Mental health markers and protective factors in students with symptoms of physical pain across WEIRD and non-WEIRD samples - a network analysis

BACKGROUND

Studies conducted in Western societies have identified variables associated with chronic pain, but few have done so across cultures. Our study aimed to clarify the relationship between specific mental health markers (i.e., depression, anxiety, posttraumatic stress disorder [PTSD], perceived stress) as well as specific protective factors (i.e., social support and self-efficacy) related to physical pain among university students across non-WEIRD and WEIRD samples.

METHOD

A total of 188 university students (131 women and 57 men) were included in the study. We used network analysis to ascertain mental health markers especially central to the experience of physical pain.

RESULTS

No statistically significant difference was found between mental health markers (i.e., depression, anxiety, perceived stress, and PTSD) and protective factors (i.e., social support and self-efficacy) associated with physical pain symptoms for Swiss students versus Indian students (M = 0.325, p = .11). In addition, networks for Swiss versus Indian students did not differ in global strength (S = 0.29, p = .803). Anxiety was the most central mental health marker, and social support was the most important protective factor related to physical pain in both countries. However, for Swiss students, perceived stress, and for Indian students, PTSD symptoms were central mental health markers related to physical pain.

CONCLUSION

Our results identify factors that may serve as important treatment targets for pain interventions among students of both countries before it becomes chronic.

What works for whom and why? Treatment effects and their moderators among forcibly displaced people receiving psychological and psychosocial interventions: study protocol for an individual patient data meta-analysis

INTRODUCTION

Forcibly displaced people (FDP) have a high risk of developing mental disorders such as post-traumatic stress (PTS) disorder. Providing adequate mental healthcare for FDP is crucial but despite overall efficacy of many existing interventions, a large proportion of FDP does not benefit from treatment, highlighting the necessity of further investigating factors contributing to individual differences in treatment outcome. Yet, the few studies that have explored moderators of treatment effects are often insufficiently powered. Therefore, the present Individual Patient Data meta-analysis (IPD-MA) will investigate treatment effects and their moderators-variables related to beneficiaries, providers, intervention and study characteristics in relation to PTS outcomes.

METHODS AND ANALYSIS

A systematic literature search will be conducted from database inception in the databases PsycINFO, Cochrane, Embase, PTSDpubs and Web of Science. Only studies published in English, German, French, Spanish, Portuguese, and Dutch will be considered. Retrieved records will be screened for eligibility. Randomised controlled trials on adult FDP receiving psychological and psychosocial interventions aimed at alleviating symptoms such as PTS compared with a control condition without intervention will be included in this IPD-MA. Subsequently, authors of eligible studies will be contacted to request individual patient data (IPD). All datasets obtained will be synthesised into one large dataset which will be analysed using a one-stage approach by conducting mixed-effects linear regression models (ie, primary analysis). Additionally, aggregate data meta-analyes will be run using a two-stage approach by conducting multivariate regression models including all IPD (transformed) and available meta-data from study reports (ie, secondary analysis). PTS will serve as primary outcome measure, while mental health outcomes other than PTS, attendance, attrition, treatment non-response and adverse outcomes will be examined as secondary outcomes.

ETHICS AND DISSEMINATION

This IPD-MA does not require ethical approval. The results will be published in international peer-reviewed journals.

PROSPERO REGISTRATION NUMBER

CRD42022299510.

Understanding the protective effect of social support on depression symptomatology from a longitudinal network perspective

BACKGROUND

Higher social support protects people from developing mental disorders. Limited evidence is available on the mechanism through which social support plays this protective role.

OBJECTIVE

To investigate the stress-buffering process of social support on depressive symptoms using a novel longitudinal dynamic symptom network approach.

METHODS

A total of 4242 adult participants who completed the first two waves (from May to October 2020) of the International Covid Mental Health Survey were included in the study. Cross-lagged panel network modelling was used to estimate a longitudinal network of self-reported social support, loneliness and depressive symptoms. Standardised regression coefficients from regularised cross-lagged regressions were estimated as edge weights of the network.

FINDINGS

The results support a unidirectional protective effect of social support on key depressive symptoms, partly mediated through loneliness: A higher number of close confidants and accessible practical help was associated with decreased anhedonia (weight=-0.033) and negative self-appraisal symptoms (weight=-0.038). Support from others was also negatively associated with loneliness, which in turn associated with decreased depressed mood (weight=0.086) and negative self-appraisal (weight=0.077). We identified a greater number of direct relationships from social support to depressive symptoms among men compared with women. Also, the edge weights from social support to depression were generally stronger in the men's network.

CONCLUSIONS

Reductions in negative self-appraisal might function as a bridge between social support and other depressive symptoms, and, thus, it may have amplified the protective effect of social support. Men appear to benefit more from social support than women.

CLINICAL IMPLICATIONS

Building community-based support networks to deliver practical support, and loneliness reduction components are critical for depression prevention interventions after stressful experiences.

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

AIMS OF THE STUDY

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

CLINICAL TRIAL NUMBERS

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

CARDIORENAL SYNDROME AND COVID-19

The purpose of this paper is to analyses the cases with cardiorenal syndrome, and the ratio of cardiovascular disease and COVID-19. Prospective methods were used to conduct this research, including the period (January 2020-December 2021). Cases of patients treated at the Nephrology Clinic at the University Clinical Center of Kosovo (UCCK) have been studied. The categorical variables were analyzed with the X² test and the Fisher exact test. The study included 120 patients with acute renal disease treated at the Nephrology Clinic at the University Clinical Center of Kosovo (UCCK), of which 46 (38.3%) female and 74 (61.6%) male. Of the 120 patients included in the study 4 were 18-34 years old, 8 were 35-49 years old, 30 were 50-64 years old, and 78 were > 65 years old. There is a strong link between cardiorenal syndrome and age. Regarding cardiorenal syndrome and its association with other diseases in this prospective study were found these concomitant diseases such as: diabetes mellitus type 2, secondary anemia, hypothyroidism, hyperparathyroidism, pneumonia, sepsis, ascites, mesenteric tumor, hyperkalemia, and Covid-19 Infection. There is a strong link between cardiorenal syndrome and COVID-19 Infection. In recent decades various studies have been done against the definition of cardiorenal syndrome, the understanding of pathophysiology, the use of new biomarkers that represent a new dimension in the diagnostic algorithm, and the difficulties in treating this syndrome.

Scaling-up problem management plus for refugees in Switzerland - a qualitative study

BACKGROUND

Refugees are at an increased risk of developing symptoms of mental disorders but face various structural and socio-cultural barriers to accessing mental health care. The SPIRIT project (Scaling-up Psychological Interventions in Refugees In SwiTzerland) seeks to promote the resilience of refugees and improve their access to mental health care. For this purpose, Problem Management Plus (PM+), an evidence-based low-intensity psychological intervention delivered by trained non-specialist "helpers", is being scaled-up in Switzerland.

OBJECTIVE

To identify factors influencing the process of the large-scale implementation of PM + for refugees in Switzerland and to develop recommendations to guide the implementation process.

METHODS

22 semi-structured interviews were conducted with key informants (Syrian refugees who previously participated in PM+, PM + helpers, health professionals working with refugees and decision-makers from the migration, integration, social, and health sectors). The data were analyzed using thematic analysis, combining an inductive and deductive approach.

RESULTS

The data revealed three major themes, which might have an impact for the longer-term implementation of PM + in Switzerland. First, preconditions for successful integration in the health system prior to scaling-up such as sustainable funding or the introduction of a stepped care approach. Second, the requirements for the PM + intervention supporting scale-up such as quality control during PM + delivery, PM + modality, time and setting when PM + is offered or the views on task sharing. Third, the perceived benefits of scaling-up PM + in Switzerland.

CONCLUSIONS

Our results have shown that PM + must be scaled-up within a stepped care approach, including a functioning triage system and sustainable funding. Rather than selecting one modality or setting, it seemed preferable to offer a variety of formats and settings to achieve maximum reach and benefits. A successful scale-up of PM + in Switzerland might have various benefits. Communicating them to policy-makers and health providers, might enhance their acceptability of the intervention and their willingness to adopt PM + in regulatory structure and promote it.

Posttraumatic Stress Disorder in Refugees

The number of refugees and internally displaced people in 2022 is the largest since World War II, and meta-analyses demonstrate that these people experience elevated rates of mental health problems. This review focuses on the role of posttraumatic stress disorder (PTSD) in refugee mental health and includes current knowledge of the prevalence of PTSD, risk factors, and apparent differences that exist between PTSD in refugee populations and PTSD in other populations. An emerging literature on understanding mechanisms of PTSD encompasses neural, cognitive, and social processes, which indicate that these factors may not function exactly as they have functioned previously in other PTSD populations. This review recognizes the numerous debates in the literature on PTSD in refugees, including those on such issues as the conceptualization of mental health and the applicability of the PTSD diagnosis across cultures, as well as the challenge of treating PTSD in low- and-middle-income countries that lack mental health resources to offer standard PTSD treatments. Expected final online publication date for the Annual Review of Clinical Psychology, Volume 19 is May 2023. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

Peer-provided psychological intervention for Syrian refugees: results of a randomised controlled trial on the effectiveness of Problem Management Plus

BACKGROUND

The mental health burden among refugees in high-income countries (HICs) is high, whereas access to mental healthcare can be limited.

