Effective Screening for Emotional Distress in Refugees: The Refugee Health Screener

Mental health screening in unaccompanied asylum-seeking children: screening tool selection and feasibility in the UK National Health Service

There has been an increasing number of applications from unaccompanied asylum-seeking children (UASC) in the United Kingdom in recent years. It is well-known that this population is at high-risk of developing mental health disorders, which require early detection and intervention to facilitate successful integration. This paper describes the introduction of mental health screening for unaccompanied asylum-seeking children in a National Health Service (NHS) outpatient clinic in central London. This follows the results of a two-year retrospective analysis of the health needs of the population in our clinic, which identified a high incidence of disturbance to mood and sleep. We describe the selection process for a culturally appropriate and validated screening tool, piloting the Refugee Health Screener (RHS) tool with 20 UASC in clinic, and using preliminary findings to inform a more targeted referral to community Child and Adolescent Mental Health Services (CAMHS). We conclude that implementation of the RHS-13 is feasible for widespread mental health screening for UASC in an NHS setting, and provide suggestions for future research directions within this field.

Understanding risk factors for perinatal distress in Syrian refugee mothers: insights from Lebanon

PURPOSE

The perinatal period is a critical phase in a woman's life, marked by unique mental health challenges. This study focuses on Syrian mothers in Lebanon, a vulnerable population often exposed to displacement and conflict-related stressors. The aim is to identify risk factors for perinatal distress, including symptoms of depression, anxiety, and post-traumatic stress disorder (PTSD), among Syrian mothers within one year of giving birth.

METHODS

Data collection included quantitative assessments using the Refugee Health Screener-13 (RHS-13), and qualitative insights from in-depth interviews. The assessment period was extended to cover the year following childbirth to provide a broader perspective on perinatal distress.

RESULTS

The study revealed significant risk factors, specifically a history of mental illness and chronic disease. While maternal age and number of children were considered potential risk factors, they were not statistically significant in the quantitativeanalysis but were highlighted in the qualitative interviews.

CONCLUSIONS

This research offers valuable insights for healthcare providers, policymakers, and organizations working with Syrian refugee women in Lebanon. Addressing these risk factors can improve mental health outcomes for perinatal women affected by war and displacement, underscoring the need for proactive mental health screening during pregnancy and postpartum.

Evaluation of Mental Health Problems of Syrian People Under Temporary State Protection in Türkiye: The Role of Refugee Health Screener-15

Since the Syrian civil war, Türkiye has received more than 3.6 million Syrian people who sought protection and have been provided a temporary state protection status, making the country the largest host country in the world. This study aimed to investigate depression and anxiety levels of Syrian people accommodated in a relatively developed part of a south-eastern city, Şanlıurfa. Adaptation of the Refugee Health Screener (RHS-15) scale, an objectively designed screening tool for prevalent mental disorders among refugees, is another distinctive feature of this investigation. Using a snowball sampling method, 454 Syrian people aged 18 or older were administered four inventories in their Arabic and Turkish, including the Refugee Health Screener-15 (RHS-15), Beck Anxiety Scale (BAI), Beck Depression Inventory-II (BDI), and Post Migration Living Difficulties Checklist (PMLD). Using a path analysis model, the mediating role of the RHS-15 was examined in the effect of the PMLD, which is considered one-dimensional, on the BAI and BDI variables. The study showed low levels of depression (8.51 ± 2.96) and anxiety (7.86 ± 2.43) that corresponded well to low RHS-15 (6.36 ± 2.31) and PMLD (15.64 ± 2.83) scores. In path analysis, the RHS variable has a significant direct effect on the BAI and BDI variables, with an increase in the RHS variable correlated with an increase in the BAI variable and BDI variable, respectively. The RHS-15 scores were significantly higher among married participants, those with poor financial status, those having 3-4 children and those with physical problems. A more reflective population sample would provide better insight into depression and anxiety levels of Syrian people accommodated in Türkiye.

Unexplored avenues: a narrative review of cognition and mood in postmenopausal African women with female genital circumcision/mutilation/cutting

Recent ageing research has projected the lifespan and proportion of postmenopausal women living in low- and middle-income countries to substantially increase over the years, especially on the African continent. An important subgroup within the African postmenopausal population is those with female genital circumcision/mutilation/cutting (FGC). Practised across 31 African nations, FGC holds cultural significance as it is deemed essential to marriage and successful womanhood. Perhaps because of this, most FGC studies have primarily focused on women's reproductive functioning and their mood experiences. These studies also usually exclude postmenopausal women from their cohorts. Consequently, cognition and age-related cognitive decline and preservation remain understudied. Therefore, we investigated what is known about mood and cognition in local and immigrant postmenopausal African women with FGC. To do this, we carried out a narrative review searching PubMed, PsycInfo, and Google Scholar databases. Boolean combinations of keywords related to FGC, cognition, ageing, and mood were used, with a focus on cognition and ageing-related terms. Only studies published in English, those that recruited African women with FGC aged 50 years and older, and those that investigated cognitive and/or mood-related experiences were included. Ten studies were found; these included quantitative, qualitative, and case reports. The age range of cohorts across included studies was 13-90 years; women who were likely postmenopausal formed a minority within the cohorts (4.5%-25%). There were no studies assessing memory or cognition beyond those looking at FGC-related memories, which were vivid, especially if women had type III FGC (Pharaonic) or were older at the time of FGC. Although most of these women reported experiencing negative emotions concerning FGC, quantitative reports showed that only a minority of women experienced post-traumatic stress disorder, anxiety, or depression. Thus, there remains an urgent need to bring this understudied group into ageing and dementia research. Future research should adopt mixed-methods with culturally sensitive methodologies to investigate the lived experience of ageing as well as cognitive changes. A holistic understanding of ageing women from the Horn of Africa's experiences and needs will support an improvement in the quality of care delivered to this cohort in both local and immigrant contexts.

Prevalence and associated factors for poor mental health among young migrants in Sweden: a cross-sectional study

BACKGROUND

Young migrants face multiple challenges that can affect their mental, sexual and reproductive health.

OBJECTIVE

To assess the prevalence of self-reported poor mental health and its associated demographic, post-migration and sexual risk behaviour factors among young migrants (aged 15-25) in Sweden.

METHODS

Data were drawn from a cross-sectional survey conducted with migrants aged 15-65 years old in Sweden between December 2018 and November 2019 (n = 6449). Among these, 990 participants aged 15-25 were eligible for the study. Mental health was measured using the Refugee Health Screener-13. Missing data indicator analysis and multivariable logistic regression models were conducted to estimate the association between mental health, sexual risk behaviour, demographic and migration-related variables.

RESULTS

Of the 990 participants, 59% reported poor mental health. Participants reporting poor mental health were more likely to be female (AOR:1.63, 95% CI:1.18-2.25), to have lived in Sweden more than three years (AOR:2.16, 95% CI:1.17-3.97), to engage in any sexual risk behaviour (AOR:1.99, 95% CI:1.25-3.17), and to live alone (AOR:1.95, 95% CI:1.25-3.03) or with friends they already knew (AOR:1.60, 95% CI:1.37-4.91). People arriving from the Americas (AOR:0.54, 95% CI:0.33-0.88), Asia (AOR:0.44, 95% CI:0.22-0.86), Europe (AOR:0.30, 95% CI:0.14-0.61) and Africa (AOR 0.37, 95% CI: 0.23-0.60) had lower odds of poor mental health than those arriving from Syria.

