Go with your gut! The beneficial mood effects of intuitive decisions.

People make countless decisions every day. We explored the self-regulatory function of decisions and assumed that the very act of making a decision in everyday life enhances people's mood. We expected that this decision-related mood change would be more pronounced for intuitive decisions than for analytical ones. The ease of making a decision and the feeling of rightness were expected to mediate the effect of intuitive (vs. analytical) decisions on participants' mood. In a preregistered experimental experience sampling study, participants from the general population were asked to report when they were about to make an everyday decision over the course of 14 days (N = 256 participants, 6,779 decisions). For each decision, participants were randomly instructed to decide either based on their intuition or based on careful analysis. We assessed several variables before and immediately after the decision. Participants also reported retrospectively on their choices in voluntary follow-up assessments. Making a decision per se immediately enhanced participants' mood. This mood enhancement was stronger for intuitive compared to analytic decisions and persisted until follow-up. Ease of decision, but not feeling of rightness, mediated this effect. Intuitive decisions compared to analytic decisions were more likely to be implemented and led to greater satisfaction and pleasantness of the chosen option. Having more options for a particular decision led to generally higher mood improvement and satisfaction. This is the first empirical demonstration showing that using one's gut has beneficial effects in everyday life. Study limitations and implications for theory and practice are discussed. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

[Risk Factors for Secondary Traumatic Stress (STS) and Post-Traumatic Stress Disorder (PTSD) in Interpreters with Personal Trauma Experience]. / Risikofaktoren für sekundären traumatischen Stress (STS) und Posttraumatische Belastungsstörung (PTBS) bei Dolmetschenden mit eigener Traumaerfahrung.

BACKGROUND: Interpreters play a crucial role in the care of refugees. However, little attention has been paid to the mental health of interpreters. Despite increased levels of secondary traumatic stress (STS) and increased prevalence of post-traumatic stress disorder (PTSD) among interpreters in the refugee context, there has been little research on risk factors for STS and PTSD in this population. The aim of this study was to investigate potential risk factors for STS and PTSD symptom severity. METHODS: A Germany-wide online survey was conducted among interpreters for refugees in 2019. Only those who stated that they had experienced at least one traumatic event were included in the study. The final sample comprises N=83 interpreters. The examination of the potential risk factors (primary traumatic events, traumatic content, and personal refugee background) as well as the interaction between primary traumatic events and traumatic content was carried out using moderated multiple regression. RESULTS: There was exclusively found a positive association between the number of primary traumatic events for both STS (p=0.003) and PTSD symptom severity (p=0.042). DISCUSSION/CONCLUSION: In the present study, the number of primary traumatic events experienced was identified as a potential risk factor for STS and PTSD. The institutionalization of preventive measures such as regular supervision, follow-up talks, and interpreter-specific training could make an important contribution to protecting the mental health of interpreters. Further research is needed to gain a better understanding of risk factors for STS and PTSD in interpreters.

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

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

Location-scale modeling as an integrative approach to symptom dynamics during psychotherapy: An illustration with depressive symptoms.

OBJECTIVE: Depressive symptom dynamics, including change trajectories and symptom variability, have been related to therapy outcomes. However, such dynamics have often been examined separately and related to outcomes of interest using two-step analyses, which are characterized by several limitations. Here, we show how to overcome these limitations using location-scale models in a dynamic structural equation modeling framework. METHOD: We introduce location-scale modeling in an accessible manner to pave the way for its use in research integrating within-person dynamics and intervention-related change in psychopathology, and we illustrate this modeling approach in a large-scale internet-based intervention for depression (N = 1,656). Using eight data points sampled across about 8 weeks, we predicted improvement across the intervention (50% symptom reduction) as a function of early change and symptom variability. RESULTS: Early symptom change was associated with a more likely improvement across therapy. Variability of symptoms beyond change trajectories during the intervention was associated with less likely improvement. CONCLUSIONS: Location-scale models, and dynamic structural equation modeling more generally, are well suited to modeling how patterns of symptom change during psychotherapy are related to important (e.g., therapy) outcomes. Our illustrative application of location-scale modeling showed that symptom variability was associated with less overall improvement in depressive symptoms. However, this finding requires replication with more intensive sampling of symptoms before final conclusions can be drawn on when and how to distinguish maladaptive from adaptive variability during psychotherapy. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Sex and gender differences in risk factors for posttraumatic stress disorder: A systematic review and meta-analysis of prospective studies.