OBJECTIVE

To examine the effectiveness of a peer-provided psychological intervention (Problem Management Plus; PM+) in reducing symptoms of common mental disorders (CMDs) among Syrian refugees in the Netherlands.

METHODS

We conducted a single-blind, randomised controlled trial among adult Syrian refugees recruited in March 2019-December 2021 (No. NTR7552). Individuals with psychological distress (Kessler Psychological Distress Scale (K10) >15) and functional impairment (WHO Disability Assessment Schedule (WHODAS 2.0) >16) were allocated to PM+ in addition to care as usual (PM+/CAU) or CAU only. Participants were reassessed at 1-week and 3-month follow-up. Primary outcome was depression/anxiety combined (Hopkins Symptom Checklist; HSCL-25) at 3-month follow-up. Secondary outcomes included depression (HSCL-25), anxiety (HSCL-25), post-traumatic stress disorder (PTSD) symptoms (PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition; PCL-5), impairment (WHODAS 2.0) and self-identified problems (PSYCHLOPS; Psychological Outcomes Profiles). Primary analysis was intention-to-treat.

FINDINGS

Participants (n=206; mean age=37 years, 62% men) were randomised into PM+/CAU (n=103) or CAU (n=103). At 3-month follow-up, PM+/CAU had greater reductions on depression/anxiety relative to CAU (mean difference -0.25; 95% CI -0.385 to -0.122; p=0.0001, Cohen's d=0.41). PM+/CAU also showed greater reductions on depression (p=0.0002, Cohen's d=0.42), anxiety (p=0.001, Cohen's d=0.27), PTSD symptoms (p=0.0005, Cohen's d=0.39) and self-identified problems (p=0.03, Cohen's d=0.26), but not on impairment (p=0.084, Cohen's d=0.21).

CONCLUSIONS

PM+ effectively reduces symptoms of CMDs among Syrian refugees. A strength was high retention at follow-up. Generalisability is limited by predominantly including refugees with a resident permit.

CLINICAL IMPLICATIONS

Peer-provided psychological interventions should be considered for scale-up in HICs.

Methylation of the glucocorticoid receptor gene (NR3C1) in dyads mother-child exposed to intimate partner violence in Cameroon: Association with anxiety symptoms

BACKGROUND

The glucocorticoid receptor (GR), which is encoded by the NR3C1 (Nuclear Receptor Subfamily 3 Group C Member 1) gene plays an important role in the modulation of the hypothalamic-pituitary-adrenal (HPA) axis activity by providing feedback regulation which allows termination of the stress response. Little is known about epigenetic programming at the level of NGFI-A (nerve growth factor-inducible protein A) putative binding site (CpG) of the NR3C1 exon 1F in dyads mother-child exposed to intimate partner violence (IPV) more specifically in an unstudied region such as the sub-Saharan Africa where levels of violence are very high.

OBJECTIVE

Examine NR3C1 exon 1F methylation in response to IPV and possible association with cortisol concentration and mental health.

METHOD

We recruited 20 mother-child dyads exposed to IPV and a control group of 20 mother-child dyads not exposed to IPV. We administered self-reported questionnaires to measure mother's mental health and collected saliva samples for cortisol dosage and bisulfite sequencing of DNA methylation.

RESULTS

Regarding the mothers, our results showed a significant difference in methylation level at CpG 16-21 sites of the NR3C1 exon 1F promoter region between the groups. In the exposed group as compared to the control group, there was a significant positive association between the level of methylation at CpG 16-21 sites and mother's mental health in particular anxiety symptoms. However, we did not find any significant correlation between methylation level and cortisol concentration. In children, we did not find any significant results.

CONCLUSION

This study highlights a NGFI-A putative binding site (CpG 16-21) that is more methylated in mothers exposed to IPV and which may have the potential to confer vulnerability for psychopathologies.

Relationship between behavioral and mood responses to monetary rewards in a sample of Indian students with and without reported pain

Physical pain has become a major health problem with many university students affected by it worldwide each year. Several studies have examined the prevalence of pain-related impairments in reward processing in Western, Educated, Industrialized, Rich, and Democratic (WEIRD) countries but none of the studies have replicated these findings in a non-western cultural setting. Here, we aimed to investigate the prevalence of physical pain symptoms in a sample of university students in India and replicate our previous study conducted on university students in Switzerland, which showed reduced mood and behavioral responses to reward in students with significant pain symptoms. We grouped students into a sub-clinical (N = 40) and a control group (N = 48) to test the association between pain symptoms and reward processes. We used the Fribourg reward task and the pain sub-scale of the Symptom Checklist (SCL-27-plus) to assess physical symptoms of pain. We found that 45% of the students reported high levels of physical symptoms of pain and interestingly, our ANOVA results did not show any significant interaction between reward and the groups either for mood scores or for outcomes related to performance. These results might yield the first insights that pain-related impairment is not a universal phenomenon and can vary across cultures.

Resilience of people with chronic medical conditions during the COVID-19 pandemic: a 1-year longitudinal prospective survey

BACKGROUNDS

Individuals with chronic medical conditions are considered highly exposed to COVID-19 pandemic stress, but emerging evidence is demonstrating that resilience is common even among them. We aimed at identifying sustained resilient outcomes and their predictors in chronically ill people during the first year of the pandemic.

METHODS

This international 4-wave 1-year longitudinal online survey included items on socio-demographic characteristics, economic and living situation, lifestyle and habits, pandemic-related issues, and history of mental disorders. Adherence to and approval of imposed restrictions, trust in governments and in scientific community during the pandemic were also investigated. The following tools were administered: the Patient Health Questionnaire, the Generalized Anxiety Disorder scale, the PTSD Checklist DSM-5, the Oslo Social Support Scale, the Padua Inventory, and the Portrait Values Questionnaire.

RESULTS

One thousand fifty-two individuals reporting a chronic condition out of 8011 total participants from 13 countries were included in the study, and 965 had data available for the final model. The estimated probability of being "sustained-resilient" was 34%. Older male individuals, participants employed before and during the pandemic or with perceived social support were more likely to belong to the sustained-resilience group. Loneliness, a previous mental disorder, high hedonism, fear of COVID-19 contamination, concern for the health of loved ones, and non-approving pandemic restrictions were predictors of not-resilient outcomes in our sample.

CONCLUSIONS

We found similarities and differences from established predictors of resilience and identified some new ones specific to pandemics. Further investigation is warranted and could inform the design of resilience-building interventions in people with chronic diseases.

Symptoms of anxiety and depression during the COVID-19 pandemic in six European countries and Australia - Differences by prior mental disorders and migration status

BACKGROUND

Little is known about changes of mental health during the COVID-19 pandemic in potentially disadvantaged groups. We investigated changes in anxiety and depression symptoms during the first year of the pandemic in six European countries and Australia by prior mental disorders and migration status.

METHODS

Overall, 4674 adults answered a web-based survey in May-June 2020 and were followed by three repeated surveys up to February 2021. Information on psychosocial, financial and demographic, living conditions, prior mental disorders, depression and anxiety symptoms during the pandemic and migration status was collected. Weighted general estimation equations modelling was used to investigate the association between prior mental disorders, migration status, and symptoms over time.

RESULTS

Most participants were <40 years old (48%), women (78%) and highly educated (62%). The baseline prevalence of depressive and anxiety symptoms ranged between 19%-45% and 13%-35%, respectively. In most countries, prevalence rates remained unchanged throughout the pandemic and were higher among people with prior mental disorders than without even after adjustment for several factors. We observed interactions between previous mental disorders and symptoms of anxiety or depression over time in two countries. No difference by migration status was noted.

LIMITATIONS

Convenience sampling limits generalizability. Self-assessed symptoms of depression and anxiety might involve some misclassification.

CONCLUSIONS

Depression and anxiety symptoms were worse among individuals with prior mental disorders than without, but there was no clear trend of worsening mental health in the observed groups during the observed period.

Development of health care workers' mental health during the SARS-CoV-2 pandemic in Switzerland: two cross-sectional studies

BACKGROUND

Virus outbreaks such as the current SARS-CoV-2 pandemic are challenging for health care workers (HCWs), affecting their workload and their mental health. Since both, workload and HCW's well-being are related to the quality of care, continuous monitoring of working hours and indicators of mental health in HCWs is of relevance during the current pandemic. The existing investigations, however, have been limited to a single study period. We examined changes in working hours and mental health in Swiss HCWs at the height of the pandemic (T1) and again after its flattening (T2).

METHODS

We conducted two cross-sectional online studies among Swiss HCWs assessing working hours, depression, anxiety, and burnout. From each study, 812 demographics-matched participants were included into the analysis. Working hours and mental health were compared between the two samples.