CONCLUSION

The prevalence of poor mental health among young migrants in Sweden was high, with specific subgroups (women, asylum seekers, people arriving from Syria, and those residing longer in Sweden) being particularly vulnerable. Our results indicate the interconnectedness between poor mental health and sexual risk behaviour in this population. Thus, policies targeting young migrants should ensure that healthcare services screen for both poor sexual and mental health at the same time.

Refugees' integration and emotional distress over the course of 9 months

Background

High prevalence rates of mental disorders are reported in refugees due to experiencing substantial pre-, peri-, and post-migration stress. While long-term studies indicated that emotional distress of refugees either stagnates or ameliorates over time, long-term research on refugees' integration and its' interaction with emotional distress is limited. The examined long-term predictors for refugees' emotional distress and integration in this study were, amongst others, severe physical abuse in childhood, residence status and length of stay.

Methods

The sample included 46 refugees, 91.3% male, mean age 20.8 years. Trained psychologists screened for emotional distress with the use of the Refugee Health Screener in a semi-structured interview. Integration progress was screened using the Integration Index with the subdimensions psychological, economic, political, social, linguistic and navigational integration. Longitudinal differences for emotional distress and integration sub-dimensions were evaluated by sign tests and t-tests. The longitudinal course of integration was evaluated with a Mixed ANOVA. Further, two hierarchical regression analyses were performed to analyze longitudinal predictors of emotional distress and integration.

Results

Overall, emotional distress decreased, and integration increased over time. In particular, the sub-dimensions of social, economic, and linguistic integration increased significantly over time. Two regression analyses determined significant predictors of (a) emotional distresst1 (adjusted R2  = 0.46): psychotherapy (ß = 0.35, p = 0.020), emotional distresst0 (ß = 0.34, p = 0.031), and integrationt0 (ß = -0.29, p = 0.043), and one significant predictor of (b) integrationt1 (adjusted R2  = 0.70): integrationt0 (ß = 0.89, p < 0.001).

Conclusion

This is the first study to longitudinally examine the Integration Index with all subdimensions. Over the course of 9 months refugees' overall integration, and the sub-dimensions of social, economic, and linguistic integration increased. Whilst the emotional distress of initially highly distressed refugees ameliorated over the course of nine months, their symptom severity remained clinically significant. Results emphasize the importance of early integration for the long-term development of mental health and integration in refugees. Refugees' emotional distress and integration are intertwined and need to be addressed promptly after refugees' entry into the host country.

Improve Mental Health (Improve-MH) in refugee families using a culturally adapted, general practitioner-delivered psychotherapeutic intervention combined with Triple P Online parenting programme: study protocol of a multicentre randomised controlled trial

INTRODUCTION

Germany and the European Union have experienced successive waves of refugees since 2014, resulting in over 1.6 million arrivals, including families with young children. These vulnerable populations often face xenophobia, discrimination, substandard living conditions and limited healthcare access, contributing to a high prevalence of mental health problems (MHP). Our primary goal is to proactively address MHP in refugee parents and prevent its potential impact on their children through effective early interventions. Using a low-threshold, primary care-based approach, we aim to enhance parenting skills and address parental psychopathology, creating a supportive environment for parents and children.

METHODS AND ANALYSIS

In this randomised controlled trial, 188 refugee parents of 6-year-old children or younger who meet the clinical cut-off on the MHP scale will participate. They are randomly assigned to either the experimental psychotherapeutic intervention, delivered by general practitioners (10-week Improve intervention), or treatment as usual, in a ratio of 1:1. The randomisation will be masked only for outcome assessors. Improve includes face-to-face sessions with general practitioners, an interactive online parenting programme (Triple P Online) and regular protocol-based telephone calls by psychologists. Primary outcomes will assess the intervention's effects on parental and child MHP and parenting skills, with secondary outcomes including psychosocial and physical health indicators. Outcomes will be assessed at pre, post and at 3-month and 6-month follow-ups. The study is scheduled to run from February 2019 to July 2025.

ETHICS AND DISSEMINATION

The project Improve-MH (application number 602) was approved by the local ethics committee of Ruhr-University of Bochum and is being conducted in accordance with the Declaration of Helsinki. The study is also conducted in full accordance with the German Data Protection Act, and the Good Clinical Practice guideline (GCP) and is sensitive to specific ethical considerations. Results will be disseminated at scientific conferences, published in peer-reviewed journals and provided to consumers of healthcare.

TRIAL REGISTRATION NUMBER

The trial was prospectively registered at the German Clinical Trials Register (Deutsches Register Klinischer Studien, DRKS-ID: DRKS00019072) on 16 March 2020.

"Sometimes it can be like an icebreaker": A mixed method evaluation of the implementation of the Refugee Health Screener-13 (RHS-13)

Background

Forced migrants are at risk of developing mental illness, yet challenges remain with underutilization of mental healthcare among this population. This study examined the implementation of the Refugee Health Screener-13 (RHS-13) in the health assessment for forced migrants in eight primary health care centres in Stockholm Region, Sweden.

Methods

A mixed-methods convergent parallel design was used, combining nurses self-reported quantitative data on the levels and reasons for RHS-13 use in the health assessment with qualitative interview data on the barriers and facilitators for RHS-13 use. The Consolidated Framework for Implementation Research (CFIR) was used as a coding framework for the qualitative analysis.

Results

Levels of RHS-13 use varied between primary health care centres, resulting in two groups: three centres with high-level (65-92%) and five centres with low-level (0-36%) implementation. Factors related to the tool itself, as well as the inner and outer context, influenced the use of RHS-13. Language barriers, insufficient time, and lack of trust in the validity and utility of RHS-13 were the main barriers, while its availability in many languages and that it was perceived as an important complement to the health assessment were the main facilitators.

Conclusion

RHS-13 contributes to the standardization of assessing mental health in the health assessment. Identifying context-based implementation strategies and addressing language and time issues as well as nurses trust in the tool's utility are recommended to enhance the use of RHS-13.

Empowerment group therapy for refugees with affective disorders: results of a multicenter randomized controlled trial

BACKGROUND

Against the background of missing culturally sensitive mental health care services for refugees, we developed a group intervention (Empowerment) for refugees at level 3 within the stratified Stepped and Collaborative Care Model of the project Mental Health in Refugees and Asylum Seekers (MEHIRA). We aim to evaluate the effectiveness of the Empowerment group intervention with its focus on psychoeducation, stress management, and emotion regulation strategies in a culturally sensitive context for refugees with affective disorders compared to treatment-as-usual (TAU).

METHOD

At level 3 of the MEHIRA project, 149 refugees and asylum seekers with clinically relevant depressive symptoms were randomized to the Empowerment group intervention or TAU. Treatment comprised 16 therapy sessions conducted over 12 weeks. Effects were measured with the Patient Health Questionnaire-9 (PHQ-9) and the Montgomery-Åsberg Depression Rating Scale (MÅDRS). Further scales included assessed emotional distress, self-efficacy, resilience, and quality of life.

RESULTS

Intention-to-treat analyses show significant cross-level interactions on both self-rated depressive symptoms (PHQ-9; F(1,147) = 13.32, p < 0.001) and clinician-rated depressive symptoms (MÅDRS; F(1,147) = 6.91, p = 0.01), indicating an improvement in depressive symptoms from baseline to post-intervention in the treatment group compared to the control group. The effect sizes for both scales were moderate (d = 0.68, 95% CI 0.21-1.15 for PHQ-9 and d = 0.51, 95% CI 0.04-0.99 for MÅDRS).