Women are at higher risk than men for developing posttraumatic stress disorder (PTSD), but underlying mechanisms are still unclear. Comprehensive knowledge about these mechanisms is necessary to develop tailored, sex- and gender-sensitive preventive interventions. This systematic review and meta-analysis examined sex-/gender-dependent risk factors, that is, risk factors with sex/gender differences in (a) vulnerability or (b) prevalence/severity, as well as sex-/gender-specific risk factors, that is, and (c) risk factors present in one sex/gender only. We searched PubMed, Web of Science, PsycINFO, PsycArticles, and PSYNDEX for articles published until October 16, 2022. We included prospective studies that assessed risk factors to predict subsequent PTSD symptom severity, as measured with the Clinician-Administered PTSD scale. The primary outcomes were sex/gender stratified pooled for sex-/gender-dependent vulnerability and sex-/gender-specific risk factors and pooled odds ratio (OR) or standardized mean difference (SMD) for sex-/gender-dependent risk factor prevalence/severity. We screened 17,270 records and included 117 reports from 45 studies (N = 13,752) in the systematic review. Seventeen studies (N = 4,257; 1,827 women, 2,430 men) were included in the meta-analysis. Regarding risk factor vulnerability, analyses revealed no significant sex/gender differences except for acute stress symptoms, with stronger associations for men (b = 0.11, SE = 0.06, p < .05). Regarding risk factor prevalence/severity, women reported more severe immediate psychological stress responses (range SMD = 0.23-0.56) and more commonly had a history of mental illness (OR = 1.81, 1.27-2.58). Men showed higher trauma load (SMD = -0.15, -0.29 to 0.01). Few women-specific and no men-specific factors were identified. Results suggest that women's heightened immediate psychological stress response drives sex/gender disparities in PTSD symptom severity. Preventive interventions should thus target women early after trauma. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

An internet-based cognitive behavioural intervention for adults with depression in Arabic-speaking countries: A randomized controlled trial.

Internet-based interventions have proven to be effective for the treatment of depression in different samples, but evidence from the Middle East and North Africa (MENA) region is scarce. The aim of this study was to investigate the acceptance and efficacy of an internet-based cognitive behavioural writing intervention for Arabic-speaking participants with depression living in the MENA region. A total of 259 participants (167 female, age in years: M = 25.58, SD = 6.39) with depressive symptoms indicative of clinical relevance were randomly allocated to a treatment group (TG; nTG = 128) or a waitlist control group (WG; nWG = 131). The TG received an internet-based intervention over a 6-week period. The primary outcome was depressive symptoms, and secondary outcomes were anxiety and quality of life (QoL). T-tests with change scores from pre- to post-treatment were used for data analyses. Intention-to-treat (ITT) as well as completer analyses were calculated. The ITT analysis revealed significant differences between the TG and WG in depression (T257 = -4.89, p < 0.001, d = 0.70) and QoL (T257 = 3.39, p < 0.001, d = 0.47). Significant differences regarding anxiety symptoms (T257 = 3.25, p < 0.05, d = 0.53) were identified for the completer sample. The general dropout rate was 39.9%. The results indicate the feasibility and efficacy of an internet-based cognitive behavioural writing intervention in adults from Arabic-speaking countries. The development and implementation of such interventions can be used to improve access to psychological help and adequate treatment.

Randomized controlled trial of two internet-based written therapies for world trade center workers and survivors with persistent PTSD symptoms.