RESULTS

Compared to prior to the pandemic, the share of participants working less hours was the same in both samples, whereas the share of those working more hours was lower in the T2 sample. The level of depression did not differ between the samples. In the T2 sample, participants reported more anxiety, however, this difference was below the minimal clinically important difference. Levels of burnout were slightly higher in the T2 sample.

CONCLUSIONS

Two weeks after the health care system started to transition back to normal operations, HCWs' working hours still differed from their regular hours in non-pandemic times. Overall anxiety and depression among HCWs did not change substantially over the course of the current SARS-CoV-2 pandemic.

Scalable psychological interventions for Syrian refugees in Europe and the Middle East: STRENGTHS study protocol for a prospective individual participant data meta-analysis

INTRODUCTION

The World Health Organization's (WHO) scalable psychological interventions, such as Problem Management Plus (PM+) and Step-by-Step (SbS) are designed to be cost-effective non-specialist delivered interventions to reduce symptoms of common mental disorders, such as anxiety, depression and post-traumatic stress disorder (PTSD). The STRENGTHS consortium aims to evaluate the effectiveness, cost-effectiveness and implementation of the individual format of PM+ and its group version (gPM+), as well as of the digital SbS intervention among Syrian refugees in seven countries in Europe and the Middle East. This is a study protocol for a prospective individual participant data (IPD) meta-analysis to evaluate (1) overall effectiveness and cost-effectiveness and (2) treatment moderators of PM+, gPM+ and SbS with Syrian refugees.

METHODS AND ANALYSIS

Five pilot randomised controlled trials (RCTs) and seven fully powered RCTs conducted within STRENGTHS will be combined into one IPD meta-analytic dataset. The RCTs include Syrian refugees of 18 years and above with elevated psychological distress (Kessler Psychological Distress Scale (K10>15)) and impaired daily functioning (WHO Disability Assessment Schedule 2.0 (WHODAS 2.0>16)). Participants are randomised into the intervention or care as usual control group, and complete follow-up assessments at 1-week, 3-month and 12-month follow-up. Primary outcomes are symptoms of depression and anxiety (25-item Hopkins Symptom Checklist). Secondary outcomes include daily functioning (WHODAS 2.0), PTSD symptoms (PTSD Checklist for DSM-5) and self-identified problems (PSYCHLOPS). We will conduct a one-stage IPD meta-analysis using linear mixed models. Quality of evidence will be assessed using the GRADE approach, and the economic evaluation approach will be assessed using the CHEC-list.

ETHICS AND DISSEMINATION

Local ethical approval has been obtained for each RCT. This IPD meta-analysis does not require ethical approval. The results of this study will be published in international peer-reviewed journals.

From the Mother to the Child: The Intergenerational Transmission of Experiences of Violence in Mother-Child Dyads Exposed to Intimate Partner Violence in Cameroon

Intimate partner violence (IPV) is a widespread social problem with serious consequences for the health of both women and their children. However, little is known about the combined effect of maternal childhood abuse and current exposure to IPV with respect to the psychopathological symptoms of the mother-child dyad. In a Cameroonian cultural setting, where IPV affects more than half of women, we aimed to better understand how mother's childhood abuse and current IPV co-occur to lead to psychopathological symptoms in the mother-child dyad. With the help of a non-governmental organization in Cameroon, we recruited 49 mother-child dyads exposed to IPV, along with 25 mother-child dyads who had not been exposed, and who functioned as a control group. All mothers completed a set of questionnaires, including the Revised Conflict Tactics Scale to assess IPV; the Child Trauma Questionnaire to examine their childhood trauma; the Child Behavior Checklist to assess their children's psychopathological traits; the Hospital Anxiety and Depression Scale; and the Symptom Checklist. We found that physical abuse experienced by mothers during childhood was associated with IPV in adulthood, and specifically sexual abuse, p = .001. In addition, we found that the accumulation of maternal childhood abuse and current IPV was related to anxiety and depression symptoms in mothers, all R² ≥ .18, all ps ≤ .015, as well as to externalized symptoms in children, all R² ≥ .27, all ps ≤ .017. Our results suggest the intergenerational transmission of experiences of childhood abuse and current IPV, which calls for the development of interventions and care strategies for the mother-child dyad.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION

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

Feasibility and acceptability of Problem Management Plus (PM+) among Syrian refugees and asylum seekers in Switzerland: a mixed-method pilot randomized controlled trial

BACKGROUND

Syrian refugees in Switzerland face several barriers in accessing mental health care. Cost-effective psychological interventions are urgently needed to meet the mental health needs of refugees. Problem Management Plus (PM+) is an evidence-based, psychological intervention delivered by trained non-specialist 'helpers'.

OBJECTIVE

To assess the feasibility and acceptability of PM+ among Syrian refugees in Switzerland.

METHODS

We conducted a single-blind pilot randomized controlled trial (RCT) with Syrian refugees impaired by psychological distress (K10 > 15 and WHODAS 2.0 > 16). Participants were randomized to PM+ or Enhanced Treatment As Usual (ETAU). Participants were assessed at baseline, and 1 week and 3 months after the intervention, and completed measures indexing mental health problems and health care usage. Semi-structured interviews were conducted with different stakeholders.

RESULTS

N = 59 individuals were randomized into PM+ (n = 31) or ETAU (n = 28). N = 18 stakeholders were interviewed about facilitators and barriers for the implementation of PM+. Retention rates in the trial (67.8%) and mean intervention attendance (M = 3.94 sessions, SD = 1.97) were high. No severe events related to the study were reported. These findings indicate that the trial procedures and PM+ were feasible, acceptable and safe.

CONCLUSIONS

The findings support the conduct of a definitive RCT and show that PM+ might have the potential to be scaled-up in Switzerland. The importance, as well as the challenges, of implementing and scaling-up PM+ in high-income countries, such as Switzerland, are discussed.

Moral injury related to immigration detention on Nauru: a qualitative study

BACKGROUND

Immigration detention is associated with detrimental mental health outcomes but little is known about the underlying psychological processes. Moral injury, the experience of transgression of moral beliefs, may play an important role.

OBJECTIVE

Our aim was to explore moral injury appraisals and associated mental health outcomes related to immigration detention on Nauru.

METHODS

In this retrospective study, we conducted in-depth interviews with 13 individuals who had sought refuge in Australia and, due to arriving by boat, had been transferred to immigration detention on Nauru. At the time of the study, they lived in Australia following medical transfer. We used reflexive thematic analysis to develop themes from the data.

RESULTS

Major themes included 1) how participants' home country experience and the expectation to get protection led them to seek safety in Australia; 2) how they experienced deprivation, lack of agency, violence, and dehumanization after arrival, with the Australian government seen as the driving force behind these experiences; and 3) how these experiences led to feeling irreparably damaged. The participant statement 'In my country they torture your body but in Australia they kill your mind.' conveyed these three key themes in our analysis.

CONCLUSION

Our findings suggest that moral injury may be one of the processes by which mandatory immigration detention can cause harm. Although refugees returned to Australia from offshore detention may benefit from interventions that specifically target moral injury, collective steps are needed to diminish deterioration of refugee mental health. Our results highlight the potentially deleterious mental health impact of experiencing multiple subtle and substantial transgressions of one's moral frameworks. Policy makers should incorporate moral injury considerations to prevent eroding refugee mental health.

Child maltreatment and NR3C1 exon 1F methylation, link with deregulated hypothalamus-pituitary-adrenal axis and psychopathology: A systematic review

BACKGROUND

Epigenetics offers one promising method for assessing the psychobiological response to stressful experiences during childhood. In particular, deoxyribonucleic acid (DNA) methylation has been associated with an altered hypothalamus-pituitary-adrenal (HPA) axis and the onset of mental disorders. Equally, there are promising leads regarding the association between the methylation of the glucocorticoid receptor gene (NR3C1-1_F) and child maltreatment and its link with HPA axis and psychopathology.

OBJECTIVE

The current study aimed to assess the evidence of a link among child maltreatment, NR3C1-1_F methylation, HPA axis deregulation, and symptoms of psychopathology.

METHODS

We followed the Prisma guidelines and identified 11 articles that met our inclusion criteria.

RESULTS

We found that eight studies (72.72%) reported increased NR3C1-1_F methylation associated with child maltreatment, specifically physical abuse, emotional abuse, sexual abuse, neglect, and exposure to intimate partner violence, while three studies (27.27%) found no significant association. Furthermore, a minority of studies (36.36%) provided additional measures of symptoms of psychopathology or cortisol in order to examine the link among NR3C1-1_F methylation, HPA axis deregulation, and psychopathology in a situation of child maltreatment. These results suggest that NR3C1-1_F hypermethylation is positively associated with higher HPA axis activity, i.e. increased production of cortisol, as well as symptoms of psychopathology, including emotional lability-negativity, externalizing behavior symptoms, and depressive symptoms.

CONCLUSION

NR3C1-1_F methylation could be one mechanism that links altered HPA axis activity with the development of psychopathology.