CONCLUSION

In the MEHIRA project comparing an SCCM approach versus TAU, the Empowerment group intervention at level 3 showed effectiveness for refugees with moderately severe depressive symptoms.

"It is worth hanging in there" - Psychotherapeutic experiences shaping future motivation for outpatient psychotherapy with refugee clients in Germany

BACKGROUND

A high prevalence of mental disorders in refugees contrasts with a low rate of treatment and limited access to health care services. In addition to pre-, peri- and post-migration stress, language, cultural barriers together with lack of information about cost reimbursement, and access to German (mental) health care institutions are discussed as barriers to use of available services. Such barriers together with insufficient experience of treating traumatized refugee clients may lower therapists' motivation and facilities to accept refugee clients. A model project called "Fearless" trained, and supervised therapists, translators, and peer counsellors to reduce these barriers and increase therapists' motivation and engagement in future treatment of refugees.

METHODS

From a total 14 therapists participating in the project N = 13 were available for semi-structured interviews. The interviews were scheduled during or after their outpatient psychotherapy of refugee clients and lasted one hour on average. Based on qualitative assessment strategies, open questions addressed the therapists' experience of challenges, enrichments, and motivation throughout the therapy. Therapists' responses were analyzed using content structuring qualitative content analysis.

RESULTS

Three major challenges modulated therapists' future motivation for treating refugee clients: specific bureaucratic efforts (e.g., therapy application), organizational difficulties (e.g., scheduling appointments), and clients' motivation (e.g., adherence, reliability). Still, most interviewed therapists (n = 12) evaluated the therapy as enriching and expressed their motivation to accept refugee clients in the future (n = 10).

CONCLUSION

Results recommend the reduction of bureaucratic effort (e.g., regular health insurance cover for all refugees) and implementation of organizational support (e.g., peer counsellors) in support of therapists' motivation for future treatment of refugee clients. Further structural support e.g., with organizing and financing professional translators and referring refugee clients to psychotherapists should be deployed nationwide. We recommend the training in, and supervision of, the treatment of refugee clients as helpful additional modules in psychotherapy training curricula to raise therapists' motivation to work with refugee clients.

Health outcomes and female genital mutilation/cutting: how much is due to the cutting itself?

While Female Genital Mutilation/Cutting (FGM/C) continues to garner global attention, FGM/C-affected migrant communities, who are often racialized minorities in the U.S., face additional challenges which may impact their physical and mental health and well-being. It has been proposed that an overly narrow focus on the female genitalia or FGM/C status alone, while ignoring the wider social experiences and perceptions of affected migrant women, will result in incomplete or misleading conclusions about the relationship between FGM/C and migrant women's health. A cross-sectional study was conducted across two waves of Somali and Somali Bantu women living in the United States, (n = 879 [wave 1], n = 654 [wave 2]). Socio-demographics, self-reported FGM/C status, perceived psychological distress, and self-reported FGM/C-related health morbidity was examined against self-reported experiences of everyday discrimination and perceived psychosocial support. In statistical models including age and educational attainment as potentially confounding socio-demographic variables, as well as self-reported FGM/C status, self-reported discrimination, and perceived psychosocial support, self-reported discrimination was the variable most strongly associated with poor physical health and psychological distress (i.e., FGM/C-related health morbidity and psychological distress), with greater perceived psychosocial support negatively associated with psychological distress, when controlling for all the other variables in the model. FGM/C status was not significantly associated with either outcome. Discrimination, more frequently reported among 'No FGM/C' (i.e., genitally intact or unmodified) women, was most frequently perceived as linked to religion and ethnicity. Our findings are consistent with views that discrimination drives negative outcomes. In this population, discrimination may include the 'quadruple jeopardy' of intersecting relationships among gender, race, religion, and migration status. We find that self-reported experiences of discrimination-and not FGM/C status per se-is associated with adverse physical and mental health consequences in our sample drawn from Somali migrant communities living in the United States, and that social support may help to mitigate these consequences. Our findings thus reinforce calls to better contextualize the relationship between FGM/C and measures of health and well-being among Somali women in the United States (regardless of their FGM/C status), taking psychosocial factors more centrally into account.Clinical Trials.Gov ID no. NCT03249649, Study ID no. 5252. Public website: https://clinicaltrials.gov/ct2/show/NCT03249649.

Is legal status associated with mental illness among newly arrived refugees in Sweden: an epidemiological study

BACKGROUND

There are about 80 million forcibly displaced people globally. Migrants are at heightened risk for mental illness compared to host country populations. While previous research highlights the need to adequately assess mental illness, few have taken the diversity among newly arrived migrants into account. This study aims to estimate the prevalence and associated risk factors of mental illness among asylum seekers, quota and other refugees in Stockholm, Sweden.

METHODS

Using a cross-sectional design, data was collected as part of a mental health screening initiative integrated into routine health examinations in two health care clinics in Stockholm. Screening was done with the Refugee Health Screener, RHS-13, a validated instrument for assessing mental health in refugee populations.

RESULTS

A total of 1163 individuals were eligible for screening, of whom 566 participated (response rate 48.6%). Among the participants, 47.9% indicated symptoms of mental illness. Compared with asylum seekers, the risk of mental illness was lower among quota and other refugees (adjusted odds ratio 0.60, 95% confidence interval 0.37-1.00). Female sex, higher age, coming from a middle-income country and low probability of being granted asylum were significant predictors of mental illness.

CONCLUSION

Refugee legal status is associated with mental illness. Asylum seekers are at greater risk of mental illness compared to quota and other refugees. Our findings call for screening for mental illness among newly arrived migrants, especially among those with pending residence permits.

Unaccompanied foreign minors and mental health: Implementation and evaluation of the RHS-15 screening procedure for unaccompanied foreign minors

Background and objective

The recent notable increase in refugees' flows, with refugee children and adolescents relocating worldwide, posed severe challenges to the different national healthcare systems. Social groups such as refugees fleeing from their countries because of persecution, wars and violence are considered at high risk of developing mental health-related problems. Despite international and national policies legally regulating the reception process and protecting health-related rights, including the mental well-being of refugee migrants, there is a theoretical and applied need for evidence-based instruments and procedures to support mental health within this population. Recent evidence refers to the Refugee Health Screener-15 (RHS-15) as a reliable and valid instrument for the early detection of trauma-related mental health problems. In this scenario, this study aimed to test the RHS screening process within a multidisciplinary first intervention reception context for unaccompanied refugee minors.

Design

The RHS-15 was administered with the support of cultural-linguistic mediators to 81 unaccompanied minor residents in a first intervention facility in Milan, Italy. This study aimed to assess psychometric characteristics, such as reliability, sensitivity and specificity feasibility and its implementation within a first intervention reception process.

Results

The analysis resulted in the validation of the RHS in its 13-item format. The results highlighted and confirmed an efficient delivery, excellent reliability and a positive predictive and convergent validity of the 13-item version. Further analysis showed an excellent ability to avoid false negatives, although there was a clear tendency to identify false positives.

Conclusions

The early identification of vulnerabilities among refugee minors is recommended to promote their long-term overall well-being. Integrating the screening results with additional observational elements and more specific diagnostic tools is recommended to gain a comprehensive perspective of the minors' well-being.

