The associations of hair cortisol and DHEA with posttraumatic stress disorder symptoms in refugees.

BACKGROUND: Exposure to traumatic events, ongoing adversity, and posttraumatic stress disorder (PTSD) are associated with altered activity of the hypothalamic-pituitary-adrenal (HPA) axis, but findings are mixed. This may be explained in part by heterogeneity in PTSD symptom profiles. AIM: The aim of this study was to investigate the complex relationships between the number of traumatic events and post-displacement stressors, individual symptoms of PTSD, and HPA-axis hormones cortisol and dehydroepiandrosterone (DHEA) in refugees. METHODS: Adult (18+ years) Syrian refugees with increased levels of distress participating in a randomized controlled trial completed baseline measures to assess traumatic events (trauma checklist), post-displacement stressors (Post-Migration Living Difficulties checklist), symptoms of PTSD (PTSD Checklist for DSM-5; PCL-5), and provided a hair sample for additional stress hormone analyses. We used R-packages qgraph and bootnet to perform network analysis on the number of traumatic events and post-displacement stressors, individual symptoms of PTSD, and HPA-axis hormones cortisol and DHEA. The final network model was corrected for depression severity. RESULTS: 115 (53% male, M age = 36.9, SD = 12.7) of 206 participants provided a hair sample. A higher number of traumatic events was directly associated with three symptoms of the PTSD cluster arousal and reactivity, i.e., sleep disturbance, hypervigilance and physiological reactivity, and with three other PTSD symptoms, namely flashbacks, avoidance of reminders, and self-destructive behavior. A higher number of post-displacement stressors was associated with four symptoms of the PTSD cluster cognition and mood, i.e., trauma-related amnesia, negative beliefs, blaming of self/others, and detachment, as well as with intrusive thoughts, sleep disturbance, hypervigilance, and exaggerated startle response. The number of traumatic events and post-displacement stressors were not associated with cortisol or DHEA. Cortisol was positively associated with two symptoms of the PTSD cluster cognition and mood, i.e., negative beliefs and negative trauma-related emotions, and negatively associated with avoidance of reminders. DHEA was positively associated with restricted affect and with three symptoms of the PTSD symptom cluster arousal and reactivity, i.e., irritability/anger, sleep disturbance, and self-destructive behavior, and negatively associated with avoidance of thoughts. CONCLUSIONS: This study demonstrated that exposure to traumatic events and post-displacement stressors is not related to cortisol and DHEA, but that cortisol and DHEA are differentially related to individual symptoms of PTSD. While lower levels of both cortisol and DHEA were associated with increased avoidance, higher levels of cortisol were mostly associated with symptoms of the PTSD cluster cognition and mood and higher levels of DHEA were mostly associated with symptoms of the PTSD cluster arousal and reactivity. These findings contribute to explaining the variability of findings in the literature on HPA-axis activity in PTSD. ETHICS: The study was approved by the Research Ethics Review Committee at VU Medical Center, the Netherlands (Protocol ID: NL61361.029.17, 7 September 2017) and prospectively registered online (https://www.trialregister.nl/trial/6665).

The effect of a low-level psychological intervention (PM+) on post-migration living difficulties - Results from two studies in Switzerland and in the Netherlands.

AIMS OF THE STUDY: After arriving in host countries, most refugees are confronted with numerous post-migration stressors (e.g., separation from family, discrimination, and employment difficulties). Post-migration living difficulties (PMLDs) significantly contribute to the development and persistence of mental disorders. Effective treatment approaches focusing on reducing post-migration stress are urgently needed. The aim of the present study was to examine the effect of a brief psychological intervention, Problem Management Plus (PM+), on PMLDs among Syrian refugees in two European countries. METHODS: We merged data from two single-blind feasibility trials with Syrian refugees experiencing elevated levels of psychological distress and impaired functioning in Switzerland (N = 59) and the Netherlands (N = 60). Participants were randomised to receive either five sessions of PM+ or an enhanced care-as-usual control condition. PMLDs were assessed at baseline and 3 months after the intervention. To estimate treatment effect on PMLD, linear mixed model analysis was performed. RESULTS: Three months after the intervention, participants in the PM+ condition reported significantly fewer PMLDs compared to the control condition. Further analyses at item-level showed that interpersonal and family related PMLDs, such as "worries about family back home" significantly improved over time in the PM+ condition. CONCLUSIONS: This exploratory study suggests that brief psychological interventions have the potential to reduce PMLDs in refugees and asylum seekers. The reduction of post-migration stress in turn may subsequently lead to an overall reduction in psychological distress. CLINICAL TRIAL NUMBERS: BASEC Nr. 2017-0117 (Swiss trial) and NL61361.029.17, 7 September 2017 (Dutch trial).

