Linguistic predictors of symptom change in an internet-based cognitive behavioural intervention for prolonged grief symptoms.

This study investigates linguistic predictors of reduction in prolonged grief symptoms following a writing intervention in an internet-based cognitive behavioural therapy for people bereaved by cancer. Data stem from a randomized control clinical trial with 70 people. The Linguistic Inquiry and Word Count program was used to analyse patient language. Absolute change scores and reliable change index were used to calculate reduction in grief symptoms and clinical significant change. Best subset regression and Mann-Whitney U tests were conducted. A higher reduction of prolonged grief symptoms was correlated with more social words in the first module (ß = -.22, p = .042), less risk (ß = .33, p = .002) and body words (ß = .22, p = .048) in the second module and more time words in the third module (ß = -.26, p = .018). Patients with clinically significant change showed a higher median in function words in the first module (p = .019), a lower median in risk words in the second module (p = .019) and a higher median in assent words in the last module (p = .014) compared to patients without clinically significant change. Findings suggest that it may be beneficial for therapists to encourage a more detailed description of patients' relationship with their deceased relative during the first module, a change in perspective during the second module and a summary of past, present and future aspects at the end of therapy. Future studies should include mediation analyses to allow causal attribution of the studied effects.

Factors Associated With Treatment Response in an Internet-Based Intervention for Prolonged Grief Disorder After Cancer Bereavement.

Internet-based psychological interventions have proven effective in the treatment of prolonged grief disorder (PGD). Yet, some patients do not benefit from treatment in a clinically significant way. We aimed to examine predictors of symptom reduction in an Internet-based intervention for PGD after cancer bereavement, in order to identify possible treatment mechanisms and discern directions for future intervention design. A secondary analysis of data from a randomized wait-list controlled trial on an Internet-based intervention for PGD after cancer bereavement was conducted. Multiple regression models were used (1) to test for the influence of pretreatment PGD, working alliance, avoidance and gender on PGD symptom reduction; and (2) to explore further predictors of treatment success with a best subset selection protocol. The regression models explained 18% (Model 1) and 34% (Model 2) of variance in symptom reduction. Participants with more favorable symptom change had more severe pretreatment PGD scores and better working alliance. Those with lower social support and less posttraumatic growth experienced more PGD symptom change. In conclusion, therapeutic alliance is an important factor that should be monitored and fostered. Findings regarding social support and posttraumatic growth need further replication and clarification.

Course and prediction of body image dissatisfaction during pregnancy: a prospective study.

BACKGROUND: During pregnancy, women`s bodies undergo rapid changes in body weight and body size within a relatively short period of time. Pregnancy may therefore be associated with an increased vulnerability for the development of body image dissatisfaction that has been linked to adverse health outcomes for mother and child. The present study aims to examine changes in body image during pregnancy as well as predictors of body image dissatisfaction. This is the first study using a tailored, multidimensional measure of body image especially developed for the pregnant population. METHODS: A prospective longitudinal design with a quantitative approach was applied. Healthy pregnant women (N = 222) were assessed using standardized instruments at two time points (T1: 18th-22th week of gestation, T2: 33th-37th week of gestation). The impact of demographic, weight- and health-related, behavioral, and psychological factors assessed at T1 on body image dissatisfaction at T1 and T2 was examined using stepwise linear regression analyses. RESULTS: T-tests for paired samples revealed that dissatisfaction with strength-related aspects of body image, dissatisfaction with body parts, and concerns about sexual attractiveness increased significantly from the middle to the end of pregnancy. In contrast, preoccupation with appearance, dissatisfaction with complexion, and prioritization of appearance over function were significantly reduced over time. Stepwise linear regression analyses revealed that factors influencing body image depend on the component of body image investigated. Overall, a low level of self-esteem and a high level of pregnancy-specific worries were risk factors for several components of body image dissatisfaction. Besides these, poor sleep quality, low levels of physical activity, disturbed eating behavior, and higher levels of BMI and weight gain were significant predictors. CONCLUSIONS: The results highlight the multidimensional nature of body image and show positive as well as negative changes during pregnancy. Overall, modifiable psychological, behavioral, and weight-related factors appear relevant to the extent of body image dissatisfaction.

Therapist-Assisted Web-Based Intervention for Prolonged Grief Disorder After Cancer Bereavement: Randomized Controlled Trial.

