Effects of a self-guided digital mental health self-help intervention for Syrian refugees in Egypt: A pragmatic randomized controlled trial.

BACKGROUND: Digital mental health interventions for smartphones, such as the World Health Organization (WHO) Step-by-Step (SbS) program, are potentially scalable solutions to improve access to mental health and psychosocial support in refugee populations. Our study objective was to evaluate the effectiveness of SbS as self-guided intervention with optional message-based contact-on-demand (COD) support on reducing psychological distress, functional impairment, symptoms of posttraumatic stress disorder (PTSD), and self-identified problems in a sample of Syrian refugees residing in Egypt. METHODS AND FINDINGS: We conducted a 2-arm pragmatic randomized controlled trial. A total of 538 Syrians residing in Egypt with elevated levels of psychological distress (Kessler Psychological Distress Scale; K10 > 15) and reduced psychosocial functioning (WHODAS 2.0 > 16) were randomized into SbS + CAU (N = 266) or CAU only (N = 272). Primary outcomes were psychological distress (Hopkins Symptom Checklist 25) and impaired functioning (WHO Disability Assessment Schedule 2.0) at 3-month follow-up. Secondary outcomes were symptoms of PTSD (PTSD Checklist for DSM-5 short form, PCL-5 short) and self-identified problems (Psychological Outcomes Profiles Scale, PSYCHLOPS). Intention-to-treat (ITT) analyses showed significant but small effects of condition on psychological distress (mean difference: -0.15; 95% CI: -0.28, -0.02; p = .02) and functioning (mean difference: -2.04; 95% CI: -3.87, -0.22; p = .02) at 3-month follow-up. There were no significant differences between groups on symptoms of PTSD and self-identified problems. Remission rates did not differ between conditions on any of the outcomes. COD was used by 9.4% of participants for a median of 1 contact per person. The main limitations are high intervention dropout and low utilization of COD support. CONCLUSIONS: The trial provides a real-world implementation case, showing small positive effects of a digital, potentially scalable and self-guided mental health intervention for Syrian refugees in Egypt in reducing psychological distress and improving overall functioning. Further user-centered adaptations are required to improve adherence and effectiveness while maintaining scalability. TRIAL REGISTRATION: German Register for Clinical Studies DRKS00023505.

Effect of Cultural Adaptation of a Smartphone-Based Self-Help Programme on Its Acceptability and Efficacy: Randomized Controlled Trial.

Background: Research on cultural adaptation of psychological interventions indicates that a higher level of adaptation is associated with a higher effect size of the intervention. However, direct comparisons of different levels of adaptations are scarce. Aims: This study used a smartphone-based self-help programme called Step-by-Step (Albanian: Hap-pas-Hapi) for the treatment of psychological distress among Albanian-speaking immigrants in Switzerland and Germany. Two levels of cultural adaptation (i.e., surface vs. deep structure adaptation) were compared. We hypothesised that the deep structure adaptation would enhance the acceptance and efficacy of the intervention. Method: We conducted a two-arm, single-blind randomised controlled trial. Inclusion criteria were good command of the Albanian language, age above 18, and elevated psychological distress (Kessler Psychological Distress Scale score above 15). Primary outcome measures were the total score of the Hopkins Symptom Checklist and the number of participants who completed at least three (out of five) sessions. Secondary outcomes were global functioning, well-being, post-traumatic stress, and self-defined problems. Results: Two-hundred-twenty-two participants were included, of which 18 (8%) completed the post-assessments. The number of participants who completed the third session was equal in both conditions, with N = 5 (5%) and N = 6 (6%) respectively. Discussion: Drop-out rates were high in both conditions, and no group difference was found regarding the acceptance of the intervention. The high drop-out rate stands in contrast with other trials testing Step-by-Step. Future research should examine cultural factors impacting recruitment strategies, as insights could help to reduce participant drop-out rates in clinical trials.

Why Did Our Trial Not Work Out? A Qualitative Analysis.