Annual Research Review: Breaking cycles of violence - a systematic review and common practice elements analysis of psychosocial interventions for children and youth affected by armed conflict.

BACKGROUND: Globally, one in 10 children live in regions affected by armed conflict. Children exposed to armed conflict are vulnerable to social and emotional difficulties, along with disrupted educational and occupational opportunities. Most armed conflicts occur in low- and middle-income countries (LMICs), where mental health systems are limited and can be further weakened by the context of war. Research is needed to determine feasible and cost-effective psychosocial interventions that can be delivered safely by available mental health workforces (including nonspecialists). A vital first step toward achieving this is to examine evidence-based psychosocial interventions and identify the common therapeutic techniques being used across these treatments. METHODS: A systematic review of psychosocial interventions for conflict-affected children and youth living in LMICs was performed. Studies were identified through database searches (PsycINFO, PubMed, Cochrane Central Register of Controlled Trials, PILOTS and Web of Science Core Collection), hand-searching of reference lists, and contacting expert researchers. The PracticeWise coding system was used to distill the practice elements within clinical protocols. RESULTS: Twenty-eight randomized controlled trials and controlled trials conducted in conflict-affected settings, and 25 efficacious treatments were identified. Several practice elements were found across more than 50% of the intervention protocols of these treatments. These were access promotion, psychoeducation for children and parents, insight building, rapport building techniques, cognitive strategies, use of narratives, exposure techniques, and relapse prevention. CONCLUSIONS: Identification of the common practice elements of effective interventions for conflict-affected children and youth can inform essential future treatment development, implementation, and evaluation for this vulnerable population. To further advance the field, research should focus on identifying which of these elements are the active ingredients for clinical change, along with attention to costs of delivery, training, supervision and how to sustain quality implementation over time.

Peer-provided psychological intervention for Syrian refugees: results of a randomised controlled trial on the effectiveness of Problem Management Plus.

BACKGROUND: The mental health burden among refugees in high-income countries (HICs) is high, whereas access to mental healthcare can be limited. OBJECTIVE: To examine the effectiveness of a peer-provided psychological intervention (Problem Management Plus; PM+) in reducing symptoms of common mental disorders (CMDs) among Syrian refugees in the Netherlands. METHODS: We conducted a single-blind, randomised controlled trial among adult Syrian refugees recruited in March 2019-December 2021 (No. NTR7552). Individuals with psychological distress (Kessler Psychological Distress Scale (K10) >15) and functional impairment (WHO Disability Assessment Schedule (WHODAS 2.0) >16) were allocated to PM+ in addition to care as usual (PM+/CAU) or CAU only. Participants were reassessed at 1-week and 3-month follow-up. Primary outcome was depression/anxiety combined (Hopkins Symptom Checklist; HSCL-25) at 3-month follow-up. Secondary outcomes included depression (HSCL-25), anxiety (HSCL-25), post-traumatic stress disorder (PTSD) symptoms (PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition; PCL-5), impairment (WHODAS 2.0) and self-identified problems (PSYCHLOPS; Psychological Outcomes Profiles). Primary analysis was intention-to-treat. FINDINGS: Participants (n=206; mean age=37 years, 62% men) were randomised into PM+/CAU (n=103) or CAU (n=103). At 3-month follow-up, PM+/CAU had greater reductions on depression/anxiety relative to CAU (mean difference -0.25; 95% CI -0.385 to -0.122; p=0.0001, Cohen's d=0.41). PM+/CAU also showed greater reductions on depression (p=0.0002, Cohen's d=0.42), anxiety (p=0.001, Cohen's d=0.27), PTSD symptoms (p=0.0005, Cohen's d=0.39) and self-identified problems (p=0.03, Cohen's d=0.26), but not on impairment (p=0.084, Cohen's d=0.21). CONCLUSIONS: PM+ effectively reduces symptoms of CMDs among Syrian refugees. A strength was high retention at follow-up. Generalisability is limited by predominantly including refugees with a resident permit. CLINICAL IMPLICATIONS: Peer-provided psychological interventions should be considered for scale-up in HICs.

Feasibility and acceptability of Problem Management Plus (PM+) among Syrian refugees and asylum seekers in Switzerland: a mixed-method pilot randomized controlled trial.

