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

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

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

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

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

IntroductionRates of mental health disorders in resettled refugees surpass those of the host population (Hameed et al, KJM 2018;11 20-23). However, most studies suggest heterogenicity between populations, suggesting a need for a non-generalized approach to resettled-refugee mental health (Silove et al, World Psychiatry 2017;16 130-139). Since the Taliban assumed control in August 2021, the United States has taken in about 90,000 Afghan refugees (Green, Wilson Center 2023), 15,000 have settled in Houston, Texas (Schneider, Texas Standard 2023).ObjectivesThis study investigates factors that may predict higher rates of distress and symptoms of PTSD and depression within an Afghan refugee community resettled in Houston, Texas.MethodsSeventy-four Afghan refugees located in Houston, Texas were surveyed for demographic information and physical or emotional symptoms as directed by the Refugee Health Screener-15 (RHS-15). An average score of ≥ 12 on the RHS-15 or a self-reported distress score ≥5 indicated a positive result on the screening tool. Mann-Whitney and Fisher’s exact tests were used to compare differences in patient baseline characteristics and responses stratified by a positive RHS-15 or distress screen. Spearman’s Rank Correlation Coefficient was used to assess the correlation between selected response variables and outcomes as well as between the RHS-15 and distress scores.Results40% of subjects scored ≥12 on the RHS-15 and 35% indicated a distress score ≥ 5. Income differed significantly between the RHS <12 group and the RHS ≥12 group (p=.02). The RHS <12 group had a higher proportion of individuals in the lowest income bracket, < $10,000, and a greater proportion in the $20,000-$30,000 bracket. Meanwhile, the RHS ≥12 group had a higher proportion in the $10,000-20,000 income bracket. There was a negative correlation between self-reported health scores with both RHS-15 score (ρ=-.508, p<.001) and distress score (ρ=-.423, p=.001) as well as between neighborhood support levels and distress scores(ρ=-.314, p=.018).ConclusionsThis Afghan refugee cohort shows theoretical rates of PTSD and MDD higher than the average American (40.3% RHS-15 score vs. 3.6% PTSD and 8.3% MDD) (NIH 2023). The increased risk of mental disorder may be attributed to lower perceived community support, poor physical health, and low socioeconomic status. If income growth is a function of increased time spent in the United States, the unique pattern in income between the two RHS groups may reflect a “honeymoon period” that has previously been demonstrated in studies on migrants and culture shock (Maillet et al, APMH 2023; 50 563–575). Following this honeymoon period, however, lower income may predict worsened mental health in resettled refugees. These results support multi-factorial initiatives to support resettled refugees especially in areas of community interconnectedness, health and economic support.Disclosure of InterestNone Declared

Research background and purpose The aim of the article is to present a literature review concerning the situation of individuals after a mental health crisis in the labor market. The review is divided into two main thematic areas. The first concerns the concept of a mental health crisis, with particular emphasis on the distinctions between medical, psychosocial, and rehabilitative perspectives. The second area review of literature employers’ requirements for disabled employees caring for employees’ mental health in corporate practice. Design/methodology/approach The authors made a review of the literature on mental health crises and on vocational rehabilitation and inclusion, together with an analysis of employer requirements for employees with disabilities (the present article). It also shows what actions employers take regarding employees’ mental health and psychological crises. Findings Psychological crises have a distinctly negative impact on occupational engagement; however, their consequences may be effectively mitigated through appropriate interventions at both organizational and individual levels. The key challenge lies in the development of personalized support strategies that take into account the specific characteristics of the labor market as well as the individual needs of employees. An integrated approach, combining health - related and professional support, may contribute to the establishment of sustainable solutions that promote mental health in the workplace. The research findings indicate that at the organizational level, effective support strategies can be implemented to counteract the adverse effects of psychological crises. Preventive measures include regular mental health assessments, stress management training, and monitoring of workload, all of which constitute essential components of prevention. Value added and limitations This study thus contributes to understanding the problems and challenges faced by individuals after mental health crises in the context of the labor market, while also providing guidance for measures aimed at their effective rehabilitation and vocational integration perspective.

