Temporal trends in mortality and associated factors among persons with mental disorders: A register-based cohort study.

This study aims to examine 20-year temporal trends in all-cause mortality among psychiatric patients and investigating impacts of risk factors on the time trends based on 218,703 Finnish adults with mental disorders who were discharged from 87 psychiatric hospitals between 1 Jan 1995 and 31 Dec 2014. The age-period-cohort analysis of Poisson model with random hospital effects estimated temporal trends in death rate and associated factors at individual, healthcare system, and society levels, following the WHO multilevel intervention framework model for six major psychiatric diagnosis. The adjusted annual mortality declined by 2.2 % annually (RR: 0.978 [95 % CI 0.976-0.980]) for all individuals, and by 2.8 % after adjusting for all risk factors, with varied decreasing rate between 2.0 % and 3.6 % by diagnosis. Individual level factors accounted for the declining rate by 54.5 % for all patients, with the highest impact on patients with personality disorders, followed by patients with affective disorders and patients with schizophrenia. Identified declining trends and associated factors which are preventable and modifiable for individuals with specific psychiatric diagnosis may lead to develop targeted service and intervention strategies in bringing down mortality further for the population.

Effect of trauma on asylum seekers and refugees receiving a WHO psychological intervention: a mediation model.

Background: Scalable psychological interventions such as the WHO's Self-Help Plus (SH+) have been developed for clinical and non-clinical populations in need of psychological support. SH+ has been successfully implemented to prevent common mental disorders among asylum seekers and refugees who are growing in number due to increasing levels of forced migration. These populations are often exposed to multiple, severe sources of traumatisation, and evidence of the effect of such events on treatment is insufficient, especially for non-clinical populations.Objective: We aim to study the effect of potentially traumatic experiences (PTEs) and the mediating role of symptoms of posttraumatic stress disorder (PTSD) on the improvement following SH+.Method: Participants allocated to SH+ who received at least three sessions (N = 345) were extracted from two large, randomised, European prevention trials involving asylum seekers and refugees. Measures of distress, depression, functional impairment, and post-traumatic stress symptoms were administered at baseline and 6 months post-intervention, together with measures of well-being and quality of life. Adjusted models were constructed to examine the effect of PTEs on post-intervention improvement. The possible mediating role of PTSD symptoms in this relationship was then tested.Results: Increasing numbers of PTEs decreased the beneficial effect of SH+ for all measures. This relationship was mediated by symptoms of PTSD when analysing measures of well-being and quality of life. However, this did not apply for measures of mental health problems.Conclusions: Exposure to PTEs may largely reduce benefits from SH+. PTSD symptomatology plays a specific, mediating role on psychological well-being and quality of life of participants who experienced PTE. Healthcare professionals and researchers should consider the role of PTEs and PTSD symptoms in the treatment of migrants and refugees and explore possible feasible add-on solutions for cases exposed to multiple PTEs.

Increasing numbers of potentially traumatic experiences can decrease the beneficial effect of a manualized group psychotherapeutic intervention in migrants and refugees across multiple countries.In absence of a full threshold diagnosis of post-traumatic stress disorder, post-traumatic stress symptoms still mediate the relation between potentially traumatic experiences and some outcome improvements at follow-up.While the moderating role of number of potentially traumatic experiences applies to all outcomes (depression symptoms, psychological distress, functional impairment, well-being, and quality of life), the mediating role of post-traumatic stress symptoms in this relation only applies to well-being and quality of life.

How to adopt technologies in home care: a mixed methods study on user experiences and change of home care in Finland.

BACKGROUND: There is a need for better adoption of technology to meet the needs of home care professionals, older people, and informal caregivers. METHODS: Mixed methods were used to describe and analyse quantitative and qualitative data in a Finnish governmental programme called KATI. The study was three-fold: it 1) listed what kinds of technologies were piloted and deployed in a national study, 2) provided information from the perspectives of home care professionals about requirements to use technology by using focus-group interviews, and 3) assessed experiences of how the adoption of technology changes work and work processes over time by using repeated surveys. Informants in interviews (n = 25) and surveys (n = 90) were home care professionals, who also described the perspectives of older people and informal caregivers. The conceptual models framing the study were adapted from the Technology Acceptance Model and DirVA PROVE-IT. RESULTS: There were 80 technology pilots, in which variety of technologies were followed in home care. Familiarity with, commitment to and understanding of technology benefits were considered to be requirements for the technology to be used. The adoption of technology provided new skills and information about older people's wellbeing, realisation of treatment and new possibilities in home care. It developed new procedures to focus on older people's needs and motivated professionals by gained concrete aid. It enabled them to leave out some concrete procedures as unnecessary. On the other hand, there were also pessimistic and negative experiences when technology use provided nothing new or did not change anything. CONCLUSIONS: The adoption of technology is dependent on the technology and its integration into the prevailing service practice. When they both work, it is possible to leave out unnecessary procedures in care, allocate resources and save time. It is possible to be aware of older people's safety and how they cope at home, find new ways to get involved in older people's lives, gain insight, and make changes at work. Continuous on-site training, modifications in service practices and communication throughout organisations is needed.

