Depression among Turkish and Moroccan immigrant populations in Northwestern Europe: a systematic review of prevalence and correlates.

BACKGROUND: This systematic review aimed to synthesize the prevalence and correlates of depressive disorders and symptoms of Turkish and Moroccan immigrant populations in Northwestern Europe, formulating evidence-informed recommendations for clinical practice. METHODS: We conducted a systematic search in PsycINFO, MEDLINE, Science Direct, Web of Knowledge, and Cochrane databases for records up to March 2021. Peer-reviewed studies on adult populations that included instruments assessing prevalence and/or correlates of depression in Turkish and Moroccan immigrant populations met inclusion criteria and were assessed in terms of methodological quality. The review followed the relevant sections of the Preferred Reporting Items for Systematic Reviews and Meta-analyses reporting (PRISMA) guideline. RESULTS: We identified 51 relevant studies of observational design. Prevalence of depression was consistently higher among people who had an immigrant background, compared to those who did not. This difference seemed to be more pronounced for Turkish immigrants (especially older adults, women, and outpatients with psychosomatic complaints). Ethnicity and ethnic discrimination were identified as salient, positive, independent correlates of depressive psychopathology. Acculturation strategy (high maintenance) was related to higher depressive psychopathology in Turkish groups, while religiousness appeared protective in Moroccan groups. Current research gaps concern psychological correlates, second- and third-generation populations, and sexual and gender minorities. CONCLUSION: Compared to native-born populations, Turkish immigrants consistently showed the highest prevalence of depressive disorder, while Moroccan immigrants showed similar to rather moderately elevated rates. Ethnic discrimination and acculturation were more often related to depressive symptomatology than socio-demographic correlates. Ethnicity seems to be a salient, independent correlate of depression among Turkish and Moroccan immigrant populations in Northwestern Europe.

Associations among migration risk factors, cultural identity conflict, and psychological symptoms among Syrian emerging adults with refugee backgrounds in the Netherlands.

OBJECTIVES: In the present study, we examined relations between premigration, perimigration, and postmigration risk factors (i.e., potentially traumatic events [PTEs], postmigration living problems [PMLPs], stressful life events) and psychological symptoms (i.e., anxiety/depression, posttraumatic stress) in Syrian emerging adults with refugee backgrounds; we also tested cultural identity conflict as a possible mediator of these relations. We expected that greater exposure to migration risk factors was associated with more psychological symptoms and that higher cultural identity conflict would contribute to these associations. METHODS: We used data from the first wave of Karakter, a longitudinal study of 158 Syrians with refugee backgrounds (69.0% men, age range 18-35). Participants completed a questionnaire assessing PTEs, PMLPs, stressful life events, cultural identity conflict, and symptoms of anxiety/depression and posttraumatic stress. RESULTS: Correlational analyses indicated that more PTEs and stressful life events were related to higher levels of cultural identity conflict and more psychological symptoms. Furthermore, greater cultural identity conflict was associated with more psychological symptoms. We did not observe indirect effects of cultural identity conflict in the mediation analyses. CONCLUSIONS: Results suggest that postmigration stressors and cultural identity conflict are associated with psychological symptoms among Syrian emerging adults who have resettled in the Netherlands.

Cultural Identity Conflict and Psychological Well-Being in Bicultural Young Adults: Do Self-Concept Clarity and Self-Esteem Matter?

ABSTRACT: The present study examined the relationship between cultural identity conflict and psychological well-being, as well as the role of self-concept clarity and self-esteem in mediating this linkage. Elevated cultural identity conflict was hypothesized to be associated with lower psychological well-being via both (lower) self-concept clarity and (lower) self-esteem, with self-concept clarity preceding self-esteem. In a cross-sectional design, 473 bicultural young adults (age range, 18-35) completed an online questionnaire assessing cultural identity conflict, self-concept clarity, self-esteem, emotional distress, psychopathological symptoms, and satisfaction with life. Correlation analyses revealed that elevated cultural identity conflict was positively associated with emotional distress and psychopathological symptoms, and negatively associated with satisfaction with life. Mediation analyses indicated that these associations were mediated by lower self-concept clarity and lower self-esteem. The results support the importance of interventions that foster the development of skills in bicultural young adults to obtain more self-concept clarity and promote self-esteem and psychological well-being.

