-income countries, there are 2.7 refuges per 1000 national population, girls and women account for nearly 50% of this refuge population. In these high-income countries, compared with the general population refuge women have higher prevalence of mental illness. Thus, this review was conducted to examine the barriers to and facilitators of access to mental health services for refugee women in high-income countries for refugee resettlement.

METHODS

We searched MEDLINE, EMBASE, PsycINFO, and CINAHL databases for research articles written in English with qualitative component. The last search date was on March 14, 2020. A narrative synthesis was conducted to gather key synthesis evidence. Refugee women (aged 18 and older) that could receive mental health services were included. Men and women under non-refugee migrant legal status were excluded. Studies were evaluated studies using the Critical Appraisal Skills Programme (CASP) qualitative checklist.

RESULTS

Of the four databases searched, 1258 studies were identified with 12 meeting the inclusion criteria. Three studies were cross-sectional by design, eight studies used a qualitative approach and one studies used mixed approach. The major barriers identified were language barriers, stigmatization, and the need for culturally sensitive practices to encourage accessing mental health care within a religious and cultural context. There were several studies that indicated how gender roles and biological factors played a role in challenges relating to accessing mental health services. The major facilitators identified were service availability and awareness in resettlement countries, social support, and the resilience of refugee women to gain access to mental health services.

CONCLUSION

This review revealed that socio-economic factors contributed to barriers and facilitators to accessing mental health among women refugees and asylum seekers. Addressing those social determinants of health can reduce barriers and enhance facilitators of access to mental health care for vulnerable populations like refugee women. A key limitation of the evidence in this review is that some data may be underreported or misreported due to the sensitive and highly stigmatizing nature of mental health issues among refugee populations.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020180369.

Perceived health, adversity, and posttraumatic stress disorder in Syrian and Iraqi refugees

BACKGROUND

Exposure to armed conflict and fleeing country of origin for refugees has been associated with poorer psychological health.

METHODS

Within the first month following their arrival in the United States, 152 Syrian and Iraqi refugees were screened in a primary care setting for posttraumatic stress disorder (PTSD), anxiety, and depression and rated their perceived health, and perceived level of adversity of violence, armed conflict/flight. The moderating effects of psychiatric symptoms on the relation between perceived adversity and perceived health were assessed.

RESULTS

Three models based on diagnosis (PTSD, anxiety, and depression) were tested. While significant effects were found on perceived adversity negatively influencing perceived health across diagnoses, slightly different patterns emerged based on diagnosis.

DISCUSSION

Findings suggest that refugees' perception regarding adversity of violence, armed conflict, and flight may contribute to perceived health, with a moderating role of clinically significant symptoms of PTSD, anxiety, and depression.

Association of cultural origin and migration status with work-related mental health of migrants and refugees in Europe: a systematic review protocol

IntroductionMigrants make up a significant proportion of the European working population. Previous studies have already shown that migrants and refugees often suffer from poor work-related conditions in the host country, which might have an impact on mental health. Thus, the main objective of this systematic review is to analyse and summarise existing research on work-related conditions of migrants and refugees in Europe and to investigate the relationship of these conditions with their mental health.

METHODS AND ANALYSIS

Three electronic databases (PubMed/MEDLINE, PsycINFO and CINAHL) will be systematically searched for eligible articles using quantitative study designs (randomised controlled trials, cohort, case-control and cross-sectional studies with and without control groups) written in English, German, French, Italian, Polish, Spanish or Turkish and published from 1st January 2016 onwards. The primary health outcomes will be diagnosed psychiatric and psychological disorders, suicide and suicide attempts, psychiatric and psychological symptoms, and perceived distress. The secondary health outcomes will be more general concepts of mental health such as well-being, life satisfaction and quality of life. Outcome measures must have been assessed by validated questionnaires. Screening of all articles, reference lists of included studies and relevant reviews as well as data extraction will be performed independently by two review authors. Methodological quality of primary studies will be assessed and discussed. The results of the primary studies will be summarised descriptively. Migrants and natives, migrants and refugees, migrants of different cultural backgrounds and migrants living in different host countries will be compared in terms of the association between their work-related conditions and their mental health.

ETHICS AND DISSEMINATION

This systematic review is excluded from ethical approval because it will use previously approved published data from primary studies. The results of this review will be submitted to a related peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42021244840.

Engaging Refugees With a Culturally Adapted Digital Intervention to Improve Sleep: A Randomized Controlled Pilot Trial

Refugees are exposed to multiple stressors affecting their mental health. Given various barriers to mental healthcare in the arrival countries, innovative healthcare solutions are needed. One such solution could be to offer low-threshold treatments, for example by culturally adapting treatments, providing them in a scalable format, and addressing transdiagnostic symptoms. This pilot trial examined the feasibility, acceptance, and preliminary effectiveness of a culturally adapted digital sleep intervention for refugees. Sixty-six refugees participated, with 68.2% of them seeking psychological help for the first time. Only three participants did not show clinically significant insomnia severity, 93.9% reported past traumatic experiences. Participants were randomly assigned to the intervention group (IG) or the waitlist control group (CG). Insomnia severity, measured by the Insomnia Severity Index, and secondary outcomes (sleep quality, fear of sleep, fatigue, depression, wellbeing, mental health literacy) were assessed at baseline, 1 and 3 months after randomization. The self-help intervention included four modules on sleep hygiene, rumination, and information on mental health conditions associated with sleep disturbances. 66.7% of the IG completed all modules. Satisfaction with the intervention and its perceived cultural appropriateness were high. Linear multilevel analyses revealed a small, non-significant intervention effect on insomnia severity of Hedge's g = 0.28 at 3-months follow-up, comparing the IG to the CG [F _{2, 60} = 0.88, p = 0.421]. This non-confirmatory pilot trial suggests that low-threshold, viable access to mental healthcare can be offered to multiple burdened refugees by culturally adapting an intervention, providing it in a scalable format, and addressing a transdiagnostic symptom.