Self-Help Plus for refugees and asylum seekers: an individual participant data meta-analysis.

QUESTION: Refugees and asylum seekers are at high risk of mental disorders due to various stressors before, during and after forceful displacement. The WHO Self-Help Plus (SH+) intervention was developed to manage psychological distress and a broad range of mental health symptoms in vulnerable populations. This study aimed to examine the effects and moderators of SH+ compared with Enhanced Care as Usual (ECAU) in reducing depressive symptoms among refugees and asylum seekers. STUDY SELECTION AND ANALYSIS: Three randomised trials were identified with 1795 individual participant data (IPD). We performed an IPD meta-analysis to estimate the effects of SH+, primarily on depressive symptoms and second on post-traumatic stress, well-being, self-identified problems and functioning. Effects were also estimated at 5-6 months postrandomisation (midterm). FINDINGS: There was no evidence of a difference between SH+ and ECAU+ in reducing depressive symptoms at postintervention. However, SH+ had significantly larger effects among participants who were not employed (ß=1.60, 95% CI 0.20 to 3.00) and had lower mental well-being levels (ß=0.02, 95% CI 0.001 to 0.05). At midterm, SH+ was significantly more effective than ECAU in improving depressive symptoms (ß=-1.13, 95% CI -1.99 to -0.26), self-identified problems (ß=-1.56, 95% CI -2.54 to -0.59) and well-being (ß=6.22, 95% CI 1.60 to 10.90). CONCLUSIONS: Although SH+ did not differ significantly from ECAU in reducing symptoms of depression at postintervention, it did present benefits for particularly vulnerable participants (ie, unemployed and with lower mental well-being levels), and benefits were also evident at midterm follow-up. These results are promising for the use of SH+ in the management of depressive symptoms and improvement of well-being and self-identified problems among refugees and asylum seekers.

Recovery-oriented mental health principles in psychiatric hospitals: How service users, family members and staff perceive the realization of practices.

AIMS: The aim of the study was to describe and compare how recovery-oriented mental health principles have been realized in Finnish psychiatric hospitals from the viewpoint of different stakeholders (service users, family members and staff). DESIGN: A multimethod research design was adopted to combine both quantitative and qualitative descriptive methods. METHODS: A total of 24 focus group interviews were conducted with service users (n = 33), family members (n = 3) and staff (n = 53) on 12 psychiatric Finnish hospital wards (October 2017). The interview topics were based on six recovery-oriented principles (WHO QualityRights Tool Kit, 2012). A quantitative deductive analysis was conducted to describe and compare the realization of the recovery-oriented principles between three stakeholder groups. A qualitative deductive content analysis was used to describe participants' perceptions of the realization of recovery-oriented principles in practice. The GRAMMS guideline was used in reporting. RESULTS: Out of six recovery-oriented principles, 'Dignity and respect' was found to have been realized to the greatest extent on the psychiatric wards. The most discrepancy between the participant groups was seen in the 'Evaluation of recovery'. Service users and family members found the realization of the practices of all principles to be poorer than the staff members did. Wide variation was also found at the ward level between perceptions among participants, and descriptions of the realization of the principles in psychiatric hospital practice. CONCLUSION: Perceptions about the realization of recovery-oriented principles in practice in Finnish psychiatric hospitals vary between different stakeholder groups. This variation is linked to differing ward environments. IMPACT: More research is needed to understand the factors associated with variation in perceptions of recovery principles. PATIENT OR PUBLIC CONTRIBUTION: Service users and family members participated in this study.

Risk factors for mental disorder development in asylum seekers and refugees resettled in Western Europe and Turkey: Participant-level analysis of two large prevention studies.