Geographical Disparities and Settlement Factors and Mental Health of Refugees Living in Germany

(1) Background: Approximately half of all refugees living in Germany experience discrimination, which may negatively affect their mental health. Moreover, German refugees have experienced hostility, especially in eastern regions. (2) Aims: We examined the effect of perceived discrimination on refugees' mental health in Germany, with a particular focus on possible regional differences of refugee mental health and perceived discrimination. (3) Method: The data of 2075 refugees who arrived in Germany between 2013 and 2016, from a large-scale survey, was analysed using binary logistic regression. The refugee health screener, 13-item version, was used to assess psychological distress. All effects were investigated for the entire sample and both sexes independently. (4) Results: A third of refugees experienced discrimination which increased the risk of psychological distress (OR = 2.25 [1.80, 2.8]). Those living in eastern Germany were more than twice as likely to report experiences of discrimination, compared to their counterparts living in western Germany (OR = 2.52 [1.98, 3.21]). Differences were noted between males and females, and religious attendance. (5) Conclusions: Perceived discrimination is a risk factor for refugee mental health, particularly female refugees in eastern Germany. An east-west regional difference may be explained by socio-structural factors, rural placement, differential historical exposure to migrant populations, and a greater presence of right-wing and populist parties in eastern Germany.

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.

Welcome, how are you doing? - towards a systematic mental health screening and crisis management for newly arriving refugees

Background: Compared to the general German population, refugees in Germany are a high-risk group for trauma spectrum disorders. Currently, many barriers exist for the implementation of a screen-and-treat approach for mental disorders as part of the routine health care provision during the early stage of the immigration process.Objective: The aim of the present study was to develop and test a systematic screening approach to identify individual refugees in need of mental health care during the initial immigration phase.Method: 167 newly arrived refugees underwent a screening interview with the Refugee Health Screener (RHS) carried out by Intercultural Therapy Assistants (ITAs). The ITAs were super-vised by psychologists at a reception centre in Bielefeld, Germany. A subsample of 48 persons partici-pated in clinical validation interviews.Results: Findings demonstrated the need for and feasibility of a systematic screening during the initial immigration phase. However, established cut-off values of the RHS had to be adapted and the screening procedure had to be adjusted due to the needs of a significant number of refugees in severe psychological crises.Conclusion: A systematic screening that is applied shortly after arrival facilitates the early identification of refugees at risk of developing mental disorders and may be helpful to prevent chronic symptom development and an aggravation of psychological crises.

School-based mental health screenings with Ukrainian adolescent refugees in Germany: Results from a pilot study

Since the Russian invasion of Ukraine in February 2022, high numbers of Ukrainians, mostly women and children, have left the country. As of today, Germany has accepted more than one million refugees fleeing from Ukraine including ~200,000 children and adolescents registered in German schools. Since refugee minors are typically affected by high rates of mental health issues, the identification of potential psychological problems at an early stage after arrival is essential in order to make timely referrals for vulnerable youth to diagnostic or treatment services possible. The aim of the present study was to test the feasibility of a classroom-based mental health screening procedure and to assess symptoms of PTSD, depression, and anxiety in a small sample of adolescents who had fled to Germany. Forty-two adolescents (n = 20 girls) took part in the study. Screening results showed that more than half of the sample had elevated ratings in the Refugee Health Screener (RHS) and about 45% reported clinically significant levels of PTSD. Overall, the amount of both mental health problems and current worries related to the war was significantly higher in girls compared to boys. In general, screenings were well received by the adolescents. The findings of this pilot study point to a considerable level of mental health problems and distress in adolescent refugees affected by the recent war in Ukraine. Brief psychological screenings within the school setting might represent a promising approach to identifying potential mental health disorders as early as possible in newly arriving refugee youth.

Diagnostic test accuracy of screening tools for post-traumatic stress disorder among refugees and asylum seekers: A systematic review and meta-analysis

Background

Refugees and asylum seekers often experience traumatic events resulting in a high prevalence of post-traumatic stress disorder (PTSD). Undiagnosed PTSD can have detrimental effects on resettlement outcomes. Immigration medical exams provide an opportunity to screen for mental health conditions in refugee and asylum seeker populations and provide links to timely mental health care.

Objective

To assess the diagnostic accuracy of screening tools for PTSD in refugee and asylum seeker populations.

Methods

We systematically searched Medline, Embase, PsycINFO, CENTRAL and CINAHL up to 29 September 2022. We included cohort-selection or cross-sectional study designs that assessed PTSD screening tools in refugee or asylum seeker populations of all ages. All reference standards were eligible for inclusion, with a clinical interview considered the gold standard. We selected studies and extracted diagnostic test accuracy data in duplicate. Risk of bias and applicability concerns were addressed using QUADAS-2. We meta-analyzed findings using a bivariate random-effects model. We partnered with a patient representative and a clinical psychiatrist to inform review development and conduct.

Results

Our review includes 28 studies (4,373 participants) capturing 16 different screening tools. Nine of the 16 tools were developed specifically for refugee populations. Most studies assessed PTSD in adult populations, but three included studies focused on detecting PTSD in children. Nine studies looked at the Harvard Trauma Questionnaire (HTQ) with diagnostic cut-off points ranging from 1.17 to 2.5. Meta-analyses revealed a summary point sensitivity of 86.6% (95%CI 0.791; 0.917) and specificity of 78.9% (95%CI 0.639; 0.888) for these studies. After evaluation, we found it appropriate to pool other screening tools (Posttraumatic Stress Disorder Checklist, the Impact of Event Scale, and the Posttraumatic Diagnostic Scale) with the HTQ. The area under the curve for this model was 79.4%, with a pooled sensitivity of 86.2% (95%CI 0.759; 0.925) and a specificity of 72.2% (95%CI 0.616; 0.808).

Conclusions

Our review identified several screening tools that perform well among refugees and asylum seekers, but no single tool was identified as being superior. The Refugee Health Screener holds promise as a practical instrument for use in immigration medical examinations because it supports the identification of PTSD, depression, and anxiety across diverse populations. Future research should consider tool characteristics beyond sensitivity and specificity to facilitate implementation in immigration medical exams.

Registration

Open Science Framework: 10.17605/OSF.IO/PHNJV.

The impact of experiencing severe physical abuse in childhood on adolescent refugees' emotional distress and integration during the COVID-19 pandemic

Background

Accumulating evidence highlights the importance of pre- and post- migration stressors on refugees' mental health and integration. In addition to migration-associated stressors, experiences earlier in life such as physical abuse in childhood as well as current life stress as produced by the COVID-19-pandemic may impair mental health and successful integration - yet evidence on these further risks is still limited. The present study explicitly focused on the impact of severe physical abuse in childhood during the COVID-19 pandemic and evaluated the impact of these additional stressors on emotional distress and integration of refugees in Germany.

Methods

The sample included 80 refugees, 88.8% male, mean age 19.7 years. In a semi-structured interview, trained psychologists screened for emotional distress, using the Refugee Health Screener, and integration status, using the Integration Index. The experience of severe physical abuse in childhood was quantified as a yes/no response to the question: "Have you been hit so badly before the age of 15 that you had to go to hospital or needed medical attention?" Multiple hierarchical regression analyses further included gender, age, residence status, months since the start of the COVID-19 pandemic and length of stay in Germany to predict emotional distress and integration.

Results

Two regression analyses determined significant predictors of (1) emotional distress (adjusted R ² = 0.23): duration of being in the pandemic (ß = 0.38, p < 0.001) and severe physical abuse in childhood (ß = 0.31, p = 0.005), and significant predictors of (2) integration (adjusted R ² = 0.53): length of stay in Germany (ß = 0.62, p < 0.001), severe physical abuse in childhood (ß = 0.21, p = 0.019) and emotional distress (ß = -0.28, p = 0.002).

Conclusion

In addition to migration-associated stressors, severe physical abuse in childhood constitutes a pre-migration risk, which crucially affects the well-being, emotional distress and integration of refugees in Germany.