Posttraumatic stress disorder (PTSD) remains prevalent among individuals exposed to the 9/11 World Trade Center (WTC) terrorist attacks. The present study compared an Internet-based, therapist-assisted psychotherapy for PTSD to an active control intervention in WTC survivors and recovery workers with WTC-related PTSD symptoms (n = 105; 75% syndromal PTSD). Participants were randomized to integrative testimonial therapy (ITT), focused on WTC-related trauma, or modified present-centered therapy (I-MPCT), each comprising 11 assigned written narratives. The primary outcome was baseline-to-post-treatment change in PTSD symptoms on the PTSD Checklist for DSM-5 (PCL-5). Secondary measures included PTSD symptom clusters, depressive/anxiety symptoms, functioning, and quality of life. A significant main effect of time was observed for the primary outcome (average "large" effect size improvement, d = 1.49). Significant and "moderate-to-large" main effects of time were also observed for all PTSD symptom clusters, depressive symptoms, quality of life, and mental health-related functioning (d range=0.62-1.33). Treatment and treatment-by-time interactions were not significant. In planned secondary analyses incorporating 3-month follow-up measures, ITT was associated with significantly greater reductions than I-MPCT in PTSD avoidance and negative alterations in cognitions and mood, anxiety, and mental health-related functioning. Both therapies significantly lowered PTSD symptoms, suggesting they may benefit hard-to-reach individuals with chronic WTC-related PTSD symptoms.

Higher risk-less data: A systematic review and meta-analysis on the role of sex and gender in trauma research.

Women and men are at different risk for posttraumatic stress disorder (PTSD). It is unclear, however, how studies on PTSD risk factors integrate this knowledge into their research. Moreover, the temporal development of women's higher PTSD risk is unknown. In this systematic review and meta-analysis, we examine how prospective studies on PTSD development (k = 47) consider sex and gender across four domains (samples, terminology, analyses, and reporting). Further, we differentially analyze sex/gender differences within five time intervals from 1 month to 5 years posttrauma. PTSD prevalence (OR = 1.72 [1.27-2.34]) and severity (g = 0.31 [0.09, 0.53]) were increased for women relative to men at 1 month posttrauma already, that is, at the first timepoint of a possible PTSD diagnosis. PTSD severity was elevated for women compared to men across all time intervals, but evidence for increased PTSD prevalence for women relative to men was less stable with longer follow-ups. Despite women's higher PTSD burdens, they were clearly underrepresented in samples (68.3% male, 31.7% female participants). Only 5.0% of studies explained or described their understanding of sex and gender, and only 2.6% used sex as discovery variable, that is, investigating sex-dependent risk mechanisms. Sex and gender aspects in design, data, and discussion were considered by only one-third of studies each. Trauma research falls short of its potential to adequately consider sex and gender. Sex- and gender-sensitive practices can advance rigor, innovation, and equity in psychopathology research. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Changes in trauma appraisal during brief internet-based exposure and cognitive restructuring treatment for Arabic-speaking people with PTSD.

Background: Maladaptive trauma appraisal plays an important role in the development and maintenance of posttraumatic stress disorder (PTSD). While studies have demonstrated the effectiveness of exposure and cognitive treatments for PTSD symptomatology, the effect of such treatments on specific trauma appraisals is still not well understood.Objective: The study investigated the effect of an exposure and a cognitive restructuring internet-based treatment on specific trauma appraisals in Arabic-speaking participants with PTSD.Method: 334 participants received either an exposure (n = 167) or a cognitive restructuring (n = 167) internet-based treatment. PTSD symptom severity (PCL-5) and specific trauma appraisals (TAQ) were assessed at pre- and post-treatment. Changes in specific trauma appraisals within and between the two treatments were analyzed using multi-group change modelling. Associations between changes in PTSD symptom severity and changes in trauma appraisals were evaluated using Pearson product-moment correlation. For both treatments, participants with versus without reliable improvement were compared regarding changes in specific trauma appraisals using Welch tests. Analyses were performed on 100 multiple imputed datasets.Results: Both treatments yielded significant changes in shame, self-blame, fear, anger, and alienation (all ps < .001). Changes in betrayal were only significant in the cognitive restructuring treatment (p < .001). There was no evidence of differences between treatments for any specific trauma appraisal. Changes in PTSD symptom severity were significantly associated with changes in trauma appraisals (all ps < .001). In both treatments, participants who experienced reliable improvement in PTSD symptom severity showed significantly larger pre- to post-treatment changes in specific trauma appraisals compared to those without reliable improvement. Again, differences in betrayal were only significant in the cognitive restructuring treatment.Conclusions: The findings indicate that both treatments are effective in reducing trauma appraisals in Arabic-speaking people with PTSD. Changes in trauma appraisal seem to be associated with changes in PTSD symptomatology.Trial registration: German Clinical Trials Register identifier: DRKS00010245.