Objective: To address problems with low rates of detection and treatment of depression of pregnant and postpartum women, many advocate depression screening in obstetrical settings.This study evaluated the Healthy Start depression initiative to assess whether it resulted in diminished rates of depressive symptoms and increased rates of detection, referral, and treatment among pregnant and postpartum women.Methods: Three cohorts were used to examine the program impact: a pre-Healthy Start depression initiative cohort, a post-Healthy Start depression initiative cohort that was enrolled in New Haven Healthy Start, and a post-Healthy Start depression initiative cohort not enrolled in the New Haven program.Participants included 1,336 pregnant and postpartum women receiving obstetrical care at publicly funded health care clinics.Measures included the Primary Care Evaluation of Mental Disorders Brief Patient Health Questionnaire; the PTSD Symptom Scale; a five-item modification of the Conflict Tactics Scale; and questions regarding alcohol, illicit substances, and general medical and obstetrical history. Results:The Healthy Start depression initiative changed neither levels of depressive symptoms nor use of depression treatment in unselected populations.The initiative may have decreased the rate of referral for depression in the cohort under study.

Pregnant asylum seekers' perspective on mental health screening: A qualitative study☆

Background This study aimed to identify a suitable and acceptable method to screen for depression, anxiety and PTSD in pregnant asylum seekers. Methods We conducted eight semi-structured interviews with pregnant asylum seekers. Before the interview participants filled out the Refugee Health Screener 15 (RHS-15) and a demographic questionnaire. During the semi-structured interview, we discussed the acceptability and suitability of the RHS-15 to screen and start dialogue about PTSD, anxiety and depression. To analyse data, an inductive thematic analysis was performed by two researchers. The interviews took place at the Asylum Seeker Centre of Ter Apel, the Netherlands in the months of November and December 2020. Results The following themes were identified: ‘Importance of mental health screening', ‘Talking about mental health' and ‘Use of the RHS-15'. Pregnant asylum seekers find themselves in an underserved, and disadvantaged situation. They find it meaningful and acceptable to talk about mental health with their midwife or other health care professionals, but they would not initiate a conversation on mental health spontaneously. They would appreciate encouragement in disclosing matters regarding their mental health and help with navigating the healthcare system. Barriers and enablers to talk about mental health included a language barrier, cultural differences, relationship with health care providers and practical barriers. Participants considered the RHS-15 suitable for mental health screening. Conclusions This is the first study in Europe that assesses the suitability and acceptability of mental health screening in pregnant asylum seekers from their perspective. Asylum-seeking women appreciate mental health screening during pregnancy and think the RHS-15 is an acceptable and suitable method. Further research is necessary for health care providers and policy makers to implement mental health screening for pregnant asylum seekers. Key messages The results of this study suggest that asylum-seeking women deem mental health screening during pregnancy nessesairy and find the RHS-15 a suitable and acceptible method of screening. This is the first study in Europe that investigates the opinion of pregnant asylum seekers on mental health screenings.

Depression remains underdiagnosed in primary care, particularly in low- and middle-income countries (LMICs). Despite advocacy for mental health integration into primary care, evidence on practical implementation strategies in diverse international settings is limited. This study evaluated the feasibility of implementing practice-driven systematic depression screening among adult patients with diabetes mellitus (DM) across primary care practices in four countries. The Major Depressive Disorder Management in Primary Care (MDD Minds) initiative implemented a 12-week quality improvement pilot across nine primary care practices in Brazil, Japan, Kenya, and Nigeria. Practices received local coaching, educational resources, and adaptable workflow tools to screen adult patients with DM for depression during routine care visits. Data on screening rates, depression identification, and resource provision were collected using standardized forms. Among 1,592 adult patients with diabetes seen during the 12-week implementation period, 582 (36.6%) were newly screened for depression. Practices without baseline depression documentation identified depression in 54.9% of screened patients, compared to 12.2% in practices with existing documentation, demonstrating substantial under-detection in settings without systematic screening. Of those screened, 105 (18.0%) had positive screens indicating depressive symptoms. An additional 211 patients (13.3%) had prior documented depression diagnoses. In total, 326 patients (19.6%) were diagnosed with depressive symptoms. This multi-country implementation study demonstrates that systematic depression screening integrated into routine diabetes care is feasible across diverse primary care settings when supported by adaptable workflows and structured coaching. Findings highlight the importance of local ownership and context-specific implementation strategies for integrating mental health screening into chronic disease management in global primary care.

