[Health of people with selected citizenships in Germany: prevalence of non-communicable diseases and associated social as well as migration-related factors]. / Gesundheit von Menschen mit ausgewählten Staatsangehörigkeiten in Deutschland: Prävalenzen nichtübertragbarer Erkrankungen und damit assoziierte soziale sowie migrationsbezogene Faktoren.

BACKGROUND: Health chances and risks of people with a history of migration vary according to a wide range of factors. This paper aims to describe the health of people with selected citizenships on the basis of four non-communicable diseases (chronic disease or long-term health problem in general, coronary heart disease, diabetes mellitus, depression) and to identify associated social and migration-related factors. METHODS: Analyses are based on data from the multilingual and multimodal interview survey "German Health Update: Fokus" (GEDA Fokus), which was conducted among 18- to 79-year-olds with Croatian, Italian, Polish, Syrian, or Turkish citizenship living in Germany (November 2021 to May 2022). Poisson regressions were used to calculate prevalence ratios and 95% confidence intervals to examine the association between the individual indicators and social as well as migration-related characteristics. RESULTS: In particular, a low sense of belonging to the society in Germany and self-reported experiences of discrimination in everyday life are associated with higher prevalence of a chronic disease or long-term health problem and - according to self-reported medical diagnoses - with depression and partly with coronary heart disease and diabetes. DISCUSSION: Given the importance of subjective sense of belonging to the society in Germany and self-reported experience of discrimination for the health outcomes studied, the results point to health inequalities among people with selected citizenships that may indicate mechanisms of social exclusion.

Development of a prototype for high-frequency mental health surveillance in Germany: data infrastructure and statistical methods.

In the course of the COVID-19 pandemic and the implementation of associated non-pharmaceutical containment measures, the need for continuous monitoring of the mental health of populations became apparent. When the pandemic hit Germany, a nationwide Mental Health Surveillance (MHS) was in conceptual development at Germany's governmental public health institute, the Robert Koch Institute. To meet the need for high-frequency reporting on population mental health we developed a prototype that provides monthly estimates of several mental health indicators with smoothing splines. We used data from the telephone surveys German Health Update (GEDA) and COVID-19 vaccination rate monitoring in Germany (COVIMO). This paper provides a description of the highly automated data pipeline that produces time series data for graphical representations, including details on data collection, data preparation, calculation of estimates, and output creation. Furthermore, statistical methods used in the weighting algorithm, model estimations for moving three-month predictions as well as smoothing techniques are described and discussed. Generalized additive modelling with smoothing splines best meets the desired criteria with regard to identifying general time trends. We show that the prototype is suitable for a population-based high-frequency mental health surveillance that is fast, flexible, and able to identify variation in the data over time. The automated and standardized data pipeline can also easily be applied to other health topics or other surveys and survey types. It is highly suitable as a data processing tool for the efficient continuous health surveillance required in fast-moving times of crisis such as the Covid-19 pandemic.

Mental health and well-being in the first year of the COVID-19 pandemic among different population subgroups: evidence from representative longitudinal data in Germany.

OBJECTIVES: To examine potential deteriorations in mental health and well-being in the first COVID-19 pandemic year compared with the previous decade focusing on the following vulnerable subgroups in Germany: women with minor children in the household, those living without a partner, younger and older adults, those in a precarious labour market situation, immigrants and refugees, and those with pre-existing physical or mental health risks. DESIGN: Analyses of secondary longitudinal survey data using cluster-robust pooled ordinary least squares models. PARTICIPANTS: More than 20 000 individuals (aged 16+ years) in Germany. PRIMARY AND SECONDARY OUTCOME MEASURES: Mental Component Summary Scale (MCS) of the 12-item Short-Form Health Survey measuring mental health-related quality of life, single item on life satisfaction (LS). RESULTS: We find a decline in the average MCS in the 2020 survey that is not particularly striking in the overall time course, still resulting in a mean score below those of all preceding waves since 2010. We find no change in LS from 2019 to 2020 against the background of a general upward trend. Regarding vulnerability factors, only the results on age and parenthood are partially in line with our expectations. In 2020, LS declined among the youngest adults; MCS declined among mothers (and women and men without children) but not fathers. Unlike respective comparison groups, refugees, those unemployed before the pandemic and those with pre-existing mental health risks experienced no MCS declines in 2020, whereas persons living without a partner, the eldest, and those with pre-existing health risks exhibited continued increases in LS. CONCLUSIONS: There is no evidence for substantial breakdowns in mental health or subjective well-being in the first pandemic year in the German population or its subgroups, particularly when considering developments of the previous decade. Since the majority of hypothesised vulnerable groups to pandemic stressors showed more stable MCS and LS, our results warrant further study.