Exposure and cognitive restructuring treatment in Arabic-speaking individuals with PTSD yield significant changes in shame, self-blame, fear, anger, and alienation.Changes in PTSD symptoms are positively associated with changes in specific trauma appraisals.There is no evidence of differences between both treatments for any specific trauma appraisal.

Higher Depressive Symptoms in Irregular Menstrual Cycles: Converging Evidence from Cross-Sectional and Prospective Assessments.

BACKGROUND: Menstrual cycle regularity is an important marker of reproductive health and associated with physiological and psychological illnesses, as well as experiencing stress. We hypothesized that individuals with irregular menstrual cycles report higher depressive symptom severity, after controlling for stress occurrence. METHODS: The hypothesis was examined through two measurement approaches: a cross-sectional and a prospective, longitudinal study. In the cross-sectional study, participants (n = 394) reported depressive symptoms and their overall menstrual cycle regularity. In the longitudinal study, participants (n = 77) completed questionnaires on depressive symptoms and stress during the mid-follicular and periovulatory phase of one menstrual cycle. Depressive symptoms were compared between participants with regular and irregular cycles through a Welch t test and an ANCOVA. RESULTS: Participants with irregular menstrual cycles reported more depressive symptoms in the cross-sectional analysis. Similarly, in the longitudinal analysis, the group with a current irregular menstrual cycle reported more depressive symptoms after controlling for stress occurrence. When including only complete data sets without multiple imputation (n = 52), the direction of the effects remained but did not reach statistical significance. CONCLUSIONS: The results indicate an association between depressive symptoms and menstrual cycle irregularity. Limitations were that although we investigated the menstrual cycle prospectively, it would have been more precise to include two or more cycles and daily sex hormone measurements. Further limitations were the suboptimal statistical power and the data collection during the COVID pandemic. We give recommendations on how to incorporate the association of depressive symptoms and cycle irregularity in future study designs on women's mental health.

Internet-based transdiagnostic treatment for emotional disorders in Arabic- and Farsi-speaking refugees: study protocol of a randomized controlled trial.

BACKGROUND: Refugee populations have an increased risk for mental disorders, such as depression, anxiety, and posttraumatic stress disorders. Comorbidity is common. At the same time, refugees face multiple barriers to accessing mental health treatment. Only a minority of them receive adequate help. The planned trial evaluates a low-threshold, transdiagnostic Internet-based treatment. The trial aims at establishing its efficacy and cost-effectiveness compared with no treatment. METHODS: N = 131 treatment-seeking Arabic- or Farsi-speaking patients, meeting diagnostic criteria for a depressive, anxiety, and/or posttraumatic stress disorder will be randomized to either the intervention or the waitlist control group. The intervention group receives an Internet-based treatment with weekly written guidance provided by Arabic- or Farsi-speaking professionals. The treatment is based on the Common Elements Treatment Approach (CETA), is tailored to the individual patient, and takes 6-16 weeks. The control group will wait for 3 months and then receive the Internet-based treatment. DISCUSSION: The planned trial will result in an estimate of the efficacy of a low-threshold and scalable treatment option for the most common mental disorders in refugees. TRIAL REGISTRATION: German Registry for Clinical Trials DRKS00024154. Registered on February 1, 2021.

A web-based psychological support program for caregivers of children with rare chronic diseases: a randomized controlled trial.