Trauma-Focused Art Therapy in the Treatment of Posttraumatic Stress Disorder: A Pilot Study.

Research showed that more than 30% of patients with Posttraumatic Stress Disorder (PTSD) do not benefit from evidence-based treatments: Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) or Eye Movement Desensitization and Reprocessing (EMDR). These are patients with prolonged and multiple traumatization, with poor verbal memory, and patients with emotional over-modulation. Retelling traumatic experiences in detail is poorly tolerated by these patients and might be a reason for not starting or not completing the recommended treatments. Due to lack of evidence, no alternative treatments are recommended yet. Art therapy may offer an alternative and suitable treatment, because the nonverbal and experiential character of art therapy appears to be an appropriate approach to the often wordless and visual nature of traumatic memories. The objective of this pilot study was to test the acceptability, feasibility, and applicability of trauma-focused art therapy for adults with PTSD due to multiple and prolonged traumatization (patients with early childhood traumatization and refugees from different cultures). Another objective was to identify the preliminary effectiveness of art therapy. Results showed willingness to participate and adherence to treatment of patients. Therapists considered trauma-focused art therapy feasible and applicable and patients reported beneficial effects, such as more relaxation, externalization of memories and emotions into artwork, less intrusive thoughts of traumatic experiences and more confidence in the future. The preliminary findings on PTSD symptom severity showed a decrease of symptoms in some participants, and an increase of symptoms in other participants. Further research into the effectiveness of art therapy and PTSD is needed.

The dissociative post-traumatic stress disorder (PTSD) subtype: A treatment outcome cohort study in veterans with PTSD.

OBJECTIVES: Dissociation is a prevalent phenomenon among veterans with post-traumatic stress disorder (PTSD) that may interfere with the effectiveness of treatment. This study aimed to replicate findings of a dissociative PTSD subtype, to identify corresponding patterns in coping style, symptom type, and symptom severity, and to investigate its impact on post-traumatic symptom improvement. METHODS: Latent profile analysis (LPA) was applied to baseline data from 330 predominantly (97%) male treatment-seeking veterans (mean age 39.5 years) with a probable PTSD. Multinomial logistic models were used to identify predictors of dissociative PTSD. Eighty veterans with PTSD that commenced with psychotherapy were invited for a follow-up measure after 6 months. The majority (n = 64, 80% response rate) completed the follow-up measure. Changes in post-traumatic stress between baseline and follow-up were explored as a continuous distal outcome. RESULTS: Latent profile analysis revealed four distinct patient profiles: 'low' (12.9%), 'moderate' (33.2%), 'severe' (45.1%), and 'dissociative' (8.8%) PTSD. The dissociative PTSD profile was characterized by more severe pathology levels, though not post-traumatic reactions symptom severity. Veterans with dissociative PTSD benefitted equally from PTSD treatment as veterans with non-dissociative PTSD with similar symptom severity. CONCLUSIONS: Within a sample of veterans with PTSD, a subsample of severely dissociative veterans was identified, characterized by elevated severity levels on pathology dimensions. The dissociative PTSD subtype did not negatively impact PTSD treatment. PRACTITIONER POINTS: The present findings confirmed the existence of a distinct subgroup veterans that fit the description of dissociative PTSD. Patients with dissociative PTSD subtype symptoms uniquely differed from patients with non-dissociative PTSD in the severity of several psychopathology dimensions. Dissociative and non-dissociative PTSD patients with similar post-traumatic severity levels showed similar levels of improvement after PTSD treatment. The observational design and small sample size caution interpretation of the treatment outcome data. The IES-R questionnaire does not assess all PTSD DSM-IV diagnostic criteria (14 of 17), although it is considered a valid measure for an indication of PTSD.

Predicting post-traumatic stress disorder treatment response in refugees: Multilevel analysis.