Prevalence of mental disorders in refugees and asylum seekers: a systematic review and meta-analysis

BACKGROUND

Studies have identified high rates of mental disorders in refugees, but most used self-report measures of psychiatric symptoms. In this study, we examined the percentages of adult refugees and asylum seekers meeting diagnostic criteria for major depressive disorder (MDD), post-traumatic stress disorder, bipolar disorder (BPD), and psychosis.

METHODS

A systematic literature search in three databases was conducted. We included studies examining the prevalence of MDD, post-traumatic stress disorder, BPD, and psychosis in adult refugees according to a clinical diagnosis. To estimate the pooled prevalence rates, we performed a meta-analysis using the Meta-prop package in Stata (PROSPERO: CRD42018111778).

RESULTS

We identified 7048 records and 40 studies (11 053 participants) were included. The estimated pooled prevalence rates were 32% (95% CI 26-39%; I ² = 99%) for MDD, 31% (95% CI 25-38%; I ² = 99.5%) for post-traumatic stress disorder, 5% (95% CI 2-9%; I ² = 97.7%) for BPD, and 1% (95% CI 1-2%; I ² = 0.00%) for psychosis. Subgroup analyses showed significantly higher prevalence rates of MDD in studies conducted in low-middle income countries (47%; 95% CI 38-57%, p = 0.001) than high-income countries studies (28%; 95% CI 22-33%), and in studies which used the Mini-International Neuropsychiatric Interview (37%; 95% CI 28-46% p = 0.05) compared to other diagnostic interviews (26%; 95% CI 20-33%). Studies among convenience samples reported significant (p = 0.001) higher prevalence rates of MDD (35%; 95% CI 23-46%) and PTSD (34%; 95% CI 22-47%) than studies among probability-based samples (MDD: 30%; 95% CI 21-39%; PTSD: 28%; 95% 19-37%).

CONCLUSIONS

This meta-analysis has shown a markedly high prevalence of mental disorders among refugees. Our results underline the devastating effects of war and violence, and the necessity to provide mental health intervention to address mental disorders among refugees. The results should be cautiously interpreted due to the high heterogeneity.

Predictors of the 10 year course of mental health and quality of life for trauma-affected refugees after psychological treatment

Background: Trauma-affected refugee patients benefit from psychological treatment to different degrees. Only a handful of studies has investigated potential predictors of treatment outcome that could throw light on the great variability in outcomes reported for this group. Such knowledge may be vital to better tailor prevention and treatment efforts to the needs of different individuals and subgroups among these patients. Objective: In a naturalistic and longitudinal study, the aim was to analyse demographics and traumatic exposure as potential predictors of the participants' long-term trajectories of mental health symptoms and quality of life. Method: A group of 54 multi-origin adult refugee patients with complex traumatic exposure, such as armed conflicts, persecution, torture, and childhood adversities, were interviewed face to face over up to 10 years; at therapy admittance, and at varying points in time during and after psychotherapy. Checklists of war-related and childhood trauma, mental health symptoms, and quality of life were included in the interviews. In linear mixed effects analyses, interaction was analysed with potential predictors included separately because of the sample size. Time was modelled as continuous from inclusion into the study. Results: Gender predicted the course of symptoms of post-traumatic stress, anxiety, and depression, and of quality of life in physical health and social relationships. Childhood family violence and experiences of torture predicted the course of depression, whereas the extent of exposure to war-related trauma events and having experienced torture predicted the course of anxiety. Conclusions: The results indicated greater chronicity in male refugees, in refugees who had experienced domestic violence during childhood, in refugees who had experienced torture, and in refugees with more numerous types of potentially traumatic war-related experiences. The findings highlight the need for gender-sensitive research, rehabilitative efforts, and treatment. HIGHLIGHTS In a 10 year longitudinal and naturalistic therapy follow-up study of traumatized refugees, female gender, childhood trauma, war trauma, and torture predicted mental health and quality of life outcomes.Male participants responded less than females to therapy.

Trajectories of psychosocial symptoms and wellbeing in asylum seekers and refugees exposed to traumatic events and resettled in Western Europe, Turkey, and Uganda