BACKGROUND: Approximately 50% of rare diseases have symptom onset during childhood. A high level of nursing care and an often uncertain prognosis put caregivers of the affected children at high risk for psychological distress. At the same time, their caregivers have limited access to appropriate psychological care. The aim of this study was to evaluate a web-based psychological support program for caregivers of children with chronic rare diseases (WEP-CARE). METHODS: German-speaking parents (recruited between May 2016 and March 2018) caring for children aged 0-25 years with a rare disease showing clinically relevant anxiety symptoms, were assigned to either the WEP-CARE (n = 38) or treatment as usual (n = 36) condition within a randomized controlled trial. The primary outcome measure was parental anxiety, assessed with the Generalized Anxiety Disorder Questionnaire (GAD-7). Secondary outcomes were fear of disease progression, depression, coping, quality of life and user satisfaction. The group differences were tested through repeated-measures analyses of variance. The WEP-CARE group was additionally followed up three months after the treatment. RESULTS: A significant time-group interaction was found for anxiety (F (1,35) = 6.13, p = .016), fear of disease progression (F (1,331) = 18.23, p < .001), depression (F (1,74) = 10.79, p = .002) and coping (F (1,233) = 7.02, p = .010), suggesting superiority of the WEP-CARE group. Sustainability of the treatment gains regarding anxiety, fear of disease progression and coping was confirmed at the 6-month follow-up assessment (p < .01). A significant interaction effect could not be found for quality of life (F(1,2) = 0.016; p = .899). Both participating parents and therapists were satisfied with WEP-CARE. CONCLUSIONS: Our results underline the efficacy and feasibility of WEP-CARE for parents of children with various rare diseases.

[Blended care: state of research and possibilities for implementation]. / Blended Care: Stand der Forschung und Implementierungsmöglichkeiten.

BACKGROUND: Psychotherapy is effective in treating mental disorders; however, not all patients benefit to the same extent and treatment gains are not always maintained. Blended care (BC) has the potential to improve psychotherapeutic care by combining traditional psychotherapy with online contents. OBJECTIVE: To explore the potential of BC for psychotherapeutic care and investigate its implementation possibilities. MATERIAL AND METHODS: Presentation of the effectiveness of various BC modalities, attitudes of users and decision-makers, and discussion of recommendations for its implementation. RESULTS: Indications for the effectiveness of BC in different modalities has been shown in several studies. Both therapists and patients prefer BC over a purely online intervention and want customizable contents; however, it remains unclear for which patients BC is a particularly suitable treatment option. CONCLUSION: Various combinations of BC have the potential to be an effective and financially viable treatment option. Successful implementation requires better education about BC and the provision of the necessary infrastructure.

Exposure Versus Cognitive Restructuring Techniques in Brief Internet-Based Cognitive Behavioral Treatment for Arabic-Speaking People With Posttraumatic Stress Disorder: Randomized Clinical Trial.