Background: Syrian refugees in Switzerland face several barriers in accessing mental health care. Cost-effective psychological interventions are urgently needed to meet the mental health needs of refugees. Problem Management Plus (PM+) is an evidence-based, psychological intervention delivered by trained non-specialist 'helpers'. Objective: To assess the feasibility and acceptability of PM+ among Syrian refugees in Switzerland. Methods: We conducted a single-blind pilot randomized controlled trial (RCT) with Syrian refugees impaired by psychological distress (K10 > 15 and WHODAS 2.0 > 16). Participants were randomized to PM+ or Enhanced Treatment As Usual (ETAU). Participants were assessed at baseline, and 1 week and 3 months after the intervention, and completed measures indexing mental health problems and health care usage. Semi-structured interviews were conducted with different stakeholders. Results: N = 59 individuals were randomized into PM+ (n = 31) or ETAU (n = 28). N = 18 stakeholders were interviewed about facilitators and barriers for the implementation of PM+. Retention rates in the trial (67.8%) and mean intervention attendance (M = 3.94 sessions, SD = 1.97) were high. No severe events related to the study were reported. These findings indicate that the trial procedures and PM+ were feasible, acceptable and safe. Conclusions: The findings support the conduct of a definitive RCT and show that PM+ might have the potential to be scaled-up in Switzerland. The importance, as well as the challenges, of implementing and scaling-up PM+ in high-income countries, such as Switzerland, are discussed.

Antecedentes: Los refugiados Sirios en Suiza enfrentan varias barreras para acceder a la atención en salud mental. Se necesitan con urgencia intervenciones psicológicas costo-efectivas, para satisfacer las necesidades de salud mental de los refugiados. Enfrentar Problemas Plus (PM + por sus siglas en inglés) es una intervención psicológica basada en la evidencia proporcionada por 'ayudantes' capacitados no especializados.Objetivo: Evaluar la viabilidad y aceptabilidad de PM + entre los refugiados sirios en Suiza.Métodos: Realizamos un ensayo controlado aleatorizado (ECA) piloto simple y ciego con refugiados sirios afectados por angustia psicológica (K10 > 15 y WHODAS 2.0 > 16). Los participantes fueron asignados al azar a PM + o Tratamiento usual mejorado (TUM). Los participantes fueron evaluados al inicio del estudio, 1 semana, y 3 meses después de la intervención, y completaron instrumentos que referencian problemas de salud mental y el uso de la atención médica. Se realizaron entrevistas semiestructuradas con diferentes partes relevantes.Resultados:N = 59 individuos fueron asignados al azar a PM + (n = 31) o TUM (n = 28). N = 18 partes relevantes fueron entrevistados sobre facilitadores y barreras para la implementación de PM +. Las tasas de retención en el ensayo (67,8%) y la asistencia media a la intervención (M = 3,94 sesiones, DE = 1,97) fueron altas. No se informaron eventos graves relacionados con el estudio. Estos hallazgos indican que los procedimientos del ensayo y PM + fueron factibles, aceptables y seguros.Conclusiones: Los hallazgos apoyan la realización de un ECA definitivo y muestran que PM + podría tener el potencial de ampliarse en Suiza. Se discute la importancia, así como los desafíos, de implementar y ampliar PM + en países de altos ingresos, como Suiza.

Scalable psychological interventions for Syrian refugees in Europe and the Middle East: STRENGTHS study protocol for a prospective individual participant data meta-analysis.