BACKGROUND: In asylum seekers and refugees, the frequency of mental disorders, such as depression, anxiety and post-traumatic stress disorder, is higher than the general population, but there is a lack of data on risk factors for the development of mental disorders in this population. AIM: This study investigated the risk factors for mental disorder development in a large group of asylum seekers and refugees resettled in high- and middle-income settings. METHODS: Participant-level data from two randomized prevention studies involving asylum seekers and refugees resettled in Western European countries and in Turkey were pooled. The two studies randomized participants with psychological distress, but without a diagnosis of mental disorder, to the Self-Help Plus psychological intervention or enhanced care as usual. At baseline, exposure to potentially traumatic events was measured using the Harvard Trauma Questionnaire-part I, while psychological distress and depressive symptoms were assessed with the General Health Questionnaire and the Patient Health Questionnaire. After 3 and 6 months of follow-up, the proportion of participants who developed a mental disorder was calculated using the Mini International Neuropsychiatric Interview. RESULTS: A total of 1,101 participants were included in the analysis. At 3- and 6-month follow-up the observed frequency of mental disorders was 13.51% (115/851) and 24.30% (207/852), respectively, while the frequency estimates after missing data imputation were 13.95% and 23.78%, respectively. After controlling for confounders, logistic regression analysis showed that participants with a lower education level (p = .034), a shorter duration of journey (p = .057) and arriving from countries with war-related contexts (p = .017), were more at risk of developing mental disorders. Psychological distress (p = .004), depression (p = .001) and exposure to potentially traumatic events (p = .020) were predictors of mental disorder development. CONCLUSIONS: This study identified several risk factors for the development of mental disorders in asylum seekers and refugees, some of which may be the target of risk reduction policies. The identification of asylum seekers and refugees at increased risk of mental disorders should guide the implementation of focused preventative psychological interventions.

Impairments in psychological functioning in refugees and asylum seekers.

Refugees are at increased risk for developing psychological impairments due to stressors in the pre-, peri- and post-migration periods. There is limited knowledge on how everyday functioning is affected by migration experience. In a secondary analysis of a study in a sample of refugees and asylum seekers, it was examined how aspects of psychological functioning were differentially affected. 1,101 eligible refugees and asylum seekers in Europe and Türkiye were included in a cross-sectional analysis. Gender, age, education, number of relatives and children living nearby, as well as indicators for depressive and posttraumatic symptoms, quality of life, psychological well-being and functioning, and lifetime potentially traumatic events were assessed. Correlations and multiple regression models with World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) 12-item version's total and six subdomains' scores ('mobility', 'life activities', 'cognition', 'participation', 'self-care', 'getting along') as dependent variables were calculated. Tests for multicollinearity and Bonferroni correction were applied. Participants reported highest levels of impairment in 'mobility' and 'participation', followed by 'life activities' and 'cognition'. Depression and posttraumatic symptoms were independently associated with overall psychological functioning and all subdomains. History of violence and abuse seemed to predict higher impairment in 'participation', while past events of being close to death were associated with fewer issues with 'self-care'. Impairment in psychological functioning in asylum seekers and refugees was related to current psychological symptoms. Mobility and participation issues may explain difficulties arising after resettlement in integration and exchange with host communities in new contexts.

Trajectories of psychosocial symptoms and wellbeing in asylum seekers and refugees exposed to traumatic events and resettled in Western Europe, Turkey, and Uganda.

Background: Longitudinal studies examining mental health trajectories in refugees and asylum seekers are scarce. Objectives: To investigate trajectories of psychological symptoms and wellbeing in refugees and asylum seekers, and identify factors associated with these trajectories. Method: 912 asylum seekers and refugees from the control arm of three trials in Europe (n = 229), Turkey (n = 320), and Uganda (n = 363) were included. We described trajectories of psychological symptoms and wellbeing, and used trauma exposure, age, marital status, education, and individual trial as predictors. Then, we assessed the bidirectional interactions between wellbeing and psychological symptoms, and the effect of each predictor on each outcome controlling for baseline values. Results: Symptom improvement was identified in all trials, and for wellbeing in 64.7% of participants in Europe and Turkey, versus 31.5% in Uganda. In Europe and Turkey domestic violence predicted increased symptoms at post-intervention (ß = 1.36, 95% CI 0.17-2.56), whilst murder of family members at 6-month follow-up (ß = 1.23, 95% CI 0.27-2.19). Lower wellbeing was predicted by murder of family member (ß = -1.69, 95% CI -3.06 to -0.32), having been kidnapped (ß = -1.67, 95% CI -3.19 to -0.15), close to death (ß = -1.38, 95% CI -2.70 to -0.06), and being in the host country ≥2 years (ß = -1.60, 95% CI -3.05 to -0.14). In Uganda at post-intervention, having been kidnapped predicted increased symptoms (ß = 2.11, 95% CI 0.58-3.65), and lack of shelter (ß = -2.51, 95% CI -4.44 to -0.58) and domestic violence predicted lower wellbeing (ß = -1.36, 95% CI -2.67 to -0.05). Conclusion: Many participants adapt to adversity, but contextual factors play a critical role in determining mental health trajectories.