The Association of Conflict-Related Trauma with Markers of Mental Health Among Syrian Refugee Women: The Role of Social Support and Post-Traumatic Growth

Background

Syrian refugee women not only suffered the refuging journey but also faced the burden of being the heads of their households in a new community. We aimed to investigate the mental health status, traumatic history, social support, and post-traumatic growth (PTG) of Syrian refugee women.

Methods

A cross-sectional study was conducted using a structured interviewer-administered survey between August and November 2019. Syrian refugee women who head their households and live outside camps were eligible. The survey included items investigating socio-demographic characteristics and conflict-related physical trauma history. The Refugee Health Screener-15 (RHS-15) scale was used to screen for emotional distress symptoms of depression, anxiety, and post-traumatic stress disorder (PTSD), with a score range of 0-4 and higher scores indicating emotional distress. The Multidimensional Scale of Perceived Social Support (MSPSS) was utilized to assess the perceived support from family, friends, and significant others (score range 1-7), with scores of 3-5 and 5.1-7.0 representing moderate and high support, respectively. The PTG Inventory (PTGI) scale investigated the positive transformation following trauma; the score range was 0-5, and the cutoff point of ≥3 defined moderate-to-high growth levels.

Results

Out of 140 invited refugee women, 95 were included, with a response rate of 67.9%. Their mean (SD) age was 41.30 (11.75) years, 50.5% were widowed, and 17.9% reported their husbands as missing persons. High levels of conflict-related traumatic exposure were found, including threats of personal death (94.7%), physical injury (92.6%), or both (92.6%); and a history of family member death (92.6%), missing (71.6%), or injury (53.7%). The mean (SD) RHS-15 score was above average (2.08 (0.46)), and most women (90.5%) were at high risk for depression, anxiety, and PTSD symptoms. The mean (SD) MSPSS score was 5.08 (0.71), representing moderate social support, with friends' support being the highest (5.23 (0.85)). The mean (SD) PTGI score was 2.44 (0.48), indicating low growth, with only 12.6% of women experiencing moderate-to-high growth levels. Spiritual change and personal strength had the highest sub-scores, with moderate-to-high growth levels experienced by 97.9% and 84.2%, respectively. Most women were more optimistic and religious, had feelings of self-reliance and better difficulties adapting, and were stronger than they thought. Statistically significant correlations of MSPSS and its subscales with RHS-15 and PTGI were detected.

Conclusion

Significant but unspoken mental health problems were highly prevalent among Syrian refugee women and an imminent need for psychological support to overcome traumatic exposure. The role of social support seems to be prominent and needs further investigation.

[Mental Health Screening of Syrian Refugees in Germany: The Refugee Health Screener]

Mental Health Screening of Syrian Refugees in Germany: The Refugee Health Screener Objectives: This study investigated the psychometric properties of the time-efficient Refugee Health Screener (RHS-13 and RHS-15) for assessing mental disorders among Syrian refugees in Germany. Methods: The RHS-15 was compared with benchmark screeners on psychological distress such as depression, anxiety, somatisation and post-traumatic stress symptoms and its diagnostic quality was assessed using appropriate methods (e. g. ROC-analyses). Results: Participants were 116 Syrian refugees (age: M = 37), 69 % of them men. The RHS-13 screened 57 % and the RHS-15 screened 66 % of participants as positive for psychological distress. Both RHS versions had very good reliability and validity and reliably identified clinically relevant psychological problems related to depression, anxiety, somatisation or PTSD. The RHS-13 proved to be more economical and slightly more valid. Conclusions: Consistent with previous findings, our results suggest that the RHS is an efficient and valid screening tool for common mental health disorders among Syrian refugees in Germany.

Mental Health Screening Approaches for Resettling Refugees and Asylum Seekers: A Scoping Review

Refugees and asylum seekers often face delayed mental health diagnoses, treatment, and care. COVID-19 has exacerbated these issues. Delays in diagnosis and care can reduce the impact of resettlement services and may lead to poor long-term outcomes. This scoping review aims to characterize studies that report on mental health screening for resettling refugees and asylum seekers pre-departure and post-arrival to a resettlement state. We systematically searched six bibliographic databases for articles published between 1995 and 2020 and conducted a grey literature search. We included publications that evaluated early mental health screening approaches for refugees of all ages. Our search identified 25,862 citations and 70 met the full eligibility criteria. We included 45 publications that described mental health screening programs, 25 screening tool validation studies, and we characterized 85 mental health screening tools. Two grey literature reports described pre-departure mental health screening. Among the included publications, three reported on two programs for women, 11 reported on programs for children and adolescents, and four reported on approaches for survivors of torture. Programs most frequently screened for overall mental health, PTSD, and depression. Important considerations that emerged from the literature include cultural and psychological safety to prevent re-traumatization and digital tools to offer more private and accessible self-assessments.

The Impact of an Insecure Asylum Status on Mental Health of Adult Refugees in Germany

Background

Forcibly displaced people have a higher chance of developing post-traumatic stress disorder (PTSD) compared to people who have not experienced displacement. In addition to potentially traumatic events due to war, persecution, and flight, post-migration living stressors are an important influencing factor. Among these, an insecure asylum status is one of the main stressors with which forcibly displaced people must cope. The aim of this study was to investigate the additive effect of an insecure asylum status on PTSD symptomatology in refugees, over and above the influence of other pre- and peri-migration factors, in particular potentially traumatic event types reported and duration of stay in Germany.

Method

Two overlapping convenience samples of 177 and 65 adult refugees that were assessed at different timepoints were interviewed by means of face-to-face interviews. Interviews were conducted in either Arabic, Farsi, Kurmancî, English, or German with the assistance of interpreters where necessary. Besides residence status and potentially traumatic events experienced, mental distress was assessed via the Refugee Health Screener-15 (RHS-15; Study A) and the PTSD Checklist for DSM-5 (PCL-5; Study B).

Results

In both samples, an insecure asylum status explained a significant additional amount of variance of PTSD symptomatology, on top of traumatic events experienced and time since arrival in Germany.

Conclusion

Results suggest that refugees with an insecure asylum status are at higher risk for experiencing increased PTSD symptomatology. Policy changes of asylum procedure in receiving countries could have a positive impact on refugees' mental health.

Psychological Distress, Post-Traumatic Stress, and Suicidal Ideation Among Resettled Nepali-Speaking Bhutanese Refugees in the United States: Rates and Predictors

INTRODUCTION

Bhutanese refugees may exhibit psychological distress (PD), post-traumatic stress (PTS), and suicidal ideation (SI), but little is known about predictors of these mental health problems.

PURPOSE

To examine rates and predictors of PD, PTS, and SI among Bhutanese refugees.

METHODS

Cross-sectional correlational study of 209 Bhutanese refugees in Midwestern United States. Data were collected using the Hopkins Symptom Checklist/Nepali version and Refugee Health Screener-15/PTS subscale and then analyzed using simultaneous multiple regression.

RESULTS

Rates of PD, PTS, and SI were 18.7%, 8.1%, and 7.7%, respectively. Significant predictors of PD were a history of mental health treatment (p<.001) and fewer years of schooling (p = .032). Predictors of PTS were history of mental health treatment (p<.001), female gender (p = .016), fewer years of schooling (p = .012), and being single/previously married (p = .004). PTS predicted SI (ρ<.001).

DISCUSSION

Health providers should routinely assess Bhutanese refugees' mental health status for timely further assessment and treatment.