Time trends in mental health indicators in Germany's adult population before and during the COVID-19 pandemic.

Background: Times of crisis such as the COVID-19 pandemic are expected to compromise mental health. Despite a large number of studies, evidence on the development of mental health in general populations during the pandemic is inconclusive. One reason may be that representative data spanning the whole pandemic and allowing for comparisons to pre-pandemic data are scarce. Methods: We analyzed representative data from telephone surveys of Germany's adults. Three mental health indicators were observed in ~1,000 and later up to 3,000 randomly sampled participants monthly until June 2022: symptoms of depression (observed since April 2019, PHQ-2), symptoms of anxiety (GAD-2), and self-rated mental health (latter two observed since March 2021). We produced time series graphs including estimated three-month moving means and proportions of positive screens (PHQ/GAD-2 score ≥ 3) and reports of very good/excellent mental health, as well as smoothing curves. We also compared time periods between years. Analyses were stratified by sex, age, and level of education. Results: While mean depressive symptom scores declined from the first wave of the pandemic to summer 2020, they increased from October 2020 and remained consistently elevated throughout 2021 with another increase between 2021 and 2022. Correspondingly, the proportion of positive screens first decreased from 11.1% in spring/summer 2019 to 9.3% in the same period in 2020 and then rose to 13.1% in 2021 and to 16.9% in 2022. While depressive symptoms increased in all subgroups at different times, developments among women (earlier increase), the youngest (notable increase in 2021) and eldest adults, as well as the high level of education group (both latter groups: early, continuous increases) stand out. However, the social gradient in symptom levels between education groups remained unchanged. Symptoms of anxiety also increased while self-rated mental health decreased between 2021 and 2022. Conclusion: Elevated symptom levels and reduced self-rated mental health at the end of our observation period in June 2022 call for further continuous mental health surveillance. Mental healthcare needs of the population should be monitored closely. Findings should serve to inform policymakers and clinicians of ongoing dynamics to guide health promotion, prevention, and care.

[Mental health surveillance at the Robert Koch Institute - strategies for monitoring the mental health of the population]. / Mental Health Surveillance am Robert Koch-Institut ­ Strategien zur Beobachtung der psychischen Gesundheit der Bevölkerung.

The continuous and systematic surveillance of the health of populations is fundamental for effective public health practice. In light of the growing importance of mental health within population health, a Mental Health Surveillance for Germany is being established at the Robert Koch Institute. Its aim is to continually provide reliable information on the current state and development of the mental health of the population.Three surveillance strategies are currently being pursued: 1) Regular comprehensive assessments aim to describe the mental health status of the population using a wide range of indicators and data sources and to observe long-term developments. They build on existing work in epidemiology and health services research. 2) High-frequency monitoring of a selection of indicators is used for the early detection of trends. 3) A continuous literature review collates current findings on mental health developments in the COVID-19 pandemic on a monthly basis. The latter two strategies were implemented in response to new information needs in the pandemic.This paper describes and discusses these three strategies and their functions, limitations, and potential for development. Their results are communicated through different forms of reporting and serve to identify needs for action and research in public mental health. The further development and long-term operation of the Mental Health Surveillance as a whole has the potential to facilitate the achievement of public mental health objectives and to contribute on different levels to the improvement of population health.

A house is not a home: a network model perspective on the dynamics between subjective quality of living conditions, social support, and mental health of refugees and asylum seekers.