INTRODUCTION: The World Health Organization's (WHO) scalable psychological interventions, such as Problem Management Plus (PM+) and Step-by-Step (SbS) are designed to be cost-effective non-specialist delivered interventions to reduce symptoms of common mental disorders, such as anxiety, depression and post-traumatic stress disorder (PTSD). The STRENGTHS consortium aims to evaluate the effectiveness, cost-effectiveness and implementation of the individual format of PM+ and its group version (gPM+), as well as of the digital SbS intervention among Syrian refugees in seven countries in Europe and the Middle East. This is a study protocol for a prospective individual participant data (IPD) meta-analysis to evaluate (1) overall effectiveness and cost-effectiveness and (2) treatment moderators of PM+, gPM+ and SbS with Syrian refugees. METHODS AND ANALYSIS: Five pilot randomised controlled trials (RCTs) and seven fully powered RCTs conducted within STRENGTHS will be combined into one IPD meta-analytic dataset. The RCTs include Syrian refugees of 18 years and above with elevated psychological distress (Kessler Psychological Distress Scale (K10>15)) and impaired daily functioning (WHO Disability Assessment Schedule 2.0 (WHODAS 2.0>16)). Participants are randomised into the intervention or care as usual control group, and complete follow-up assessments at 1-week, 3-month and 12-month follow-up. Primary outcomes are symptoms of depression and anxiety (25-item Hopkins Symptom Checklist). Secondary outcomes include daily functioning (WHODAS 2.0), PTSD symptoms (PTSD Checklist for DSM-5) and self-identified problems (PSYCHLOPS). We will conduct a one-stage IPD meta-analysis using linear mixed models. Quality of evidence will be assessed using the GRADE approach, and the economic evaluation approach will be assessed using the CHEC-list. ETHICS AND DISSEMINATION: Local ethical approval has been obtained for each RCT. This IPD meta-analysis does not require ethical approval. The results of this study will be published in international peer-reviewed journals.

A systematic review and meta-analysis of diagnostic test accuracy studies of self-report screening instruments for common mental disorders in Arabic-speaking adults.

BACKGROUND: Self-report screening instruments are frequently used as scalable methods to detect common mental disorders (CMDs), but their validity across cultural and linguistic groups is unclear. We summarized the diagnostic accuracy of brief questionnaires on symptoms of depression, anxiety and posttraumatic stress disorder (PTSD) among Arabic-speaking adults. METHODS: Five databases were searched from inception to 22 January 2021 (PROSPERO: CRD42018070645). Studies were included when diagnostic accuracy of brief (maximally 25 items) psychological questionnaires was assessed in Arabic-speaking populations and the reference standard was a clinical interview. Data on sensitivity/specificity, area under the curve, and data to generate 2 × 2 tables at various thresholds were extracted. Meta-analysis was performed using the diagmeta package in R. Quality of studies was assessed with QUADAS-2. RESULTS: Thirty-two studies (N participants = 4042) reporting on 17 questionnaires with 5-25 items targeting depression/anxiety (n = 14), general distress (n = 2), and PTSD (n = 1) were included. Seventeen studies (53%) scored high risk on at least two QUADAS-2 domains. The meta-analysis identified an optimal threshold of 11 (sensitivity 76.9%, specificity 85.1%) for the Edinburgh Postnatal Depression Scale (EPDS) (n studies = 7, n participants = 711), 7 (sensitivity 81.9%, specificity 87.6%) for the Hospital Anxiety and Depression Scale (HADS) anxiety subscale and 6 (sensitivity 73.0%, specificity 88.6%) for the depression subscale (n studies = 4, n participants = 492), and 8 (sensitivity 86.0%, specificity 83.9%) for the Self-Reporting Questionnaire (SRQ-20) (n studies = 4, n participants = 459). CONCLUSION: We present optimal thresholds to screen for perinatal depression with the EPDS, anxiety/depression with the HADS, and CMDs with the SRQ-20. More research on Arabic-language questionnaires, especially those targeting PTSD, is needed.

Problems faced by Syrian refugees and asylum seekers in Switzerland.