Background: An online self-help programme for the treatment of depression called Hap-pas-Hapi was tested among Albanian-speaking immigrants in Switzerland and Germany, and two different levels of cultural adaptation were compared. Despite a massive recruitment effort, an insufficient number of participants could be recruited, and the drop-out rate was over 90%. Aims: We conducted a qualitative study to better understand the reasons for the non-use of Hap-pas-Hapi. Method: Eleven interviews were conducted with 17 Albanian-speaking participants aged 19-59. Participants were recruited for the purpose of this study and were not participants from the trial. They went through the recruitment material and the Hap-pas-Hapi introduction module, commented on the graphic design, usability, content, and shared their views about mental health and self-help. Results: Participants criticised the lack of a "design system" (i.e., a clearly identifiable and consistent graphic design) on social media for Hap-pas-Hapi, and the recruitment messages were unclear. The programme itself was perceived to be important and helpful for the community at large, but most participants said that they would not use it for themselves. The younger generation would have preferred an application in German or French, while the older generation did not see a benefit in using an online self-help programme to manage their psychological distress. Negative beliefs about mental disorders and psychological interventions were perceived to be common in this target group. Discussion: A professional recruitment strategy, a more careful selection of the target population (e.g., age groups) and different kinds of adaptations might have resulted in a better acceptance of the intervention. At the same time, anti-stigma campaigns and psychoeducation are needed to enhance treatment motivation.

Cost-Effectiveness of Digital Mental Health Versus Usual Care During Humanitarian Crises in Lebanon: Pragmatic Randomized Trial.

BACKGROUND: There is evidence from meta-analyses and systematic reviews that digital mental health interventions for depression, anxiety, and stress-related disorders tend to be cost-effective. However, no such evidence exists for guided digital mental health care in low and middle-income countries (LMICs) facing humanitarian crises, where the needs are highest. Step-by-Step (SbS), a digital mental health intervention for depression, anxiety, and stress-related disorders, proved to be effective for Lebanese citizens and war-affected Syrians residing in Lebanon. Assessing the cost-effectiveness of SbS is crucial because Lebanon's overstretched health care system must prioritize cost-effective treatment options in the face of continuing humanitarian and economic crises. OBJECTIVE: This study aims to assess the cost-effectiveness of SbS in a randomized comparison with enhanced usual care (EUC). METHODS: The cost-effectiveness analysis was conducted alongside a pragmatic randomized controlled trial in 2 parallel groups comparing SbS (n=614) with EUC (n=635). The primary outcome was cost (in US $ for the reference year 2019) per treatment response of depressive symptoms, defined as >50% reduction of depressive symptoms measured using the Patient Health Questionnaire (PHQ). The secondary outcome was cost per remission of depressive symptoms, defined as a PHQ score <5 at last follow-up (5 months post baseline). The evaluation was conducted first from the health care perspective then from the societal perspective. RESULTS: Taking the health care perspective, SbS had an 80% probability to be regarded as cost-effective compared with EUC when there is a willingness to pay US $220 per additional treatment response or US $840 per additional remission. Taking the wider societal perspective, SbS had a >75% probability to be cost-saving while gaining response or remission. CONCLUSIONS: To our knowledge, this study is the first cost-effectiveness analysis based on a large randomized controlled trial (n=1249) of a guided digital mental health intervention in an LMIC. From the principal findings, 2 implications flowed, from the (1) health care perspective and (2) wider societal perspective. First, our findings suggest that SbS is associated with greater health benefits, albeit for higher costs than EUC. It is up to decision makers in health care to decide if they find the balance between additional health gains and additional health care costs acceptable. Second, as seen from the wider societal perspective, there is a substantial likelihood that SbS is not costing more than EUC but is associated with cost-savings as SBS participants become more productive, thus offsetting their health care costs. This finding may suggest to policy makers that it is in the interest of both population health and the wider Lebanese economy to implement SbS on a wide scale. In brief, SbS may offer a scalable, potentially cost-saving response to humanitarian emergencies in an LMIC. TRIAL REGISTRATION: ClinicalTrials.gov NCT03720769; https://clinicaltrials.gov/ct2/show/NCT03720769. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/21585.

Cultural concepts of distress among Albanian young adults living in Switzerland - a qualitative study.