BACKGROUND: Providing adequate living conditions for forcibly displaced people represents a significant challenge for host countries such as Germany. This study explores refugee mental health's reciprocal, dynamic relationship with post-migration living conditions and social support. METHODS: The study sample included 325 Arabic- or Farsi-speaking asylum seekers and refugees residing in Germany since 2014 and seeking mental health treatment. Associations between reported symptoms of post-traumatic stress and depression and the subjective quality of living conditions and perceived social support were analyzed using a two-level approach including multiple linear regression and network analyses. RESULTS: Post-migration quality of living conditions and perceived social support were significantly associated with negative mental health outcomes on both levels. In the network, both post-migration factors were negatively connected with overlapping symptoms of psychiatric disorders, representing potential target symptoms for psychological treatment. CONCLUSION: Post-migration quality of living conditions and social support are important factors for refugee mental health and should be targeted by various actors fostering mental well-being and integration.

Mental Health and Integration: A Qualitative Study on the Struggles of Recently Arrived Refugees in Germany.

Introduction: Forcibly displaced people are at particular risk of mental health problems and also face specific integration challenges upon resettlement. Existing literature suggests that there may be a bidirectional relationship between mental health and integration. The present study seeks to understand the relationship between integration processes and mental health problems or significant negative emotional experiences among adult refugees in Germany. Method: Applying a qualitative approach, we conducted 54 semi-structured interviews with refugees and asylum seekers who arrived in Germany between 2013 and 2018 currently residing in Berlin, Leipzig, or the Duisburg area in North Rhine-Westphalia. Data was collected between December 2018 and September 2019. We analyzed transcripts inductively using thematic analysis. Results: Five themes covering the various links between integration and mental health problems or significant negative emotional experiences were identified. First, we found that the mental health consequences of past adverse experiences, as well as ongoing worries about those left behind in the homeland, can seriously impede refugees' ability to pursue activities key to integration. Second, the process of applying for and securing asylum can result in uncertainty and fear, which, in turn, burden the individual and may impact motivation for integration. Third, many of our participants described mental health ramifications related to feeling stuck and thwarted in the pursuit of building a life, especially in securing employment. Fourth, some participants described feeling so overwhelmed by fundamental tasks throughout the integration process, namely, language learning and bureaucratic processes, that these take a psychological toll. Fifth, we identified several forms of social disconnection between refugees and members of the host community due to xenophobia, social and cultural differences, physical and emotional isolation in refugee camps, as well as with co-nationals and fellow refugees. Negative emotions, mistrust, and socio-cultural differences that emerge throughout the integration processes seem to erode social cohesion among refugee communities, potentially further threatening mental health. Conclusion: Mental health problems and integration processes appear to be closely related across different areas of integration. Innovative solutions to challenges identified by members of the refugee community in Germany stand to benefit mental health and integration outcomes simultaneously.

A qualitative study on resilience in adult refugees in Germany.

BACKGROUND: Because refugees face significant adversities before, during, and after resettlement, resilience is of central importance to this population. However, strengths-based research on post-migration refugee experiences is sparse. METHODS: We conducted semi-structured interviews with 54 adult refugee participants who arrived in Germany between 2013 and 2018 in their preferred language. We analyzed different aspects of resilience in these interviews using thematic analysis. RESULTS: Nine themes were identified. Four themes manifest resilience in different ways and encompass cognitive as well as behavioral strategies for facing adversity, self-ascriptions of resilience as a personal trait or lasting characteristic, and the role of volunteering, work, and activism for refugee causes. Five themes capture factors that facilitate resilience: social support, experiencing migration as an opportunity generally and for women in particular, being a parent, and being young. CONCLUSIONS: This study adds to a growing body of knowledge about resilience among adult refugees. It may support clinicians working with refugees by making them aware of specific manifestations of resilience and factors promoting positive adaptation specific to this client group. It also contributes to a more strengths-based view on refugee mental health and processes of integration.

Faith-Based Coping Among Arabic-Speaking Refugees Seeking Mental Health Services in Berlin, Germany: An Exploratory Qualitative Study.