Background: Longitudinal studies examining mental health trajectories in refugees and asylum seekers are scarce. Objectives: To investigate trajectories of psychological symptoms and wellbeing in refugees and asylum seekers, and identify factors associated with these trajectories. Method: 912 asylum seekers and refugees from the control arm of three trials in Europe (n = 229), Turkey (n = 320), and Uganda (n = 363) were included. We described trajectories of psychological symptoms and wellbeing, and used trauma exposure, age, marital status, education, and individual trial as predictors. Then, we assessed the bidirectional interactions between wellbeing and psychological symptoms, and the effect of each predictor on each outcome controlling for baseline values. Results: Symptom improvement was identified in all trials, and for wellbeing in 64.7% of participants in Europe and Turkey, versus 31.5% in Uganda. In Europe and Turkey domestic violence predicted increased symptoms at post-intervention (ß = 1.36, 95% CI 0.17-2.56), whilst murder of family members at 6-month follow-up (ß = 1.23, 95% CI 0.27-2.19). Lower wellbeing was predicted by murder of family member (ß  = -1.69, 95% CI -3.06 to -0.32), having been kidnapped (ß  = -1.67, 95% CI -3.19 to -0.15), close to death (ß =  -1.38, 95% CI -2.70 to -0.06), and being in the host country ≥2 years (ß =  -1.60, 95% CI -3.05 to -0.14). In Uganda at post-intervention, having been kidnapped predicted increased symptoms (ß = 2.11, 95% CI 0.58-3.65), and lack of shelter (ß  = -2.51, 95% CI -4.44 to -0.58) and domestic violence predicted lower wellbeing (ß  = -1.36, 95% CI -2.67 to -0.05). Conclusion: Many participants adapt to adversity, but contextual factors play a critical role in determining mental health trajectories.

Traumatized Refugees in Psychotherapy: Long-Term Changes in Personality, Mental Health, Well-Being, and Exile Life Functioning

ABSTRACT

This pre- and posttreatment study of 22 severely traumatized adult refugees spanned a mean of 6.5 years. Changes in personality functioning, mental health, and well-being were examined using the Rorschach Performance Assessment System, Harvard Trauma Questionnaire, Hopkins Symptom Checklist-25, and the World Health Organization's Quality of Life-BREF questionnaire. A paired samples t-test revealed significant improvement after psychotherapy in traumatic ideation and initial severe disruptions in thought processes, reality testing, perception, self and other representations, and relational capacity (Cohen's d = 0.46-0.59). Symptoms of anxiety, depression, and posttraumatic stress were significantly reduced (d = 0.54-0.84), quality of life in the physical health and psychological health domains increased significantly (d = 0.87 and 0.97), and percentage of participants with exile language proficiency and work/study status increased significantly. The findings demonstrate the potential of psychotherapy to contribute to normalizing perceptual, cognitive, and relational capacities in severely traumatized refugees, paramount to well-being and functioning in exile.

"This course is like a compass to us" - a qualitative study on newly settled migrants' perceptions of civic and health orientation in Sweden

BACKGROUND

Migrants face structural, socio-political barriers in their resettlement processes that negatively affect their health. Migration also adversely impacts resources such as social capital and health literacy that are of importance for health and integration into society. Hence, there is a need for health promotion in the early post-migration phase. In Sweden, newly settled refugee migrants who have received a residence permit are offered an Introduction programme including a civic orientation course. The program is intended to facilitate access to the labour market and promote integration. The aim of the study was to explore participants' perceptions and experiences of a civic orientation course with added health communication.

METHODS

We performed six focus group discussions: two in Arabic, two in Farsi and two in Somali. The discussions were facilitated by native speaking moderators. Participants were 32 men and women recruited from civic orientation classes in the county of Stockholm. We used an interview guide with semi-structured questions. The data were analysed using a method for content analysis for focus group discussions.

RESULTS

Three main categories were identified: (1) 'The course gives valuable information but needs adjustments', which includes that the civic and health orientation is needed earlier, during the asylum phase, and that planning and course content need adjustments. (2) 'The health communication inspired participants to focus on their health', which includes that the health communication was useful and inspired uptake of healthier habits. (3) 'Participation in the course promoted independence and self-confidence', which includes that the course gave insights into society and values in Sweden, and promoted independence and new social contacts.

CONCLUSION

This study adds knowledge about the users' perspectives on the potential of civic orientation to promote the health and integration of newly settled migrants, describing ways in which civic orientation with added health communication promoted health and empowerment. However, the content and delivery of the course need adjustment to better fit the migrants' life situations and varying pre-existing knowledge.

Refugee Mental Health, Global Health Policy, and the Syrian Crisis

The most recent global refugee figures are staggering, with over 82.4 million people forcibly displaced and 26.4 million registered refugees. The ongoing conflict in Syria is a major contributor. After a decade of violence and destabilization, over 13.4 million Syrians have been displaced, including 6.7 million internally displaced persons and 6.7 million refugees registered in other countries. Beyond the immediate political and economic challenges, an essential component of any response to this humanitarian crisis must be health-related, including policies and interventions specific to mental health. This policy and practice review addresses refugee mental health in the context of the Syrian crisis, providing an update and overview of the current situation while exploring new initiatives in mental health research and global health policy that can help strengthen and expand services. Relevant global health policy frameworks are first briefly introduced, followed by a short summary of recent research on refugee mental health. We then provide an update on the current status of research, service provision, and health policy in the leading destinations for Syrians who have been forcibly displaced. This starts within Syria and then turns to Turkey, Lebanon, Jordan, and Germany. Finally, several general recommendations are discussed, including the pressing need for more data at each phase of migration, the expansion of integrated mental health services, and the explicit inclusion and prioritization of refugee mental health in national and global health policy.

