Low access and inadequate treatment in mental health care for asylum seekers and refugees in Germany-A prospective follow-up study over 12 months and a nationwide cross-sectional study.

Refugees experience elevated rates of mental health problems, but little is known about mental health service utilization and quality among asylum seekers and refugees in Europe. In a 12-month follow-up study of newly arrived refugees (N = 166, Mage  = 32.38 years, 30.7% female) and a nationwide cross-sectional study (N = 579, Mage  = 33.89 years, 36.2% female) of refugees who had been living in Germany for an average of 6 years, we examined objective need for mental health treatment, perceived need, access to treatment services, and adequacy of treatment. We defined minimally adequate mental health treatment according to the WHO World Mental Health Survey as ≥8 sessions of psychotherapy (minimally adequate psychotherapy) or pharmacotherapy plus ≥4 medical visits (minimally adequate pharmacotherapy). In both studies, two in three individuals screened for mental health symptoms and additionally perceived a need for professional treatment. Of those, less than half had contact to any service provider, with only 1 in 14 receiving minimally adequate psychotherapy. Overall, no more than one in seven of refugees in need received minimally adequate treatment. Despite a comprehensive mental health-care system, refugees' access to mental health care and the treatment provided are inadequate. Health policies are urgently needed to provide equitable mental health care for all.

School-based mental health screenings with Ukrainian adolescent refugees in Germany: Results from a pilot study.

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

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

Background: Compared to the general German population, refugees in Germany are a high-risk group for trauma spectrum disorders. Currently, many barriers exist for the implementation of a screen-and-treat approach for mental disorders as part of the routine health care provision during the early stage of the immigration process.Objective: The aim of the present study was to develop and test a systematic screening approach to identify individual refugees in need of mental health care during the initial immigration phase.Method: 167 newly arrived refugees underwent a screening interview with the Refugee Health Screener (RHS) carried out by Intercultural Therapy Assistants (ITAs). The ITAs were super-vised by psychologists at a reception centre in Bielefeld, Germany. A subsample of 48 persons partici-pated in clinical validation interviews.Results: Findings demonstrated the need for and feasibility of a systematic screening during the initial immigration phase. However, established cut-off values of the RHS had to be adapted and the screening procedure had to be adjusted due to the needs of a significant number of refugees in severe psychological crises.Conclusion: A systematic screening that is applied shortly after arrival facilitates the early identification of refugees at risk of developing mental disorders and may be helpful to prevent chronic symptom development and an aggravation of psychological crises.

A systematic complementary screening procedure during the initial immigration phase was found to be useful for the identification of refugees in need of mental health care.The procedure could be implemented both safely and efficiently in conjunction with the initial medical check-up for recently arrived refugees.Responding to the needs of the refugees immediately following their arrival in Germany, we adjusted the cut-off of the screening instrument and suggest to explicitly include a detection procedure for severe psychological crises.

The efficacy of Narrative Exposure Therapy for Children (KIDNET) as a treatment for traumatized young refugees versus treatment as usual: update to the study protocol for the multi-center randomized controlled trial YOURTREAT.

BACKGROUND: The trial YOURTREAT aims to compare the pragmatic, short-term psychotherapy Narrative Exposure Therapy for Children (KIDNET) with treatment as usual (TAU) for the treatment of young refugees in Germany. This update outlines changes made to the study protocol in response to the current COVID-19 pandemic with the aim of allowing the continuation of the clinical trial while ensuring the safety of the staff and the participants, maintaining methodological quality, and ensuring compliance with legal regulations. METHODS: The major amendments to the original study protocol include (1) the possibility of using telehealth technology for the conduction of diagnostic and therapy sessions, (2) a reduction of the diagnostic set, and (3) an increased flexibility in the time frame of the study protocol. DISCUSSION: The adaptations to the study protocol made it feasible to continue with the trial YOURTREAT during the COVID-19 pandemic. Although the diagnostic set had to be shortened, the primary outcomes and the main secondary outcomes remain unimpaired by the amendment. Therefore, we expect the trial to provide evidence regarding effective treatment options for young refugees in Germany, a population that has received little scientific attention so far and has only very limited access to mental health care in the German health care system. In light of the current pandemic, which globally increases the risk of mental problems, the situation for young refugees is likely to aggravate further. Thus, the clinical and social relevance of the present trial YOURTREAT is even more important in these particular times. TRIAL REGISTRATION: German Clinical Trials Register (Deutsches Register Klinischer Studien; DRKS) DRKS00017222 . Registered on May 15, 2019.