Objectives: Existing research recognizes the critical role that social, sociodemographic, and acculturative processes play in increasing vulnerability for experiencing psychological distress among second-generation migrants. However, to date, far too little attention has been given to the study of psychological distress in this social group. The main objective of this study is to examine cultural identities, as well as expressions and causes of psychological distress among second-generation Albanian-speaking migrants in Switzerland. Methods: Semi-structured qualitative interviews were conducted with 13 Albanian-speaking participants between 19 and 35 years of age using the interview of the Barts Explanatory Model Inventory. Data were analyzed by qualitative content analysis using MAXQDA-2018 software. Findings: Study participants showed bicultural identities, which caused value conflicts and a feeling of being "caught" between Swiss and Albanian culture. Some participants experienced the fear of disappointing their parents. Others find it difficult to deal with conflicting norms and values. Parentification was another important cause within their cultural concept of distress. At the same time, (implicit) social support, i.e., spending time with the family and the community, was an important coping mechanism. Conclusion: Second-generation immigrants are exposed to specific risk factors for psychological distress. A better understanding of these risk factors and their coping mechanisms is essential for providing them with meaningful support services, both in prevention and psychotherapy.

User-centered development of an internet-based CBT intervention for the treatment of loneliness in older individuals.

Background: Loneliness is a widespread phenomenon associated with a number of negative health outcomes. Older individuals may constitute one important target group with a need for effective interventions. However, despite evidence showing that addressing maladaptive social cognition (e.g., via cognitive behavioral therapy [CBT]) is the most effective intervention strategy for reducing loneliness, most existing programs aimed at older individuals do not use that method. Further, in terms of mental health service use, older individuals have been found to be an extremely undertreated population. When developing interventions, active involvement of end users in the development process is essential to increase later uptake. Objective: The aim of the present study was to develop an internet-based CBT intervention for loneliness in older individuals (i.e., aged ≥65 years) applying a user-centered design. The present report provides an in-depth description of the development process. Methods: Two phases of qualitative data collection were conducted in parallel with intervention development using a sample of N = 12 participants including both potential end users (i.e., older adults) as well as experts (i.e., psychotherapists). Measures included semi-structured interviews and usability testing. Results: In Phase 1 interviews, participants indicated that they were predominantly positive about the idea of an internet-based program for loneliness targeting older individuals. Individualization and interactivity were named as crucial features. In Phase 2, usability testing of a prototype program provided important insights into technical barriers to intervention use. Further, participants reported that they were missing content on philosophy/theology and the role of descendants/relatives. Valuable insights from Phase 1 and Phase 2 were incorporated into the intervention program resulting in a 7-module internet-based self-help CBT intervention. Discussion: Findings of this study highlight the significance of including relevant stakeholders in the development process of an intervention. Additionally, results emphasize the high acceptance of internet-based interventions in this population, but also underline the need for considering age-specific aspects when developing treatments.

Correction: Effects of a WHO-guided digital health intervention for depression in Syrian refugees in Lebanon: A randomized controlled trial.

[This corrects the article DOI: 10.1371/journal.pmed.1004025.].

Differential Pathways from Child Maltreatment Types to Insecure Adult Attachment Styles via Psychological and Social Resources: A Bayesian Network Analysis.

Child maltreatment has been linked to insecure adult attachment. However, it is not yet clear how different child maltreatment types are associated with attachment-related anxiety and avoidance in adulthood; and whether resilience against these insecure attachment styles is dependent on risk-specific resources. Therefore, this study explored differential pathways from child maltreatment types to attachment-related anxiety and avoidance in adulthood and examined whether psychological resources (self-esteem) and social resources (perceived social support) show risk-specific effects. An online survey retrospectively assessed experiences of child maltreatment, the level of attachment-related anxiety and avoidance in adulthood, self-esteem, and perceived social support in N = 604 former members of fundamentalist Christian faith communities (mean age = 41.27 years, SD = 12.50; 65.90% female). Cross-sectional data was analyzed using Bayesian network analysis. Only emotional child maltreatment showed direct relationships to insecure adult attachment. Specifically, emotional abuse and emotional neglect were associated with anxious and avoidant adult attachment, respectively. The effects of other child abuse types on adult attachment were mediated through emotional abuse, which indicated patterns of complex traumatization. Self-esteem mediated the effect of emotional abuse on anxious attachment, while perceived social support mediated the effect of emotional neglect on avoidant attachment. Social support was also linked to self-esteem and was therefore also important for individuals with experiences of emotional abuse. This study showed that child maltreatment types and their interactions are meaningfully linked to attachment-related anxiety and avoidance in adulthood. Interventions for survivors of child maltreatment should focus on risk-specific resources to support their resilience.