Burnout, depression and anxiety among Swiss medical students - A network analysis

It is well established that burnout in medical students is associated with depression and anxiety at a syndromal level. Moreover, there is an ongoing debate about the extent to which burnout overlaps with depression and anxiety. The emerging network approach to psychopathology offers a new perspective on the interrelations between mental disorders focusing on symptom-level association. In this cross-sectional study, we exploratively investigated the associations among burnout, depression, and anxiety in 574 swiss medical students using a network analytic approach for the first time. Symptoms of depression and anxiety were assessed with the Patient Health Questionnaire and Generalized Anxiety Disorder respectively. Burnout was assessed with two single-item questions, one referring to emotional exhaustion and the other to depersonalization. We found a dense network in which at least one dimension of burnout was related to eleven of the sixteen included symptoms. This suggests that burnout is closely related to depression and anxiety but also has its own characteristics. Notably, suicidal ideation was not associated with either emotional exhaustion or depersonalization after adjusting for the influence of the remaining symptoms of anxiety and depression. Hence, the well-documented relationship between burnout and suicidal ideation in medical students may be entirely mediated by the experience of anxiety and depression. Hence, the well-documented relationship between burnout and suicidal ideation in medical students might be fully mediated by the experience of anxiety and depression. The collection of the sample after the first wave of infections during the SARS-CoV2 pandemic and the non-representativeness of the investigated sample limit the study's generalizability.

An exploratory study of embitterment in traumatized refugees

BACKGROUND

Refugees and asylum seekers are frequently exposed to violence, human rights violations and unstable living conditions before, during, and after their displacement. Elevated prevalence rates of psychiatric disorders in forcibly displaced persons are well documented. However, less is known about other problems related to common refugee experiences, such as embitterment, moral injury, and diminished self-efficacy, and how they are related to trauma exposure and post-migration living difficulties.

METHODS

A cross-sectional sample of 71 refugees and asylum seekers in treatment were examined regarding exposure to potentially traumatic events, post-migration living difficulties, moral injury appraisals, self-efficacy, and embitterment.

RESULTS

Elevated levels of embitterment were reported by 68% of participants. The regression analysis revealed that greater moral injury appraisals and low levels of self-efficacy were significantly associated with higher levels of embitterment.

CONCLUSION

The results provide first insights into embitterment and associated factors in refugee populations. Furthermore, they highlight the significance of moral transgressions and low levels of self-efficacy emerging from displacement and traumatic experiences for the development of mental health problems in a clinical sample of refugees. The findings have implications for future research, policy development and clinical practice.

HPA-axis activity and the moderating effect of self-esteem in the context of intimate partner violence in Cameroon

BACKGROUND

The experience of intimate partner violence (IPV) is stressful. One objective way to monitor it is to assess victims' stress response by measuring the concentration of their salivary cortisol, the major stress hormone released by the hypothalamic-pituitary-adrenal axis.

OBJECTIVE

We investigated how the IPV experienced by women in Cameroon affects their stress levels and those of their children.

METHOD

We recruited 50 mother-child dyads exposed to IPV and a control group of 25 mother-child dyads. All mothers completed questionnaires, including the Revised Conflict Tactics Scale to assess IPV, the Sense of Coherence Scale, and the Self-Esteem Scale, to assess their psychological resources. Mothers were asked to collect 3 saliva samples from themselves and 3 from their children on a single weekday: immediately after waking up, 30 minutes after waking up, and 45 minutes after waking up. The total cortisol secretion over the first hour after awakening was determined by calculating the area under the curve with respect to the ground (AUCg).

RESULTS

Mothers exposed to IPV exhibited higher total post-awakening cortisol concentrations compared with those in the control group. However, no significant difference was found between exposed and non-exposed children. In addition, higher IPV, specifically injuries, was significantly and positively associated with greater AUCg among mothers exhibiting lower self-esteem. When self-esteem was high, however, no significant effect of IPV on AUCg was observed.

CONCLUSIONS

Of particular clinical significance is that self-esteem can modulate the stress levels of women exposed to IPV, a valuable insight into the development of effective psychosocial interventions to support IPV victims in sub-Saharan Africa.

A network analysis of postmigration living difficulties in refugees and asylum seekers

BACKGROUND

The prevalence of mental disorders among asylum seekers and refugees is elevated compared to the general population. The importance of post-migration living difficulties (PMLDs), stressors faced after displacement, has recently been recognized due to research demonstrating their moderating role of on mental health outcomes. Traditionally, PMLDs were investigated as count variables or latent variables, disregarding plausible interrelationships among them.

OBJECTIVES

To use network analysis to investigate the associations among PMLDs.

METHODS

Based on a cross-sectional measurement of seventeen PMLDs in a clinical sample of traumatized asylum seekers and refugees (N = 151), a partial correlation network was estimated, and its characteristics assessed.

RESULTS

The network consisted of 71 of the 120 possible edges. The strongest edge was found between 'Communication difficulties' and 'Discrimination'. 'Loneliness, boredom, or isolation' had highest predictability.

CONCLUSION

Our finding of an association between communication difficulties and discrimination has been documented before and is of importance given the known negative impact of discrimination on mental and physical health outcomes. The high predictability of isolation is indicative of multiple associations with other PMLDs and highlights its importance among the investigated population. Our results are limited by the cross-sectional nature of our study and the relatively modest sample size.

Problems faced by Syrian refugees and asylum seekers in Switzerland

BACKGROUND

Refugees and asylum seekers are susceptible to developing common mental disorders due to their exposure to stressful experiences before, during and after their flight. The Syrian Civil War, which started in 2011, has led to a massive number of Syrians seeking refuge and asylum in European countries, including Switzerland. Currently, Syrians are the second-largest refugee and asylum-seeking population in Switzerland. However, very little is known about the problems faced by this new population in Switzerland and their needs relating to mental health services. Identifying the problems faced by this community is crucial to providing adapted and tailored mental health services to Syrian refugees in Switzerland.

AIM OF HE STUDY

The current study aimed to identify problems that Syrian refugees and asylum seekers face daily while living in Switzerland in order to inform the adaptation of a brief psychological intervention.

METHODS

We used a cross-sectional, qualitative design and collected data according to The Manual for Design, Implementation, Monitoring and Evaluation of Mental Health and Psychosocial Assistance Programs for Trauma Survivors in order to identify problems perceived by the target population. Free-listing, open-ended interviews were conducted with 30 adult Syrian refugees and asylum seekers and analyzed using thematic analysis.

RESULTS

The results show that besides physical health problems, Syrians experience primarily two types of problems: practical and psychological (emotional) problems. These two types of problems are closely interrelated. The most common practical problems (problems with government and authorities, problems related to residence permits, problems with integration, cultural differences, language problems, problems related to education, problems related to employment, and problems with housing) were reported by almost half of all participants. Symptoms of mental disorders and feelings of uncertainty, frustration and injustice were the most common psychological problems and were mentioned by more than one third of the participants. The finding that almost half of the participants reported typical symptoms of mental health disorders suggests that a considerable number of Syrian refugees and asylum seekers might need mental healthcare.

CONCLUSIONS

Authorities, practitioners and researchers should recognize that Syrian refugees and asylum seekers are strongly affected by a broad range of problems. Besides practical problems, they suffer a multitude of psychological problems, and a significant number of them report, among other issues, symptoms of mental health disorders. Officials working with this population should be aware of this vulnerability and be prepared to refer clients in need of mental healthcare to mental healthcare providers. Moreover, the significant variety and number of problems experienced by this population should be taken into consideration when developing solutions tailored to their needs.

BACKGROUND

Refugees and asylum seekers are susceptible to developing common mental disorders due to their exposure to stressful experiences before, during and after their flight. The Syrian Civil War, which started in 2011, has led to a massive number of Syrians seeking refuge and asylum in European countries, including Switzerland. Currently, Syrians are the second-largest refugee and asylum-seeking population in Switzerland. However, very little is known about the problems faced by this new population in Switzerland and their needs relating to mental health services. Identifying the problems faced by this community is crucial to providing adapted and tailored mental health services to Syrian refugees in Switzerland.

AIM OF HE STUDY

The current study aimed to identify problems that Syrian refugees and asylum seekers face daily while living in Switzerland in order to inform the adaptation of a brief psychological intervention.

METHODS

We used a cross-sectional, qualitative design and collected data according to The Manual for Design, Implementation, Monitoring and Evaluation of Mental Health and Psychosocial Assistance Programs for Trauma Survivors in order to identify problems perceived by the target population. Free-listing, open-ended interviews were conducted with 30 adult Syrian refugees and asylum seekers and analyzed using thematic analysis.

RESULTS

The results show that besides physical health problems, Syrians experience primarily two types of problems: practical and psychological (emotional) problems. These two types of problems are closely interrelated. The most common practical problems (problems with government and authorities, problems related to residence permits, problems with integration, cultural differences, language problems, problems related to education, problems related to employment, and problems with housing) were reported by almost half of all participants. Symptoms of mental disorders and feelings of uncertainty, frustration and injustice were the most common psychological problems and were mentioned by more than one third of the participants. The finding that almost half of the participants reported typical symptoms of mental health disorders suggests that a considerable number of Syrian refugees and asylum seekers might need mental healthcare.