OBJECTIVES: Given the recent peak in refugee numbers and refugees' high odds of developing post-traumatic stress disorder (PTSD), finding ways to alleviate PTSD in refugees is of vital importance. However, there are major differences in PTSD treatment response between refugees, the determinants of which are largely unknown. This study aimed at improving PTSD treatment for adult refugees by identifying PTSD treatment response predictors. DESIGN: A prospective longitudinal multilevel modelling design was used to predict PTSD severity scores over time. We analysed data from a randomized controlled trial with pre-, post-, and follow-up measurements of the safety and efficacy of eye movement desensitization and reprocessing and stabilization in asylum seekers and refugees suffering from PTSD. METHODS: Lack of refugee status, comorbid depression, demographic, trauma-related and treatment-related variables were analysed as potential predictors of PTSD treatment outcome. Treatment outcome data from 72 participants were used. RESULTS: The presence (B = 6.5, p = .03) and severity (B = 6.3, p < .01) of a pre-treatment depressive disorder predicted poor treatment response and explained 39% of the variance between individuals. CONCLUSIONS: Refugee patients who suffer from PTSD and severe comorbid depression benefit less from treatment aimed at alleviating PTSD. Results highlight the need for treatment adaptations for PTSD and comorbid severe depression in traumatized refugees, including testing whether initial targeting of severe depressive symptoms increases PTSD treatment effectiveness. PRACTITIONER POINTS: There are differences in post-traumatic stress disorder (PTSD) treatment response between traumatized refugees. Comorbid depressive disorder and depression severity predict poor PTSD response. Refugees with PTSD and severe depression may not benefit from PTSD treatment. Targeting comorbid severe depression before PTSD treatment is warranted. This study did not correct for multiple hypothesis testing. Comorbid depression may differentially impact alternative PTSD treatments.

Somatization in refugees: a review.

PURPOSE: To present a review of the literature concerning medically unexplained physical symptoms in refugees. METHODS: We outline a variety of definitions and explanations of somatization, as well as the role of culture in the concept of disease. In addition, we present a review of the epidemiological literature about somatization in refugees. RESULTS: Refugees from non-Western countries exhibit more unexplained somatic symptoms than the general Western population. Although different studies have employed different methodologies and are therefore difficult to compare, it can be concluded that refugees form a particular population in which somatization is prominent. CONCLUSIONS: Potential, not mutually exclusive, explanations of the high number of somatic symptoms in the refugee population include general psychopathology, specifically traumatisation, results of torture, and stigmatisation of psychiatric care. There are implications for assessment, clinical treatment and further research concerning somatization in refugees.

Seven-year follow-up study of symptoms in asylum seekers and refugees with PTSD treated with trauma-focused groups.

OBJECTIVE: To examine sustainability of symptom outcomes of a 1-year phase-based trauma-focused, multimodal, and multicomponent group therapy in a day treatment program for posttraumatic stress disorder (PTSD) over an average period of 7 years. METHOD: Iranian and Afghan patients (N = 69) were assessed with self-rated symptom checklists for PTSD, anxiety, and depression symptoms before (T1), after (T2), and up to 11 years upon completion of the treatment (T3). A series of mixed model regression analyses was applied to determine the course of the measured symptoms over time. RESULTS: At T2, all symptoms were reduced, but PTSD symptoms showed the strongest reduction. The trend of symptom reduction continued up to 5 years posttreatment and was similar for all the examined symptoms. After 5 years, all symptoms started to worsen, but remained under baseline levels at T3. CONCLUSIONS: The applied treatment appears to improve mental health of the studied sample on both the short and longer term.

Is legal status impacting outcomes of group therapy for posttraumatic stress disorder with male asylum seekers and refugees from Iran and Afghanistan?

