Mental Disorders In Refugees Research Articles

A Systematic Review and Meta-Analysis of Longitudinal Studies on Posttraumatic Stress Disorders in Refugees and Asylum Seekers

AbstractPosttraumatic stress disorder (PTSD) is among the common mental disorders in refugees and asylum seekers; however, it is unclear if population prevalence declines or persists after resettlement. Therefore, this study aimed to identify longitudinal studies reporting PTSD among refugees and asylum seekers in upper-middle and high-income countries and to conduct a meta-analysis to map the trajectory of PTSD prevalence over time in order to inform policymakers. Seven electronic databases were searched for relevant prospective longitudinal studies. The Joanna Briggs Institute (JBI) scale was used to assess the quality of studies, and we excluded studies with a high risk of bias leaving 21 studies: 13 with moderate and 8 with a low risk of bias. The total follow-up period ranged from 1 to 7 years. Random effects meta-analysis pooling all studies suggested a baseline prevalence of 17.65% in the immediate period after resettlement (up to 1 year after arrival) and a trend for decreasing prevalence to 11.64% over time. However, studies with over 6 years of follow-up indicated a higher longitudinal prevalence of 13–17%, and in the low-risk-of-bias study subgroup, the prevalence did not decrease (ranging between 27.54 and 30.10%), which raises the possibility that PTSD prevalence may not substantially decrease in the first 6 years after resettlement. The finding that studies with a low risk of bias reported a larger prevalence of PTSD persisting over time highlights the importance of conducting high-quality longitudinal studies to inform policy. Appropriate long-term interventions are needed to decrease the impact of traumatic events on the mental health of refugees and asylum seekers.

“It is worth hanging in there” – Psychotherapeutic experiences shaping future motivation for outpatient psychotherapy with refugee clients in Germany

BackgroundA high prevalence of mental disorders in refugees contrasts with a low rate of treatment and limited access to health care services. In addition to pre-, peri- and post-migration stress, language, cultural barriers together with lack of information about cost reimbursement, and access to German (mental) health care institutions are discussed as barriers to use of available services. Such barriers together with insufficient experience of treating traumatized refugee clients may lower therapists’ motivation and facilities to accept refugee clients. A model project called “Fearless” trained, and supervised therapists, translators, and peer counsellors to reduce these barriers and increase therapists’ motivation and engagement in future treatment of refugees.MethodsFrom a total 14 therapists participating in the project N = 13 were available for semi-structured interviews. The interviews were scheduled during or after their outpatient psychotherapy of refugee clients and lasted one hour on average. Based on qualitative assessment strategies, open questions addressed the therapists’ experience of challenges, enrichments, and motivation throughout the therapy. Therapists’ responses were analyzed using content structuring qualitative content analysis.ResultsThree major challenges modulated therapists’ future motivation for treating refugee clients: specific bureaucratic efforts (e.g., therapy application), organizational difficulties (e.g., scheduling appointments), and clients’ motivation (e.g., adherence, reliability). Still, most interviewed therapists (n = 12) evaluated the therapy as enriching and expressed their motivation to accept refugee clients in the future (n = 10).ConclusionResults recommend the reduction of bureaucratic effort (e.g., regular health insurance cover for all refugees) and implementation of organizational support (e.g., peer counsellors) in support of therapists’ motivation for future treatment of refugee clients. Further structural support e.g., with organizing and financing professional translators and referring refugee clients to psychotherapists should be deployed nationwide. We recommend the training in, and supervision of, the treatment of refugee clients as helpful additional modules in psychotherapy training curricula to raise therapists’ motivation to work with refugee clients.

Culturally adapted cognitive behavioural group therapy for mental disorders in refugees plus problem solving training (ReTreat): study protocol for a multicentre randomised controlled trial

IntroductionSince a high proportion of refugees in Germany suffer from mental disorders, culturally adapted treatments are needed that target a broad range of symptoms. There is much evidence for the...

Using Imagery Rescripting to Treat Posttraumatic Stress Disorder in Refugees: A Case Study

Posttraumatic stress disorder (PTSD) is among the most prevalent mental disorders in refugees. Imagery Rescripting (ImRs) has gained growing interest as an innovative and effective treatment for several disorders, including PTSD. The technique aims to change the meaning of traumatic memories by asking the patient to imagine a different outcome of a particular memory. As ImRs focuses on meeting individual needs, it can be tailored to patients with different cultural and religious backgrounds and may be a promising intervention for refugees. This case study therefore illustrates the application and challenges of ImRs as a stand-alone treatment for a refugee patient. The patient had experienced multiple traumatic events during flight and met full criteria for PTSD according to the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5; total score of 32). The treatment was conducted with the assistance of an interpreter and consisted of 12 100-min sessions, during which the most distressing traumatic events were rescripted. Cognitive restructuring and imagery modification—another imagery-based intervention showing some similarities with ImRs—was applied as an additional intervention to address feelings of contamination. At the end of treatment, symptoms were reduced and the patient no longer met diagnostic criteria for PTSD (CAPS-5 total score of 25); however, only change in self-reported symptoms reached clinical significance. Challenges during treatment included frequent dissociative symptoms that were managed by instructing the patient to use antidissociative skills during ImRs. Findings corroborate ImRs as a feasible approach for the treatment of PTSD in patients with complex trauma histories.

