Scoping Review: Digital Mental Health Interventions for Children and Adolescents Affected by War.

OBJECTIVE: Over 200 million children and adolescents live in countries affected by violent conflict, are likely to have complex mental health needs, and struggle to access traditional mental health services. Digital mental health interventions have the potential to overcome some of the barriers in accessing mental health support. We performed a scoping review to map existing digital mental health interventions relevant for children and adolescents affected by war, examine the strength of the evidence base, and inform the development of future interventions. METHOD: Based on a pre-registered strategy, we systematically searched MEDLINE, Embase, Global Health, APA PsychInfo, and Google Scholar from the creation of each database to 30th September 2022, identifying k=6,843 studies. Our systematic search was complemented by extensive consultation with experts from the GROW Network. RESULTS: The systematic search identified 6 relevant studies: one evaluating digital mental health interventions for children and adolescents affected by war and five for those affected by disasters. Experts identified 35 interventions of possible relevance. The interventions spanned from universal prevention to specialist-guided treatment. Most interventions directly targeted young people and parents/carers and were self-guided. A quarter of the interventions were tested through randomized controlled trials. Because most interventions were not culturally or linguistically adapted to relevant contexts, their implementation potential was unclear. CONCLUSION: There is very limited evidence for the use of digital mental health interventions for children and adolescents affected by war at present. The review provides a framework to inform the development of new interventions.

Implementation of an evidence-based trauma-focused treatment for traumatised children and their families during the war in Ukraine: a project description.

The full-scale invasion of Ukraine by Russia in February 2022 led to an increase of traumatic events and mental health burden in the Ukrainian general population. The (ongoing) traumatisation can have a crucial impact on children and adolescents as they are especially vulnerable for developing trauma-related disorders such as Post Traumatic Stress Disorder (PTSD) or Depression. To date, these children have only very limited access to trauma-focused evidence-based treatments (EBTs) by trained mental health specialists in Ukraine. The fast and effective implementation of these treatments in Ukraine is crucial to improve the psychological wellbeing of this vulnerable population. This letter to the editor describes an ongoing project which implements a trauma-focused EBT called 'Trauma-Focused Cognitive Behavioural Therapy' (TF-CBT) in Ukraine during the war. In collaboration with Ukrainian and international agencies, the project 'TF-CBT Ukraine' was developed and implemented starting in March 2022. The project entails a large training programme for Ukrainian mental health specialists and the implementation of TF-CBT with children and their families in and from Ukraine. All components of the project are scientifically evaluated on a patient and therapist level, cross-sectionally and longitudinally, in a mixed-methods design. All together nine training cohorts with N = 133 Ukrainian therapists started the programme, all monthly case consultations (15 groups) and treatments of patients are still ongoing. Lessons learnt from this first large-scale implementation project on an EBT for children and adolescents impacted by trauma in Ukraine will help inform the field on challenges and also possibilities to expand such efforts. On a broader level, this project could be one small step in the process of helping children overcome the negative effects and experience resilience in the context of a war-torn nation.

"What I thought was so important isn't really that important": international perspectives on making meaning during the first wave of the COVID-19 pandemic.

BACKGROUND: The global COVID-19 pandemic has had a significant impact on the physical and mental health of people everywhere. The aim of the study is to understand how people living in 15 countries around the globe experience an unexpected crisis which threatens their health and that of loved ones, and how they make meaning of this disruption in their narratives. METHODS: Data were collected through an anonymous online survey during May-September 2020, which was during or just after the first wave of the COVID-19 pandemic, depending on the country. The questionnaire included demographic and three open-ended questions as prompts for stories about experiences during the initial months of the pandemic. The text was analyzed through inductive thematic content analysis and quantified for full sample description, demographic and subsequently international comparisons. RESULTS: The final qualitative dataset included stories from n = 1685 respondents. The sample was 73.6% women and 26.4% men. The mean age of participants was 39.55 years (SD = 14.71). The identified four groups of overarching themes were: The presence and absence of others; Rediscovering oneself; The meaning of daily life; Rethinking societal and environmental values. We discuss the prevalence of each theme for the sample as a whole and differences by demographic groups. The most prevalent theme referred to disruptions in interpersonal contacts, made meaningful by the increased appreciation of the value of relationships, present in (45.6%) of stories. It was more prevalent in the stories of women compared to men (χ² = 24.88, p = .001). CONCLUSIONS: The paper provides a detailed overview of the methodology, the main themes identified inductively in the stories and differences according to select demographic variables. We identify several major ways of making meaning of the pandemic. The pandemic has impacted many aspects of people's lives which give it meaning, no matter where they live.