Antecedentes: Estudios longitudinales que examinan las trayectorias de la salud mental en los refugiados y solicitantes de asilo son escasos.Objetivos: Investigar las trayectorias de los síntomas psicológicos y el bienestar en refugiados y solicitantes de asilo, e identificar factores asociados a estas trayectorias.Métodos: Se incluyeron 912 solicitantes de asilos y refugiados del brazo control de tres ensayos clínicos en Europa (n = 229), Turquía (n = 320) y Uganda (n = 363). Describimos las trayectorias psicológicas de los síntomas y el bienestar, y utilizamos la exposición traumática, la edad, el estado marital, la educación y el juicio individual como predictores. Después, evaluamos las interacciones bidireccionales entre el bienestar y los síntomas psicológicos, y el efecto de cada uno de los predictores en cada resultado controlando por los valores iniciales.Resultados: Se identificó una mejoría en los síntomas en todos los ensayos, y del bienestar en el 64.7% de los participantes en Europa y Turquía, versus el 31.5% en Uganda. En Europa y en Turquía, la violencia doméstica predijo el incremento de síntomas de después de la intervención (ß = 1.36, 95% CI 0.17 a 2.56), mientras que el homicidio de algún miembro familiar a los 6 meses de seguimiento (ß = 1.23, 95% CI 0.27 a 2.19). Un menor bienestar fue predicho por el homicidio de algún miembro de la familia (ß = −1.69, 95% CI −3.06 a −0.32), haber sido secuestrado (ß = −1.67, 95% CI −3.19 a −0.15), haber estado próximo a la muerte (ß = −1.38, 95% CI −2.70 a −0.06), y estar en el país de acogida ≥2 años (ß = −1.60, 95% CI −3.05 a −0.14). En Uganda, después de la intervención, haber sido secuestrado predijo un aumento de los síntomas (ß =2.11, 95% CI 0.58 a 3.65), y la falta de refugio (ß = −2.51, 95% CI −4.44 a −0.58) y la violencia doméstica predijo un menor bienestar (ß = −1.36, 95% CI −2.67 a −0.05).Conclusión: Muchos participantes se adaptan a la adversidad, pero los factores contextuales juegan un papel crítico en determinar las trayectorias de la salud mental.

An International Study of Correlates of Women's Positive Body Image.

Positive body image (PBI) has received attention in the recent research literature. Despite this, its role in daily functioning in different cultural contexts, particularly its potential relationship with academic outcomes, is still lacking. This study aimed to offer an international perspective on the association between PBI and body mass index (BMI), perceived academic achievement, and educational aspirations, as well as the mediating role of self-esteem. A cross-national study was conducted in eight European countries with a total of 2653 female university students. Participants completed an online survey measuring PBI (conceptualized as body appreciation), self-esteem, perceived academic achievement and aspirations, and body mass index (BMI). Results revealed differences in PBI between countries (low magnitude). PBI correlated negatively with BMI in all national groups (low-to-moderate magnitude). Mediation analysis showed that self-esteem mediated the association between PBI and academic variables. Findings from this study suggest that building students' self-esteem and PBI can be a suitable way to boost academic success.

An Evidence-Based Educational Intervention for Reducing Coercive Measures in Psychiatric Hospitals: A Randomized Clinical Trial.