Mental health service areas in Switzerland.

OBJECTIVES: Small area analysis is a health services research technique that facilitates geographical comparison of services supply and utilization rates between health service areas (HSAs). HSAs are functionally relevant regions around medical facilities within which most residents undergo treatment. We aimed to identify HSAs for psychiatric outpatient care (HSA-PSY) in Switzerland. METHODS: We used HSAr, a new and automated methodological approach, and comprehensive psychiatric service use data from insurances to identify HSA-PSY based on travel patterns between patients' residences and service sites. Resulting HSA-PSY were compared geographically, demographically and regarding the use of inpatient and outpatient psychiatric services. RESULTS: We identified 68 HSA-PSY, which were reviewed and validated by local mental health services experts. The population-based rate of inpatient and outpatient service utilization varied considerably between HSA-PSY. Utilization of inpatient and outpatient services tended to be positively associated across HSA-PSY. CONCLUSIONS: Wide variation of service use between HSA-PSY can hardly be fully explained by underlying differences in the prevalence or incidence of disorders. Whether other factors such as the amount of services supply did add to the high variation should be addressed in further studies, for which our functional mapping on a small-scale regional level provides a good analytical framework.

Feasibility and uptake of a digital mental health intervention for depression among Lebanese and Syrian displaced people in Lebanon: a qualitative study.

Introduction: Digital interventions are increasingly regarded as a potential solution for the inaccessibility of mental health treatment across low-and-middle-income settings, especially for common mental disorders. Step-by-Step (SbS) is a digital, guided self-help intervention for depression found effective in two Randomized Controlled Trials (RCTs) in Lebanon. For research implementation and further scale-up, this paper reports the results of a qualitative evaluation of SbS among the Lebanese and others and displaced Syrians in Lebanon. Methods: Thirty-four Key Informant Interviews (KIIs) were executed with participants of the RCTs, SbS staff members, and external stakeholders. Questions garnered feedback about the feasibility, acceptability, enabling factors, and barriers to adhering to the research, implementation, and the SbS intervention. A thematic analysis was conducted using NVivo, and key themes, topics, and recommendations, on research methods and the intervention itself, were generated and reported. Results: Results showed a high level of acceptability of SbS among Lebanese and Syrians and identified sub-groups for whom acceptance or use might be lower, such as older adults and people with limited access to the internet or smartphones. Furthermore, interviews identified the main enabling factors and barriers to adherence related to the research design, content, and delivery approach. Barriers related to feasibility included lengthy assessments as part of the RCTs, and mistrust related to delays in study compensations. Other common challenges were forgetting login credentials, poor internet connection, being busy and competing needs. Enabling factors and best practices included motivating participants to use the intervention through the weekly support provided by helpers, setting an oral contract for commitment, and dividing the compensations into several installments as part of the RCTs. Recommendations regarding sustainability were given. Discussion: The findings show that overall, SbS is feasible, acceptable, and much needed in Lebanon among the Lebanese and Syrians. This assessment identifies reasons for low adherence to the research and the intervention and presents improvement solutions. Recommendations generated in this paper inform the upscale of SbS and the planning, design, and implementation of future digital interventions in research and service provision settings in the mental health field.

Effects of a WHO-guided digital health intervention for depression in Syrian refugees in Lebanon: A randomized controlled trial.