BACKGROUND: Refugees and asylum seekers are susceptible to developing common mental disorders due to their exposure to stressful experiences before, during and after their flight. The Syrian Civil War, which started in 2011, has led to a massive number of Syrians seeking refuge and asylum in European countries, including Switzerland. Currently, Syrians are the second-largest refugee and asylum-seeking population in Switzerland. However, very little is known about the problems faced by this new population in Switzerland and their needs relating to mental health services. Identifying the problems faced by this community is crucial to providing adapted and tailored mental health services to Syrian refugees in Switzerland. AIM OF HE STUDY: The current study aimed to identify problems that Syrian refugees and asylum seekers face daily while living in Switzerland in order to inform the adaptation of a brief psychological intervention. METHODS: We used a cross-sectional, qualitative design and collected data according to The Manual for Design, Implementation, Monitoring and Evaluation of Mental Health and Psychosocial Assistance Programs for Trauma Survivors in order to identify problems perceived by the target population. Free-listing, open-ended interviews were conducted with 30 adult Syrian refugees and asylum seekers and analyzed using thematic analysis. RESULTS: The results show that besides physical health problems, Syrians experience primarily two types of problems: practical and psychological (emotional) problems. These two types of problems are closely interrelated. The most common practical problems (problems with government and authorities, problems related to residence permits, problems with integration, cultural differences, language problems, problems related to education, problems related to employment, and problems with housing) were reported by almost half of all participants. Symptoms of mental disorders and feelings of uncertainty, frustration and injustice were the most common psychological problems and were mentioned by more than one third of the participants. The finding that almost half of the participants reported typical symptoms of mental health disorders suggests that a considerable number of Syrian refugees and asylum seekers might need mental healthcare. CONCLUSIONS: Authorities, practitioners and researchers should recognize that Syrian refugees and asylum seekers are strongly affected by a broad range of problems. Besides practical problems, they suffer a multitude of psychological problems, and a significant number of them report, among other issues, symptoms of mental health disorders. Officials working with this population should be aware of this vulnerability and be prepared to refer clients in need of mental healthcare to mental healthcare providers. Moreover, the significant variety and number of problems experienced by this population should be taken into consideration when developing solutions tailored to their needs. BACKGROUND: Refugees and asylum seekers are susceptible to developing common mental disorders due to their exposure to stressful experiences before, during and after their flight. The Syrian Civil War, which started in 2011, has led to a massive number of Syrians seeking refuge and asylum in European countries, including Switzerland. Currently, Syrians are the second-largest refugee and asylum-seeking population in Switzerland. However, very little is known about the problems faced by this new population in Switzerland and their needs relating to mental health services. Identifying the problems faced by this community is crucial to providing adapted and tailored mental health services to Syrian refugees in Switzerland. AIM OF HE STUDY: The current study aimed to identify problems that Syrian refugees and asylum seekers face daily while living in Switzerland in order to inform the adaptation of a brief psychological intervention. METHODS: We used a cross-sectional, qualitative design and collected data according to The Manual for Design, Implementation, Monitoring and Evaluation of Mental Health and Psychosocial Assistance Programs for Trauma Survivors in order to identify problems perceived by the target population. Free-listing, open-ended interviews were conducted with 30 adult Syrian refugees and asylum seekers and analyzed using thematic analysis. RESULTS: The results show that besides physical health problems, Syrians experience primarily two types of problems: practical and psychological (emotional) problems. These two types of problems are closely interrelated. The most common practical problems (problems with government and authorities, problems related to residence permits, problems with integration, cultural differences, language problems, problems related to education, problems related to employment, and problems with housing) were reported by almost half of all participants. Symptoms of mental disorders and feelings of uncertainty, frustration and injustice were the most common psychological problems and were mentioned by more than one third of the participants. The finding that almost half of the participants reported typical symptoms of mental health disorders suggests that a considerable number of Syrian refugees and asylum seekers might need mental healthcare. CONCLUSIONS: Authorities, practitioners and researchers should recognize that Syrian refugees and asylum seekers are strongly affected by a broad range of problems. Besides practical problems, they suffer a multitude of psychological problems, and a significant number of them report, among other issues, symptoms of mental health disorders. Officials working with this population should be aware of this vulnerability and be prepared to refer clients in need of mental healthcare to mental healthcare providers. Moreover, the significant variety and number of problems experienced by this population should be taken into consideration when developing solutions tailored to their needs. BACKGROUND: Refugees and asylum seekers are susceptible to developing common mental disorders due to their exposure to stressful experiences before, during and after their flight. The Syrian Civil War, which started in 2011, has led to a massive number of Syrians seeking refuge and asylum in European countries, including Switzerland. Currently, Syrians are the second-largest refugee and asylum-seeking population in Switzerland. However, very little is known about the problems faced by this new population in Switzerland and their needs relating to mental health services. Identifying the problems faced by this community is crucial to providing adapted and tailored mental health services to Syrian refugees in Switzerland. AIM OF HE STUDY: The current study aimed to identify problems that Syrian refugees and asylum seekers face daily while living in Switzerland in order to inform the adaptation of a brief psychological intervention. METHODS: We used a cross-sectional, qualitative design and collected data according to The Manual for Design, Implementation, Monitoring and Evaluation of Mental Health and Psychosocial Assistance Programs for Trauma Survivors in order to identify problems perceived by the target population. Free-listing, open-ended interviews were conducted with 30 adult Syrian refugees and asylum seekers and analyzed using thematic analysis. RESULTS: The results show that besides physical health problems, Syrians experience primarily two types of problems: practical and psychological (emotional) problems. These two types of problems are closely interrelated. The most common practical problems (problems with government and authorities, problems related to residence permits, problems with integration, cultural differences, language problems, problems related to education, problems related to employment, and problems with housing) were reported by almost half of all participants. Symptoms of mental disorders and feelings of uncertainty, frustration and injustice were the most common psychological problems and were mentioned by more than one third of the participants. The finding that almost half of the participants reported typical symptoms of mental health disorders suggests that a considerable number of Syrian refugees and asylum seekers might need mental healthcare. CONCLUSIONS: Authorities, practitioners and researchers should recognize that Syrian refugees and asylum seekers are strongly affected by a broad range of problems. Besides practical problems, they suffer a multitude of psychological problems, and a significant number of them report, among other issues, symptoms of mental health disorders. Officials working with this population should be aware of this vulnerability and be prepared to refer clients in need of mental healthcare to mental healthcare providers. Moreover, the significant variety and number of problems experienced by this population should be taken into consideration when developing solutions tailored to their needs.