Cognitive mechanisms underlying the association between trauma exposure, mental health and social engagement in refugees: A longitudinal investigation

BackgroundsRefugees and asylum-seekers are at heightened risk for developing psychological symptoms following exposure to trauma and displacement. Despite this, relatively little is known about the cognitive mechanisms that underlie common mental disorders in refugees. MethodsIn this study, we investigated the associations between self-efficacy, beliefs about others (relating to benevolence and trust) and psychological and social outcomes in 1079 refugees from Arabic, Farsi, Tamil or English-speaking backgrounds who were residing in Australia. Participants completed an online survey assessing exposure to potentially traumatic events (PTEs), at baseline (T1), and self-efficacy, beliefs about others, PTSD symptoms, depression symptoms, anger and social engagement at baseline (T1) and six months later (T2). ResultsA path analysis revealed that greater PTE exposure was associated with lower self-efficacy and lower positive beliefs about others at T1. Self-efficacy at T1 was negatively associated with depression and anger at T2, while positive beliefs about others at T1 were positively associated with social engagement and greater depression symptoms at T2. LimitationsLimitations of this study included the fact that the study sample was not necessarily representative of the broader refugee population, and in particular may have overrepresented those with higher education levels. ConclusionsFindings point to the critical role that cognitive variables play in the maintenance of psychological symptoms in forcibly displaced persons, and highlight the importance of targeting these in psychological interventions to promote positive posttraumatic mental health.

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

Studies have identified high rates of mental disorders in refugees, but most used self-report measures of psychiatric symptoms. In this study, we examined the percentages of adult refugees and asylum seekers meeting diagnostic criteria for major depressive disorder (MDD), post-traumatic stress disorder, bipolar disorder (BPD), and psychosis. A systematic literature search in three databases was conducted. We included studies examining the prevalence of MDD, post-traumatic stress disorder, BPD, and psychosis in adult refugees according to a clinical diagnosis. To estimate the pooled prevalence rates, we performed a meta-analysis using the Meta-prop package in Stata (PROSPERO: CRD42018111778). We identified 7048 records and 40 studies (11 053 participants) were included. The estimated pooled prevalence rates were 32% (95% CI 26-39%; I 2 = 99%) for MDD, 31% (95% CI 25-38%; I 2 = 99.5%) for post-traumatic stress disorder, 5% (95% CI 2-9%; I 2 = 97.7%) for BPD, and 1% (95% CI 1-2%; I 2 = 0.00%) for psychosis. Subgroup analyses showed significantly higher prevalence rates of MDD in studies conducted in low-middle income countries (47%; 95% CI 38-57%, p = 0.001) than high-income countries studies (28%; 95% CI 22-33%), and in studies which used the Mini-International Neuropsychiatric Interview (37%; 95% CI 28-46% p = 0.05) compared to other diagnostic interviews (26%; 95% CI 20-33%). Studies among convenience samples reported significant (p = 0.001) higher prevalence rates of MDD (35%; 95% CI 23-46%) and PTSD (34%; 95% CI 22-47%) than studies among probability-based samples (MDD: 30%; 95% CI 21-39%; PTSD: 28%; 95% 19-37%). This meta-analysis has shown a markedly high prevalence of mental disorders among refugees. Our results underline the devastating effects of war and violence, and the necessity to provide mental health intervention to address mental disorders among refugees. The results should be cautiously interpreted due to the high heterogeneity.

Effectiveness of Self-Help Plus in Preventing Mental Disorders in Refugees and Asylum Seekers in Western Europe: A Multinational Randomized Controlled Trial