BACKGROUND: Most displaced people with mental disorders in low- and middle-income countries do not receive effective care, and their access to care has deteriorated during the Coronavirus Disease 2019 (COVID-19) pandemic. Digital mental health interventions are scalable when digital access is adequate, and they can be safely delivered during the COVID-19 pandemic. We examined whether a new WHO-guided digital mental health intervention, Step-by-Step, in which participants were supported by a nonspecialist helper, was effective in reducing depression among displaced people in Lebanon. METHODS AND FINDINGS: We conducted a single-blind, 2-arm pragmatic randomized clinical trial, comparing guided Step-by-Step with enhanced care as usual (ECAU) among displaced Syrians suffering from depression and impaired functioning in Lebanon. Primary outcomes were depression (Patient Health Questionnaire, PHQ-9) and impaired functioning (WHO Disability Assessment Schedule-12, WHODAS) at posttreatment. Secondary outcomes included subjective well-being, anxiety, post-traumatic stress, and self-described problems. A total of 569 displaced people from Syria with depression (PHQ-9 ≥ 10) and impaired functioning (WHODAS > 16) were randomized to Step-by-Step (N = 283; lost to follow-up: N = 167) or ECAU (N = 286; lost to follow-up: 133). Participants were considered to be lost to follow-up when they did not fill in the outcome measures at posttest or follow-up. Recruitment started on December 9, 2019 and was completed on July 9, 2020. The last follow-up assessments were collected in December 2020. The study team had access to the online platform, where they could see treatment arm assignment for each participant. All questionnaires were completed by participants online. Intention-to-treat (ITT) analyses showed intervention effects on depression (standardized mean differences [SMDs]: 0.48; 95% CI: 0.26; 0.70; p < 0.001), impaired functioning (SMD: 0.35; 95% CI: 0.14; 0.56; p < 0.001), post-traumatic stress (SMD: 0.36; 95% CI: 0.16; 0.56; p < 0.001), anxiety (SMD: 0.46; 95% CI: 0.24; 0.68; p < 0.001), subjective well-being (SMD: 0.47; 95% CI: 0.26; 0.68; p < 0.001), and self-identified personal problems (SMD: 0.49; 95% CI 0.28; 0.70; p < 0.001). Significant effects on all outcomes were maintained at 3 months follow-up. During the trial, one serious adverse event occurred, unrelated to the intervention. The main limitation of the current trial is the high dropout rate. CONCLUSIONS: In this study, we found that a guided, digital intervention was effective in reducing depression in displaced people in Lebanon. The guided WHO Step-by-Step intervention we examined should be made available to communities of displaced people that have digital access. TRIAL REGISTRATION: ClinicalTrials.gov NCT03720769.

Mental health stigma and discrimination in Ethiopia: evidence synthesis to inform stigma reduction interventions.

BACKGROUND: People with mental illnesses are at an increased risk of experiencing human rights violations, stigma and discrimination. Even though mental health stigma and discrimination are universal, there appears to be a higher burden in low- and middle-income countries. Anti-stigma interventions need to be grounded in local evidence. The aim of this paper was to synthesize evidence on mental health stigma and discrimination in Ethiopia to inform the development of anti-stigma interventions. METHODS: This evidence synthesis was conducted as a part of formative work for the International Study of Discrimination and Stigma Outcomes (INDIGO) Partnership research program. Electronic searches were conducted using PubMed for scientific articles, and Google Search and Google Scholar were used for grey literature. Records fulfilling eligibility criteria were selected for the evidence synthesis. The findings were synthesized using a framework designed to capture features of mental health stigma to inform cultural adaptation of anti-stigma interventions. RESULTS: A total of 37 records (2 grey literature and 35 scientific articles) were included in the evidence synthesis. Some of these records were described more than once depending on themes of the synthesis. The records were synthesized under the themes of explanatory models of stigma (3 records on labels and 4 records on symptoms and causes), perceived and experienced forms of stigma (7 records on public stigma, 6 records on structural stigma, 2 records on courtesy stigma and 4 records on self-stigma), impact of stigma on help-seeking (6 records) and interventions to reduce stigma (12 records). Only two intervention studies assessed stigma reduction- one study showed reduced discrimination due to improved access to effective mental health care, whereas the other study did not find evidence on reduction of discrimination following a community-based rehabilitation intervention in combination with facility-based care. CONCLUSION: There is widespread stigma and discrimination in Ethiopia which has contributed to under-utilization of available mental health services in the country. This should be addressed with contextually designed and effective stigma reduction interventions that engage stakeholders (service users, service providers, community representatives and service developers and policy makers) so that the United Nations universal health coverage goal for mental health can be achieved in Ethiopia.

Identifying well-being profiles and resilience characteristics in ex-members of fundamentalist Christian faith communities.