Relationship between anxiety, post-traumatic stress, insomnia and fibromyalgia among female refugees in jordan: A cross-sectional study

WHAT IS KNOWN ON THE SUBJECT?: Fibromyalgia (FM) is a syndrome of chronic widespread pain, typically associated with fatigue, sleep, cognitive dysfunction and disordered mood. FM may limit an individual's ability to participate in everyday work and social activities, thereby making it difficult to maintain normal relationships with other individuals. While it has been studied in different populations and settings, the impact of FM and associated psychological factors has not been previously studied among female war refugees. WHAT DOES THE PAPER ADD TO EXISTING KNOWLEDGE?: The study showed the high impact of FM on female refugees in Jordan; approximately three quarters of the participants had a moderate to severe FM impact. Refugees settled in Irbid city, Iraq, showed increased age, anxiety and post-traumatic stress disorder correlated with a higher FM impact. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: The study recommends evaluation of the impact of FM among all female refugees living in Jordan, along with its neighbouring countries hosting refugees. Healthcare providers, including mental health nurses, should be aware of the role of PTSD and anxiety on the impact of FM. Accordingly, healthcare workers should design appropriate mental health treatment plans to help to decrease the impact of FM. Mental health nurses should evaluate FM impact among all refugees worldwide. Nurses in Jordan are recommended to share their experience with nurses outside of Jordan as this may help with funds being obtained and the implementation of advanced psychological interventions.

ABSTRACT

INTRODUCTION: Fibromyalgia (FM) is a syndrome of chronic widespread pain. While it has been studied in different populations and settings, the impact of FM and its associated psychological factors has not been previously studied among female war refugees.

AIM

To assess the impact of FM and its associated factors in female refugees.

METHODS

A cross-sectional study was conducted. The impact of FM, anxiety, post-traumatic stress (PTSD) and insomnia was investigated.

RESULTS

288 refugees previously diagnosed with FM were recruited. The results showed that 73.62% of the participants had a moderate to severe FM impact. Refugees settled in Irbid city were six times more likely to have a higher FM impact than refugees settled in Zarqa, and Iraqi refugees were more likely to have a higher impact than Syrian. Increased age, anxiety and PTSD were correlated with a greater impact.

CONCLUSION

Mental health nursing services should be directed towards female refugees, particularly those with increased age, anxiety and PTSD.

IMPLICATIONS FOR PRACTICE

Mental health nurses should evaluate the FM impact among all refugees worldwide. Furthermore, nurses in Jordan are recommended to share their experiences with nurses outside of Jordan, as this may help to raise funds and implement advanced psychological interventions.

A network meta-analysis of psychosocial interventions for refugees and asylum seekers with PTSD

INTRODUCTION

Refugees and asylum seekers are vulnerable to common mental disorders, including post-traumatic stress disorder (PTSD). Using a network meta-analysis (NMA) approach, the present systematic review compared and ranked psychosocial interventions for the treatment of PTSD in adult refugees and asylum seekers.

METHODS

Randomised studies of psychosocial interventions for adult refugees and asylum seekers with PTSD were systematically identified. PTSD symptoms at postintervention was the primary outcome. Standardised mean differences (SMDs) and ORs were pooled using pairwise and NMA. Study quality was assessed with the Cochrane Risk of Bias (RoB) tool, and certainty of evidence was assessed through the Confidence in Network Meta-Analysis application.

RESULTS

A total of 23 studies with 2308 participants were included. Sixteen studies were conducted in high-income countries, and seven in low-income or middle-income countries. Most studies were at low risk of bias according to the Cochrane RoB tool. NMA on PTSD symptoms showed that cognitive behavioural therapy (CBT) (SMD=-1.41; 95% CI -2.43 to -0.38) and eye movement desensitisation and reprocessing (EMDR) (SMD=-1.30; 95% CI -2.40 to -0.20) were significantly more effective than waitlist (WL). CBT was also associated with a higher decrease in PTSD symptoms than treatment as usual (TAU) (SMD -1.51; 95% CI -2.67 to -0.36). For all other interventions, the difference with WL and TAU was not significant. CBT and EMDR ranked best according to the mean surface under the cumulative ranking. Regarding acceptability, no intervention had less dropouts than inactive interventions.

CONCLUSION

CBT and EMDR appeared to have the greatest effects in reducing PTSD symptoms in asylum seekers and refugees. This evidence should be considered in guidelines and implementation packages to facilitate dissemination and uptake in refugee settings.

Investigating the link between subjective sleep quality, symptoms of PTSD and level of functioning in a sample of trauma-affected refugees

STUDY OBJECTIVES

To examine whether baseline sleep quality is associated with baseline symptoms of posttraumatic stress disorder (PTSD) and level of functioning, and whether baseline sleep quality and improvement of sleep quality are specific predictors of change in PTSD symptoms and level of functioning.

METHODS

Data were derived from a four-armed randomised controlled superiority trial (N=219 trauma-affected refugees). All four groups received treatment as usual consisting of a 10-12 months bio-psycho-social treatment program with an additional differential treatment component added to each arm. We performed bivariate correlation analyses, multiple linear regression analyses and mediation analyses to examine associations between baseline sleep quality, change in sleep quality and treatment response for PTSD symptoms and level of functioning.

RESULTS

Baseline sleep quality correlated with symptoms of PTSD (r = .33) and level of functioning (r=0.15). Baseline sleep quality, improvement of sleep quality and improvement of general well-being were predictors of treatment response for symptoms of PTSD and level of functioning when controlling for age, gender, and baseline symptoms of PTSD and depression.

CONCLUSIONS

We found that good sleep quality at baseline and improvement of sleep quality were predictors of PTSD treatment response. However, treatment response was more closely associated with improvement in general well-being. The results indicate that the effect of improved sleep quality was partly mediated by a more general mental state improvement. Further research is needed to differentiate if a selected subgroup of patients may profit from sleep enhancing treatment.