Introduction: Self-Help Plus (SH+) is a group-based psychological intervention developed by the World Health Organization for managing stress. Objective: To assess the effectiveness of SH+ in preventing mental disorders in refugees and asylum seekers in Western Europe. Methods: We conducted a randomized controlled trial in 5 European countries. Refugees and asylum seekers with psychological distress (General Health Questionnaire score ≥3), but without a Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) or ICD/10 diagnosis of mental disorder, as assessed with the Mini International Neuropsychiatric Interview (MINI), were randomized to SH+ or enhanced treatment as usual (ETAU). The primary outcome was the frequency of mental disorders with the MINI at 6 months. Secondary outcomes included the frequency of mental disorders at postintervention, self-identified problems, psychological symptoms, and other outcomes. Results: Four hundred fifty-nine individuals were randomly assigned to SH+ or ETAU. For the primary outcome, we found no difference in the frequency of mental disorders at 6 months (Cramer V = 0.007, p = 0.90, RR = 0.96; 95% CI 0.52–1.78), while the difference significantly favored SH+ at after the intervention (secondary outcome, measured within 2 weeks from the last session; Cramer V = 0.13, p = 0.01, RR = 0.50; 95% CI 0.29–0.87). Conclusions: This is the first randomized indicated prevention study with the aim of preventing the onset of mental disorders in asylum seekers and refugees in Western Europe. As a prevention effect of SH+ was not observed at 6 months, but rather after the intervention only, modalities to maintain its beneficial effect in the long term need to be identified.

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

ABSTRACT Background: Refugees and asylum seekers face various stressors due to displacement and are especially vulnerable to common mental disorders. To effectively manage psychological distress in this population, innovative interventions are required. The World Health Organization (WHO) Self-Help Plus (SH+) intervention has shown promising outcomes in reducing symptoms of common mental disorders among refugees and asylum seekers. However, individual participant differences in response to SH+ remain largely unknown. The Individual Participant Data (IPD) meta-analysis synthesizes raw datasets of trials to provide cutting-edge evidence of outcomes that cannot be examined by conventional meta-analytic approaches. Objectives: This protocol outlines the methods of a series of IPD meta-analyses aimed at examining the effects and potential moderators of SH+ in (a) reducing depressive symptoms at post-intervention and (b) preventing the six-month cumulative incidence of mental disorders in refugees and asylum seekers. Method: RCTs on SH+ have been identified through WHO and all authors have agreed to share the datasets of the trials. The primary outcomes of the IPD meta-analyses are (a) reduction in depressive symptoms at post-intervention, and (b) prevention of six-month cumulative incidence of mental disorders. Secondary outcomes include post-traumatic stress disorder symptoms, well-being, functioning, quality of life, and twelve-month cumulative incidence of mental disorders. One-stage IPD meta-analyses will be performed using mixed-effects linear/logistic regression. Missing data will be handled by multiple imputation. Conclusions: These results will enrich current knowledge about the response to SH+ and will facilitate its targeted dissemination. The results of these IPD meta-analyses will be published in peer-reviewed journals.

Suicide attempt and suicide in refugees in Sweden - a nationwide population-based cohort study.

Despite a reported high rate of mental disorders in refugees, scientific knowledge on their risk of suicide attempt and suicide is scarce. We aimed to investigate (1) the risk of suicide attempt and suicide in refugees in Sweden, according to their country of birth, compared with Swedish-born individuals and (2) to what extent time period effects, socio-demographics, labour market marginalisation (LMM) and morbidity explain these associations. Three cohorts comprising the entire population of Sweden, 16-64 years at 31 December 1999, 2004 and 2009 (around 5 million each, of which 3.3-5.0% refugees), were followed for 4 years each through register linkage. Additionally, the 2004 cohort was followed for 9 years, to allow analyses by refugees' country of birth. Crude and multivariate hazard ratios (HRs) with 95% confidence intervals (CIs) were computed. The multivariate models were adjusted for socio-demographic, LMM and morbidity factors. In multivariate analyses, HRs regarding suicide attempt and suicide in refugees, compared with Swedish-born, ranged from 0.38-1.25 and 0.16-1.20 according to country of birth, respectively. Results were either non-significant or showed lower risks for refugees. Exceptions were refugees from Iran (HR 1.25; 95% CI 1.14-1.41) for suicide attempt. The risk for suicide attempt in refugees compared with the Swedish-born diminished slightly across time periods. Refugees seem to be protected from suicide attempt and suicide relative to Swedish-born, which calls for more studies to disentangle underlying risk and protective factors.

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

IntroductionThis article describes two randomised controlled trials that will evaluate the effectiveness and cost-effectiveness of Self-Help Plus (SH+), a group self-help intervention developed by the WHO to reduce distress. In...