There is a lack of empirical research on the heterogeneity in well-being of individuals who disaffiliated (i.e., left or were expelled) from an exclusionary and demanding faith community. Thus, little quantitative knowledge exists on factors related to resilience in these individuals. Therefore, the study aims were twofold: (1) to identify profiles of well-being in ex-members; and (2) to examine the characteristics of the identified profiles. A cross-sectional online survey assessed ex-members of various fundamentalist Christian faith communities. Latent profile analysis identified latent heterogeneity within the sample. Well-being profile indicators included perceived stress, psychopathological symptoms, affect, and satisfaction with life. Profile-related characteristics included socio-demographics (i.e., gender, age), membership (i.e., reason for joining, duration, extent of involvement, reasons for exit, social support during exit, and time since the exit), and resilience-supporting resources (i.e., social support, self-esteem, sense of coherence, personality, socio-economic status). In the final sample (N = 622, Mage = 41.34 years; 65.60% female), four distinct profiles were identified: resilient (25.70%), normative (36.40%), vulnerable (27.20%), and adverse (10.70%). The resilient profile was characterised by higher age, lower reporting of abuse or maltreatment as exit reason, and highest levels of resilience-supporting resources. Ex-members of fundamentalist Christian faith communities differ substantially in their well-being. Membership aspects were only weakly related to current well-being, with the exception of the exit reason of abuse or maltreatment. This study provided novel quantitative insights into the well-being profiles of individuals who disaffiliated from a fundamentalist Christian faith community in German-speaking countries.

Guided digital health intervention for depression in Lebanon: randomised trial.

BACKGROUND: Most people with mental disorders in communities exposed to adversity in low-income and middle-income countries (LMICs) do not receive effective care. Digital mental health interventions are scalable when digital access is adequate, and can be safely delivered during the COVID-19 pandemic. OBJECTIVE: To examine the effects of a new WHO-guided digital mental health intervention, Step-by-Step, supported by a non-specialist helper in Lebanon, in the context of concurring economic, humanitarian and political crises, a large industrial disaster and the COVID-19 pandemic. METHODS: We conducted a single-blind, two-arm pragmatic randomised trial, comparing guided Step-by-Step with enhanced care as usual (ECAU) among people suffering from depression and impaired functioning. Primary outcomes were depression (Patient Health Questionnaire 9 (PHQ-9)) and impaired functioning (WHO Disability Assessment Schedule-12 (WHODAS)) at post-treatment. FINDINGS: 680 people with depression (PHQ-9>10) and impaired functioning (WHODAS>16) were randomised to Step-by-Step or ECAU. Intention-to-treat analyses showed effects on depression (standardised mean differences, SMD: 0.71; 95% CI: 0.45 to 0.97), impaired functioning (SMD: 0.43; 95% CI: 0.21 to 0.65), post-traumatic stress (SMD: 0.53; 95% CI: 0.27 to 0.79), anxiety (SMD: 0.74; 95% CI: 0.49 to 0.99), subjective well-being (SMD: 0.37; 95% CI: 0.12 to 0.62) and self-identified personal problems (SMD: 0.56; 95% CI 0.29 to 0.83). Significant effects on all outcomes were retained at 3-month follow-up. CONCLUSIONS: Guided digital mental health interventions can be effective in the treatment of depression in communities exposed to adversities in LMICs, although some uncertainty remains because of high attrition. CLINICAL IMPLICATIONS: Guided digital mental health interventions should be considered for implementation in LMICs. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov NCT03720769.

Mental health stigma at primary health care centres in Lebanon: qualitative study.