BACKGROUND: Legal status and other resettlement stressors are known to impact mental health of asylum seekers and refugees. However, the ways in which they interact with treatment of posttraumatic stress disorder (PTSD) with these populations is still poorly understood. The aim of this study was to examine whether legal status and other resettlement stressors influence outcomes of a trauma-focused group PTSD treatment within a day-treatment setting with asylum seekers and refugees. METHODS: Sixty six male Iranian and Afghan patients with PTSD residing in the Netherlands were assessed with self-rated symptom checklists for PTSD, anxiety and depression, and a demographic questionnaire one week before and two weeks after the treatment. Multivariate linear regression analysis was used to examine the impact of legal status and living arrangements on the treatment outcomes per symptom domain. RESULTS: The results suggest that both asylum seekers and refugees can be helped with their mental health complaints with a trauma-focused group therapy for PTSD regardless of their legal status. Obtaining a refugee status in a course of the treatment appears to improve the treatment outcomes. CONCLUSIONS: Legal status is impacting outcomes of group therapy for PTSD with male asylum seekers and refugees. Asylum seekers may benefit from group treatment regardless of unstable living conditions.

Psychopathology and resilience in older adults with posttraumatic stress disorder: a randomized controlled trial comparing narrative exposure therapy and present-centered therapy.

Objective: Using data from a randomized controlled trial on psychotherapy for posttraumatic stress disorder (PTSD) in older adults (aged >55), this study aimed at analysing the efficacy of two psychological interventions in terms of self-reported symptoms, comorbid psychopathology and resilience outcomes. Method: Thirty-three outpatients (age 55-81) with PTSD were randomly assigned to eleven sessions of narrative exposure therapy or present-centered therapy. Self-reported symptom severity of PTSD, depression and general psychopathology, along with measures of resilience (self-efficacy, quality of life and posttraumatic growth cognitions), were target outcomes. Harvard Trauma Questionnaire, Beck Depression Inventory, Brief Symptom Inventory, General Efficacy Scale, World Health Organization Quality of Life Assessment and Meaning of War Scale (personal growth) were assessed pre-treatment, post-treatment and at four months follow-up. Because of variable inter-assessment intervals, a piecewise mixed effects growth model was used to investigate treatment effects. Results: Neither post-treatment, nor at mean follow-up, between-group effects were found. At follow-up, significant medium to large within-group effect sizes were found in the NET-group for psychopathology (self-reported PTSD: Cohen's d = 0.54, p < .01; depression: Cohen's d = 0.51, p = .03; general psychopathology: Cohen's d = 0.74, p = .001), but not so in the PCT-group. Resilience (self-efficacy, quality of life and personal growth cognitions) did not significantly change in either group. Conclusions: In older adults with PTSD, the efficacy of NET extended beyond PTSD, reducing not only self-reported symptoms of PTSD but also comorbid depression and general psychopathology.

Objetivo: Utilizando datos de un ensayo controlado aleatorizado sobre psicoterapia para pacientes con trastorno de estrés postraumático (TEPT) en adultos mayores (> 55 años), este estudio tuvo como objetivo analizar la eficacia de dos intervenciones psicológicas respecto a síntomas autoinformados, psicopatología comorbida, y resultados de resiliencia.Método: Treinta y tres pacientes ambulatorios (de 55 a 81 años) con TEPT fueron asignados al azar a once sesiones de terapia de exposición narrativa (NET en sus siglas en ingles) o terapia centrada en el presente (TCP). Los resultados que se midieron fueron, el autoreporte de la gravedad de síntomas de estrés postraumático, depresión y psicopatología general, junto con medidas de resiliencia (autoeficacia, calidad de vida y cogniciones de crecimiento postraumático). Se evaluaron antes del tratamiento, después del tratamiento y a los cuatro meses de seguimiento con los siguientes cuestionarios: Cuestionario de trauma de Harvard, el Inventario de depresión de Beck, el Inventario breve de síntomas, la Escala de eficacia general, Evaluación de la Calidad de Vida y de Significado de la Guerra de la Organización Mundial de la Salud (crecimiento personal). Debido a los intervalos variables entre evaluaciones, se utilizó un modelo de crecimiento de efectos mixtos por partes para investigar los efectos del tratamiento.Resultados: No se encontraron diferencias entre los grupos ni posteriores al tratamiento ni durante el seguimiento medio. En el seguimiento, se encontraron tamaños de efecto significativos medianos a grandes dentro del grupo NET. para psicopatología (TEPT autoinformado: d de Cohen = 0.54, p < .01; depresión: d de Cohen = 0,51, p = 0,03; psicopatología general: d de Cohen = 0,74, p = 0,001), pero no así en el grupo TCP. La resiliencia (autoeficacia, calidad de vida y cogniciones de crecimiento personal) no tuvieron cambios significativos en ninguno de los grupos.Conclusiones: En adultos mayores con TEPT, la eficacia de la NET se extendió más allá del TEPT, reduciendo no sólo síntomas autoinformados de TEPT, sino también depresión comórbida y psicopatología general.

