Predictors and Patterns of Dropout From Psychiatric Treatment Among Trauma-Affected Refugees: A Large Data Pool Analysis.

Dropout from mental health treatment is a substantial hindrance to relevant and effective treatment. Despite the high prevalence of PTSD among refugees, research into their treatment dropout has received limited attention. This study aimed to identify patterns and predictors of treatment dropout versus completion through different treatment stages. The sample included 940 patients with a refugee background undergoing outpatient treatment for PTSD in Denmark. All patients were offered 10 medical doctor sessions and 16-20 psychotherapy sessions. Dropout was analysed in three stages: (1) during the first six MD sessions, (2) during the first eight psychotherapy sessions upon completion of Stage 1, and (3) during psychotherapy sessions 9 to 16. A stepwise multiple regression analysis was conducted for each stage to identify predictors of stage-specific dropout. Counter to expectations, both early dropout and full completion were associated with better symptom outcomes, relative to late-treatment dropout. Key predictors varied by stage, with younger age predicting early dropout, whereas chronic pain and poor Danish proficiency predicted late dropout. Female gender and a clearly articulated motivation for active participation were predictors for full treatment completion. Practical advice is suggested to accommodate at-risk patients and to re-evaluate patient engagement after familiarisation with treatment.

Negotiating Engagement, Worthiness of Care and Cultural Identities Through Intersubjective Recognition: Migrant Patient Perspectives on the Cultural Formulation Interview in Danish Mental Healthcare.

This qualitative study presents migrant patient perspectives on using the Cultural Formulation Interview (CFI) in mental health assessments in Denmark. Empirical data consisted of 20 recorded CFI sessions and 16 patient interviews, coded with a constructivist grounded theory approach. Empirical findings prompted us to draw on the theoretical framework of intersubjective recognition in the analytical process. Our analysis showed how patients had multiple previous experiences of misrecognition in life and healthcare. This seemed to restrain their self-esteem and available positions for expressing preferences and reservations during the CFI and led to negotiations of worthiness of care. Despite occasional lack of flow and information in the recorded CFI sessions, patients subsequently recounted how they felt the CFI recognised the complexity and context of their cultural identities and illness narratives. Patients described how the CFI-guided provider approach of curiosity and empowerment carried significant meaning and left them feeling dignified, hopeful and engaged in future care. Intersubjective recognition is fundamental in all human interaction, but we argue that the recognising CFI approach is particularly important in vulnerable and asymmetrical mental health assessment encounters where access to care is determined and when working with migrants or other marginalised groups.

Satisfaction with mental health treatment among patients with a non-Western migrant background: a survey in a Danish specialized outpatient mental health clinic.

BACKGROUND: Global migration increases ethnic and cultural diversity and demands mental health services to adapt to provide all patients with equal access to good quality care. Patient satisfaction surveys can inform this service delivery, thus we explored patient satisfaction among non-Western migrants receiving treatment in a Danish specialized outpatient mental health clinic [Competence Centre for Transcultural Psychiatry (CTP)]. METHODS: We used multivariate logistic regression models to estimate associations between 'Overall treatment satisfaction' and treatment-related items plus potential confounders from a cross-sectional patient satisfaction survey (n = 686). The satisfaction questionnaire was a self-report measurement tool developed locally at CTP. Participants were non-Western migrants above 18 years with Post-Traumatic Stress Disorder (PTSD) or depression diagnoses according to ICD-10. RESULTS: Most participants (n = 497; 82.6%) reported overall satisfaction with their mental health treatment, but less than half (n = 311; 48.8%) reported an improvement in health and situation after end of treatment. Participants who experienced a subjective improvement in their health and situation had significantly higher odds of being satisfied with their mental health treatment [odds ratio (OR) = 8.5, 95% confidence interval (CI): 4.0-18.1]. Perceptions of influence on the treatment course (OR = 4.7, 95% CI: 2.4-9.2), and of understanding and respect for one's cultural background (OR = 3.4, 95% CI: 1.5-7.6) were significantly associated with treatment satisfaction. Age and sex were insignificant in the final regression model. CONCLUSIONS: Implications for practice based on our findings are to enhance person-centred care and shared decision-making with all patients regardless of cultural background and to prioritize pre- and postgraduate training in cultural competences and cultural humility for healthcare providers.