Structural and socio-cultural barriers to accessing mental healthcare among Syrian refugees and asylum seekers in Switzerland.

Background: Due to their experiences of major stressful life events, including post-displacement stressors, refugees and asylum seekers are vulnerable to developing mental health problems. Yet, despite the availability of specialized mental health services in Western European host countries, refugees and asylum seekers display low mental healthcare utilization. Objective: The aim of this study was to explore structural and socio-cultural barriers to accessing mental healthcare among Syrian refugees and asylum seekers in Switzerland. Method: In this qualitative study, key-informant (KI) interviews with Syrian refugees and asylum seekers, Swiss healthcare providers and other stakeholders (e.g. refugee coordinators or leaders) were conducted in the German-speaking part of Switzerland. Participants were recruited using snowball sampling. Interviews were audiotaped and transcribed, and then analysed using thematic analysis, combining deductive and inductive coding. Results: Findings show that Syrian refugees and asylum seekers face multiple structural and socio-cultural barriers, with socio-cultural barriers being perceived as more pronounced. Syrian key informants, healthcare providers, and other stakeholders identified language, gatekeeper-associated problems, lack of resources, lack of awareness, fear of stigma and a mismatch between the local health system and perceived needs of Syrian refugees and asylum seekers as key barriers to accessing care. Conclusions: The results show that for Syrian refugees and asylum seekers in Switzerland several barriers exist. This is in line with previous findings. A possible solution for the current situation might be to increase the agility of the service system in general and to improve the willingness to embrace innovative paths, rather than adapting mental healthcare services regarding single barriers and needs of a new target population.

Revista Europea de PsicotraumatologíaAntecedentes: Debido a sus experiencias de eventos vitales estresantes mayores, incluidos los estresores posteriores al desplazamiento, los refugiados y solicitantes de asilo son vulnerables a desarrollar problemas de salud mental. Sin embargo, a pesar de la disponibilidad de servicios especializados de salud mental en los países hospedadores de Europa occidental, los refugiados y los solicitantes de asilo muestran una baja utilización de cuidados salud mental.Objetivo: El objetivo de este estudio fue explorar las barreras estructurales y socioculturales para acceder a cuidados de salud mental para refugiados y solicitantes de asilo sirios, en Suiza.Método: En este estudio cualitativo, se realizaron entrevistas informante-clave (IC) con refugiados y solicitantes de asilo sirios, proveedores de cuidados de salud suizos y otros grupos de interes (por ejemplo, coordinadores o líderes de refugiados) en la parte de habla alemana de Suiza. Los participantes fueron reclutados mediante muestreo de bola de nieve. Las entrevistas fueron grabadas en audio y transcritas, y luego analizadas mediante análisis temático, combinando codificación deductiva e inductiva.Resultados: Los resultados muestran que los refugiados y solicitantes de asilo sirios, enfrentan múltiples barreras estructurales y socioculturales, siendo las socio-culturales percibidas como más pronunciadas. Los informantes-clave sirios, los proveedores de cuidados de salud y otras grupos de interes, identificaron el idioma, problemas asociados con la puerta de entrada a las instituciones, falta de recursos, falta de conciencia, miedo al estigma y discordancia entre el sistema de salud local y las necesidades percibidas de los sirios refugiados y solicitantes de asilo como barreras clave para acceder a la atención.Conclusiones: Los resultados muestran que para los refugiados y solicitantes de asilo sirios en Suiza existen varias barreras. Esto está en línea con hallazgos previos. Una posible solución para la situación actual podría ser aumentar la agilidad del sistema de servicios en general y mejorar la disposición a adoptar caminos innovadores, en lugar de adaptar los servicios de salud mental con respecto a las barreras y necesidades individuales de una nueva población objetivo.