Digitalizing a Brief Intervention to Reduce Intrusive Memories of Psychological Trauma: Qualitative Interview Study

BACKGROUND

The COVID-19 pandemic has escalated the global need for remotely delivered and scalable interventions after psychological trauma. A brief intervention involving a computer game as an imagery-competing task has shown promising results for reducing the number of intrusive memories of trauma-one of the core clinical symptoms of posttraumatic stress disorder. To date, the intervention has only been delivered face-to-face. To be tested and implemented on a wider scale, digital adaptation for remote delivery is crucial. An important first step is to develop digitalized intervention materials in a systematic way based on feedback from clinicians, researchers, and students in preparation for pilot testing with target users.

OBJECTIVE

The first aim of this study is to obtain and analyze qualitative feedback on digital intervention materials, namely two animated videos and two quizzes that explain the target clinical symptoms and provide intervention instructions. The second aim is to refine the digitalized materials based on this feedback.

METHODS

We conducted semistructured interviews with 12 participants who had delivered or had knowledge of the intervention when delivered face-to-face. We obtained in-depth feedback on the perceived feasibility of using the digitalized materials and suggestions for improvements. Interviews were assessed using qualitative content analysis, and suggested improvements were evaluated for implementation using a systematic method of prioritization.

RESULTS

A total of three overarching themes were identified from the data. First, participants were highly positive about the potential benefits of using these digital materials for remote delivery, reporting that the videos effectively conveyed key concepts of the symptom and its treatment. Second, some modifications to the materials were suggested for improving clarity. On the basis of this feedback, we made nine specific changes. Finally, participants raised some key challenges for remote delivery, mainly in overcoming the lack of real-time communication during the intervention.

CONCLUSIONS

Clinicians, researchers, and clinical psychology students were overall confident in the use of digitalized materials to remotely deliver a brief intervention to reduce intrusive memories of trauma. Guided by participant feedback, we identified and implemented changes to refine the intervention materials. This study lays the groundwork for the next step: pilot testing remote delivery of the full intervention to trauma survivors.

Identity Development and Maladaptive Personality Traits in Young Refugees and First- and Second-Generation Migrants

Refugees are often exposed to a variety of stressors and traumatic events, posing a significant risk for the development of mental disorders. Young refugees may be particularly at risk because adverse life events affect identity formation, a developmental task that is typically expected in adolescence and emerging adulthood. Trauma and cultural changes may alter identity development, potentially leading to identity diffusion, a core concept of personality disorders. However, previous research on personality pathology among refugees is scarce. In this study, we examine identity development and maladaptive personality traits in young refugees and migrants. Refugees from 22 countries of origin were recruited in a German reception center (n = 120) and a group of adults with a migration background in first- or second generation was obtained via web-based recruitment (n = 281). Identity development was measured using the Assessment of Identity Development in Adolescence - Short Form. Maladaptive personality traits were assessed with the Personality Inventory for DSM-5-Brief Form. Group differences between refugees and migrants regarding identity development and trait expression were investigated using t-tests. The relationship between the two measures and their corresponding subscales was examined by means of correlation analyses. Refugees reported significantly higher levels of identity diffusion, negative affectivity, detachment, antagonism, and disinhibition compared to migrants. No significant differences were found for psychoticism. Correlation analyses revealed low to moderate positive associations between identity diffusion and maladaptive trait expression. Possible implications for early phase of resettlement, preventive psychiatric care and further research questions are discussed.

Association of traumatic events with levels of psychological distress and depressive symptoms in male asylum seekers and refugees resettled in Italy

BACKGROUND

In recent years there has been a progressive rise in the number of asylum seekers and refugees displaced from their country of origin, with significant social, economic, public health and mental health implications. The aim of this study is to (1) describe the level of psychological distress and frequency of psychiatric disorders in a sample of male asylum seekers and refugees across different ethnic groups resettled in Italy; (2) establish whether the number of traumatic events experienced before, during and after the migration process is associated with level of psychological distress and depressive symptoms.

METHODS

In two large Italian catchment areas, over a period of 1 year a consecutive series of male asylum seekers and refugees, aged 18 or above and included in the Italian protection system, were screened for psychological distress and psychiatric disorders using validated questionnaires.

RESULTS

During the study period, 252 male asylum seekers or refugees were recruited. More than one-third of the participants (34.5%) showed clinically relevant psychological distress, and one-fourth (22.2%), met the criteria for a psychiatric diagnosis, mainly Post Traumatic Stress Disorder and depressive disorders. The number of traumatic events turned out to be a risk factor for both clinically relevant psychological distress and depressive disorders. Receiving good social support emerged as a protective factor, while migrants with unclear status were at higher risk of psychological distress than those holding or awaiting a permission.

DISCUSSION

In an unselected sample of male asylum seekers and refugees, after around 1 year of resettlement in Italy, the frequency of psychological distress and psychiatric disorders was substantial and clinically relevant. The association between traumatic events, especially post-migration problems, and mental health conditions suggests the need of developing services to assist refugees and asylum seekers to address the multi-faceted problems they experience, such as social support in host country, legal problems concerning permit status and asylum procedure, and family reunification, as well as addressing trauma and mental health issues.

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.

Barriers and facilitators to access mental health services among refugee women in high-income countries: study protocol for a systematic review

BACKGROUND

According to the United Nation High Commissioner for Refugee Global Trends report in 2019, on average, there are 2.7 refugees per 1000 national population in high-income countries, where girls and women attributed to 48% of the refugee population. Evidence shows high prevalence of mental health disorder among women refugees in comparison to the general population. To our knowledge, no systematic reviews have addressed access to mental health services for refugee women. The aim of this study will be to examine existing barriers and facilitators to accessing mental health services for refugee women in leading high-income countries for refugee resettlement.