Background: The benefits of faith-based coping or using religious and spiritual beliefs as a stabilizing force for interpreting stressful or distressing events are largely unexplored among the exodus of Arabic-speaking refugee populations from Muslim-majority countries, particularly those resettled in Europe. The present study aimed to explore the manifestation of faith-based coping strategies among Arabic-speaking refugee adults seeking mental healthcare services in Berlin, Germany and explore how favorable faith-based coping strategies can be optimized from a mental health service-delivery and broader integration perspective. Methods: A total of 17 qualitative interviews were conducted with Arabic-speaking refugee adults (six females, 11 males) seeking mental health services at the Charité Universitaetsmedizin in Berlin. Research questions aimed to solicit comprehensive perspectives from refugee adults on their mental health, with an emphasis on faith-based coping, and how this facilitated or impeded their integration into German society. Interview transcripts were translated to English from Arabic and analyzed using MAXQDA (2018) to highlight thematic patterns using a grounded theory approach. Results: Findings were structured into four themes, including: (I) faith-based coping methods during flight, (II) changes in faith practices upon arrival, (III) faith-based coping methods to address distress during integration, and (IV) advice for German mental healthcare providers. Participants who demonstrated a stronger commitment to faith were more likely to utilize faith-based coping strategies when seeking mental health services and facing the challenges of displacement and integration. Examples of faith-based coping included prayer, supplication, reciting scripture, and seeking help from a local religious leader. Conclusion: The findings suggest how faith and faith practices play a significant role in the mental health and integration of refugee populations in Germany and provide insight on how mental healthcare can be delivered in a culturally-sensitive manner, providing alternatives to the social, cultural, and linguistic barriers posed by the German health system. These findings are particularly relevant for mental health professionals, non-governmental organizations, and humanitarian aid agencies providing mental healthcare to Arabic-speaking populations recently resettled in Western contexts.

[Psychotherapy Trainees' Experience of Alliance-Focused Training as a Part of Psychotherapy Training - A Qualitative Analysis]. / Wie erlebten Ausbildungskandidaten das allianzfokussierte Training im Rahmen der Psychotherapieausbildung? ­ Eine qualitative Studie.

Interpersonal competencies of therapists in dealing with alliance ruptures is related to therapeutic success. Therefore, it is of particular importance to learn and to train these competencies. A method which was developed specially for this purpose is the Alliance-Focused Training (AFT). Seven psychotherapy trainees participated in the AFT. In semi-structured interviews pre- and post-AFT, they were asked about their expectations from and experiences with the training. The transcriptions of the interviews were analyzed using the Consensual Qualitative Research (CQR) method. Before the AFT, participants showed ambivalent attitudes and fears mainly towards self-revelation. After the training, they mainly described personal development and progress in learning to deal with alliance ruptures. Video recordings of therapy sessions, role plays and training of metacommunikation skills were experienced as being helpful and practice related. The results indicate that the AFT has a great potential for improving competencies of psychotherapists.

Psychological distress among refugees in Germany: a cross-sectional analysis of individual and contextual risk factors and potential consequences for integration using a nationally representative survey.