BACKGROUND: Cognitive behavioral interventions delivered via the internet are demonstrably efficacious treatment options for posttraumatic stress disorder (PTSD) in underserved, Arabic-speaking populations. However, the role of specific treatment components remains unclear, particularly in conflict-affected areas of the Middle East and North Africa. OBJECTIVE: This study aims to evaluate 2 brief internet-based treatments in terms of efficacy, including change in PTSD symptom severity during treatment. Both treatments were developed in line with Interapy, an internet-based, therapist-assisted cognitive behavioral therapy protocol for PTSD and adapted to the specific research question. The first treatment comprised self-confrontation and social sharing (exposure treatment; 6 sessions); the second comprised cognitive restructuring and social sharing (cognitive restructuring treatment; 6 sessions). The 2 treatments were compared with each other and with a waitlist control group. METHODS: In total, 365 Arabic-speaking participants from the Middle East and North Africa (mean age 25.49, SD 6.68 y) with PTSD were allocated to cognitive restructuring treatment (n=118, 32.3%), exposure treatment (n=122, 33.4%), or a waitlist control group (n=125, 34.2%) between February 2021 and December 2022. PTSD symptom severity, posttraumatic maladaptive cognitions, anxiety, depressive and somatoform symptom severity, and quality of life were assessed via self-report at baseline and after treatment or waiting time. PTSD symptom severity was also measured throughout treatment or waiting time. Treatment satisfaction was assessed after treatment completion. Treatment use and satisfaction were compared between the 2 treatment conditions using appropriate statistical tests (eg, chi-square and Welch tests). Multiple imputation was performed to address missing data and evaluate treatment-associated changes. These changes were analyzed using multigroup change modeling in the completer and intention-to-treat samples. RESULTS: Overall, 200 (N=240, 83.3%) participants started any of the treatments, of whom 123 (61.5%) completed the treatment. Treatment condition was not significantly associated with the proportion of participants who started versus did not start treatment (P=.20) or with treatment completion versus treatment dropout (P=.71). High treatment satisfaction was reported, with no significant differences between the treatment conditions (P=.48). In both treatment conditions, PTSD, anxiety, depressive and somatoform symptom severity, and posttraumatic maladaptive cognitions decreased, and quality of life improved significantly from baseline to the posttreatment time point (P≤.001 in all cases). Compared with the baseline assessment, overall PTSD symptom severity decreased significantly after 4 sessions in both treatment conditions (P<.001). Moreover, both treatment conditions were significantly superior to the waitlist control group regarding overall PTSD symptom severity (P<.001) and most other comorbid mental health symptoms (P<.001 to P=.03). Differences between the 2 conditions in the magnitude of change for all outcome measures were nonsignificant. CONCLUSIONS: Internet-based cognitive behavioral treatments for PTSD focusing primarily on either self-confrontation or cognitive restructuring are applicable and efficacious for Arabic-speaking participants. TRIAL REGISTRATION: German Clinical Trials Register DRKS00010245; https://drks.de/search/de/trial/DRKS00010245.

Blended-ALMAMAR app for inpatient mental health care for refugees: study protocol for a multicenter implementation study within the I-REACH consortium (Internet based REfugee mentAl healtH Care).

BACKGROUND: Refugees are at high risk for developing mental illnesses. Due to language and cultural barriers, there is need for specifically adapted therapeutic procedures for refugees in inpatient mental health care settings. Internet-based applications in refugee mother tongues have the potential to improve the outcomes of mental health care for this vulnerable population. The key research question of the present implementation study is whether the newly developed "blended ALMAMAR" app for Arabic and Farsi speaking refugees in Germany is used and accepted by patients and professionals in routine inpatient mental health care (blended care). METHODS: We present the design of an observational, prospective multicenter implementation study in eight psychiatric hospitals. We plan to recruit 100 Farsi or Arabic speaking refugees receiving in-patient treatment due to depression, anxiety disorder, posttraumatic stress disorder or substance use disorders. These patients will get access to the "blended ALMAMAR" app during their inpatient stay in a blended-care approach. We will assess the usage (e.g., duration and frequency of use of the app) as well as subjective acceptability and usability of the intervention. To identify sociodemographic and clinical factors associated with "blended ALMAMAR" usage, we will also perform clinical and questionnaire assessments. DISCUSSION: The newly developed "blended ALMAMAR" app may help to close communication gaps for the hard-to reach and vulnerable group of refugees in inpatient mental health care. It is the first blended-care intervention that addresses severely mentally ill refugees in an inpatient psychiatric setting in Germany. TRIAL REGISTRATION: The trial was registered in the German Clinical Trials Register on November 11, 2021 (DRKS00025972) and adapted on November 14, 2023.

Select or adjust? How information from early treatment stages boosts the prediction of non-response in internet-based depression treatment.