Sex differences in trauma exposure and PTSD symptomatology among refugees, internally displaced people, and asylum seekers: A systematic literature review.

This systematic review aimed to explore sex differences in exposure to traumatic events and posttraumatic stress disorder (PTSD) symptomatology among refugees, internally displaced persons (IDPs), and asylum seekers. A comprehensive search was conducted across three databases (PubMed, PsychInfo, and Embase), which yielded 2,255 studies. A total of 15 studies were included for trauma exposure assessment, and 8 studies for PTSD symptomatology assessment. The review revealed significant sex differences in trauma exposure, with women experiencing higher rates of sexual violence, while men faced greater risks of imprisonment and torture. In terms of PTSD symptomatology, our findings showed that women tend to exhibit greater symptoms of arousal and specific symptoms of avoidance such as loss of interest and avoidance of activities reminding of trauma, while men were more likely to experience estrangement and detachment. Findings regarding symptoms of reexperiencing were not entirely consistent. This review emphasizes the importance of considering sex-specific symptoms in trauma assessment among displaced populations and advocates for further research into targeted interventions, especially regarding sexual violence.

Factors affecting adherence to psychotropics in trauma-affected refugees: data from a randomized controlled trial.

Non-adherence to psychotropic drugs may reduce treatment effectiveness and may cause exacerbation of illness. Among migrant populations, studies have identified low adherence to psychotropic drugs. This study aimed to identify factors that were associated with the three basic components of adherence: non-initiation, non-implementation (blood sample), and discontinuation in a clinical sample of trauma-affected refugees diagnosed with posttraumatic stress disorder. The data for this study is derived from a randomized controlled trial (n = 108). Based on existing literature, individual sociodemographic and clinical candidate predictor variables that may affect the initiation, continuation, and implementation to psychotropics were selected as exposure variables. Logistic regression was used to assess the risk relation between non-initiation, non-implementation, discontinuation, and the individual sociodemographic and clinical factors. Three factors - level of education, turn-up rate for medical doctor sessions, and discomfort in relation to the psychotropics - were associated with non-initiation, non-implementation, or discontinuation. The relatively small sample size poses a limitation. Furthermore, factors not examined in the current study may have affected non-initiation, non-implementation, and discontinuation. The study identified level of education, turn-up rate for medical doctor sessions, and discomfort in relation to medicine as important factors in relation to treatment with psychotropics in trauma-affected refugees. Factors contributing to a low turn-up rate, and factors that are consequences of a low turn-up rate, as well as communication and trust in the patient-provider interaction need further research attention. Furthermore, there is a need for research on interventions addressing adherence for refugees with mental illness.

A balancing act: how interpreters affect the therapeutic alliance in psychotherapy with trauma-affected refugees-a qualitative study with therapists.

Objective: The therapeutic alliance (TA) has the highest predictive value concerning the success of psychotherapy. The presented study aimed to explore how the presence of an interpreter affects the TA when working with trauma-affected refugees. Method: Semi-structured interviews were conducted with seven psychologists working in an outpatient clinic specialized in mental health care for migrant and refugee patients with trauma-related mental health problems in Denmark. Interviews were transcribed verbatim and analyzed using a structuring content analysis approach. Results: TA has been described as a dynamic therapist-interpreter-patient alliance triangle consisting of three distinct but highly intertwined and mutually influential dyadic alliances. Specific factors affecting the quality of the TA were identified, e.g., interpreter being emotionally attuned yet not overly involved; interpreter being barely visible yet present as a human being. Characteristics of trauma-affected refugee patients affecting the TA formation were also identified, e.g., a high level of personal distrust, different understandings of mental disorders and psychotherapy, stigmatization, perceptions of authorities. Conclusion: The presence of interpreters was perceived ambivalently and the formation of a good TA seems to be a balancing act. Based on the findings, recommendations for forming and maintaining a good TA in interpreter-mediated psychotherapy are provided.

The Cultural Formulation Interview-Generating distance or alliance? A qualitative study of practice changes in Danish mental healthcare.