CONCLUSIONS

Authorities, practitioners and researchers should recognize that Syrian refugees and asylum seekers are strongly affected by a broad range of problems. Besides practical problems, they suffer a multitude of psychological problems, and a significant number of them report, among other issues, symptoms of mental health disorders. Officials working with this population should be aware of this vulnerability and be prepared to refer clients in need of mental healthcare to mental healthcare providers. Moreover, the significant variety and number of problems experienced by this population should be taken into consideration when developing solutions tailored to their needs.

BACKGROUND

Refugees and asylum seekers are susceptible to developing common mental disorders due to their exposure to stressful experiences before, during and after their flight. The Syrian Civil War, which started in 2011, has led to a massive number of Syrians seeking refuge and asylum in European countries, including Switzerland. Currently, Syrians are the second-largest refugee and asylum-seeking population in Switzerland. However, very little is known about the problems faced by this new population in Switzerland and their needs relating to mental health services. Identifying the problems faced by this community is crucial to providing adapted and tailored mental health services to Syrian refugees in Switzerland.

AIM OF HE STUDY

The current study aimed to identify problems that Syrian refugees and asylum seekers face daily while living in Switzerland in order to inform the adaptation of a brief psychological intervention.

METHODS

We used a cross-sectional, qualitative design and collected data according to The Manual for Design, Implementation, Monitoring and Evaluation of Mental Health and Psychosocial Assistance Programs for Trauma Survivors in order to identify problems perceived by the target population. Free-listing, open-ended interviews were conducted with 30 adult Syrian refugees and asylum seekers and analyzed using thematic analysis.

RESULTS

The results show that besides physical health problems, Syrians experience primarily two types of problems: practical and psychological (emotional) problems. These two types of problems are closely interrelated. The most common practical problems (problems with government and authorities, problems related to residence permits, problems with integration, cultural differences, language problems, problems related to education, problems related to employment, and problems with housing) were reported by almost half of all participants. Symptoms of mental disorders and feelings of uncertainty, frustration and injustice were the most common psychological problems and were mentioned by more than one third of the participants. The finding that almost half of the participants reported typical symptoms of mental health disorders suggests that a considerable number of Syrian refugees and asylum seekers might need mental healthcare.

CONCLUSIONS

Authorities, practitioners and researchers should recognize that Syrian refugees and asylum seekers are strongly affected by a broad range of problems. Besides practical problems, they suffer a multitude of psychological problems, and a significant number of them report, among other issues, symptoms of mental health disorders. Officials working with this population should be aware of this vulnerability and be prepared to refer clients in need of mental healthcare to mental healthcare providers. Moreover, the significant variety and number of problems experienced by this population should be taken into consideration when developing solutions tailored to their needs.

Cultural adaptation of Hap-pas-Hapi, an internet and mobile-based intervention for the treatment of psychological distress among Albanian migrants in Switzerland and Germany

BACKGROUND

Internet- and mobile-based mental health interventions have the potential to narrow the treatment gap in ethnic groups. Little evidence exists on the cultural adaptation of such interventions. Cultural adaptation of evidence-based interventions distinguishes between surface and deep structure adaptation. Surface refers to matching materials (e.g., illustrations, language) or methods of treatment delivery to the target population, whereas deep structure adaptation considers cultural concepts of distress (CCD). So far, CCD have only been considered to a limited extent in cultural adaptation of psychological interventions, and there is a lack of well documented adaptation procedures.

AIMS

With a cross-disciplinary and mixed-method approach, following a new conceptual framework for cultural adaptation of scalable psychological interventions, this study aimed to develop both surface and deep structure adaptations of an internet- and mobile-based intervention called Hap-pas-Hapi for the treatment of psychological distress among Albanian migrants in Switzerland and Germany.

METHODS

A qualitative ethnopsychological study was conducted to examine the target group's CCD. Focus group discussions, an online survey, and individual key informant interviews were utilised to evaluate the original intervention, adaptation drafts and the final adapted intervention. A reporting system was developed to support the decision-making process and to report all adaptations in a transparent and replicable way.

RESULTS

The ongoing involvement of target population key informants provided valuable feedback for the development of a more person-centred intervention, which might enhance treatment acceptance, motivation and adherence.

DISCUSSION

This study provides empirical and theory-based considerations and suggestions for future implementation that may foster acceptability and effectiveness of culturally adapted evidence-based interventions.

Understanding and comparison of self-reported problems of Syrian refugees in three countries

Background

Syrian refugees have high levels of mental disorders. They face multiple stressors before, during and after migration which affect their psychosocial wellbeing. Stressors after flight may vary due to different geographic, economic, cultural, socio-political contexts. Previous studies demonstrate that displacement-related factors are as likely as war exposure to contribute to distress after migration and hence, are pivotal to include in public health policy. Assessments in mental health care are mainly through nomothetic measurements, often developed in western countries. A growing body of literature recognizes the importance of clients' own perspective, especially in cross-cultural settings. The aim of this multi-country study was to describe and compare self-reported problems of Syrian refugees between Jordan, Turkey and Switzerland.

Methods

Using the semi-structured client-generated outcome measurement PSYCHLOPS enabled to identify and compare problems in various study settings: camp-based in Jordan (N = 61), community-based in Turkey (N = 46) and Switzerland (N = 57), respectively. Questionnaires were analyzed following thematic analysis. The developed coding framework allowed to qualitatively illustrate the meaning and quantitatively compare the frequency of codes.

Results

Almost all the emerged themes are related to post-migration stressors. Over half of the participants reported practical problems with an emphasis on financial, employment, government regulations, followed by psychological and physical health problems. For participants in Turkey, finances are of much more concern than in Jordan and Switzerland, whereas in Switzerland, problems with government regulations stand out.

Conclusions

This study underlines the importance of displacement-related factors with special regard to local key factors on psychosocial wellbeing. Consequently, when planning mental health care services and preventive measures such factors must be considered and addressed.

Barriers to access to outpatient mental health care for refugees and asylum seekers in Switzerland: the therapist's view

BACKGROUND

More than 120,000 refugees and asylum seekers are currently living in Switzerland. The prevalence of mental disorders among this population is significantly higher than that in the general population. While effective treatment options and cross-cultural, specialized treatment centers exist, they tend to be overloaded by their target populations. General outpatient primary health care providers might be able to compensate for the lack of specialized treatment slots. To date, however, it is unknown how often and under what conditions (e.g., length of waiting lists) refugees and asylum seekers are treated outside of specialized centers and whether there are barriers that prevent providers in outpatient settings from treating more patients in this subgroup. The present study aimed to assess the challenges and barriers faced by psychiatrists and psychotherapists working in outpatient settings in Switzerland in treating refugees and asylum seekers to determine the potential capacity of this group to provide mental health care.

METHODS

An online survey was conducted during the winter of 2017/2018. The survey was constructed in three official languages and took 10-15 min to complete. Spearman's correlations, Mann-Whitney U-Tests, and Chi-squared tests were conducted to analyze the data.

RESULTS

Eight hundred and sixty-seven (N = 867) psychotherapists and psychiatrists working in outpatient settings completed the survey: 43% of them reported having treated between 1 and 9 refugees or asylum seekers in the past 12 months, and a further 13% reported treating 10 or more. Interpreters were used for almost every other patient with a refugee or asylum-seeker background. At the same time, the funding of interpreters, as well as the funding of treatment in general, were reported to be the biggest hurdles to treating more refugees and asylum seekers.

CONCLUSIONS

Given the low number of patients rejected for capacity reasons (between 2 and 5%) and the median waiting times for the admission of new patients ranging between 2 and 3 weeks, outpatient primary mental health care providers might treat more refugees and asylum seekers and relieve specialized treatment centers. However, barriers such as lack of funding of interpreters seem to hinder them. Appropriate steps by the authorities are needed to improve the current situation.

Prolonged Grief Disorder Among Refugees in Psychological Treatment-Association With Self-Efficacy and Emotion Regulation

BACKGROUND

While Prolonged Grief Disorder (PGD) among refugees has recently started to attract scientific attention, knowledge regarding associated psychological factors remains limited. Given the multifactorial context of persecution, trauma, displacement, and exile-related difficulties, obtaining a better understanding of PGD in refugees is crucial because PGD may affect psychological well-being, level of functioning, and social integration.

METHODS

In a sample of refugees receiving psychological treatment in Switzerland (N = 88), we examined the relationship between severity of PGD and potentially associated factors such as emotion regulation, perceived self-efficacy, as well as potentially traumatic events and post-migration living difficulties.

RESULTS

In a regression analysis, difficulties in emotion regulation and lower perceived self-efficacy were associated with greater severity of PGD, while post-migration living difficulties and potentially traumatic events did not emerge as significant factors.

CONCLUSION

These findings suggest that emotion regulation and perceived self-efficacy are associated with PGD in refugees in psychological treatment and are thus potential targets for treatment interventions.

Trauma and suicidality in war affected communities

Purpose

The aim was to assess whether experiences of war trauma remain directly associated with suicidality in war affected communities when other risk factors are considered.