Late-onset PTSD in unaccompanied refugee minors: exploring the predictive utility of depression and anxiety symptoms.

Following resettlement in Western countries, unaccompanied refugee minors (URM) are at risk of developing posttraumatic stress disorder (PTSD). It is unclear to what extent PTSD in this group may become manifest at later stages following resettlement and which factors are associated with late onset. We examined data from URM collected 1 (T1) and 2 years (T2) following resettlement for differences between groups with no PTSD, PTSD at T1, and late-onset PTSD (at T2 only) using multinomial regression and path analysis. Of the children and adolescents (ages 12-18) completing both assessments (N = 554), 223 (40%) met criteria for PTSD at T1, and 88 (16%) endorsed late-onset PTSD. Late-onset PTSD was associated with traumatic event exposure, older age, and low education. In the late-onset PTSD group, the predictive effects of traumatic event exposure on symptom severity at T2 were fully mediated by depression and anxiety symptoms at T1. These results suggest that late-onset PTSD is a clinically relevant problem among URM that may be heralded by early depression and anxiety symptoms.

Use of the cultural formulation with refugees.

This article discusses the experiences of mental health professionals who applied the Cultural Formulation (CF) of the DSM-IV for assessment of psychopathology and treatment needs of refugees in the Netherlands. The CF approach proved to be a useful tool in the assessment and diagnostic phase of clinical treatment. However, patients reported problems with defining their own culture and providing explanations of illness and therapists had difficulty identifying culturally-based difficulties in the clinical relationship. Additional information was needed about working with interpreters, therapists' attitudes towards the culture of the patient and towards their own culture, patients' previous experiences with discrimination and inaccessibility of care, gender issues, and specific cultures and subcultures. A more structured approach to conducting the CF is recommended. We developed the "Cultural Formulation Interview" for this purpose. The adaptations are aimed at improving the CF for use with refugee populations, as well as for more general use in transcultural psychiatry.

Symptom manifestation and treatment effectiveness, -obstacles and -facilitators in Turkish and Moroccan groups with depression in European countries: A systematic review.

BACKGROUND: This study examined the state of the art relevant for clinical practice on symptom manifestation of depression or depression-related idioms of distress, the treatment effectiveness and obstacles and facilitators for therapeutic success in Turkish and Moroccan immigrant populations with depression in Europe. METHODS: We conducted a systematic search in PsycINFO, MEDLINE, Science Direct, Web of Knowledge, and Cochrane databases (1970- 31 July 2017). Peer-reviewed studies, with adult populations, and an instrument assessing depressive symptoms met inclusion criteria and were evaluated following quality guidelines. RESULTS: We included 13 studies on symptom manifestation, 6 on treatment effectiveness, and 17 on obstacles and facilitators, published between 2000 and 2017, from Germany, the Netherlands, Austria and Sweden (n Turkish individuals = 11,533; n Moroccan individuals = 5278; n native individuals = 303,212). Both ethnic groups more often reported combined mood and somatic symptoms (and anxiety in the case of Turkish groups) than natives, and had higher levels of symptoms. There was no report on effectiveness of pharmacotherapy and there was weak evidence of the effectiveness of examined psychological treatments for depression in Turkish groups. No treatment has been examined in Moroccan groups. Salient obstacles to therapeutic success were socioeconomic problems, higher level of psychological symptoms at baseline, and negative attitudes towards psychotherapy. Possible facilitators were interventions attuned to social, cultural and individual needs. Results were most representative of first generation, low SES Turkish immigrant patients, and Moroccan-Dutch members of the general populations. CONCLUSION: Turkish and Moroccan immigrants with depression presented a comorbid symptom profile with more intertwined depressive and somatic complaints. There were indications that the available therapies are insufficient for Turkish groups, but the current evidence is scarce and heterogeneous, and RCTs suffer from methodological limitations.