Mental health screening and assessment tools for forcibly displaced children: a systematic review

Background: An unprecedentedly large number of people worldwide are forcibly displaced, of which more than 40 percent are under 18 years of age. Forcibly displaced children and youth have often been exposed to stressful life events and are therefore at increased risk of developing mental health issues. Hence, early screening and assessment for mental health problems is of great importance, as is research addressing this topic. However, there is a lack of evidence regarding the reliability and validity of mental health assessment tools for this population. Objective: The aim of the present study was to synthesise the existing evidence on psychometric properties of patient reported outcome measures [PROMs] for assessing the mental health of asylum-seeking, refugee and internally displaced children and youth. Method: Systematic searches of the literature were conducted in four electronic databases: MEDLINE, PsycINFO, Embase and Web of Science. The methodological quality of the studies was examined using the COSMIN Risk of Bias checklist. Furthermore, the COSMIN criteria for good measurement properties were used to evaluate the quality of the outcome measures. Results: The search yielded 4842 articles, of which 27 met eligibility criteria. The reliability, internal consistency, structural validity, hypotheses testing and criterion validity of 28 PROMs were evaluated. Conclusion: Based on the results with regard to validity and reliability, as well as feasibility, we recommend the use of several instruments to measure emotional and behavioural problems, PTSD symptoms, anxiety and depression in forcibly displaced children and youth. However, despite a call for more research on the psychometric properties of mental health assessment tools for forcibly displaced children and youth, there is still a lack of studies conducted on this topic. More research is needed in order to establish cross-cultural validity of mental health assessment tools and to provide optimal cut-off scores for this population. HIGHLIGHTS Research on the psychometric properties of mental health screening and assessment tools for forcibly displaced children and youth is slowly increasing.However, based on the current evidence on the validity and reliability of screening and assessment tools for forcibly displaced children, we are not able to recommend a core set of instruments. Instead, we provide suggestions for best practice.More research of sufficient quality is important in order to establish crsoss-cultural validity and to provide optimal cut-off scores in mental health screening and assessment tools for different populations of forcibly displaced children and youth.

A Mental Health Profile of 900 Newly Arrived Refugees in Denmark Using ICD-10 Diagnoses

(1) Background: Recognizing mental health problems in newly arrived refugees poses a challenge. Little is known of the mental health profile of refugees currently arriving in Northern Europe. (2) Method: In total, we included 900 adult (≥18 years old) refugees arriving in Aarhus, Denmark, between 1 January 2014 and 1 January 2020. All participants accepted an offer of a voluntary systematic health assessment from the municipality in Aarhus, including a mental health screening. (3) Results: Within this cohort, 26% (237/900) of the participants were referred to the Department of Psychiatry, Aarhus University Hospital, 24% (212/900) were in contact with the department and 21% (185/900) received ≥1 psychiatric diagnosis. Within the subpopulation referred (n = 237), 64% (152/237) were diagnosed with post-traumatic stress disorder (PTSD) (DF431), 14% (34/237) with neurotic, stress-related and somatoform disorders (F40–F48) and 13% (30/237) with major mood disorders (F30–F39). Among the participants referred to the Department of Psychiatry and participants receiving a diagnosis, we found an overrepresentation of participants originating from the Southern Asian region (Pakistan, Afghanistan and Iran) and with an age above 44 years. (4) Conclusion: We found a high prevalence of both referrals and psychiatric diagnoses in newly arrived refugees. Attention to psychiatric conditions in refugees and systematic health assessments during resettlement are needed.

Prevalences of mental distress and its associated factors in unaccompanied refugee minors in Germany

Prevalences for mental disorders within minor refugees are comparatively high and heterogeneous. To reduce heterogeneity and identify high-risk subgroups, we compared unaccompanied refugee minors (URM) to accompanied refugee minors (ARM) regarding depressive symptoms and mental distress. Furthermore, we examined associative factors of mental distress in URM on a broad scale. We conducted a survey with a cross-sectional design in four German University hospitals. The sample consisted of n = 172 URM and n = 52 ARM aged 14-21. Depressive symptoms were assessed via the Patient Health Questionnaire (PHQ-9). Mental distress was assessed by the Refugee Health Screener (RHS-15). Mann-Whitney test was used to examine differences between URM and ARM. Associated factors of mental distress were evaluated via a stepwise multiple regression analysis. URM showed significantly higher mean scores for PHQ-9 (p < .001) and RHS-15 (p < .001) compared to ARM indicating medium effect sizes. Furthermore, URM were significantly more likely to surpass the cut-off for depression (61.6% vs. 30.8%) and overall mental distress (81.4% vs. 53.8%) compared to ARM. The factors Number of stressful life events (SLE), Female gender, and Fear of deportation were found to be associated with an increased mental distress in URM, whereas Weekly contact to a family member, School attendance, and German language skills were accompanied with lower distress scores. All six factors accounted for 32% of the variance of mental distress in URM (p < .001). Within minor refugees, URM are a highly vulnerable subgroup, which should receive particular attention and more targeted measures by health authorities. Our results indicate that these measures should comprise a rapid promotion of family contact, school attendance, language acquisition, and the fast processing of asylum applications. However, the cross-sectional design limits the interpretability of the results.

Mental health service utilization and perceived barriers to treatment among adult refugees in Germany

Background: Prevalence rates of posttraumatic stress disorder and depression are high among refugees in Germany. However, knowledge on subjective as well as objective need for psychotherapy and utilization of psychotherapeutic treatment is scarce. Both structural and personal barriers regarding utilization of mental health services must be addressed in order to increase treatment efficiency. Objective: The aim of this study was to determine the objective as well as the perceived need for treatment, the utilization of mental health care among refugees in the past 12 months, and the perceived barriers to treatment. Method: By means of face-to-face interviews, an unselected convenience sample of 177 adult refugees were interviewed in either Arabic, Farsi, Kurmancî, English, or German. The general sample was reached through social workers. In addition to the Refugee Health Screener-15 (RHS-15), utilization of psychotherapeutic and psychiatric care as well as the subjective needs and barriers to treatment were assessed. Results: According to the RHS-15 54.8% of participants (n = 97) suffered from relevant mental health problems. However, although 28 (28.9%) of the 97 participants who scored above the RHS-15 cut-off perceived a need for therapy, none of them had received psychotherapy as recommended by the German S3 Guidelines. Missing information about mental health and language difficulties were the most frequently cited barriers to mental health services. Conclusions: Psychologically distressed refugees do not receive sufficient treatment. The reduction of barriers to treatment as well as extension of mental health services to lower thresholds should be considered in the future.

Female Genital Mutilation/Cutting among Somali Women in the U.S. State of Arizona: Evidence of Treatment Access, Health Service Use and Care Experiences

BACKGROUND

Female genital mutilation/cutting (FGM/C) is associated with adverse sexual, reproductive and psychological sequelae. The aim of this study was to quantitatively explore factors related to satisfaction with FGM/C-related care in the US focusing on access to care, health service utilization, and women's experiences.

METHODS

A community-based survey of 879 Ethnic Somali and Somali Bantu women using snowball sampling was conducted in Arizona. Bivariate, multivariable and ordered logistics analyses assessed the relationship between the aforementioned factors measured along six dimensions: non-discrimination, physical, economic, informational, health system accessibility and individual-level health service use factors.