Importance: Investing in health care staffs' education can change the scope of action and improve care. The effectiveness of staff education remains inconclusive. Objective: To examine whether an evidence-based educational intervention for nurses decreases the use of seclusion rooms in psychiatric hospitals compared with usual practice. Design, Setting, and Participants: In this pragmatic, 2-arm parallel, stratified cluster randomized clinical trial, 28 wards in 15 psychiatric hospitals in Finland were screened for eligibility and randomly allocated (1:1). Nurses joined on either intervention (n = 13) or usual practice (n = 15) wards. The intervention was performed from May 1, 2016, to October 31, 2017. The follow-up data for January 1 to December 31, 2017, were collected from hospital registers in 2018. Data analysis was performed October 27, 2021. Interventions: Evidence-based education delivered during 18 months, including 8 months of active education, followed by a 10-month maintenance period. Main Outcomes and Measures: The primary outcome was the occurrence of patient seclusion (events per total number of patients). Results: Of 28 psychiatric hospital wards screened (437 beds and 648 nurses), 27 wards completed the study. A total of 8349 patients were receiving care in the study wards, with 53% male patients and a mean (SD) age of 40.6 (5.7) years. The overall number of seclusions was 1209 (14.5%) in 2015 and 1349 (16.5%) in 2017. In the intervention group, the occurrence rate of seclusion at the ward level decreased by 5.3% from 629 seclusions among 4163 patients (15.1%) to 585 seclusions among 4089 patients (14.3%) compared with a 34.7% increase from 580 seclusions among 4186 patients (13.9%) to 764 seclusions among 4092 patients (18.7%) in the usual practice group. The adjusted rate ratio was 0.86 (95% CI, 0.40-1.82) in 2015 and 0.66 (95% CI, 0.31-1.41) in 2017 (P = .003). However, the number of forced injections increased in the intervention group from 317 events among 4163 patients (7.6%) in 2015 to 486 events among 4089 patients (11.9%) in 2017 compared with an increase in the usual practice group from 414 events among 4186 patients (9.9%) in 2015 to 481 events among 4092 patients (11.8%) in 2017. Seven adverse events were reported. Conclusions and Relevance: In this randomized clinical trial, the educational intervention had a limited effect on the change of occurrence rate of patient seclusion, whereas the use of forced injections increased. More studies are needed to better understand the reasons for these findings. Trial Registration: ClinicalTrials.gov Identifier: NCT02724748.

Cost-effectiveness of the Self-Help Plus Intervention for Adult Syrian Refugees Hosted in Turkey.

Importance: The cost-effectiveness of the Self-Help Plus (SH+) program, a group-based, guided, self-help psychological intervention developed by the World Health Organization for people affected by adversity, is unclear. Objective: To investigate the cost-utility of providing the SH+ intervention combined with enhanced usual care vs enhanced usual care alone for Syrian refugees or asylum seekers hosted in Turkey. Design, Setting, and Participants: This economic evaluation was performed as a prespecified part of an assessor-blinded randomized clinical trial conducted between October 1, 2018, and November 30, 2019, with 6-month follow-up. A total of 627 adults with psychological distress but no diagnosed psychiatric disorder were randomly assigned to the intervention group or the enhanced usual care group. Interventions: The SH+ program was a 5-session (2 hours each), group-based, stress management course in which participants learned self-help skills for managing stress by listening to audio sessions. The SH+ sessions were facilitated by briefly trained, nonspecialist individuals, and an illustrated book was provided to group members. Th intervention group received the SH+ intervention plus enhanced usual care; the control group received only enhanced usual care from the local health care system. Enhanced usual care included access to free health care services provided by primary and secondary institutions plus details on nongovernmental organizations and freely available mental health services, social services, and community networks for people under temporary protection of Turkey and refugees. Main Outcomes and Measures: The primary outcome measure was incremental cost per quality-adjusted life-year (QALY) gained from the perspective of the Turkish health care system. An intention-to-treat analysis was used including all participants who were randomized and for whom baseline data on costs and QALYs were available. Data were analyzed September 30, 2020, to July 30, 2021. Results: Of 627 participants (mean [SD] age, 31.3 [9.0] years; 393 [62.9%] women), 313 were included in the analysis for the SH+ group and 314 in the analysis for the enhanced usual care group. An incremental cost-utility ratio estimate of T£6068 ($1147) per QALY gained was found when the SH+ intervention was provided to groups of 10 Syrian refugees. At a willingness to pay per QALY gained of T£14 831 ($2802), the SH+ intervention had a 97.5% chance of being cost-effective compared with enhanced usual care alone. Conclusions and Relevance: This economic evaluation suggests that implementation of the SH+ intervention compared with enhanced usual care alone for adult Syrian refugees or asylum seekers hosted in Turkey is cost-effective from the perspective of the Turkish health care system when both international and country-specific willingness-to-pay thresholds were applied.