Development and evaluation of diversity-oriented competence training for the treatment of depressive disorders.

Studies in Europe indicate that some ethnic minorities have higher rates of mental disorders and less favorable treatment outcomes than their counterparts from majority groups. To date, efforts regarding training to reduce disparities have mainly focused on ethnocultural competences of therapists, with less attention paid to other aspects of diversity, such as sex/gender and socioeconomic status. In this study, we aim to determine the effectiveness of a population-specific, diversity-oriented competence training designed to increase therapists' competencies to integrate aspects of diversity features in clinical assessment, diagnosis, and treatment of depressive disorders in Turkish- and Moroccan-Dutch patients. A group of 40 therapists were location-based assigned to either training or a control condition (no training). Self-reported diversity competence, a knowledge test, and therapists' satisfaction with training were used to monitor the training and to measure competence levels at baseline, post-training, and three-month follow-up. Attitude-awareness and knowledge components of the self-reported diversity competence and test-measured knowledge increased in the training condition. Most gains remained stable at follow-up except test-measured knowledge after controlling for percentage of ethnic minority patients in caseload. There were no changes regarding therapists' self-reported skills. Therapists expressed medium-high satisfaction with the training, acknowledging the relevance of diversity competence for their daily practice. Future training must ensure better adjustment to therapists' pre-existing knowledge and be followed by long-term efforts to maintain competence levels and enhance competence transfer within teams.

Acculturation and mental health among ghanaians in The Netherlands.

BACKGROUND: The current literature on the relationship between cultural adaptation and mental health is premature to offer a comprehensive explanation about the ways acculturation exerts either positive or adverse effects on the mental health of migrants. AIM: This study is an empirical approach towards understanding the magnitude of the relationship between consequences of cultural adaptation and psychological distress. METHODS: Two samples of Ghanaian migrants in The Netherlands were included: a clinical group (n = 36) and a non-clinical community group (n = 97). Data were acquired by administering a semi-structured interview. Quantified data were analysed using multivariate techniques. RESULTS: Contradictory to our hypotheses, the reported level of mental health symptoms in both groups was relatively low, suggesting a substantial resilience among the Ghanaian group. Confirming our hypotheses, specific dimensions of the acculturation process were associated with health status, particularly affiliation with cultural traditions and feelings of loss concerning the country of birth. CONCLUSIONS: Acculturation demands capture critical elements of migrants' experiences that warrant professional interventions tailored to their specific needs. A subtle balance between holding on to the supportive cultural traditions together with moderate involvement in ruminating about pre-migration life, in conjunction with acquiring instrumental skills of the host culture, is a starting position for better health.

Help-seeking behaviour regarding mental health problems of Mediterranean migrants in the Netherlands: familiarity with care, consultation attitude and use of services.

BACKGROUND: Ethnic minority groups differ in the pattern of their seeking help, and in their use of and attitude towards mental health systems. To meet the mental health needs of ethnic minority populations, insights into determinants of their help-seeking orientations are of great concern. AIM: To investigate help-seeking behaviour regarding mental health problems in terms of familiarity, attitude and service use among Mediterranean migrants in the Netherlands. METHODS: Samples of Mediterranean citizens in the general population (N = 292) and of Mediterranean (N = 114) and indigenous Dutch outpatients (N = 59) currently treated in mental health care were included. Data were acquired by administering a semi-structured interview. Quantified data were analysed using multivariate techniques. RESULTS: More recently arrived participants were less familiar with mental health services. Moroccan, lower educated and recently arrived respondents reported a more negative attitude towards consulting these agencies. The help-seeking behaviour of the Mediterranean participants was relatively similar to that of the indigenous Dutch subjects. CONCLUSIONS: With regard to care-seeking routes and use of mental health services, more inter-ethnic similarities than differences emerged. Sociodemographic variables like age, education and length of residence shape the process of help-seeking and service use.