Materials and methods

In the main sample 3313 participants from former Yugoslavia who experienced war trauma were recruited using a random sampling in five Balkan countries. In the second sample 854 refugees from former Yugoslavia recruited through registers and networking in three Western European countries. Sociodemographic and data on trauma exposure, psychiatric diagnoses and level of suicidality were assessed.

Results

In the main sample 113 participants (3.4%) had high suicidality, which was associated with number of potentially traumatic war experiences (odds ratio 1.1) and war related imprisonment (odds ratio 3) once all measured risk factors were considered. These associations were confirmed in the refugee sample with a higher suicidality rate (10.2%).

Discussion and conclusions

Number of potentially traumatic war experiences, in particular imprisonment, may be considered as a relevant risk factor for suicidality in people affected by war.

Protocol for a randomized controlled trial: peer-to-peer Group Problem Management Plus (PM+) for adult Syrian refugees in Turkey

Background

A large proportion of Syrians have been exposed to potentially traumatic events, multiple losses, and breakdown of supportive social networks and many of them have sought refuge in host countries where they also face post-migration living difficulties such as discrimination or integration problems or both. These adversities may put Syrian refugees at high risk for common mental disorders. In response to this, the World Health Organization (WHO) developed a trans-diagnostic scalable psychological intervention called Problem Management Plus (PM+) to reduce psychological distress among populations exposed to adversities. PM+ has been adapted for Syrian refugees and can be delivered by non-specialist peer lay persons in the community.

Methods

A randomized controlled trial (RCT) will be conducted with 380 Syrian refugees in Turkey. After providing informed consent, participants with high levels of psychological distress (scoring above 15 on the Kessler-10 Psychological Distress Scale (K10)) and functional impairment (scoring above 16 on the WHO Disability Assessment Schedule 2.0, or WHODAS 2.0) will be randomly assigned to Group PM+/enhanced care as usual (Group PM+/E-CAU) (n = 190) or E-CAU (n = 190). Outcome assessments will take place 1 week after the fifth session (post-assessment), 3 months after the fifth session and 12 months after baseline assessment. The primary outcome is psychological distress as measured by the Hopkins Symptom Checklist (HSCL-25). Secondary outcomes include functional impairment, post-traumatic stress symptoms, self-identified problems, and health system and productivity costs. A process evaluation will be conducted to explore the feasibility, challenges and success of the intervention with 25 participants, including participants, facilitators, policy makers and mental health professionals.

Discussion

The treatment manual of the Syrian-Arabic Group PM+ and training materials will be made available through the WHO once the effectiveness and cost-effectiveness of Group PM+ have been established.

Trial registration

Clinical Trial Registration: ClinicalTrials.gov Identifier NCT03960892. Unique protocol ID: 10/2017. Prospectively registered on 21 May 2019.

Effectiveness of a peer-refugee delivered psychological intervention to reduce psychological distress among adult Syrian refugees in the Netherlands: study protocol

Background: Syrian refugees face multiple hardships and adversities which put them at risk for the development of mental health problems. However, access to adequate mental health care in host countries is limited. The WHO has developed Problem Management Plus (PM+), a brief, scalable psychological intervention, delivered by non-specialist helpers, that addresses common mental disorders in people affected by adversity. This study is part of the STRENGTHS project, that aims to evaluate peer-refugee delivered psychological interventions for Syrian refugees in Europe and the Middle East. Objective: To evaluate the effectiveness and cost-effectiveness of the peer-refugee delivered PM+ intervention among Syrian refugees with elevated levels of psychological distress in the Netherlands. Methods: PM+ will be tested in a randomized controlled trial (RCT) among Arabic-speaking Syrian refugees in the Netherlands aged 18 years and above with self-reported psychological distress (Kessler Psychological Distress Scale; K10 >15) and impaired daily functioning (WHO Disability Assessment Schedule; WHODAS 2.0 >16). Participants (N = 380) will be randomized into care as usual with PM+ (CAU/PM+, n = 190) or CAU only (CAU, n = 190). Baseline, 1-week post-intervention, and 3-month and 12-month follow-up assessments will be conducted. Primary outcomes are symptoms of depression and anxiety. Secondary outcomes are functional impairment, posttraumatic stress disorder symptoms, self-identified problems, anger, health and productivity costs, and hair cortisol concentrations. A process evaluation will be carried out to evaluate treatment dose, protocol fidelity and stakeholder views on barriers and facilitators to implementing PM+. Results and Conclusions: PM+ has proved effectiveness in other populations and settings. After positive evaluation, the adapted manual and training materials for individual PM+ will be made available through the WHO to encourage further replication and scaling up. Trial registration: Trial registration Dutch Trial Registry, NL7552, registered prospectively on March 1, 2019. Medical Ethics Review Committee VU Medical Center Protocol ID 2017.320, 7 September 2017.

Structural and socio-cultural barriers to accessing mental healthcare among Syrian refugees and asylum seekers in Switzerland

Background: Due to their experiences of major stressful life events, including post-displacement stressors, refugees and asylum seekers are vulnerable to developing mental health problems. Yet, despite the availability of specialized mental health services in Western European host countries, refugees and asylum seekers display low mental healthcare utilization. Objective: The aim of this study was to explore structural and socio-cultural barriers to accessing mental healthcare among Syrian refugees and asylum seekers in Switzerland. Method: In this qualitative study, key-informant (KI) interviews with Syrian refugees and asylum seekers, Swiss healthcare providers and other stakeholders (e.g. refugee coordinators or leaders) were conducted in the German-speaking part of Switzerland. Participants were recruited using snowball sampling. Interviews were audiotaped and transcribed, and then analysed using thematic analysis, combining deductive and inductive coding. Results: Findings show that Syrian refugees and asylum seekers face multiple structural and socio-cultural barriers, with socio-cultural barriers being perceived as more pronounced. Syrian key informants, healthcare providers, and other stakeholders identified language, gatekeeper-associated problems, lack of resources, lack of awareness, fear of stigma and a mismatch between the local health system and perceived needs of Syrian refugees and asylum seekers as key barriers to accessing care. Conclusions: The results show that for Syrian refugees and asylum seekers in Switzerland several barriers exist. This is in line with previous findings. A possible solution for the current situation might be to increase the agility of the service system in general and to improve the willingness to embrace innovative paths, rather than adapting mental healthcare services regarding single barriers and needs of a new target population.

Emotional Reactivity, Emotion Regulation Capacity, and Posttraumatic Stress Disorder in Traumatized Refugees: An Experimental Investigation

Refugees who suffer from posttraumatic stress disorder (PTSD) often react with strong emotions when confronted with trauma reminders. In this study, we aimed to investigate the associations between low emotion regulation capacity (as indexed by low heart rate variability [HRV]), probable PTSD diagnosis, and fear and anger reaction and recovery to trauma-related stimuli. Participants were 81 trauma-exposed refugees (probable PTSD, n = 23; trauma-exposed controls, n = 58). The experiment comprised three 5-min phases: a resting phase (baseline); an exposition phase, during which participants were exposed to trauma-related images (stimulus); and another resting phase (recovery). We assessed HRV at baseline, and fear and anger were rated at the end of each phase. Linear mixed model analyses were used to investigate the associations between baseline HRV and probable DSM-5 PTSD diagnosis in influencing anger and fear responses both immediately after viewing trauma-related stimuli and at the end of the recovery phase. Compared to controls, participants with probable PTSD showed a greater increase in fear from baseline to stimulus presentation, d = 0.606. Compared to participants with low emotion regulation capacity, participants with high emotion regulation capacity showed a smaller reduction in anger from stimulus presentation to recovery, d = 0.548. Our findings indicated that following exposure to trauma-related stimuli, probable PTSD diagnosis predicted increased fear reactivity, and low emotion regulation capacity predicted decreased anger recovery. Impaired anger recovery following trauma reminders in the context of low emotion regulation capacity might contribute to the increased levels of anger found in postconflict samples.

The Association of Post-traumatic and Postmigration Stress with Pain and Other Somatic Symptoms: An Explorative Analysis in Traumatized Refugees and Asylum Seekers

Objective

Post-traumatic stress disorder (PTSD) and somatic symptoms, such as pain, are frequently seen in refugees. Their relationship is poorly understood, and the treatment of these comorbid conditions can be very challenging. The current cross-sectional study examined pain and other somatic symptoms and their relationship with trauma history, PTSD symptom clusters, and current living difficulties among treatment-seeking refugees.

Methods

One hundred thirty-four treatment-seeking traumatized refugees (78% male, mean age = 42 years) were assessed regarding lifetime traumatic experiences, symptoms of post-traumatic stress, overall pain and somatic symptoms, and postmigration living difficulties.

Results

An exploratory factor analysis of the 12 somatic symptoms revealed two distinct factors: somatic symptoms related to bodily dysfunction ("weakness") and somatic symptoms related to increased sympathetic activity ("arousal"). DSM-5 PTSD Criteria D "alterations in cognitions and mood" and E "alterations in arousal and reactivity" were primarily related to "weakness," while PTSD Criterion E "alterations in arousal and reactivity" and postmigration living difficulties were associated with "arousal." Overall pain was associated primarily with living difficulties and PTSD Criterion D and Criterion E.