BACKGROUND: Mental health-related stigma is a global public health concern and a major barrier to seeking care. In this study, we explored the role of stigma as a barrier to scaling up mental health services in primary health care (PHC) centres in Lebanon. We focused on the experiences of Healthcare Providers (HCPs) providing services to patients with mental health conditions (MHCs), the views of policy makers, and the perceptions of stigma or discrimination among individuals with MHCs. This study was conducted as part of INDIGO-PRIMARY, a larger multinational stigma reduction programme. METHODS: Semi-structured qualitative interviews (n = 45) were carried out with policy makers (n = 3), PHC management (n = 4), PHC staff (n = 24), and service users (SUs) (n = 14) between August 2018 and September 2019. These interviews explored mental health knowledge, attitudes and behaviour of staff, challenges of providing treatment, and patient outcomes. All interviews were coded using NVivo and a thematic coding framework. RESULTS: The results of this study are presented under three themes: (1) stigma at PHC level, (2) stigma outside PHC centres, and (3) structural stigma. SUs did not testify to discrimination from HCPs but did describe stigmatising behaviour from their families. Interestingly, at the PHC level, stigma reporting differed among staff according to a power gradient. Nurses and social workers did not explicitly report incidents of stigma but described patients with MHCs as uncooperative, underscoring their internalized negative views on mental health. General practitioners and directors were more outspoken than nurses regarding the challenges faced with mental health patients. Mental health professionals revealed that HCPs still hold implicitly negative views towards patients with MHCs however their attitude has improved recently. Our analysis highlights five layers of stigma affecting SUs. CONCLUSION: This qualitative study reveals that stigma was still a key concern that affects patients with MHC. SUs reported experiencing overt stigmatising behaviour in the community but less explicit discrimination in a PHC setting. Our findings emphasise the importance of (1) combatting structural stigma through legal reform, (2) addressing interpersonal stigma, (3) committing PHC management to deliver high quality mental health integrated services, and (4) reducing intrapersonal stigma by building public empathy.

Cultural concepts of distress and complex PTSD: Future directions for research and treatment.

Complex post-traumatic stress disorder (CPTSD) was introduced as a new diagnostic category in ICD-11. It encompasses PTSD symptoms along with disturbances in self-organisation (DSO), i.e., affect dysregulation, negative self-concept, and disturbances in relationships. Quantitative research supports the validity of CPTSD across different cultural groups. At the same time, evidence reveals cultural variation in the phenomenology of PTSD, which most likely translates into cultural variation with regard to DSO. This theoretical review aims to set the ground for future research on such cultural aspects in the DSO. It provides a theoretical introduction to cultural clinical psychology, followed by a summary of evidence on cultural research related to PTSD and DSO. This evidence suggests that the way how DSO symptoms manifest, and the underlying etiological processes, are closely intertwined with cultural notions of the self, emotions, and interpersonal relationships and interpersonal relationships. We propose directions for future research and implications for culturally sensitive clinical practice.

Efficacy of internet-based interventions for common mental disorder symptoms and psychosocial problems in older adults: A systematic review and meta-analysis.

BACKGROUND: Although a high proportion of older adults suffer from common mental disorder symptoms and psychosocial problems, only a small number of older individuals seek psychological treatment. Internet-based interventions have the potential to bridge this treatment gap. However, while there is extensive literature on internet-based treatments in younger to middle-aged adults, research on older individuals is lacking. OBJECTIVE: We aimed to summarize narratively and empirically the existing literature on the efficacy of internet-based interventions for the treatment of common mental disorder symptoms and psychosocial problems (loneliness, stress) in older individuals. METHODS: This systematic review and meta-analysis was registered in PROSPERO (registration number: CRD42021235129). Systematic literature searches were conducted in PsycInfo, Ageline, Medline, CINHAL, and Psyndex. Studies were eligible for inclusion if they a) focused on older adults, b) assessed the efficacy of an internet-delivered psychological intervention, c) included a control condition and d) assessed common mental disorder symptoms or psychosocial problems as outcomes. Meta-analyses were conducted based on studies that included a passive, minimally active or placebo control condition to estimate pooled effects on overall symptom severity as well as on specific psychological outcomes. RESULTS: 11 Studies met inclusion criteria, with the majority of interventions focusing on depression or anxiety symptoms and being based on CBT principles. Significant large effect of internet-based interventions for older adults were found for overall symptom severity (depression, anxiety, PTSD, stress) as well as for depression symptom severity. No significant effects were found for anxiety symptom severity. DISCUSSION: Our findings provide preliminary support that internet-based interventions might be a feasible and effective intervention method for the treatment of common mental disorder symptoms and stress in older adults. However, research in this area is still at an early stage. More studies are needed to shed light on the role of various treatment and patient characteristics in the efficacy of internet-delivered treatments.

Stigma against mental health disorders in Nepal conceptualised with a 'what matters most' framework: a scoping review.