The efficacy of recommended treatments for veterans with PTSD: A metaregression analysis.

Soldiers and veterans diagnosed with PTSD benefit less from psychotherapy than non-military populations. The current meta-analysis identified treatment predictors for traumatised soldiers and veterans, using data from studies examining guideline recommended interventions, namely: EMDR, exposure, cognitive, cognitive restructuring, cognitive processing, trauma-focused cognitive behavioural, and stress management therapies. A systematic search identified 57 eligible studies reporting on 69 treated samples. Exposure therapy and cognitive processing therapy were more effective than EMDR and stress management therapy. Group-only therapy formats performed worse compared with individual-only formats, or a combination of both formats. After controlling for study design variables, EMDR no longer negatively predicted treatment outcome. The number of trauma-focused sessions, unlike the total number of psychotherapy sessions, positively predicted treatment outcome. We found a relationship between PTSD pretreatment severity levels and treatment outcome, indicating lower treatment gains at low and high PTSD severity levels compared with moderate severity levels. Demographic variables did not influence treatment outcome. Consequently, soldiers and veterans are best served using exposure interventions to target PTSD. Our results did not support a group-only therapy format. Recommended interventions appear less effective at relatively low and high patient PTSD severity levels. Future high-quality studies are needed to determine the efficacy of EMDR.

Trauma exposure and refugee status as predictors of mental health outcomes in treatment-seeking refugees.

Aims and method This study aimed to identify predictors of symptom severity for post-traumatic stress disorder (PTSD) and depression in asylum seekers and refugees referred to a specialised mental health centre. Trauma exposure (number and domain of event), refugee status and severity of PTSD and depression were assessed in 688 refugees. Results Symptom severity of PTSD and depression was significantly associated with lack of refugee status and accumulation of traumatic events. Four domains of traumatic events (human rights abuse, lack of necessities, traumatic loss, and separation from others) were not uniquely associated with symptom severity. All factors taken together explained 11% of variance in PTSD and depression. Clinical implications To account for multiple predictors of symptom severity including multiple traumatic events, treatment for traumatised refugees may need to be multimodal and enable the processing of multiple traumatic memories within a reasonable time-frame.

The effectiveness of art therapy in the treatment of traumatized adults: a systematic review on art therapy and trauma.

Art therapy has often been applied in the treatment of traumatized adults, and good results in clinical practice have been reported. However, although art therapy experts underline these benefits, the effectiveness of art therapy in trauma treatment has not been established by systematic review. The aim of this systematic review is to identify and evaluate empirical evidence of the effectiveness of art therapy for trauma treatment. As a result of the systematic review, six controlled, comparative studies on art therapy for trauma in adult patients were found. In half of the included studies, a significant decrease in psychological trauma symptoms was found in the treatment groups, and one study reported a significant decrease in depression. Although there are limitations in the number of included studies, the number of participants, the heterogeneity of included studies, and their methodological quality, the results contribute to insight into the effectiveness of art therapy in trauma treatment and form an evidence base for the urgent need for further research on art therapy and trauma treatment.

The importance of ethnic similarity in the therapist-patient dyad among Surinamese migrants in Dutch mental health care.

Empirical evidence is equivocal on whether ethnic matching in the therapist-patient dyad is preferred by ethnic minority patients and whether it leads to treatment satisfaction. The aim of this study was to establish the importance of ethnic similarity in mental health care among Surinamese migrants in the Netherlands. A convenience sample of Surinamese out-patients in community mental health care (N = 96) was interviewed. Data were analysed using logistic multivariate techniques. The majority of the Surinamese out-patients (in particular recently residing participants) rated ethnic matching as relevant; a considerable minority considered compassion and expertise to be more relevant than ethnic background. Most out-patients reported to be satisfied with the services, especially females and respondents treated by an ethnically similar therapist. Ethnic similarity in the patient-therapist dyad is a strong predictor for satisfaction with mental health care services. However, although it is preferred by many, ethnic matching per se is no must - empathy, expertise and world view sharing are reported to be of considerable importance as well.