METHODS

We designed and registered a study protocol for a systematic review. We will conduct a literature search (from inception onwards) in MEDLINE, EMBASE, PsycINFO, and CINAHL. Research articles having a qualitative component (i.e., qualitative, mixed, or multi-method) will be eligible. Study populations of interest will be refugee women at any age that can receive mental health services in leading high-income countries for refugee resettlement (e.g., 14 countries from North America, Europe, and Oceania). Eligibility will be restricted to studies published in English. The primary outcome will be all barriers and facilitators related to accessing mental health services. Two reviewers will independently screen all citations, full-text articles, and abstract data. Potential conflicts will be resolved through discussion. The study methodological quality (or bias) will be appraised using appropriate tools. Reporting will follow the Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) statement. A narrative synthesis will be conducted, and summary of findings tables will be produced. As it will be a systematic review, without human participants' involvement, there will be no requirement for ethical approval.

DISCUSSION

The systematic review will present key evidence on barriers and facilitators to access mental health services among refugee women in leading resettlement countries. The findings will be used to inform program developers, policymakers, and other stakeholders to enhance mental health services for refugee women. The final manuscript will be disseminated through a peer-reviewed journal and scientific conferences.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020180369.

COVID-19 and the Mental Health of People From Refugee Backgrounds

Approximately 1 in 10 of the current 26 million people who are refugees reside in high-income countries. They have commonly experienced trauma related to violence, insecurity, persecution and shortage of food and medicine. Our research suggests that COVID-19 and its health and social sequalae may be triggering past traumatic reactions, exacerbating mental health problems and undermining functioning. The purpose of this article is to promptly communicate these anecdotal findings to general health practitioners to ensure informed and sensitive health care delivery to this vulnerable population.

Anxiety, depression and post-traumatic stress disorder in refugees resettling in high-income countries: systematic review and meta-analysis

BACKGROUND

The number of refugees is at its highest since the Second World War and on the rise. Many refugees suffer from anxiety, depression and post-traumatic stress disorder (PTSD), but exact and up-to-date prevalence estimates are not available.

AIMS

To report the pooled prevalence of anxiety and mood disorders and PTSD in general refugee populations residing in high-income countries and to detect sources of heterogeneity therein.

METHOD

Systematic review with meta-analyses and meta-regression.

RESULTS

Systematic searches (final search date 3 August 2019) yielded 66 eligible publications that reported 150 prevalence estimates (total sample N = 14 882). Prevalence rates were 13 and 42% (95% CI 8-52%) for diagnosed and self-reported anxiety, 30 and 40% (95% CI 23-48%) for diagnosed and self-reported depression, and 29 and 37% (95% CI 22-45%) for diagnosed and self-reported PTSD. These estimates are substantially higher relative to those reported in non-refugee populations over the globe and to populations living in conflict or war settings, both for child/adolescent and adult refugees. Estimates were similar over different home and resettlement areas and independent of length of residence.

CONCLUSIONS

Our data indicate a challenging and persisting disease burden in refugees due to anxiety, mood disorders and PTSD. Knowing this is relevant for the development of public health policies of host countries. Scalable interventions, tailored for refugees, should become more readily available.

Self-harming behaviours of asylum seekers and refugees in Europe: A systematic review

The increasing number of asylum seekers and refugees in Europe calls for even more professionals to take care of refugees' mental health. Although different studies claim that migration could be a potential risk factor for self-harming behaviours, an in-depth exploration of the presence and characteristics of self-harm in the context of asylum is needed. In accordance with PRISMA guidelines, a systematic review was conducted across the databases Scopus, PubMed, Web of Knowledge and PsycArticles, regarding the main features of self-harming behaviour among refugees in Europe. Twelve articles and 3 main trajectories were identified: (1) A context at-risk: self-harm and detention centres; (2) A target at-risk: self-harm and unaccompanied minors; (3) A comparison between the mental health of asylum seekers and natives. Research on this topic in Europe is still underdeveloped and disorganised. Studies have mainly carried out wider quantitative investigations on mental health, usually overlapping self-harm with suicide. Detention centres emerged as the most widely investigated context and the one with the highest risk for self-harming behaviours. Instead, unaccompanied minors emerged as a particularly vulnerable category. Research in this field should be improved, combining quantitative and qualitative methods for a deeper understanding of the meanings of self-harm across cultures.

A brief transdiagnostic psychological intervention for Afghan asylum seekers and refugees in Austria: a randomized controlled trial

BACKGROUND

Asylum seekers and refugees are at great risk for developing mental disorders. Afghan refugees are a particularly vulnerable group with a low average education and mental health literacy level. Traumatic experiences and hardship before and during migration are predictive of mental health problems. However, post-migration living difficulties (PMLDs) also account for a large proportion of mental distress in such populations, which, critically, are not sufficiently considered in treatment protocols and research investigations. Indeed, the evidence base for the treatment of refugees and asylum seekers is sparse and limited mainly to trauma-specific treatments, where refugees may likely suffer from other mental health problems such as depression or anxiety.