AIMS: Stigma related to mental disorders is a barrier to quality mental healthcare. This scoping review aimed to synthesise literature on stigma related to mental disorders in Nepal to understand stigma processes. The anthropological concept of 'what matters most' to understand culture and stigma was used to frame the literature on explanatory models, manifestations, consequences, structural facilitators and mitigators, and interventions. METHODS: We conducted a scoping review with screening guided by the Preferred Reporting Items for Systematic Review and Meta-analysis Extension for Scoping Reviews (PRISMA-ScR). A structured search was done using three international databases (PsycINFO, Medline and Web of Science), one Nepali database (NepJol) and cross-referencing for publications from 1 January 2000 through 24 June 2020. The search was repeated to include structural stigma-related terms. Quality of quantitative studies was assessed using the Systematic Assessment of Quality in Observational Research (SAQOR) tool. The review was registered through the Open Science Framework (OSF) (osf.io/u8jhn). RESULTS: The searches yielded 57 studies over a 20-year period: 19 quantitative, 19 qualitative, nine mixed methods, five review articles, two ethnographies and three other types of studies. The review identified nine stigma measures used in Nepal, one stigma intervention, and no studies focused on adolescent and child mental health stigma. The findings suggest that 'what matters most' in Nepali culture for service users, caregivers, community members and health workers include prestige, productivity, privacy, acceptance, marriage and resources. Cultural values related to 'what matters most' are reflected in structural barriers and facilitators including lack of policies, programme planning and resources. Most studies using quantitative tools to assess stigma did not describe cultural adaptation or validation processes, and 15 out of the 18 quantitative studies were 'low-quality' on the SAQOR quality rating. The review revealed clear gaps in implementation and evaluation of stigma interventions in Nepal with only one intervention reported, and most stigma measures not culturally adapted for use. CONCLUSION: As stigma processes are complex and interlinked in their influence on 'what matters most' and structural barriers and facilitators, more studies are required to understand this complexity and establish effective interventions targeting multiple domains. We suggest that stigma researchers should clarify conceptual models to inform study design and interpretations. There is a need to develop procedures for the systematic cultural adaptation of stigma assessment tools. Research should be conducted to understand the forms and drivers of structural stigma and to expand intervention research to evaluate strategies for stigma reduction.

Perspectives of healthcare providers, service users, and family members about mental illness stigma in primary care settings: A multi-site qualitative study of seven countries in Africa, Asia, and Europe.

BACKGROUND: Stigma among healthcare providers is a barrier to the effective delivery of mental health services in primary care. Few studies have been conducted in primary care settings comparing the attitudes of healthcare providers and experiences of people with mental illness who are service users in those facilities. Such research is necessary across diverse global settings to characterize stigma and inform effective stigma reduction. METHODS: Qualitative research was conducted on mental illness stigma in primary care settings in one low-income country (Nepal), two lower-middle income countries (India, Tunisia), one upper-middle-income country (Lebanon), and three high-income countries (Czech Republic, Hungary, Italy). Qualitative interviews were conducted with 248 participants: 64 primary care providers, 11 primary care facility managers, 111 people with mental illness, and 60 family members of people with mental illness. Data were analyzed using framework analysis. RESULTS: Primary care providers endorsed some willingness to help persons with mental illness but reported not having appropriate training and supervision to deliver mental healthcare. They expressed that people with mental illness are aggressive and unpredictable. Some reported that mental illness is incurable, and mental healthcare is burdensome and leads to burnout. They preferred mental healthcare to be delivered by specialists. Service users did not report high levels of discrimination from primary care providers; however, they had limited expectations of support from primary care providers. Service users reported internalized stigma and discrimination from family and community members. Providers and service users reported unreliable psychiatric medication supply and lack of facilities for confidential consultations. Limitations of the study include conducting qualitative interviews in clinical settings and reliance on clinician-researchers in some sites to conduct interviews, which potentially biases respondents to present attitudes and experiences about primary care services in a positive manner. CONCLUSIONS: Primary care providers' willingness to interact with people with mental illness and receive more training presents an opportunity to address stigmatizing beliefs and stereotypes. This study also raises important methodological questions about the most appropriate strategies to accurately understand attitudes and experiences of people with mental illness. Recommendations are provided for future qualitative research about stigma, such as qualitative interviewing by non-clinical personnel, involving non-clinical staff for recruitment of participants, conducting interviews in non-clinical settings, and partnering with people with mental illness to facilitate qualitative data collection and analysis.