Conclusions

Results indicate that somatic symptoms are of considerable concern among traumatized refugees and that different patterns of somatic symptoms are associated with different clusters of PTSD symptoms. The findings contribute to the better understanding of the symptom presentation of traumatized people who are experiencing somatization and potentially inform treatment directions and highlight the importance of screening for PTSD in refugees presenting with pain and somatic symptoms.

The effects of perceived torture controllability on symptom severity of posttraumatic stress, depression and anger in refugees and asylum seekers: A path analysis

Torture is associated with greater psychopathology, however, the specific mechanisms underlying the effects of torture remain unclear. Research suggests that the perceived uncontrollable nature of, rather than the exposure to, torture, influences the development of psychological disorders. Perceived distress during torture has also been shown to influence psychological outcomes. This cross-sectional study explored the relationship between perceived torture controllability, emotions (i.e., anger and fear) during torture, and current posttraumatic stress (PTS), depression and anger symptoms, controlling for the effects of post-migration living difficulties. Data were collected from 108 refugees and asylum seekers in treatment at two psychiatric clinics in Zurich, Switzerland. Path analyses revealed negative correlations between PTS, depression and anger symptoms, and perceived torture controllability, and positive correlations with anger and fear during torture. Furthermore, the effects of perceived torture controllability on PTS and depression symptoms were mediated by fear during torture, and on anger symptoms via anger during torture. This was over and above the effects of post-migration living difficulties on psychological symptoms. The study provides preliminary evidence that perceived uncontrollability and distress during torture might be significant risk factors for current mental health of torture survivors. These findings may have implications for informing interventions for torture survivors.

Enhancement of exposure therapy in participants with specific phobia: A randomized controlled trial comparing yohimbine, propranolol and placebo

BACKGROUND

Recent research indicates that pharmacological agents may enhance psychotherapeutic outcome. Yet, empirical results have not been conclusive with respect to two pharmacological agents, yohimbine hydrochloride (YOH) and propranolol. YOH is suggested to enhance emotional memory by elevating norepinephrine, whereas the β-adrenergic receptor antagonist propranolol might help better cope with feared situations by reducing accompanying bodily sensations.

METHODS

In this controlled trial, fifty-six participants with specific phobia were randomly assigned to either 1) virtual reality exposure therapy (VRET) plus YOH, 2) VRET plus Propranolol, or 3) VRET plus placebo. Participants in all conditions received three sessions of VRET over a period of two weeks.

RESULTS

We conducted 2 × 3 repeated measures MANOVA's. Results showed a significant effect for time, with partial eta squared ranging from ηp2 = 0.647 to ηp2 = 0.692, for specific phobia, yet no significant interaction effects were found.

CONCLUSION

No significant differences were found when VRET with YOH or a beta-blocker was compared to VRET with a non-active placebo. Implications for clinical practice and future research are discussed.

Trauma exposure and the mediating role of posttraumatic stress on somatic symptoms in civilian war victims

BACKGROUND

It has been well documented that the exposure to war has a negative effect on the psychological health of civilian. However, little is known on the impact of war exposure on the physical health of the civilian population. In addition, the link between trauma exposure and somatic symptoms remain poorly understood. This cross-sectional study examined levels of somatic symptoms in the aftermath of war, and the mediating role of posttraumatic stress symptoms in the relationship between trauma exposure and somatic symptoms.

METHODS

Civilian war survivors (N = 142) from Kosovo were assessed for potentially traumatic events, posttraumatic stress symptoms, and somatic symptoms. Data were analyzed using mediation analyses. Posttraumatic stress disorder (PTSD) symptoms were categorized based on King's four factor model (Psychol Assessment. 10: 90-96, 1998).

RESULTS

Participants reported on average more than 5 types of traumatic exposure. The cut-off indicative for PTSD was exceeded by 26.1% of participants. Symptom levels of PTSD were associated with somatic symptoms. The relationship between trauma exposure and somatic symptoms was partly mediated by the active avoidance and hyperarousal symptom clusters of PTSD.

CONCLUSION

Active avoidance and hyperarousal symptoms seem to play a key role in traumatized people suffering from somatic symptoms.

Psychiatric Disorders in Refugees and Internally Displaced Persons After Forced Displacement: A Systematic Review

Background: Protracted armed conflicts not only shape political, legal, and socio-economic structures, but also have a lasting impact on people's human migration. In 2017, the United Nations High Commissioner for Refugees reported an unprecedented number of 65.6 million individuals who were displaced worldwide as a result of armed conflicts. To date, however, little is known about these people's mental health status. Therefore, we conducted a systematic review of the prevalence of psychiatric disorders among forcibly displaced populations in settings of armed conflicts. Methods: We undertook a database search using Medline, PsycINFO, PILOTS, and the Cochrane Library, using the following keywords and their appropriate synonyms to identify relevant articles for possible inclusion: "mental health," "refugees," "internally displaced people," "survey," and "war." This search was limited to original articles, systematic reviews, and meta-analyses published after 1980. We reviewed studies with prevalence rates of common psychiatric disorders-mood and anxiety disorders, psychotic disorders, personality disorders, substance abuse, and suicidality-among adult internally displaced persons (IDPs) and refugees afflicted by armed conflicts. Results: The search initially yielded 915 articles. Of these references 38 studies were eligible and provided data for a total of 39,518 adult IDPs and refugees from 21 countries. The highest prevalence were for reported for post-traumatic stress disorder (3-88%), depression (5-80%), and anxiety disorders (1-81%) with large variation. Only 12 original articles reported about other mental disorders. Conclusions: These results show a substantial lack of data concerning the wider extent of psychiatric disability among people living in protracted displacement situations. Ambitious assessment programs are needed to support the implementation of sustainable global mental health policies in war-torn countries. Finally, there is an urgent need for large-scale interventions that address psychiatric disorders in refugees and internally displaced persons after displacement.

The impact of enhancing perceived self-efficacy in torture survivors

BACKGROUND

Perceived self-efficacy (SE) is an important factor underlying psychological well-being. Refugees suffer many experiences that can compromise SE. This study tested the impact of enhancing perceived SE on coping with trauma reminders and distress tolerance in tortured refugees.

METHODS

Torture survivors (N = 40) were administered a positive SE induction in which they retrieved mastery-related autobiographical memories, or a non-SE (NSE) induction, and then viewed trauma-related images. Participants rated their distress following presentation of each image. Participants then completed a frustration-inducing mirror-tracing task to index distress tolerance.

RESULTS

Participants in the SE condition reported less distress and negative affect, and improved coping in relation to viewing the trauma-related images than those in the NSE condition. The SE induction also led to greater persistence with the mirror-tracing task than the NSE induction.

CONCLUSIONS

These findings provide initial evidence that promoting SE in tortured refugees can assist with managing distress from trauma reminders, and promoting greater distress tolerance. Enhancing perceived SE in tortured refugees may increase their capacity to tolerate distress during therapy, and may be a useful means to improve treatment response.

Changes in Post-migration Living Difficulties Predict Treatment Outcome in Traumatized Refugees

Background: Refugee mental health is affected by traumatic stressors as well as post-migration living difficulties (PMLD). However, their interaction and causal pathways are unclear, and so far, no distinct treatment recommendations regarding exile-related stressors exist. Methods: In a 3-year follow-up study, PMLD and symptoms of post-traumatic stress (PTS), depression and anxiety were examined in a clinical sample of severely traumatized refugees and asylum seekers (N = 71). Results: In regression analysis, reduction in PMLD predicted changes over time in depression/anxiety, but not in PTS. The opposite models with PMLD changes as outcome variable proved not significant for PTS, and significant, though less predictive, for depression/anxiety. Conclusions: In addition to well-established trauma-focused interventions for the treatment of PTS, psychosocial interventions focusing on PMLD might contribute to a favorable treatment response in traumatized refugees, particularly with regard to depression and anxiety.

A Longitudinal Investigation of Moral Injury Appraisals Amongst Treatment-Seeking Refugees

There is currently an unprecedented number of forcibly displaced people worldwide. Understanding psychological mechanisms that contribute to the mental health of refugees and asylum-seekers is important for informing the development of effective interventions for these populations. Moral injury appraisals represent an important potential cognitive mechanism that may contribute to psychological symptoms following exposure to persecution, war, and displacement. In the current study, we investigated the longitudinal association between moral injury appraisals related to one's own perceived transgressions (moral injury-self), others' perceived transgressions (moral injury-other), and PTSD and depression symptoms. Participants in this study were 134 refugees receiving treatment at two outpatient clinics in Switzerland who completed survey measures investigating these concepts. Of these, 71 were followed up 2 to 4 years later. Path analyses revealed that greater depression symptoms were associated with subsequent increases in moral injury-self appraisals (β = 0.25, SE = 0.08, 95% CI [0.11, 0.43], p = 0.002). In contrast, greater moral injury-self appraisals were associated with subsequent decreases in PTSD symptoms (β = -0.23, SE = 0.11, 95% CI = [-0.44, -0.31], p = 0.035). Findings suggest that different types of moral injury appraisals may be associated with differential psychological outcomes. These results have important potential implications for policy and treatment of refugees and asylum-seekers, highlighting the importance of targeting cognitive factors in the maintenance and treatment of psychological distress, and considering the post-migration context when working with refugees.