Refugees resettling to the United States are at increased risk for mental health disorders, which can lead to difficulty with adaptation and poor health outcomes. Standardized mental health screening of refugees is often neglected at primary care and community health clinics. A pilot project aimed to initiate early mental health screening for newly resettled adult refugees was implemented at a community health center in Fargo, North Dakota. Current refugee screening processes were evaluated to determine appropriate timing for refugee mental health screening. This took into consideration time, staffing, interpreter availability and the refugee "honeymoon" phase following resettlement. The Refugee Health Screener-15 (RHS-15) was identified as an efficient, valid, and reliable tool for assessing emotional distress in this population and was integrated into refugee health screening practices. The RHS-15 was administered to 178 adult refugees with arrival dates between August 1, 2013 and July 31, 2014. Of those screened, 51 (28.6%) screened positive for risk of emotional distress. Follow-up with primary care provider was completed with 30 (59%) of those who screened positive. Half (15) requested mental health treatment. Although the largest group of refugees during this period of time were resettling from Bhutan, refugees from Iraq had greater incidence of positive screening compared with those from Bhutan. Refugees from Iraq were also found to have significantly higher scores on the RHS-15. Although there are some challenges to implementing a standardized mental health screening for refugees, this pilot reiterates the need for standardized mental health screening of refugees. Routine mental health screening should be a part of the overall comprehensive health assessment provided to refugees nationwide. Considerations should be taken in regards to how refugees from Iraq have even greater risk of mental health disorders compared to other refugee groups.

Forcibly displaced people have a higher chance of developing post-traumatic stress disorder (PTSD) compared to people who have not experienced displacement. In addition to potentially traumatic events due to war, persecution, and flight, post-migration living stressors are an important influencing factor. Among these, an insecure asylum status is one of the main stressors with which forcibly displaced people must cope. The aim of this study was to investigate the additive effect of an insecure asylum status on PTSD symptomatology in refugees, over and above the influence of other pre- and peri-migration factors, in particular potentially traumatic event types reported and duration of stay in Germany. Two overlapping convenience samples of 177 and 65 adult refugees that were assessed at different timepoints were interviewed by means of face-to-face interviews. Interviews were conducted in either Arabic, Farsi, Kurmancî, English, or German with the assistance of interpreters where necessary. Besides residence status and potentially traumatic events experienced, mental distress was assessed via the Refugee Health Screener-15 (RHS-15; Study A) and the PTSD Checklist for DSM-5 (PCL-5; Study B). In both samples, an insecure asylum status explained a significant additional amount of variance of PTSD symptomatology, on top of traumatic events experienced and time since arrival in Germany. Results suggest that refugees with an insecure asylum status are at higher risk for experiencing increased PTSD symptomatology. Policy changes of asylum procedure in receiving countries could have a positive impact on refugees' mental health.

BackgroundAccumulating evidence highlights the importance of pre- and post- migration stressors on refugees’ mental health and integration. In addition to migration-associated stressors, experiences earlier in life such as physical abuse in childhood as well as current life stress as produced by the COVID-19-pandemic may impair mental health and successful integration – yet evidence on these further risks is still limited. The present study explicitly focused on the impact of severe physical abuse in childhood during the COVID-19 pandemic and evaluated the impact of these additional stressors on emotional distress and integration of refugees in Germany.MethodsThe sample included 80 refugees, 88.8% male, mean age 19.7 years. In a semi-structured interview, trained psychologists screened for emotional distress, using the Refugee Health Screener, and integration status, using the Integration Index. The experience of severe physical abuse in childhood was quantified as a yes/no response to the question: “Have you been hit so badly before the age of 15 that you had to go to hospital or needed medical attention?” Multiple hierarchical regression analyses further included gender, age, residence status, months since the start of the COVID-19 pandemic and length of stay in Germany to predict emotional distress and integration.ResultsTwo regression analyses determined significant predictors of (1) emotional distress (adjusted R2 = 0.23): duration of being in the pandemic (ß = 0.38, p < 0.001) and severe physical abuse in childhood (ß = 0.31, p = 0.005), and significant predictors of (2) integration (adjusted R2 = 0.53): length of stay in Germany (ß = 0.62, p < 0.001), severe physical abuse in childhood (ß = 0.21, p = 0.019) and emotional distress (ß = −0.28, p = 0.002).ConclusionIn addition to migration-associated stressors, severe physical abuse in childhood constitutes a pre-migration risk, which crucially affects the well-being, emotional distress and integration of refugees in Germany.

editorial reviewed

Post‐2015 refugees in Germany: “Culture of welcome”, solidarity or exclusion?