Protocol for a randomized controlled trial: peer-to-peer Group Problem Management Plus (PM+) for adult Syrian refugees in Turkey.

BACKGROUND: A large proportion of Syrians have been exposed to potentially traumatic events, multiple losses, and breakdown of supportive social networks and many of them have sought refuge in host countries where they also face post-migration living difficulties such as discrimination or integration problems or both. These adversities may put Syrian refugees at high risk for common mental disorders. In response to this, the World Health Organization (WHO) developed a trans-diagnostic scalable psychological intervention called Problem Management Plus (PM+) to reduce psychological distress among populations exposed to adversities. PM+ has been adapted for Syrian refugees and can be delivered by non-specialist peer lay persons in the community. METHODS: A randomized controlled trial (RCT) will be conducted with 380 Syrian refugees in Turkey. After providing informed consent, participants with high levels of psychological distress (scoring above 15 on the Kessler-10 Psychological Distress Scale (K10)) and functional impairment (scoring above 16 on the WHO Disability Assessment Schedule 2.0, or WHODAS 2.0) will be randomly assigned to Group PM+/enhanced care as usual (Group PM+/E-CAU) (n = 190) or E-CAU (n = 190). Outcome assessments will take place 1 week after the fifth session (post-assessment), 3 months after the fifth session and 12 months after baseline assessment. The primary outcome is psychological distress as measured by the Hopkins Symptom Checklist (HSCL-25). Secondary outcomes include functional impairment, post-traumatic stress symptoms, self-identified problems, and health system and productivity costs. A process evaluation will be conducted to explore the feasibility, challenges and success of the intervention with 25 participants, including participants, facilitators, policy makers and mental health professionals. DISCUSSION: The treatment manual of the Syrian-Arabic Group PM+ and training materials will be made available through the WHO once the effectiveness and cost-effectiveness of Group PM+ have been established. TRIAL REGISTRATION: Clinical Trial Registration: ClinicalTrials.gov Identifier NCT03960892. Unique protocol ID: 10/2017. Prospectively registered on 21 May 2019.

Effectiveness of a peer-refugee delivered psychological intervention to reduce psychological distress among adult Syrian refugees in the Netherlands: study protocol.

Background: Syrian refugees face multiple hardships and adversities which put them at risk for the development of mental health problems. However, access to adequate mental health care in host countries is limited. The WHO has developed Problem Management Plus (PM+), a brief, scalable psychological intervention, delivered by non-specialist helpers, that addresses common mental disorders in people affected by adversity. This study is part of the STRENGTHS project, that aims to evaluate peer-refugee delivered psychological interventions for Syrian refugees in Europe and the Middle East. Objective: To evaluate the effectiveness and cost-effectiveness of the peer-refugee delivered PM+ intervention among Syrian refugees with elevated levels of psychological distress in the Netherlands. Methods: PM+ will be tested in a randomized controlled trial (RCT) among Arabic-speaking Syrian refugees in the Netherlands aged 18 years and above with self-reported psychological distress (Kessler Psychological Distress Scale; K10 >15) and impaired daily functioning (WHO Disability Assessment Schedule; WHODAS 2.0 >16). Participants (N = 380) will be randomized into care as usual with PM+ (CAU/PM+, n = 190) or CAU only (CAU, n = 190). Baseline, 1-week post-intervention, and 3-month and 12-month follow-up assessments will be conducted. Primary outcomes are symptoms of depression and anxiety. Secondary outcomes are functional impairment, posttraumatic stress disorder symptoms, self-identified problems, anger, health and productivity costs, and hair cortisol concentrations. A process evaluation will be carried out to evaluate treatment dose, protocol fidelity and stakeholder views on barriers and facilitators to implementing PM+. Results and Conclusions: PM+ has proved effectiveness in other populations and settings. After positive evaluation, the adapted manual and training materials for individual PM+ will be made available through the WHO to encourage further replication and scaling up. Trial registration: Trial registration Dutch Trial Registry, NL7552, registered prospectively on March 1, 2019. Medical Ethics Review Committee VU Medical Center Protocol ID 2017.320, 7 September 2017.