Mental health assessments in refugees and asylum seekers: evaluation of a tablet-assisted screening software

Background

Mental health problems resulting from persecution and forced migration are very common among refugees and asylum seekers and evolve into a major public health challenge in hosting societies. Language barriers often prevent timely access to appropriate health care, leading to chronic trajectories and abortive social integration. Tools for multilingual screening and assessment could be of great benefit for this particularly vulnerable population as well as for policy makers. This study aimed at testing the reliability, feasibility and usability of the Multi-Adaptive Psychological Screening Software (MAPSS), a newly developed Audio Computer-Assisted Self-Interview Software (ACASI) for touchscreen devices, for screening purposes in a clinical setting.

Methods

In a randomized cross-over design including both MAPSS and paper-pencil clinician-administered interviews, 30 treatment-seeking refugees completed clinical measures and a feasibility questionnaire to rate the user interface of MAPSS. Five professionals performed given tasks in MAPSS and completed usability questionnaires for the administration interface.

Results

Results showed no differences between the two assessment modalities with regard to symptom scores. The findings suggest good feasibility and usability of MAPSS in traumatized refugees. The administration via MAPSS was significantly shorter than the paper-pencil interview.

Conclusion

MAPSS may be a cost-effective, flexible and valid alternative to interpreter-based psychometric screening and assessment.

Using interpreters in medical consultations: What is said and what is translated-A descriptive analysis using RIAS

OBJECTIVE

To analyse the concordance of original utterances by healthcare providers (HCP) and patients with the corresponding translations by interpreters using the Roter Interaction Analysis System (RIAS).

METHODS

Video recordings of interpreted consultations were transcribed. Transcription was performed by professional interpreters, who first transcribed consultations in both languages, then provided a translation of what was said in the foreign language. Based on the translations, the videos were coded and analysed using RIAS.

RESULTS

Overall, 19 consultations with a total recording time of 865min were analysed. The main finding is the large difference in the number of utterances in the original language compared to the number of utterances in the target language: about one third of the HCPs' and the patients' utterances were not translated. In no instance were omissions explained to HCP or patient.

CONCLUSION

Interpreters in this sample did not always translate what had been said precisely; they omitted utterances by both HCPs and patients.

PRACTICE IMPLICATIONS

All participants of an interpreted consultation must be made aware of potential omissions in the process of translation. Further understanding of the causes and consequences of omissions is needed.

Comorbidity of Posttraumatic Stress Disorder and Depression in Tortured, Treatment-Seeking Refugees

Comorbid posttraumatic stress disorder (PTSD) and depression is common in refugee groups; however, little is known about the predictors and correlates of comorbidity in treatment-seeking refugees. Participants in this study were 134 refugees resettled in Switzerland. Most participants were from Turkey, Iran, and Sri Lanka, and 92.7% had been exposed to torture. Self-report measures were implemented to assess PTSD, depression, mental and physical health-related quality of life (QoL), as well as pre- and postmigration experiences. Findings indicated that approximately half the sample met criteria for PTSD and depression, 33.6% met criteria for depression only, and only 2.2% met criteria for PTSD only. Several variables emerged as predictors of comorbidity in contrast to no diagnosis: female gender, odds ratio (OR) = 0.17; age, OR = 0.93; time in Switzerland, OR = 1.16; and trauma exposure, OR = 1.19. Postmigration stress was also associated with greater likelihood of comorbidity compared with no diagnosis, OR = 1.32, and a single diagnosis, OR = 1.14. Further, dual diagnosis was associated with significantly poorer mental health-related and physical health-related QoL (mental health-related QoL: dual diagnosis vs. single diagnosis, d = -0.52 and dual diagnosis vs. no diagnosis, d = -1.30; physical health-related QoL: dual diagnosis vs. single diagnosis, d = -0.73 and dual diagnosis vs. no diagnosis: d = -1.04). Findings indicated that comorbidity was highly prevalent in this sample of treatment-seeking refugees and was associated with a substantial impairment burden. Psychological interventions for refugees should consider the dual impact of PTSD and depression symptoms to optimally decrease distress and improve QoL in this vulnerable group.

Strengthening mental health care systems for Syrian refugees in Europe and the Middle East: integrating scalable psychological interventions in eight countries

The crisis in Syria has resulted in vast numbers of refugees seeking asylum in Syria's neighbouring countries as well as in Europe. Refugees are at considerable risk of developing common mental disorders, including depression, anxiety, and posttraumatic stress disorder (PTSD). Most refugees do not have access to mental health services for these problems because of multiple barriers in national and refugee specific health systems, including limited availability of mental health professionals. To counter some of challenges arising from limited mental health system capacity the World Health Organization (WHO) has developed a range of scalable psychological interventions aimed at reducing psychological distress and improving functioning in people living in communities affected by adversity. These interventions, including Problem Management Plus (PM+) and its variants, are intended to be delivered through individual or group face-to-face or smartphone formats by lay, non-professional people who have not received specialized mental health training, We provide an evidence-based rationale for the use of the scalable PM+ oriented programmes being adapted for Syrian refugees and provide information on the newly launched STRENGTHS programme for adapting, testing and scaling up of PM+ in various modalities in both neighbouring and European countries hosting Syrian refugees.

Symptoms of posttraumatic stress disorder in a clinical sample of refugees: a network analysis

Background: Network analysis is an emerging methodology for investigating psychopathological symptoms. Given the unprecedented number of refugees and the increased prevalence of mental disorders such as posttraumatic stress disorder (PTSD) in this population, new methodologies that help us better to understand psychopathology in refugees are crucial. Objective: The objective of this study was to explore the network structure and centrality indices of DSM-5 PTSD symptoms in a cross-sectional clinical sample of 151 severely traumatized refugees with and without a formal PTSD diagnosis. Method: The R-packages qgraph and bootnet were used to estimate the structure of a PTSD symptom network and its centrality indices. In addition, robustness and significance analyses for the edges weights and the order of centrality were performed. Results: Three pairs of symptoms showed significantly stronger connections than at least half of the other connections: hypervigilance and exaggerated startle response, intrusion and difficulties falling asleep, and irritability or outbursts of anger and self-destructive or reckless behaviour. Emotional cue reactivity had the highest centrality and trauma-related amnesia the lowest. Conclusion: Although only 51.0% of participants fulfilled criteria for a probable PTSD diagnosis, emotional cue reactivity showed the highest centrality, emphasizing the importance of emotional trauma reminders in severely traumatized refugees attending an outpatient clinic. However, due to the small sample size, the results should be interpreted with care.

Attachment style and interpersonal trauma in refugees

BACKGROUND

Refugees can suffer many experiences that threaten their trust in others. Although models of refugee mental health have postulated that attachment securities may be damaged by refugee experiences, this has yet to be empirically tested. This study aimed to understand the relationship between the nature of traumatic experiences sustained by refugees and attachment styles.

METHOD

In a cross-sectional study, treatment-seeking refugees (N = 134) were assessed for traumatic exposure using the Harvard Trauma Questionnaire and Posttraumatic Diagnostic Scale. Attachment style was assessed using the Experiences in Close Relationship Scale.

RESULTS

Whereas gender and severity of interpersonal traumatic events predicted avoidant attachment style (accounting for 11% of the variance), neither these factors nor non-interpersonal trauma predicted anxious attachment.

CONCLUSIONS

Exposure to interpersonal traumatic events, including torture, is associated with enduring avoidant attachment tendencies in refugees. This finding accords with attachment theories that prior adverse interpersonal experiences can undermine secure attachment systems, and may promote avoidance of attachment seeking. This finding may point to an important process maintaining poor psychological health in refugees affected by interpersonal trauma.

Somatisation and anger are associated with symptom severity of posttraumatic stress disorder in severely traumatised refugees and asylum seekers

BACKGROUND

Most research on refugee mental health has focused on posttraumatic stress disorder (PTSD). Besides PTSD, however, traumatised refugees are often burdened by comorbid somatic and psychiatric conditions, as well as postmigration living difficulties (PMLD). It is unclear how these conditions interfere with presentation and treatment of PTSD.

METHODS

This preliminary cross-sectional study investigated 134 severely traumatised refugees and asylum seekers in treatment in two psychiatric outpatient units in Switzerland. Trauma exposure, PMLD, somatisation and explosive anger were assessed and related to symptom severity of PTSD using correlation and regression analyses.

RESULTS

PTSD symptoms were significantly related to somatisation, anger, PMLD and trauma exposure. Regression analysis revealed that PTSD symptoms were mainly predicted by somatisation and anger.

CONCLUSIONS

Symptom severity of PTSD is associated with somatisation, explosive anger and, to a lesser extent, PMLD. Standard PTSD treatment may benefit from implementing targeted strategies to assess and address these factors in traumatised refugees.