FINDINGS

Most participants possessed FGM/C (77.4%), namely Type III (40.2%). FGM/C related health service use was low (14.3%). Perceived discrimination was associated with reduced satisfaction in care (OR = 0.22; CI 0.13-0.37). For FGM/C-specific variables, only recollection of adverse physical or psychological events at the time of circumcision predicted service use (OR = 3.09; CI 1.67-5.68). Somali Bantu (OR = 0.10; CI 0.02-0.44) and highly acculturated women (OR = 0.39; CI 0.17-0.86) had lower odds of service use.

CONCLUSIONS

Achieving respectful care and outreach to women affected by FGM/C has contextual complexity. However, the clinical implications and insights provided may have broader impacts on advancing health equity for FGM/C-affected women.

A Systematic Review of Factors Affecting Mental Health and Well-Being of Asylum Seekers and Refugees in Germany

Background: Since the onset of the 2015 European refugee crisis, ~4. 46 million people have sought asylum in the European Union, with Germany logging the largest share of all asylum applications. In addition to the severe adversities before and during flight, the process of settling into a new environment involves stressors that affect psychological well-being and mental health. The aim of this systematic review was to examine contextual factors during post-migration that influence the mental health and well-being of asylum seekers and refugees (ASRs) in Germany. Methods: Following PRISMA guidelines, a systematic review was conducted across multiple databases for English and German studies published between 2015 and 2020 with index keywords. Results: From a total of 303 articles, 156 duplicates were removed and, after title review, another 87 were excluded for not meeting the inclusion criteria. After assessing the abstracts of the remaining 60 articles, 39 were excluded. Full texts of 21 articles were assessed for eligibility and after excluding 8 articles, 13 articles were included in the review. The results demonstrate high rates of psychological distress among ASRs in Germany and the significant influence of contextual factors on their mental health and psychological well-being. The risk factors for poor mental health include an uncertain asylum status, living in shared asylum accommodations, separation from the nuclear family, lack of German language skills, integration issues and discrimination, while employment is a protective factor. Conclusion: Asylum seekers and refugees have high prevalence rates of psychological distress directly influenced by contextual factors in Germany. Based on these findings, policy makers are strongly recommended to apply preventive strategies to reduce mental health problems of ASRs in Germany.

Cultural Competence in Refugee Service Settings: A Scoping Review

Purpose: Refugees and asylum seekers have unique and complex needs related to their experiences of forced displacement and resettlement. Cultural competence is widely recognized as important for the provision of effective and equitable services for refugee populations. However, the delivery of culturally appropriate services-including health care and social services-is often complicated by unclear definitions and operationalization of cultural competence. Further, the unique needs and priorities of people from refugee backgrounds are under-addressed in the cultural competence literature. This scoping review seeks to synthesize the peer-reviewed literature examining cultural competence in refugee service settings. Methods: A systematic search of four databases (EBSCO, Proquest, Scopus and Google Scholar) identified 26 relevant peer-reviewed studies for analysis. Results: A range of approaches to cultural competence were identified at the level of individual providers and organizations. Conclusion: We identified a need for greater refugee participation and perspectives in the practice of cultural competence, increased conceptual clarity and greater recognition of structural barriers. We call for further rigorous research that critically examines the concept of cultural competence and its meaning and relevance to refugee populations.

Distress and Resilience in Resettled Refugees of War: Implications for Screening

There is little work published about predictors of specific trajectory types of distress in refugees of war during early resettlement in a host country. Data about distress (Refugee Health Screener—15 (RHS-15)) and possible predictors of distress were collected at the domestic medical examination (T1) within 90 days of arrival and the civil surgeon examination (T2) 11–16 months after T1 for refugee groups from three countries (COU). Descriptive, correlative, analyses of variance, and regression techniques were used to determine trajectory type and their predictors. A higher percentage (7.3%) were distressed at T2 than at T1. By group, the Bhutanese became more distressed, the Burmese became less distressed, and Iraqi’s continued to have high distress. A regression model showed gender, loss, post-migration stress, and self-efficacy to be significant predictors of trajectory type (R² = 0.46). When the T1 RHS-15 score was added to the model, observed variance increased (R² = 0.53) and T1 RHS score accounted for the majority of variance (r = 0.64, p < 0.001), with post-migration stress accounting for markedly less (β = 0.19, p = 0.03). Loss and self-efficacy became less significant. Loss was, however, a strong predictor of delayed and chronic distress trajectory type. These data suggest that screening for distress should occur at least twice during resettlement to detect those with initial distress and those with delayed distress. Screening should be coupled with identifying other social determinants of health and a comprehensive assessment to determine the need for intervention for secondary prevention (i.e., reducing delayed distress) and treatment (reducing chronic distress).

A Pilot Study of a Psychoeducational Group Intervention Delivered at Asylum Accommodation Centers-A Mixed Methods Approach

Asylum seekers suffer high levels of distress but have restricted access to mental health care. This paper constitutes an evaluation of a psycho-educational group intervention, called AMIN, which was provided at two asylum accommodation centers in Sweden. A mixed-methods approach was used. To assess potential effectiveness, acceptability, and feasibility, quantitative outcome measures were combined with qualitative information from interviews with both intervention participants and staff providing the intervention. Potential effectiveness in reducing symptoms of distress and insomnia and in increasing physical quality of life was found, even though the intervention participants suffered from more severe distress than expected. In general, the intervention seemed to be acceptable to both participants and staff, with concrete strategies seeming more meaningful than abstract psychological techniques. Finally, regardless of the asylum process itself being a complicating factor, the intervention seemed feasible to deliver to individuals with different backgrounds and conditions. Taken together, these results indicate that some sessions may need further elaboration, but also that the transition to a randomized control trial is reasonable.

Refugee Medical Screening

The domestic medical examination of newly arrived refugees is a comprehensive medical visit. It includes a review of the overseas medical examination and a thorough medical and immigration history. It should include laboratory testing for infectious diseases, pregnancy, and other conditions as recommended by the Centers for Disease Control and Prevention and resettlement state, as well as a comprehensive physical examination with attention paid to conditions known to specific refugee groups. It should also include vaccinations for age-appropriate vaccine-preventable diseases. The concept of preventive care should be introduced, and future visits should be scheduled for preventive care.

Psychological distress among refugees in Germany: a cross-sectional analysis of individual and contextual risk factors and potential consequences for integration using a nationally representative survey

OBJECTIVES

Responding to the mental health needs of refugees remains a pressing challenge worldwide. We estimated the prevalence of psychological distress in a large refugee population in Germany and assessed its association with host country factors amenable to policy intervention and integration indicators.

DESIGN

A cross-sectional and population-based secondary analysis of the 2017 wave of the IAB-BAMF-SOEP refugee survey.

SETTING

Germany.

PARTICIPANTS

2639 adult refugees who arrived in Germany between 2013 and 2016.

MAIN OUTCOME MEASURES

Psychological distress involving symptoms of depression, anxiety and post-traumatic stress disorder was measured using the Refugee Health Screener-13.

RESULTS

Almost half of the population surveyed (41.2% (95% CI: 37.9% to 44.6%)) was affected by mild, moderate or severe levels of psychological distress. 10.9% (8.4% to 13.5%) of the population screened positive for severe distress indicative of an urgent need for care. Prevalence of distress was particularly high for females (53.0% (47.2% to 58.8%)), older refugees (aged ≥55, 70.4% (58.5% to 82.2%)) and Afghans (61.5% (53.5% to 69.5%)). Individuals under threat of deportation were at a greater risk of distress than protection status holder (risk ratio: 1.55 (95% CI: 1.14 to 2.10)), single males at a greater risk than males with nuclear families living in Germany (1.34 (1.04 to 1.74)) and those in refugee housing facilities at a greater risk than those in private housing (1.21 (1.02 to 1.43)). Distressed males had a lower likelihood of employment (0.67 (0.52 to 0.86)) and reduced participation in integration courses (0.90 (0.81 to 0.99)). A trend of reduced participation in educational programmes was observed in affected females (0.42 (0.17 to 1.01)).