METHODS/DESIGN

This trial is the first evaluation of a short-term, transdiagnostic treatment protocol for treatment-seeking Afghan refugees which addresses mental health problems and PMLDs while using an adapted version of the Problem Management Plus (PM+) protocol. Here, we will investigate the efficacy of an intervention manual with a prospective, single-center, randomized, assessor-blind, two-group trial among refugees who are on a waiting list for professional mental health treatment. Furthermore, we will investigate participants' subjective experiences with the intervention manual via in-depth interviews. One hundred twenty people will be assessed and randomly allocated to either the intervention arm or a treatment-as-usual arm. Clinical psychologists will conduct the treatment, and the sessions will take place with a Dari interpreter. The protocol consists of six 90-min sessions. The primary endpoint is the general symptom distress measure, assessed with the General Health Questionnaire 28 (GHQ-28). Secondary endpoints are the Post-Migration Living Difficulties Checklist (PMLDC), the International Trauma Questionnaire (ITQ), the World Health Organization Quality of Life Questionnaire (WHOQOL-BREF), the Psychological Outcome Profile (PSYCHLOPS), service and health care use (assessed with several items), and the Immigrant Integration Index (IPL-12).

DISCUSSION

This trial may provide substantial evidence for a brief transdiagnostic psychological intervention. Here, we intend to contribute to the treatment of mental health problems among Afghan refugees. The assessment of subjective experience with this treatment manual, as well as the evaluation of its clinical applicability, may optimize treatment acceptance and outcomes across a wide range of mental health problems among refugees.

TRIAL REGISTRATION

German Clinical Trials Register (DRKS) registration number: DRKS00016538. Universal Trial Number: U1111-1226-3285. Registered on January 7, 2019. https://www.drks.de/drks_web/setLocale_EN.do.

Identifying the critical time points for mental health of asylum seekers and refugees in high-income countries

AIMS

High heterogeneity was found in the prevalence rates of mental disorders in adult asylum seekers and refugees in high-income countries. This may be related to different problems. Among them, there is a changing exposure to risk and protective factors for mental health at different phases of these people's life before migration, and during the migratory journey and resettlement. This study aimed at identifying and distinguishing time points in which distinct risk and protective factors for the mental health of asylum seekers and refugees may occur.

METHODS

Systematic review and narrative synthesis. A systematic search was carried out for the period January 2017-August 2019, given the existence of systematic reviews of the evidence up to January 2017.

RESULTS

Two hundred and fifty-two studies were identified with our search and 31 studies were included. The critical time points identified are: (a) before the travel; (b) during the travel; (c) at initial settlement in the host country; (d) when attempting to integrate in the host country; (e) when the immigration status is challenged or revoked. Some factors such as sense of belonging in the host country can be risk factors or protective factors depending on the time point.

CONCLUSIONS

These five critical time points can guide the development and selection of well-timed preventive and treatment interventions. They could also be used to stratify samples in epidemiological studies and meta-analyses. At present, we know much more on risk factors than on protective factors. Knowing more about protective factors may inform the development of interventions to foster them.

Efficacy and acceptability of psychosocial interventions in asylum seekers and refugees: systematic review and meta-analysis

AimsIn the past few years, there has been an unprecedented increase in the number of forcibly displaced migrants worldwide, of which a substantial proportion is refugees and asylum seekers. Refugees and asylum seekers may experience high levels of psychological distress, and show high rates of mental health conditions. It is therefore timely and particularly relevant to assess whether current evidence supports the provision of psychosocial interventions for this population. We conducted a systematic review and meta-analysis of randomised controlled trials (RCTs) assessing the efficacy and acceptability of psychosocial interventions compared with control conditions (treatment as usual/no treatment, waiting list, psychological placebo) aimed at reducing mental health problems in distressed refugees and asylum seekers.

METHODS

We used Cochrane procedures for conducting a systematic review and meta-analysis of RCTs. We searched for published and unpublished RCTs assessing the efficacy and acceptability of psychosocial interventions in adults and children asylum seekers and refugees with psychological distress. Post-traumatic stress disorder (PTSD), depressive and anxiety symptoms at post-intervention were the primary outcomes. Secondary outcomes include: PTSD, depressive and anxiety symptoms at follow-up, functioning, quality of life and dropouts due to any reason.

RESULTS

We included 26 studies with 1959 participants. Meta-analysis of RCTs revealed that psychosocial interventions have a clinically significant beneficial effect on PTSD (standardised mean difference [SMD] = -0.71; 95% confidence interval [CI] -1.01 to -0.41; I2 = 83%; 95% CI 78-88; 20 studies, 1370 participants; moderate quality evidence), depression (SMD = -1.02; 95% CI -1.52 to -0.51; I2 = 89%; 95% CI 82-93; 12 studies, 844 participants; moderate quality evidence) and anxiety outcomes (SMD = -1.05; 95% CI -1.55 to -0.56; I2 = 87%; 95% CI 79-92; 11 studies, 815 participants; moderate quality evidence). This beneficial effect was maintained at 1 month or longer follow-up, which is extremely important for populations exposed to ongoing post-migration stressors. For the other secondary outcomes, we identified a non-significant trend in favour of psychosocial interventions. Most evidence supported interventions based on cognitive behavioural therapies with a trauma-focused component. Limitations of this review include the limited number of studies collected, with a relatively low total number of participants, and the limited available data for positive outcomes like functioning and quality of life.

CONCLUSIONS

Considering the epidemiological relevance of psychological distress and mental health conditions in refugees and asylum seekers, and in view of the existing data on the effectiveness of psychosocial interventions, these interventions should be routinely made available as part of the health care of distressed refugees and asylum seekers. Evidence-based guidelines and implementation packages should be developed accordingly.