BACKGROUND: Internet-based interventions produce comparable effectiveness rates as face-to-face therapy in treating depression. Still, more than half of patients do not respond to treatment. Machine learning (ML) methods could help to overcome these low response rates by predicting therapy outcomes on an individual level and tailoring treatment accordingly. Few studies implemented ML algorithms in internet-based depression treatment using baseline self-report data, but differing results hinder inferences on clinical practicability. This work compares algorithms using features gathered at baseline or early in treatment in their capability to predict non-response to a 6-week online program targeting depression. METHODS: Our training and test sample encompassed 1270 and 318 individuals, respectively. We trained random forest algorithms on self-report and process features gathered at baseline and after 2 weeks of treatment. Non-responders were defined as participants not fulfilling the criteria for reliable and clinically significant change on PHQ-9 post-treatment. Our benchmark models were logistic regressions trained on baseline PHQ-9 sum or PHQ-9 early change, using 100 iterations of randomly sampled 80/20 train-test-splits. RESULTS: Best performances were reached by our models involving early treatment characteristics (recall: 0.75-0.76; AUC: 0.71-0.77). Therapeutic alliance and early symptom change constituted the most important predictors. Models trained on baseline data were not significantly better than our benchmark. CONCLUSIONS: Fair accuracies were only attainable by involving information from early treatment stages. In-treatment adaptation, instead of a priori selection, might constitute a more feasible approach for improving response when relying on easily accessible self-report features. Implementation trials are needed to determine clinical usefulness.

Patterns of posttraumatic stress symptoms, their predictors, and comorbid mental health symptoms in traumatized Arabic-speaking people: A latent class analysis.

Many people from the Middle East and North Africa (MENA) have experienced traumatic events due to human rights abuses, violence, and conflict in the region, with potential psychological consequences including symptoms of posttraumatic stress and comorbid mental health problems. Yet, little is known about how different posttraumatic stress symptoms unfold in Arabic-speaking people who have experienced diverse traumatic events. This study examined latent classes based on posttraumatic stress symptoms, differences across classes concerning comorbid mental health symptoms and quality of life, and several predictors, including sociodemographic characteristics, social support, and trauma-related characteristics. Participants were 5,140 traumatized Arabic-speaking individuals who had registered for an online intervention. Latent class analysis was conducted to identify distinct classes based on DSM-5 posttraumatic stress symptoms. Multinomial logistic regression was used to analyze predictors of class membership. Differences between classes in severity of posttraumatic stress, depressive, anxiety, and somatoform symptoms, as well as quality of life were examined. Five different latent classes were identified: a general high posttraumatic stress symptom class (43.8%), a high posttraumatic stress symptom-low avoidance class (12.8%), a mixed posttraumatic stress symptom class (20.9%), a high dysphoric-low reexperiencing/avoidance class (14%), and a general low posttraumatic stress symptom class (8.4%). The classes differed in severity of posttraumatic stress, depressive, anxiety and somatoform symptoms, and quality of life. Consistent significant predictors of class membership were gender, social support, cumulative trauma exposure, sexual violence and direct exposure during the most distressing trauma, as well as time since the most distressing trauma. Distinct symptom classes with quantitative and qualitative differences can emerge following exposure to trauma among help-seeking Arabic-speaking people from the MENA region, with gender, social support, and trauma-related characteristics predicting symptom presentation. The results have implications for identifying distressed people and enhancing interventions based on an individual's symptom presentation.

Effects of a Self-Guided Transdiagnostic Smartphone App on Patient Empowerment and Mental Health: Randomized Controlled Trial.