Web messaging among young people in online services: A descriptive mixed-methods study.

Objective: To describe web messaging patterns and the content of web messages among young people in a Finnish national online service. Methods: A descriptive mixed-method was used. The data consisted of text-based web messaging communication between young people and a counsellor in a nationwide online service between 1 January and 31 December 2018. Web messaging patterns were analysed using descriptive statistics. The content of the messages was analysed with thematic analysis and qualitative results were presented. In addition, the factors associated with messaging patterns and content were analysed. Results: A total of 1941 messages were sent by 1354 young people. Most of them were between 12 and 17 years old and females. Less than one-fifth of young people had multiple two-way discussions with counsellor. The total period of two-way discussions and the number of words in each message varied widely. The number of words was lower in messages sent by males. The content of the messages was divided into three main themes: interpersonal relationships and environment (Social relationships), oneself (Construction of self), and health-related problems and support received from professionals (Health and wellbeing). The young people's messages mostly contained topics related to the main theme of 'Social environment'. Conclusion: Most young people sent one message only. Messages ranged from simple, single messages to complex texts describing the daily life of young people. Girls were more active in messaging, and they wrote longer texts.

Effectiveness of a WHO self-help psychological intervention for preventing mental disorders among Syrian refugees in Turkey: a randomized controlled trial.

Refugees are at high risk of developing mental disorders. There is no evidence from randomized controlled trials (RCTs) that psychological interventions can prevent the onset of mental disorders in this group. We assessed the effectiveness of a self-help psychological intervention developed by the World Health Organization, called Self-Help Plus, in preventing the development of mental disorders among Syrian refugees experiencing psychological distress in Turkey. A two-arm, assessor-masked RCT was conducted in two Turkish areas. Eligible participants were adult Syrian refugees experiencing psychological distress (General Health Questionnaire ≥3), but without a diagnosis of mental disorder. They were randomly assigned either to the Self-Help Plus arm (consisting of Self-Help Plus combined with Enhanced Care as Usual, ECAU) or to ECAU only in a 1:1 ratio. Self-Help Plus was delivered in a group format by two facilitators over five sessions. The primary outcome measure was the presence of any mental disorder assessed by the Mini International Neuropsychiatric Interview at six-month follow-up. Secondary outcome measures were the presence of mental disorders at post-intervention, and psychological distress, symptoms of post-traumatic stress disorder and depression, personally identified psychological outcomes, functional impairment, subjective well-being, and quality of life at post-intervention and six-month follow-up. Between October 1, 2018 and November 30, 2019, 1,186 refugees were assessed for inclusion. Five hundred forty-four people were ineligible, and 642 participants were enrolled and randomly assigned to either Self-Help Plus (N=322) or ECAU (N=320). Self-Help Plus participants were significantly less likely to have any mental disorders at six-month follow-up compared to the ECAU group (21.69% vs. 40.73%; Cramer's V = 0.205, p<0.001, risk ratio: 0.533, 95% CI: 0.408-0.696). Analysis of secondary outcomes suggested that Self-Help Plus was not effective immediately post-intervention, but was associated with beneficial effects at six-month follow-up in terms of symptoms of depression, personally identified psychological outcomes, and quality of life. This is the first prevention RCT ever conducted among refugees experiencing psychological distress but without a mental disorder. Self-Help Plus was found to be an effective strategy for preventing the onset of mental disorders. Based on these findings, this low-intensity self-help psychological intervention could be scaled up as a public health strategy to prevent mental disorders in refugee populations exposed to ongoing adversities.

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.

Quality of mental health services and rights of people receiving treatment in inpatient services in Finland: a cross-sectional observational survey with the WHO QualityRights Tool Kit.