Mental Disorders in Refugees: A Systematic Review and Meta-Analysis

Background: The number of refugees is highest since the second world war and on the rise. Many refugees suffer from mental disorders, but exact and up-to-date prevalence estimates and sources of heterogeneity herein (e.g., host continent, length of residency) are not available. Methods: We undertook a systematic review with meta-analyses to summarize the literature on the prevalence of mood, anxiety, and post-traumatic stress disorder (PTSD) in general refugee populations. We also investigated moderators of prevalence rates. The study protocol was pre-registered at PROSPERO (ID CRD42018100539). Findings: Systematic searches (final search date August the 3th 2019) yielded 66 eligible publications that reported 150 prevalence estimates (total N = 14,882). Prevalences for diagnosed and self-reported current anxiety were 13 and 42% (95% Confidence Interval [CI] = 8-52%) (P difference < .05), 30% and 40% (95% CI = 23-48%) for diagnosed and self-reported depression, and 29% and 37% (95% CI = 22-45%) for diagnosed and self-reported PTSD. These estimates are substantially higher relative to those reported in non-refugee populations over the globe and to that of populations living in conflict/war settings, both for adult and child/adolescent refugees. Estimates were similar over different home and resettlement areas and independent of length of residence. Interpretation: Our data indicate a huge and persisting disease burden in refugees around the globe due to poor mental health. Knowing this is relevant for the development of public health policies of host countries. Scalable interventions, tailored for refugees, should become more readily available. Funding Statement: This project was funded through continued support by Leiden University. Declaration of Interests: The authors declare no competing interests. Ethics Approval Statement: The study protocol was pre-registered at PROSPERO (ID CRD42018100539).

Mental Disorders in Refugees: A Systematic Review and Meta-Analysis

Mental Disorders in Refugees: A Systematic Review and Meta-Analysis

Emotional Distress, Medical Utilization, and Disability Claims in Adult Refugees

The refugee health screener-15 (RHS-15) is utilized as a diagnostic proxy for common mental disorders in refugees. Studies are needed to determine its clinical and social utility. A retrospective chart analysis of adult refugees compared RHS-15 scores to utilization of medical services and presence of disability claims. Refugees with negative, positive, and highly positive RHS-15 scores attended 3.1, 4.4, and 5.7 mean primary care visits and 1.6, 2.8, and 4.4 mean non-primary care visits, respectively (p < .000). The 11% (43/392) claiming disability were 5.1 times more likely to have a positive RHS-15 (OR 4.3, 95% CI 2.1-8.8). A positive RHS-15 was not predictive of a disability claim (19% PPV), and those with a negative RHS-15 were unlikely to claim disability (96% NPV). The RHS-15 score correlates with visit utilization. A positive score is not predictive of a subsequent disability claim.

The Refugee Health Screener-15 (RHS-15): development and validation of an instrument for anxiety, depression, and PTSD in refugees

ObjectiveScreening for emotional distress in newly arrived refugees is not a standard practice due to multiple barriers, one being the absence of a valid screening instrument for multiple refugee populations. The Refugee Health Screener-15 (RHS-15) was empirically developed to be a valid, efficient and effective screener for common mental disorders in refugees. MethodDevelopment followed published methods. Two hundred fifty-one refugees from three countries were screened at their public health visit with a pilot instrument, and 190 were administered diagnostic proxy instruments (DPs). Data analyses using multiple methods selected the best items for classification on DPs. Follow-up clinical service data were obtained. ResultsPost hoc analyses of the developed RHS-15 showed good sensitivity(range .81 to .95) and specificity (range .86 to .89) to DP's in two of three ethnic groups. Seventy-four percent of positive cases accepted treatment services. Of those, 79% engaged in treatment, and 92% continued treatment more than 3 months. ConclusionsThe RHS-15 is a screener for common mental disorders in newly-arrived refugees in public health. The RHS-15appears to be effective, but further prospective research in a broad range of refugee groups is required to establish generalizability. Strengths, limitations, methods to apply the RHS-15 for optimal performance, and future directions for research and implementation are discussed.

Risk of mental disorders in refugees and native Danes: a register-based retrospective cohort study

Refugees are vulnerable to mental health disorders because of migration trauma. However, register-based prevalence studies are missing. To investigate the risk of mental disorders among refugees compared with that among native Danes. Refugees (n = 29,139), who received residence permission in Denmark from 1.1.1993 to 31.12.1999 were matched 1:4 on age and sex with native Danes (n = 116,556). Civil registration numbers were linked to the Danish Psychiatric Central Register to obtain data on ICD-10 diagnosis upon discharge for all first-time psychiatric hospital contacts for refugees (n = 2,120) and native Danes (n = 5,044) between 1.1.1994 and 31.12.2003. Treated prevalence was then calculated using a Poisson regression model. Refugee men (RR = 2.02; 95%CI = 1.75-2.34) and refugee women (RR = 1.49; 95%CI = 1.29-1.72) had higher overall risks of having a first-time psychiatric contact for mental disorders than did native Danes; specific risks of psychotic, affective and neurotic disorders were even higher. The results were most striking for refugee men, and for refugees from the former Yugoslavia, Iraq and the Middle East. Refugees have high rates of various mental disorders. Healthcare services should target refugees' mental health from arrival in the receiving country.

S40.02 Mental disorders in refugees

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