CONCLUSION

The finding that a substantial minority of refugees in Germany exhibits symptoms of distress calls for an expansion of mental health services for this population. Service providers and policy-makers should consider the increased prevalence among female, older and Afghan refugees, as well as among single males, residents in housing facilities and those under threat of deportation. The associations between mental health and integration processes such as labour market, educational programme and integration course participation also warrant consideration.

Suicidal Ideation and Severity of Distress among Refugees Residing in Asylum Accommodations in Sweden

Refugees worldwide suffer high levels of distress and are at increased risk for death by suicide. The Refugee Health Screener (RHS) was developed to screen for emotional distress among refugees and can be used to assess distress severity. This paper examines the association between distress severity and suicidal ideation in a sample of refugees residing in asylum accommodations. Data from the RHS and item 9 on the Patient Health Questionnaire-9 (PHQ-9) was analyzed. Results showed that individuals at moderate and severe levels of distress were much more likely to exhibit suicidal ideation than individuals with low levels of distress. Even though we cannot conclude that individuals with low levels of distress do not have thoughts of ending their lives, further suicide assessment is warranted in asylum seekers with moderate to severe distress on the RHS.

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.

Assessing Severity of Psychological Distress Among Refugees With the Refugee Health Screener, 13-Item Version

The recent inflow of refugees to Sweden has put pressure on health care as well as revealing a need for methods regarding assessment of refugees' mental health status. The present study investigated the use of the Refugee Health Screener (RHS; Hollifield et al., 2013) to distinguish among severity levels of symptoms of psychological distress in refugees. Refugees residing in asylum accommodations (n = 510) were screened with RHS-13, together with screeners for depression, anxiety, and posttraumatic stress disorder (PTSD). Risk for mild, moderate, or severe levels of depression, anxiety, or/and PTSD was used as screening proxy. Receiver operating characteristic analysis rendered cutoff scores of 11, 18, and 25, for mild, moderate, and severe symptoms, respectively. Evaluated against each symptom scale separately, cutoffs performed well. Cutoff 11, previously identified by Hollifield et al. (2016), was also confirmed. However, utilization of additional cutoffs could improve refugee mental health by guiding clinical decision making.

Children with sickle cell disease migrating to the United States from sub-Saharan Africa

Sickle cell disease (SCD) is an inherited red blood cell disorder that occurs worldwide and results in significant morbidity and mortality. In addition to affected children who are born in the US, an increasing number of children with SCD are migrating to the US with their families or through international adoption. Children arriving as immigrants or refugees have unique medical and psychosocial challenges that require a multidisciplinary team approach which takes into account the family's primary language, culture, and health beliefs. This review focuses on the special challenges for children with SCD who emigrate from sub-Saharan Africa to the US.

Course of Mental Health in Refugees-A One Year Panel Survey

Background: Cross-sectional studies indicate that a substantial proportion of refugees have psychiatric disorders. However, longitudinal studies on the course of psychiatric symptoms and on influencing factors are scarce. The current study investigates the development of symptoms in an untreated refugee sample in Germany and seeks to identify potential predictors. Methods: Over the course of 1 year, 57 refugees participated in monthly assisted self-reports on the phone assessing emotional distress. At the same time, semi-annual, semi-structured clinical interviews focusing on posttraumatic stress disorder (PTSD) and depression were conducted. The overall dropout rate for the year was 23% for the assisted self-reports and 33% for the clinical interviews. Results: Symptoms did not systematically change over the course of the year. On the individual level, a reliable change in PTSD symptoms was observed in 13% who showed improvement and 24% who showed worsening symptoms. Figures for depression symptoms were 24 and 16% respectively. A higher number of traumatic experiences was related to a greater intensity of PTSD symptoms. In addition, postmigrational stressors were associated with a worsening of PTSD symptoms over the course of the year. Emotional distress was associated with current negative life events, unemployment, and frequent visits to physicians. Conclusions: There is on average no improvement or worsening of symptoms over the period of 1 year. However, individual courses vary, and thus show the importance of risk factors. Accordingly, the identification of risk factors such as trauma load and postmigrational stressors can be useful to determine the need of further monitoring and to provide appropriate interventions when necessary.

[Dissemination of psychotherapy modules for traumatized refugees : Experience gained from trauma work in crisis and conflict regions]

With each additional accumulative exposure to severe and traumatic stressors, the likelihood of developing mental health problems and physical diseases increases. Displaced individuals have usually experienced a number of serious threats to health due to organized violence in their home country or attacks during the flight. Frequently, domestic violence adds additional strain to the stressors experienced. The resulting impairments in psychosocial functioning reduce the resources needed for social adjustment and integration. Social exclusion then in turn often further aggravates the existing mental health complications. For the treatment of trauma spectrum disorders, different evidence-based psychotherapies are available. In high-income countries, trained and licensed psychotherapists are typically in positions to apply such interventions; however, even an advanced system with a high capacity, such as the psychotherapeutic care offered in Germany, severely struggles to manage the demands associated with the rapid addition of hundreds of thousands of displaced people. Germany's mental healthcare system at present lacks the resources, both human and technological, to effectively manage the present demands. Systematic scientific studies in resource-poor regions of war and conflict have demonstrated that the dissemination of effective treatment to local personnel, even with limited training, results in substantial improvements in the mental health challenges within the community: Organized as a cascade model, members of the refugee community learn to identify weakened fellow citizens requiring in-depth diagnostic interviews. Educated, bilingual individuals acquainted with their country's healthcare system (e. g. nurses, teachers and social workers) receive training to conduct structured interviews and evidence-based interventions under the supervision of centrally organized licensed psychotherapists. More complex cases are referred to local psychotherapists, psychiatrists or specialized treatment centers. These humanitarian efforts are based on the convention for the protection of human rights and secure the safety, freedom and dignity of these persons.

Efficient identification of mental health problems in refugees in Germany: the Refugee Health Screener

Background: A substantial number of refugees present with mental disorders. This appears particularly acute in the currently increasing refugee populations in Europe. Although EU guidelines demand the identification and support of vulnerable individuals such as survivors of trauma, no adequately validated and comprehensive mental health screening instruments for refugees residing in Europe currently exist. Objective: We studied the feasibility, validity, and reliability of the Refugee Health Screener-15 (RHS-15) - a time-efficient and easy-to-implement screening developed by Hollifield et al. (2013) - as a self-rating and interview instrument. Methods: A sample of refugees from different countries (N = 86), representative of those who had arrived around the turn of the year 2015/2016 in Germany, filled in the RHS-15 on their own. A semi-structured clinical interview was later conducted with a random subsample (n = 56). Results: Fifty-two percent of the refugees examined screened positive in the RHS-15, thus indicating current mental health problems. The RHS-15 showed a good feasibility, reliability, and validity in both the self-rating and the interview version. It detected clinically relevant mental health problems when PTSD, depression, anxiety, or somatization problems were present. A shorter 13-item version proved to be equally valid. Conclusions: Together with previous research on the RHS in refugees living in the US, this suggests that the RHS is a time-efficient and accurate instrument that is able to detect common mental health problems in a wide range of refugees. Prospectively, the RHS could be used as an instrument for identifying vulnerable refugees, for example, by integrating it in the initial medical examination in the host community, thereby initiating support.