OBJECTIVES: Responding to the mental health needs of refugees remains a pressing challenge worldwide. We estimated the prevalence of psychological distress in a large refugee population in Germany and assessed its association with host country factors amenable to policy intervention and integration indicators. DESIGN: A cross-sectional and population-based secondary analysis of the 2017 wave of the IAB-BAMF-SOEP refugee survey. SETTING: Germany. PARTICIPANTS: 2639 adult refugees who arrived in Germany between 2013 and 2016. MAIN OUTCOME MEASURES: Psychological distress involving symptoms of depression, anxiety and post-traumatic stress disorder was measured using the Refugee Health Screener-13. RESULTS: Almost half of the population surveyed (41.2% (95% CI: 37.9% to 44.6%)) was affected by mild, moderate or severe levels of psychological distress. 10.9% (8.4% to 13.5%) of the population screened positive for severe distress indicative of an urgent need for care. Prevalence of distress was particularly high for females (53.0% (47.2% to 58.8%)), older refugees (aged ≥55, 70.4% (58.5% to 82.2%)) and Afghans (61.5% (53.5% to 69.5%)). Individuals under threat of deportation were at a greater risk of distress than protection status holder (risk ratio: 1.55 (95% CI: 1.14 to 2.10)), single males at a greater risk than males with nuclear families living in Germany (1.34 (1.04 to 1.74)) and those in refugee housing facilities at a greater risk than those in private housing (1.21 (1.02 to 1.43)). Distressed males had a lower likelihood of employment (0.67 (0.52 to 0.86)) and reduced participation in integration courses (0.90 (0.81 to 0.99)). A trend of reduced participation in educational programmes was observed in affected females (0.42 (0.17 to 1.01)). CONCLUSION: The finding that a substantial minority of refugees in Germany exhibits symptoms of distress calls for an expansion of mental health services for this population. Service providers and policy-makers should consider the increased prevalence among female, older and Afghan refugees, as well as among single males, residents in housing facilities and those under threat of deportation. The associations between mental health and integration processes such as labour market, educational programme and integration course participation also warrant consideration.

Living Conditions and the Mental Health and Well-being of Refugees: Evidence from a Large-Scale German Survey.

Refugees are at an increased risk of mental health problems and low subjective well-being. Living circumstances in the host country are thought to play a vital role in shaping these health outcomes, which, in turn, are prerequisites for successful integration. Using data from a representative survey of 4325 adult refugees who arrived in Germany between 2013 and 2016, we investigated how different living conditions, especially those subject to integration policies, are associated with psychological distress and life satisfaction using linear regression models. Our findings show that an uncertain legal status, separation from family, and living in refugee housing facilities are related to higher levels of distress and decreased life satisfaction. Being employed, contact to members of the host society, and better host country language skills, by contrast, are related to reduced distress and higher levels of life satisfaction. These associations should inform decision making in a highly contested policy area.

Multidisciplinary treatment for traumatized refugees in a naturalistic setting: symptom courses and predictors.

Background: Multidisciplinary treatment approaches are commonly used in specialized psychosocial centres for the treatment of traumatized refugees, but empirical evidence for their efficacy is inconsistent. Objective: In order to obtain more evidence on the development of mental health and well-being of traumatized refugees who receive multidisciplinary treatment, symptom courses of posttraumatic stress disorder (PTSD), anxiety, depression and somatoform symptoms as well as in the subjective quality of life were investigated in the course of a multidisciplinary treatment. In addition, it was analysed if sociodemographic variables were predictors for possible changes in symptomatology and quality of life. Method: N = 76 patients of the outpatient clinic of a psychosocial centre for traumatized refugees receiving regular multidisciplinary treatment were surveyed using standardized questionnaires at three measurement points (at the beginning of treatment, and after an average of 7 and 14 months of treatment) in a single-group design. Results: Multilevel analysis showed significant improvements of symptoms of PTSD (p < .001), depression (p < .001), anxiety (p < .001), and somatoform symptoms (p = .002) as well as of the subjective quality of life (p < .001) over time. Among the tested predictors (gender, age, country of origin), age was a significant predictor for the course of somatoform symptoms (p < .05). Younger patients showed greater improvements in symptomatology over time than older ones. Conclusions: The results suggest that the received multidisciplinary treatment had a positive effect on trauma-related symptoms as well as on quality of life of traumatized refugees. There was no indication that sociodemographic characteristics predicted the symptom courses of the patients, except for somatoform symptoms. Younger patients benefitted more from multidisciplinary treatment than older ones.