BACKGROUND: This article aims to review the quality of mental health services and the rights of the people receiving treatment in inpatient hospital care in Finland using the World Health Organization's QualityRights Tool Kit as a part of a randomized controlled trial VIOLIN. So far, reports on the QualityRights Tool Kit have mainly been from low- and middle-income countries or countries lacking resources for health services. Reports from countries with well-resourced health care systems, such as the Nordic countries, are still quite few. METHODS: A cross-sectional observational survey was conducted on 13 closed inpatient psychiatric wards (acute, rehabilitation, forensic psychiatric) at eight hospitals in Finland. The data for the survey were gathered through a document review, observations, and group interviews among staff members, service users and family members. The STROBE checklist for cross-sectional studies was followed in the reporting. RESULTS: Finnish mental health services are partially or fully achieving the standards set by the WHO QualityRights Tool Kit (final scores: 2.5-2.9 out of 3). The highest final score out of the five themes (2.9/3) was achieved under Freedom from torture or cruel, inhuman or degrading treatment or punishment and from exploitation, violence and abuse. The lowest final score out of the five themes (2.5/3) was achieved under the right to exercise legal capacity and the right to personal liberty and the security of person. CONCLUSIONS: According to the findings, Finnish mental health services appear to be of high quality. However, we have identified some gaps in quality, which we have addressed in a national randomized controlled trial VIOLIN. Improvements can be realized through shared decision making and relaying information to service users.

Impact and Feasibility of Information Technology to Support Adolescent Well-Being and Mental Health at School: A Quasi-Experimental Study.

PURPOSE: Health-related behaviors that arise during adolescence can have important, sometimes lifelong, implications on a person's health. Psychiatric and neurodevelopmental diagnoses among minors have increased, and the related depressive symptoms may negatively affect quality of life. There is great potential for information technology (IT) to benefit the area of mental health for adolescents, and schools can serve as a setting in which this can be done. We tested whether the IT-based program "DepisNet" could be used as a universal school-based program to support adolescents' well-being and mental health. PATIENTS AND METHODS: We used a quasi-experimental, pre-post design with two preference arms (intervention and control groups). The study setting comprised two lower secondary schools (N=151 adolescents) in one city in Finland. To analyze the impact of the program, we compared the changes in the outcome measures between the two groups using T-tests and Mann-Whitney U-tests. We analyzed the changes within the groups using T-tests and Wilcoxon tests. RESULTS: Our analysis revealed no statistically significant differences between the groups in any of the outcomes (depression, quality of life, self-esteem, self-efficacy). Regarding adolescents' quality of life, the observed change was more positive in the intervention group, compared to that of the control group (change mean 1.36 vs -0.49), although statistical significance was not achieved (p=0.10). Our results indicated encouraging results related to the feasibility components: adherence and acceptance. CONCLUSION: Universal interventions and programs that relate to adolescent well-being and mental health can be integrated into school curricula to promote the awareness of adolescents' general well-being and mental health issues.

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

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.

Antecedentes: Los refugiados y solicitantes de asilo enfrentan numerosos estresores debido al desplazamiento y son especialmente vulnerables a trastornos de salud mental comunes. Para poder manejar efectivamente el malestar psicológico en esta población, se requieren intervenciones innovadoras. La intervención Self- Help Plus (SH+) de la Organización Mundial de la Salud (OMS) ha mostrado resultados prometedores en la reducción de síntomas de trastornos de salud mental comunes entre refugiados y solicitantes de asilo. Sin embargo, las diferencias individuales de los participantes en respuesta a SH+ permanecen mayormente desconocida. El meta-análisis de Datos de Participantes Individuales (IPD) sintetiza bases de datos puros para proveer evidencia de resultados de vanguardia que no puede ser examinada mediante enfoques meta-analíticos convencionales.Objetivos: Este protocolo delinea los métodos de una serie de meta-análisis de IPD enfocados en examinar los efectos y potenciales moderadores de SH+ en (a) reducir síntomas depresivos en la post-intervención y (b) prevenir la incidencia acumulada de trastornos mentales en refugiados y solicitantes de asilo durante seis meses.Método: Se identificaron RCT sobre SH+ a través de la OMS y todos los autores acordaron compartir la base de datos de sus ensayos. Los resultados primarios de los meta-análisis de IPD son (a) reducción en síntomas depresivos después de la intervención, y (b) prevención de la incidencia acumulada de trastornos mentales en refugiados y solicitantes de asilo durante 6 meses. Entre los resultados secundarios de incluyó síntomas de trastorno de estrés postraumático, bienestar, funcionamiento, calidad de vida e incidencia acumulada de trastornos de salud mental durante 12 meses. Se realizaran meta-análisis de IPD de una etapa usando regresión linear/logística de efectos mixtos. Los datos faltantes se manejaran mediante imputación múltiple.Conclusiones: Estos resultados enriquecerán el conocimiento actual sobre la respuesta a SH+ y facilitarán su diseminación en su público objetivo. Los resultados de estos meta-análisis de IPD serán publicados en revistas revisadas por pares.