Antecedentes: Los refugiados sirios atraviesan muchas dificultades y adversidades, las cuales los ponen en riesgo para el desarrollo de problemas de salud mental. Sin embargo, el acceso a servicios de salud mental en los países que albergan a refugiados es limitado. La Organización Mundial de la Salud (OMS) ha desarrollado la intervención de Gestión de Problemas Plus (PM+, por sus siglas en inglés), una intervención psicológica breve, en etapas, realizada por facilitadores no especialistas, y que está dirigido al abordaje de los trastornos mentales más comunes en personas afectadas por la adversidad. Este estudio es parte de un proyecto más grande llamado STRENGTHS, cuyo objetivo es evaluar las intervenciones psicológicas brindadas por un refugiado a otro adaptadas para refugiados sirios en Europa y Medio Oriente.Objetivo: Evaluar la efectividad y costo-efectividad de la adaptación de la intervención PM+ brindada por un refugiado a otro, en refugiados sirios con niveles elevados de malestar psicologico en los Países Bajos.Métodos: La adaptación de la intervención PM+ será evaluada en un ensayo clínico aleatorizado en refugiados sirios de habla árabe en los Países Bajos, en mayores de 18 años, con malestar psicológico auto-reportado (mediante la Escala de Kessler para Malestar Psicológico, K10>15) y deterioro en el funcionamiento diario (Registro de Evaluación de Discapacidad de la OMS; WHODAS 2.0 >16). Los participantes (N=380) serán distribuidos aleatoriamente en un grupo de tratamiento usual con PM+ (TU/PM+, n=190) y en uno de solo tratamiento usual (TU, n=190). Se tomarán evaluaciones de base, luego de la primera semana de la intervención, luego de los tres meses, y luego de los 12 meses. Estas evaluaciones serán asistidas por una aplicación de auto-entrevista con soporte de audio para tablet. Los resultados primarios son los síntomas de depresión y ansiedad. Los resultados primarios son los síntomas de depresión y ansiedad. Los resultados secundarios son el deterioro funcional, síntomas de estrés traumático, problemas auto-identificados, ira, costos en salud y productividad, y concentraciones de cortisol en el cabello. Se realizará un proceso de evaluación para valorar las opiniones de los interesados respecto a las barreras y facilitadores para implementar la intervención PM+, así como la dosis del tratamiento y la adherencia al protocolo.Discusión: La intervención PM+ ha mostrado efectividad en otras poblaciones y escenarios. Luego de obtener una evaluación positiva de la PM+ en refugiados sirios, se harán disponibles manuales y material de entrenamiento para PM+ individual a través de la OMS, de manera que se incentive la posterior replicación de la intervención y se aumente progresivamente su aplicación.

A Systematic Review of Amenable Resilience Factors That Moderate and/or Mediate the Relationship Between Childhood Adversity and Mental Health in Young People.

Background: Up to half of Western children and adolescents experience at least one type of childhood adversity. Individuals with a history of childhood adversity have an increased risk of psychopathology. Resilience enhancing factors reduce the risk of psychopathology following childhood adversity. A comprehensive overview of empirically supported resilience factors is critically important for interventions aimed to increase resilience in young people. Moreover, such an overview may aid the development of novel resilience theories. Therefore, we conducted the first systematic review of social, emotional, cognitive and/or behavioral resilience factors after childhood adversity. Methods: We systematically searched Web of Science, PsycINFO, and Scopus (e.g., including MEDLINE) for English, Dutch, and German literature. We included cohort studies that examined whether a resilience factor was a moderator and/or a mediator for the relationship between childhood adversity and psychopathology in young people (mean age 13-24). Therefore, studies were included if the resilience factor was assessed prior to psychopathology, and childhood adversity was assessed no later than the resilience factor. Study data extraction was based on the STROBE report and study quality was assessed with an adapted version of Downs and Black's scale. The preregistered protocol can be found at: http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42016051978. Results: The search identified 1969 studies, of which 22 were included (eight nationalities, study sample n range: 59-6780). We found empirical support for 13 of 25 individual-level (e.g., high self-esteem, low rumination), six of 12 family-level (e.g., high family cohesion, high parental involvement), and one of five community-level resilience factors (i.e., high social support), to benefit mental health in young people exposed to childhood adversity. Single vs. multiple resilience factor models supported the notion that resilience factors should not be studied in isolation, and that interrelations between resilience factors should be taken into account when predicting psychopathology after childhood adversity. Conclusions: Interventions that improve individual, family, and/or social support resilience factors may reduce the risk of psychopathology following childhood adversity. Future research should scrutinize whether resilience factors function as a complex interrelated system that benefits mental health resilience after childhood adversity.