Stories of Life during the First Wave of the COVID-19 Pandemic in Italy: A Qualitative Study.

The COVID-19 pandemic has imposed on people the need to find meaning in many unprecedented ways. The aim of this qualitative study was to explore how the general Italian population dealt with government restrictions and to understand personal experiences connected with the first wave of the pandemic in light of the personal construct theory (PCT) framework. One hundred and sixteen people (over 18 years old) completed an online survey between May and June 2020. Two independent researchers ran inductive thematic content analysis on data using a specifically developed international codebook. Five major themes were identified in the participants' narrations: difficulties, emotions, coping with lockdown measures, going back to normal, and change. The results, interpreted within the PCT transitions, showed that the pandemic represented a threat to participants' life plans, beliefs, and certainties. Some coped with it mainly by waiting for the pandemic to end and remaining firm in their beliefs and certainties, whereas others coped by trying to find alternative ways of giving sense to this experience and reconstructing personal meanings, claiming a change in their life and in society. Differentiating personal experiences of the COVID-19 pandemic is fundamental for designing personalised strategies to promote well-being.

The doctor-patient relationship and patient resilience in chronic pain: A qualitative approach to patients' perspectives.

OBJECTIVES: To study patients' perspectives about the role of the doctor-patient relationship in promoting the resilience process. METHODS: We conducted in-depth interviews with 20 chronic pain patients. Using open-ended questions, the interviews explored aspects of the doctor-patient relationship that impacted the patients' perceptions of their resilience. Thematic analysis built on an inductive, adaptive approach to data coding was employed to organize a representation of key factors affecting resilience. RESULTS: The themes emerging from the interviews inform us about how the different aspects of the doctor-patient relationship can promote patient resilience in chronic pain. Three main themes emerged: the doctor providing psychological support, promoting patients' health literacy related to chronic pain and its treatment, and empowering the patients to cooperate in finding the right treatment. This fosters patients' direct outcomes (feeling validated, health literate, and empowered), which, in turn, lead to adaptive coping responses and day-to-day disease management. These direct outcomes are crucial for patients to maintain socially and personally meaningful activities and their functional (physical) capacity. DISCUSSION: A doctor-patient relationship following the precepts of the patient-centered care is a significant resource that can lead to increased patient resilience. Thus, future interventions promoting patient resilience might consider addressing the doctor-patient relationship.

Can social support work virtually? Evaluation of rheumatoid arthritis patients' experiences with an interactive online tool.

BACKGROUND: There is strong empirical evidence that the support that chronic patients receive from their environment is fundamental for the way they cope with physical and psychological suffering. Nevertheless, in the case of rheumatoid arthritis (RA), providing the appropriate social support is still a challenge, and such support has often proven to be elusive and unreliable in helping patients to manage the disease. OBJECTIVES: To explore whether and how social support for RA patients can be provided online, and to assess the conditions under which such support is effective. An online support tool was designed to provide patients with both tailored information and opportunities to interact online with health professionals and fellow sufferers. The general purpose was to identify where the support provided did - or did not - help patients, and to judge whether the determinants of success lay more within patients - their engagement and willingness to participate - or within the design of the website itself. METHODS: The present study reports qualitative interviews with 19 users of the tool. A more specific purpose was to elaborate qualitatively on results from a quantitative survey of users, which indicated that any positive impact was confined to practical matters of pain management rather than extending to more fundamental psychological outcomes such as acceptance. RESULTS AND CONCLUSIONS: Overall, online learning and interaction can do much to help patients with the everyday stresses of their disease; however, its potential for more durable positive impact depends on various individual characteristics such as personality traits, existing social networks, and the severity and longevity of the disease.

The effect of social support features and gamification on a Web-based intervention for rheumatoid arthritis patients: randomized controlled trial.