The efficacy of Narrative Exposure Therapy for Children (KIDNET) as a treatment for traumatized young refugees versus treatment as usual: study protocol for a multi-center randomized controlled trial (YOURTREAT).

BACKGROUND: Germany hosts a large number of refugees from war-affected countries. The integration of refugees, in particular young refugees from the Middle East, is one of the major current social challenges in Germany. Mental disorders, first of all post-traumatic stress disorder (PTSD) that results from war experiences, are common among young refugees and interfere with quality of life as well as functional integration. Evidence regarding effective treatment options for this population is scarce. In this trial, we aim to evaluate the pragmatic, short-term psychotherapy Narrative Exposure Therapy for Children (KIDNET) for the treatment of young refugees in Germany. METHODS: In a rater-blinded, multi-center, randomized-controlled trial, KIDNET is compared to treatment as usual (TAU) within the general health care system. A total number of 80 young refugees who fulfill the diagnostic criteria of PTSD will be randomized to either KIDNET or TAU. Diagnostic interviews will take place at baseline before treatment as well as 6 and 12 months thereafter. They will assess exposure to traumatic events, PTSD and comorbid symptoms, as well as parameters of integration. DISCUSSION: The results of this study should provide evidence regarding effective treatment options for young refugees in Germany, a population that has been understudied and received only limited access to mental health care so far. Next to the effects of treatment on mental health outcomes, integration parameters will be investigated. Therefore, this study should provide broad insights into treatment options for young refugees and their potential implications on successful integration. TRIAL REGISTRATION: German Clinical Trials Register (Deutsches Register Klinischer Studien; DRKS), ID: DRKS00017222. Registered on 15 May 2019.

Social Fear Conditioning Paradigm in Virtual Reality: Social vs. Electrical Aversive Conditioning.

In a previous study we could show that social fear can be induced and extinguished using virtual reality (VR). In the present study, we aimed to investigate the belongingness effect in an operant social fear conditioning (SFC) paradigm which consisted of an acquisition and an extinction phase. Forty-three participants used a joystick to approach different virtual male agents that served as conditioned stimuli. Participants were randomly allocated to one of two experimental conditions. In the electroshock condition, the unconditioned stimulus (US) used during acquisition was an electric stimulation. In the social threat condition, the US consisted of an offense: a spit in the face, mimicked by a sound and a weak air blast to the participant's neck combined with an insult. In both groups the US was presented when participants were close to the agent (75% contingency for CS+). Outcome variables included subjective, psychophysiological and behavioral data. As expected, fear and contingency ratings increased significantly during acquisition and the differentiation between CS+ and CS- vanished during extinction. Furthermore, a clear difference in skin conductance between CS+ and CS- at the beginning of the acquisition indicated that SFC had been successful. However, a fast habituation to the US was found toward the end of the acquisition phase for the physiological response. Furthermore, participants showed avoidance behavior toward CS+ in both conditions. The results show that social fear can successfully be induced and extinguished in VR in a human sample. Thus, our paradigm can help to gain insight into learning and unlearning of social fear. Regarding the belongingness effect, the social threat condition benefits from a better differentiation between the aversive and the non-aversive stimuli. As next step we suggest comparing social-phobic patients to healthy controls in order to investigate possible differences in discrimination learning and to foster the development of more efficient treatments for social phobia.

Gradual extinction reduces reinstatement.

The current study investigated whether gradually reducing the frequency of aversive stimuli during extinction can prevent the return of fear. Thirty-one participants of a three-stage procedure (acquisition, extinction and a reinstatement test on day 2) were randomly assigned to a standard extinction (SE) and gradual extinction (GE) procedure. The two groups differed only in the extinction procedure. While the SE group ran through a regular extinction process without any negative events, the frequency of the aversive stimuli during the extinction phase was gradually reduced for the GE group. The unconditioned stimulus (US) was an air blast (5 bar, 10 ms). A spider and a scorpion were used as conditioned stimuli (CS). The outcome variables were contingency ratings and physiological measures (skin conductance response, SCR and startle response). There were no differences found between the two groups for the acquisition and extinction phases concerning contingency ratings, SCR, or startle response. GE compared to SE significantly reduced the return of fear in the reinstatement test for the startle response but not for SCR or contingency ratings. This study was successful in translating the findings in rodent to humans. The results suggest that the GE process is suitable for increasing the efficacy of fear extinction.