Feasibility of a Web-Based Psychoeducation Course and Experiences of Caregivers Living With a Person With Schizophrenia Spectrum Disorder: Mixed Methods Study.

BACKGROUND: Schizophrenia is a severe mental illness that burdens both patients and caregivers. OBJECTIVE: The aim of this study is to examine the feasibility of a web-based psychoeducation course targeted at caregivers of persons with schizophrenia spectrum disorders (SSDs) and to describe their experiences of living with a person with SSD based on the material caregivers produced during the web-based course. METHODS: A convergent, parallel, mixed methods study design was used. First, caregivers' engagement in the course was evaluated quantitatively. Second, the overview of the course feedback was evaluated using quantitative and qualitative methods. Third, the experiences of being a caregiver to a person with SSD were analyzed qualitatively with the thematic analysis of the writings caregivers produced during the web-based course. RESULTS: A total of 30 caregivers participated in the study and a web-based psychoeducation course. Less than two-thirds (18/30, 60%) completed the course. Content was most often logged for the first module, Orientation (3465 log-ins), and the lowest number of log-ins was recorded for the Daily life module (1061 log-ins). Feedback on the course varied; over half (10/17, 59%) of the caregivers considered the content to be very good or good, about half (9/17, 53%) considered the website layout to be good, only 6% (1/17) felt that the usability of the website was poor, and no one felt that it was very poor. From the reported experiences of being a caregiver to a person with SSD, 3 themes were formed: the caregiver's own well-being, relationship with the person with SSD, and experience of health care services. CONCLUSIONS: The web-based psychoeducation course for caregivers living with a person with SSD seems to be especially suitable for those who have little experience as a caregiver. In the future, more planning and the consideration of aspects related to the needs of specific target groups, course content, practical arrangements, and scheduling should be taken into account. In addition, although caregivers can improve their own well-being in different ways, they need regular support and cooperation from health care professionals.

Supporting Student's Mental Health: A Cross-Sectional Survey for School Nurses.

Children's and adolescents' health problems are often related to mental health, and their wellbeing should be supported in schools. This study describes school nurses' role and how equipped they are in recognizing students' mental health needs and in supporting students' mental health. Moreover, we explored the methods used and the barriers that exist for supporting students' mental health. A national survey for members of the Finnish Public Health Association working as school nurses was conducted (n = 136/648, 21%). The survey questionnaire was analyzed using descriptive statistics and qualitative data using manifest content analysis. Participants (n = 127/133, 96%) agreed that they had an important role in ensuring that students' mental health needs are met on time. Around one-third reported training needs for mental health interventions (n = 42/115, 36%), and a similar proportion (n = 42/136, 31%) indicated lacking adequate knowledge and skills for supporting mental health among culturally diverse students. Identified barriers for students getting help were a lack of options for sending students to mental health services (n = 92/134, 69%) and a lack of adequate training (n = 81/134, 68%). School nurses are key in providing early mental health support to students. Therefore, the availability of intervention education and training on assessing and supporting students' mental health is needed and should be improved.

Facilitators for improvement of psychiatric services and barriers in implementing changes: From the perspective of Finnish patients and family members.

The need for psychiatric patients and their family members to have access to quality user-friendly services has been studied for decades, yet few improvements have been made in treatment services. This study aims to explain how patients and family members have experienced facilitators of improvements, and their thoughts about barriers in the implementation of changes. An explanatory qualitative design was adopted. Data were collected using semi-structured interviews with eight focus groups made up of a total of 35 participants from mental health associations in Finland. The Theoretical Domains Framework guided the deductive data analysis. The Consolidated Criteria for Reporting Qualitative Studies (COREQ) was followed in the study. Participants in patient and family member associations had similar experiences and thoughts about facilitators of improvements in psychiatric services and barriers in the implementation of changes. For example, both participant groups experienced that promoting more positive roles of professionals could facilitate improvements in psychiatric care. On the other hand, a lack of theoretical competence and interpersonal skills of professionals could hinder change. We conclude that many of the facilitators that patients and families suggested could be addressed by enhancing collaboration and communication, having a more person-centred approach, focusing on recovery throughout the course of care, and acknowledging staff's well-being at work. Second, the barriers to implementing changes centre around the limited knowledge and skills of staff, and a paternalistic system that focuses on managing risk and administering treatment.