Assessing Predictors of Emotional Distress by Immigrant Type: An Exploration of Adult Refugees, Asylees, and SIV Holders in Maryland

Stressors and trauma experienced by persons fleeing harm or persecution can cause elevated distress. This study assessed predictors of elevated distress among newly arrived refugees, asylees, and Special Immigrant Visa (SIV) holders in Maryland. A secondary analysis of Refugee Health Screener-15 data from 4385 refugees, asylees, and SIV holders arriving in Maryland from 2014 to 2017 was conducted. Mean scores were compared across immigrant groups, and positive screening predictors were identified using logistic regression. Mean scores were highest among SIV holders and lowest among asylees. Compared to refugees, SIV holders had greater odds of screening positive; significance was reduced after adjusting for covariates. A significant interaction term was found for SIV women, who had 1.74 greater odds than SIV males. Distress varied between immigrant groups, with asylees having lowest odds of screening positive. SIV women's significant results may owe to acculturation distress, disrupted gender expectations, and resettlement difficulties.

Effectiveness and cost-effectiveness of Self-Help Plus (SH+) for preventing mental disorders in refugees and asylum seekers in Europe and Turkey: study protocols for two randomised controlled trials

INTRODUCTION

This article describes two randomised controlled trials that will evaluate the effectiveness and cost-effectiveness of Self-Help Plus (SH+), a group self-help intervention developed by the WHO to reduce distress. In these trials SH+ is being tested as a preventative intervention to lower the incidence of mental disorders in asylum seekers and refugees with psychological distress resettled in Europe and Turkey.

METHODS AND ANALYSIS

Two prospective, multicentre, randomised, rater-blinded, parallel-group studies will follow participants over a period of 12 months. One trial will be conducted in Europe and one in Turkey. In each trial, 600 asylum seekers and refugees screening positive on the General Health Questionnaire (≥3), but without a formal diagnosis of any mental disorders according to the Mini International Neuropsychiatric Interview, will be randomly allocated to SH+or to enhanced treatment-as-usual. The primary outcome will be a lower incidence of mental disorders at 6 month follow-up. Secondary outcomes will include the evaluation of psychological symptoms, functioning, well-being, treatment acceptability and indicators of intervention cost-effectiveness.

ETHICS AND DISSEMINATION

The two trials received ethical clearance from the local Ethics Committees of the participating sites (seven sites), as well as from the WHO Ethics Committee. All participants will provide informed consent before screening and before study inclusion (a two-step procedure). The results of the trials will be disseminated in agreement with a dissemination plan that includes publication(s) in peer-reviewed journals and presentations at relevant national and international conferences and meetings.

TRIALS REGISTRATION NUMBERS

NCT03571347, NCT03587896.

7ROSES, a transdiagnostic intervention for promoting self-efficacy in traumatized refugees: a first quantitative evaluation

Objective: Due to traumatic experiences and highly prevalent post-migration stressors, refugees are vulnerable for developing psychopathology. To date, research has mainly evaluated trauma-focused therapies, targeting post traumatic stresss symptoms. Treatments targeting post-migration stressors are relatively understudied. The present cohort study evaluated the potential effectiveness of 7ROSES, a transdiagnostic intervention that aims to increase self-efficacy among treatment-seeking refugees in dealing with post-migration stressors. Because it can be applied by non-specialist health care workers, it can be disseminated on a large scale, thereby increasing options for psychosocial support for refugees. Method: Forty-nine refugees (65% male, average age: 36.02 years, SD = 8.52) with psychopathology were included. Before and after participation in 7ROSES, self-efficacy was measured using the General Self-Efficacy Scale (GSES), and general psychopathology using the Brief Symptom Inventory (BSI). Results: Completers analysis yielded a significant increase in GSES scores (Z = -2.16, p = .03) and significant decrease in BSI scores (Z = -2.05, p = .04) with medium-small effects (both r = -.28). Intent-to-treat analysis, using predictive mean matching imputation, yielded significant results for the GSES (p = .012) but not for the BSI (p = .14) with small effects (GSES r = .14, BSI r = .12). Reliable change indices established negative change in 3%, no change in 70%, and positive change in 27% based on the GSES; percentages were 11.5%, 65.5%, and 23%, respectively, based on the BSI. Conclusion: Findings provide preliminary evidence that 7ROSES could improve self-efficacy and general mental health in refugees with psychopathology.

Recent approaches to provision of mental healthcare in refugee populations

PURPOSE OF REVIEW

The present review provides an overview of key issues and concepts on the provision of mental healthcare to refugees with mental health conditions.

RECENT FINDINGS

Several barriers to mental healthcare for refugees have been described, and principles for good mental care in this group have been framed. Evidence for specific interventions for refugees is available for trauma-related mental health problems. The best evidence is available for psychosocial interventions for the treatment of posttraumatic stress disorder.

SUMMARY

The worldwide increase in the number of refugees and the substantial burden of psychological distress and mental health problems associated with this condition has led to an increased research and policy interest for optimizing the provision of effective mental healthcare. To date, with the exception of trauma-related conditions, there is almost no evidence on the efficacy of psychosocial interventions for anxiety and depressive conditions, and there is no information on how mental healthcare should be embedded into existing health and social care services. Existing research and implementation activities will hopefully contribute to better characterize the effective components and elements of mental healthcare programmes for refugees.