This article presents provider experiences with the Cultural Formulation Interview (CFI) in Danish mental healthcare for migrant patients. Semi-structured interviews with 17 providers and 20 recorded CFI sessions were analyzed with a constructivist grounded theory approach. Based on our empirical material, we endorse the CFI's ability to facilitate working alliance and a profound and contextually situated understanding of the patient. Further, the CFI supported less-experienced providers in investigating cultural issues. Conversely, we found that CFI questions about cultural identity and background evoked notions of distance and 'othering' in the encounter. Nine providers had felt discomfort and professional insecurity when the CFI compelled them to introduce explanatory frameworks of culture in the mental health assessment. Eleven providers had experienced that the abstract nature of the questions inhibited patient responses or led to short and stereotypical descriptions, which had limited analytical value. We describe the contradictory CFI experiences of alliance versus distance at three levels: 1) at the CFI instrument level; 2) at the organizational level; and 3) at the contextual and structural level. We demonstrate benefits and pitfalls of using the CFI with migrants in Denmark, which is an example of a European healthcare context where cultural consultation is not an integrated concept in health education programs and where the notion of culture is contentious due to negative political rhetoric on multiculturalism.We suggest that the CFI should be introduced with thorough training; focus on fidelity; and supervision in the clinical application and understanding of the concept of culture.

Using the Cultural Formulation Interview in Denmark: Acceptability and clinical utility for medical doctors and migrant patients.

Previous studies have shown the importance of focusing on the cultural background of migrant patients in the psychiatric assessment. The Cultural Formulation Interview (CFI) offers a patient-focused approach to foreground the cultural context of the patient in the clinical encounter. Our objective was to explore the acceptability and clinical utility of the CFI for physicians and its acceptability for migrant patients seen at a transcultural mental health clinic in Denmark. In this study, the CFI was used in a second session following the standard clinical assessment to explore what additional information was gained from the CFI. Data on the use of the CFI data were collected immediately after the interview with questionnaires for medical doctors (MDs) (N = 12) and patients (N = 71). The findings showed that the CFI, in addition to standard assessment, was useful to the MDs for planning the treatment (60.0%) and for exploring the patients' view on their cultural and social context (74.7%), but less so for the diagnostic process (9.9%). Patients reported high overall satisfaction with the CFI (93.0%) and viewed it as a welcome opportunity to tell their story. The findings add to existing knowledge on the CFI in terms of acceptability for patients of a primarily Middle Eastern origin and patients using an interpreter during the CFI session. Based on the findings of this study, the CFI is recommended to clinicians for treatment planning purposes and for exploring the cultural and social context of the patient.

Treatment of traumatised refugees with basic body awareness therapy versus mixed physical activity as add-on treatment: Study protocol of a randomised controlled trial.

BACKGROUND: Treatment of traumatised refugees is one of the fields within psychiatry, which has received little scientific attention. Evidence based treatment and knowledge on the efficiency of the treatment for this complex patient group is therefore scarce. This leads to uncertainty as to which treatment should be offered and potentially lowers the quality of life for the patients. Chronic pain is very common among traumatised refugees and it is believed to maintain the mental symptoms of trauma. Hence, treating chronic pain is believed to be of high clinical value for this patient group. In clinical studies, physical activity has shown a positive effect on psychiatric illnesses such as depression and anxiety and for patients with chronic pain. However, scientific knowledge about physical activity as part of the treatment for traumatised refugees is very limited and no guidelines exist on this topic. METHODS/DESIGN: This study will include approximately 310 patients, randomised into three groups. All three groups receive psychiatric treatment as usual for the duration of 6-7 months, consisting of consultations with a medical doctor including pharmacological treatment and manual-based Cognitive Behavioural Therapy. The first group only receives treatment as usual while the second and the third groups receive either Basic-Body Awareness Therapy or mixed physical activity as add-on treatments. Each physical activity is provided for an individual 1-hour consultation per week, for the duration of 20 weeks. The study is being conducted at the Competence Centre for Transcultural Psychiatry, Mental Health Centre Ballerup in the Capital Region of Denmark. The primary endpoint of the study is symptoms of Post Traumatic Stress Disorder; the secondary endpoints are depression and anxiety as well as quality of life, functional capacity, coping with pain, body awareness and physical fitness. DISCUSSION: This study will examine the effect of physical activity for traumatised refugees. This has not yet been done in a randomised controlled setting on such a large scale before. Hereby the study will contribute to important knowledge that is expected to be used in future clinical guidelines and reference programs. TRIAL REGISTRATION: ClinicalTrials.gov NCT01955538 . Date of registration: 18 September 2013.