BACKGROUND: Rheumatoid arthritis (RA) is chronic systematic disease that affects people during the most productive period of their lives. Web-based health interventions have been effective in many studies; however, there is little evidence and few studies showing the effectiveness of online social support and especially gamification on patients' behavioral and health outcomes. OBJECTIVE: The aim of this study was to look into the effects of a Web-based intervention that included online social support features and gamification on physical activity, health care utilization, medication overuse, empowerment, and RA knowledge of RA patients. The effect of gamification on website use was also investigated. METHODS: We conducted a 5-arm parallel randomized controlled trial for RA patients in Ticino (Italian-speaking part of Switzerland). A total of 157 patients were recruited through brochures left with physicians and were randomly allocated to 1 of 4 experimental conditions with different types of access to online social support and gamification features and a control group that had no access to the website. Data were collected at 3 time points through questionnaires at baseline, posttest 2 months later, and at follow-up after another 2 months. Primary outcomes were physical activity, health care utilization, and medication overuse; secondary outcomes included empowerment and RA knowledge. All outcomes were self-reported. Intention-to-treat analysis was followed and multilevel linear mixed models were used to study the change of outcomes over time. RESULTS: The best-fit multilevel models (growth curve models) that described the change in the primary outcomes over the course of the intervention included time and empowerment as time-variant predictors. The growth curve analyses of experimental conditions were compared to the control group. Physical activity increased over time for patients having access to social support sections plus gaming (unstandardized beta coefficient [B]=3.39, P=.02). Health care utilization showed a significant decrease for patients accessing social support features (B=-0.41, P=.01) and patients accessing both social support features and gaming (B=-0.33, P=.03). Patients who had access to either social support sections or the gaming experience of the website gained more empowerment (B=2.59, P=.03; B=2.29, P=.05; respectively). Patients who were offered a gamified experience used the website more often than the ones without gaming (t91=-2.41, P=.02; U=812, P=.02). CONCLUSIONS: The Web-based intervention had a positive impact (more desirable outcomes) on intervention groups compared to the control group. Social support sections on the website decreased health care utilization and medication overuse and increased empowerment. Gamification alone or with social support increased physical activity and empowerment and decreased health care utilization. This study provides evidence demonstrating the potential positive effect of gamification and online social support on health and behavioral outcomes. TRIAL REGISTRATION: International Standard Randomized Controlled Trial Number (ISRCTN): 57366516; http://www.controlled-trials. com/ISRCTN57366516 (Archived by webcite at http://www.webcitation.org/6PBvvAvvV).

The impact of social support on the acceptance process among RA patients: a qualitative study.

Acceptance is an important component of pain management, being associated with improved quality of life and lower levels of pain and depression. In enabling patients with chronic diseases to accept unpleasant consequences and to establish a new way of living, the support they receive from their social environment may play a decisive role. In this article, we identify the key sources and types of social support that are relevant for rheumatoid arthritis (RA) patients, and explore when and how those sources are important across the different stages of the acceptance process. We conducted a qualitative study involving 20 semi-structured interviews with RA patients in Switzerland. Analysis of the data followed the precepts of grounded theory. We found that, amid the complexity and variety of patients' struggles for acceptance, there were some common experiences or 'key moments' in which social support played an important role. While three sources of support - family, physicians and the external social context - are fundamental for RA patients, all three may inhibit as well as encourage acceptance, due to the invisible and unpredictable character of the disease. There is a pervasive risk either of underestimating patients' suffering or of over-supporting, both of which prevent patients accepting the disease and developing a new 'normal' life. We conclude that sources of social support need to find a middle way between scepticism and solicitousness.

The process of acceptance among rheumatoid arthritis patients in Switzerland: a qualitative study.

BACKGROUND: Rheumatoid arthritis (RA) is a chronic, painful disease with many injurious psychological effects. Acceptance is an important component of pain management and is associated with improved quality of life, and lower levels of pain and depression. While studies have begun to identify the stages of acceptance, little is known about factors influencing the ease and speed with which patients pass through these stages. OBJECTIVE: To explore the main stages through which RA patients pass and the strategies they adopt to learn to live with the pain, and to identify factors shaping patients' capacities to achieve acceptance. METHODS: A qualitative study involving 20 semistructured interviews with RA patients in the Italian-speaking region of Switzerland was conducted. Analysis of the data followed the precepts of grounded theory. RESULTS: Although the present study revealed that acceptance is not a smooth or linear process, five main stages in patients' struggles to accommodate the newly imposed limitations were, nonetheless, identified: naming the illness; realizing the illness; resisting the illness; 'hitting the bottom'; and integrating the illness. Diagnosis proved to be an especially tortuous stage in the case of RA, and the effects of delayed diagnosis continued to be felt during the subsequent stages. Patients' understanding of the notion of acceptance and the strategies that they used to achieve it were also explored. CONCLUSIONS: Diagnosis of RA is notoriously difficult. Beyond the clinical difficulties, structural reasons for late diagnosis (symptoms being neglected by patients and medical professionals) were identifed. Delayed diagnosis hindered the acceptance process throughout, and led to more resistant behaviour and to a struggle to achieve the optimal formula for acceptance - accepting the losses of prepain life while still pursuing personal goals.