BACKGROUND: Mental disorders impact both individuals and health systems. Symptoms and syndromes often remain undetected and untreated, resulting in chronification. Besides limited health care resources, within-person barriers such as the lack of trust in professionals, the fear of stigmatization, or the desire to cope with problems without professional help contribute to the treatment gap. Self-guided mental health apps may support treatment seeking by reducing within-person barriers and facilitating mental health literacy. Digital mental health interventions may also improve mental health related self-management skills and contribute to symptom reduction and the improvement of quality of life. OBJECTIVE: This study aims to investigate the effects of a self-guided transdiagnostic app for mental health on help seeking, reduced stigma, mental health literacy, self-management skills, mental health symptoms, and quality of life using a randomized controlled design. METHODS: Overall, 1045 participants (recruited via open, blinded, and web-based recruitment) with mild to moderate depression or anxiety-, sleep-, eating-, or somatization-related psychopathology were randomized to receive either access to a self-guided transdiagnostic mental health app (MindDoc) in addition to care as usual or care as usual only. The core features of the app were regular self-monitoring, automated feedback, and psychological courses and exercises. The coprimary outcomes were mental health literacy, mental health-related patient empowerment and self-management skills (MHPSS), attitudes toward help seeking, and actual mental health service use. The secondary outcomes were psychopathological symptom burden and quality of life. Data were collected at baseline and 8 weeks and 6 months after randomization. Treatment effects were investigated using analyses of covariance, including baseline variables as predictors and applying multiple imputation. RESULTS: We found small but robust between-group effects for MHPSS (Cohen d=0.29), symptoms burden (Cohen d=0.28), and quality of life (Cohen d=0.19) 8 weeks after randomization. The effects on MHPSS were maintained at follow-up. Follow-up assessments also showed robust effects on mental health literacy and preliminary evidence for the improvement of help seeking. Predictors of attrition were lower age and higher personality dysfunction. Among the non-attritors, predictors for deterioration were less outpatient treatment and higher initial symptom severity. CONCLUSIONS: A self-guided transdiagnostic mental health app can contribute to lasting improvements in patient empowerment. Symptoms of common mental disorders and quality of life improved faster in the intervention group than in the control group. Therefore, such interventions may support individuals with symptoms of 1 or more internalizing disorders, develop health-centered coping skills, prevent chronification, and accelerate symptom improvement. Although the effects for individual users are small and predictors of attrition and deterioration need to be investigated further, the potential public health impact of a self-guided intervention can be large, given its high scalability. TRIAL REGISTRATION: German Clinical Trials Register DRKS00022531; https://drks.de/search/de/trial/DRKS00022531.

Development and Validation of a Questionnaire to Assess Role Conflicts Among Interpreters Working With Refugee Clients: The Role Conflicts Questionnaire.

Objectives: The aim of this study was to develop and validate a questionnaire to assess interpreters' role conflicts and the challenging aspects within the triad of practitioner, interpreter and refugee client. Methods: A questionnaire was developed based on previous literature. Its factor structure and construct validity were assessed in an online survey of 164 interpreters working with refugee clients. Psychological distress (BSI-18), work-related exhaustion (CBI), and secondary traumatic stress (ProQOL) were measured to test the questionnaire's convergent validity. Results: Exploratory structural equation modeling for categorical variables resulted in 23 items across four subscales. The scores of all subscales had good or excellent reliability (ω = 0.81 to ω = 0.93) and correlation analyses indicated convergent validity. Conclusion: The final questionnaire (RoCo) showed four clearly interpretable subscales and may help to identify emotional distress due to role conflicts among interpreters. Future studies should validate the questionnaire in different samples.

Mental health across two years of the COVID-19 pandemic: a 5-wave longitudinal study in Germany.

The COVID-19 pandemic has been negatively associated with mental health. However, little is known about the temporal dynamics of mental health in the longer term of the pandemic. We aimed to investigate symptom levels and changes of depression, anxiety, posttraumatic stress, and loneliness spanning two years of the pandemic; and to examine associated risk factors. This five-wave, longitudinal online study from May 2020 to April 2022 included 636 adults (Mage = 39.5 years, SD = 16.11; 84.1% female) from the German general population who completed the international COVID-19 Mental Health Survey. Symptoms of anxiety (Generalized Anxiety Disorder-7; GAD-7), depression (Patient Health Questionnaire-9; PHQ-9), posttraumatic stress (PTSD Checklist for DSM-5; PCL-5), and loneliness ("Do you feel lonely?") were assessed using mixed-effects models. Associations with anxiety and depressive symptoms were examined with having children, student status, financial worries, contamination fear, and loneliness. PHQ-9, GAD-7, PCL-5, and loneliness scores overall decreased throughout the two-year period of the pandemic but exhibited an increase during two national lockdowns. Controlled for significant associations with female gender and younger age, increased PHQ-9 and GAD-7 scores were associated with contamination fear, financial worries, and loneliness. No associations were found with having children and student status. Symptoms of depression, anxiety, posttraumatic stress, and loneliness decreased over time but varied along with the dynamics of the pandemic. Longitudinal monitoring of mental health in vulnerable subgroups is required, especially those of younger age, females, and the financially insecure.