Planteamiento: Los abordajes de tratamiento multidisciplinario se suelen utilizar en centros psicosociales especializados en el tratamiento de refugiados traumatizados, pero la evidencia empírica de su eficacia es inconsistente. Objetivo: Con el fin de obtener más pruebas sobre el desarrollo de la salud mental y el bienestar de los refugiados traumatizados que reciben tratamiento multidisciplinario, en el transcurso de un tratamiento multidisciplinario se investigó la evolución de los síntomas de trastorno de estrés postraumático (TEPT), ansiedad, depresión y somatomorfos, así como de la calidad de vida. Además, se examinó si las variables sociodemográficas predecían posibles cambios en la sintomatología y la calidad de vida. Método: Se realizó una encuesta a N=76 pacientes del ambulatorio de un centro psicosocial para refugiados traumatizados que reciben tratamiento multidisciplinario regular. Para ello, se utilizaron cuestionarios estandarizados en tres puntos de medición (al principio del tratamiento y después de un promedio de 7 y 14 meses de tratamiento, respectivamente) en un diseño de grupo único. Resultados: El análisis multinivel mostró mejorías significativas en los síntomas de TEPT (p <.001), depresión (p <.001), ansiedad (p <.001) y en los síntomas somatoformes (p = .002), así como en la calidad de vida subjetiva (p <.001) a lo largo del tiempo. Entre los predictores probados (sexo, edad, país de origen), la edad fue un predictor significativo para la evolución de síntomas somatomorfos (p <0,05). Los pacientes más jóvenes mostraron más mejoría que los mayores en la sintomatología a lo largo del tiempo. Conclusiones: Los resultados sugieren que el tratamiento multidisciplinario recibido tuvo un efecto positivo sobre los síntomas relacionados con el trauma y sobre la calidad de vida de los refugiados traumatizados. No hubo indicios de que las características sociodemográficas predijeran la evolución de los síntomas de los pacientes, excepto en los síntomas somatomorfos: Los pacientes más jóvenes se beneficiaron más de un tratamiento multidisciplinario que los más mayores.

Temporal dynamics of attention during encoding versus maintenance of working memory: complementary views from event-related potentials and alpha-band oscillations.

Working memory (WM) is strongly influenced by attention. In visual WM tasks, recall performance can be improved by an attention-guiding cue presented before encoding (precue) or during maintenance (retrocue). Although precues and retrocues recruit a similar frontoparietal control network, the two are likely to exhibit some processing differences, because precues invite anticipation of upcoming information whereas retrocues may guide prioritization, protection, and selection of information already in mind. Here we explored the behavioral and electrophysiological differences between precueing and retrocueing in a new visual WM task designed to permit a direct comparison between cueing conditions. We found marked differences in ERP profiles between the precue and retrocue conditions. In line with precues primarily generating an anticipatory shift of attention toward the location of an upcoming item, we found a robust lateralization in late cue-evoked potentials associated with target anticipation. Retrocues elicited a different pattern of ERPs that was compatible with an early selection mechanism, but not with stimulus anticipation. In contrast to the distinct ERP patterns, alpha-band (8-14 Hz) lateralization was indistinguishable between cue types (reflecting, in both conditions, the location of the cued item). We speculate that, whereas alpha-band lateralization after a precue is likely to enable anticipatory attention, lateralization after a retrocue may instead enable the controlled spatiotopic access to recently encoded visual information.

Oscillatory brain state predicts variability in working memory.

Our capacity to remember and manipulate objects in working memory (WM) is severely limited. However, this capacity limitation is unlikely to be fixed because behavioral models indicate variability from trial to trial. We investigated whether fluctuations in neural excitability at stimulus encoding, as indexed by low-frequency oscillations (in the alpha band, 8-14 Hz), contribute to this variability. Specifically, we hypothesized that the spontaneous state of alpha band activity would correlate with trial-by-trial fluctuations in visual WM. Electroencephalography recorded from human observers during a visual WM task revealed that the prestimulus desynchronization of alpha oscillations predicts the accuracy of memory recall on a trial-by-trial basis. A model-based analysis indicated that this effect arises from a modulation in the precision of memorized items, but not the likelihood of remembering them (the recall rate). The phase of posterior alpha oscillations preceding the memorized item also predicted memory accuracy. Based on correlations between prestimulus alpha levels and stimulus-related visual evoked responses, we speculate that the prestimulus state of the visual system prefigures a cascade of state-dependent processes, ultimately affecting WM-guided behavior. Overall, our results indicate that spontaneous changes in cortical excitability can have profound consequences for higher visual cognition.