BACKGROUND: Bereavement due to cancer increases the risk of prolonged grief disorder. However, specialized treatment options for prolonged grief after a loss due to illness are still scarce. OBJECTIVE: The aim of this study is to extend previous findings by evaluating a web-based cognitive behavioral intervention with asynchronous therapist support, consisting of structured writing tasks adapted specifically for prolonged grief after cancer bereavement. METHODS: The intervention was evaluated in a purely web-based randomized waitlist-controlled trial. Open-access recruitment of participants was conducted on the web. Prolonged grief (Inventory of Complicated Grief), depression, anxiety, posttraumatic stress, posttraumatic growth, somatization, sleep quality, and mental and physical health were assessed on the web via validated self-report measures. RESULTS: A total of 87 participants were randomized into the intervention group (IG; 44/87, 51%) or the waitlist control group (43/87, 49%). Of the participants, 7% (6/87) dropped out of the study (5/44, 11%, in the IG). Of the 39 completers in the IG, 37 (95%) completed all intervention tasks. The intervention reduced symptoms of prolonged grief (intention-to-treat: P<.001; η2=0.34; Cohen d=0.80) to a clinically significant extent. It had favorable effects on depression, anxiety, posttraumatic stress, posttraumatic growth, and overall mental health but not on somatization, sleep quality, or physical health. CONCLUSIONS: The web-based intervention for prolonged grief after cancer bereavement is effective in reducing symptoms of prolonged grief disorder and accompanying syndromes in a timely, easily realizable manner and addresses specific challenges of bereavement to illness. Considering web-based approaches in future mental health care policy and practice can reduce health care gaps for those who are bereaved to cancer. TRIAL REGISTRATION: German Clinical Trial Register U1111-1186-6255; https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00011001.

[Occupational Participation of Syrian Refugees with Posttraumatic Stress in Germany]. / Berufliche Teilhabe von syrischen Geflüchteten mit posttraumatischer Stress-Symptomatik in Deutschland.

OBJECTIVE: Description of employment situation and search for determinants of employment depending on symptom severity in refugees with posttraumatic stress. METHODS: Standardized interviews with 133 Syrian refugees (18 to 65 years) living in Germany with posttraumatic stress symptoms and exploratory data analysis. RESULTS: 27.1 % of the participants were employed; including 13.9 % women and 86.1 % men (p = 0.001). Links between mental health and employment can be shown (posttraumatic stress p = 0.039, depressiveness p = 0.020, somatisation p = 0.026). With regard to social support and type of trauma, as well as residence status and duration of residence, there were no differences between refugees with and without employment. CONCLUSION: The current analysis on the employment situation of a circumscribed group of Syrian refugees focuses on the importance of psychological symptom burden.

Predictors of psychological distress in Syrian refugees with posttraumatic stress in Germany.

Syria has been the main country of citizenship of refugees in Germany since 2013. Syrians face numerous human rights violations in their country that can be accompanied by the experience of potentially traumatic events, loss and displacement. Along the migration process, refugees are exposed to various factors that can have an impact on mental health. The aim of this study is to investigate sociodemographic, war- and flight-related as well as post-migration factors as predictors of posttraumatic stress, depression, somatization and anxiety in Syrian refugees with posttraumatic stress symptoms based in Germany. Data were based on the baseline sample of the "Sanadak" randomized-controlled trial. A total of 133 adult Syrian refugees participated in the study. A questionnaire covered sociodemographic and flight-related questions as well as standardized instruments for symptoms of PTSD (PDS-5), depression (PHQ-9), somatization (PHQ-15), anxiety (GAD-7), generalized self-efficacy (GSE), religiousness (Z-Scale), social support (ESSI) and mental health stigma (SSMIS-SF). Linear regression models were executed to predict mental health outcomes. Sociodemographic predictors (i.e., female sex, higher education) and flight-related predicting factors (i.e., variability of traumatic events) have a negative impact on mental health in Syrian refugees with posttraumatic stress symptoms in Germany. Mental health stigma predicts worse mental health outcomes. Post-migration factors have a major impact on mental health, such as low income, lack of social support, low life satisfaction or a strongly felt connection to Syria. Somatization is an important manifestation of mental distress in Syrian refugees with posttraumatic stress symptoms. Our study showed a range of factors predicting the mental health of Syrian refugees with posttraumatic stress symptoms. Measures to foster mental health could be securing financial security, promoting gender equality and tailored psychosocial programs addressing mental health stigma, loss and social support networks.

Psychometric properties of the German version of the Depressive and Anxious Avoidance in Prolonged Grief Questionnaire (DAAPGQ).

The Depressive and Anxious Avoidance in Prolonged Grief Questionnaire (DAAPGQ) was developed to measure depressive and anxious avoidance behaviors, which, according to cognitive-behavioral models, are supposed to play an important role in the development and maintenance of prolonged grief. The present study aimed to develop a German version of the DAAPGQ and evaluate its psychometric properties and validity within a representative sample of the German general population (N = 2531). The German-language DAAPGQ was developed using a forward-backward translation procedure. Then, a subsample of individuals who reported having lost a significant other (N = 1371) of a representative sample was assessed with the German DAAPGQ, along with information on sociodemographic characteristics, prolonged grief symptom severity (PG-13), general anxiety (GAD-2) and depression (PHQ-2). The factor structure of the DAAPGQ was evaluated using confirmatory factor analyses, reliability by calculating internal consistency on subscale level and convergent validity by correlations between DAAPQG subscale sores with PG-13, GAD-2 and PHQ-2 sum scores. As expected, a two-factor model with correlated latent variables showed good fit to the data, replicating findings from the original version. Internal consistency was high for both subscales (Cronbach's α .86 and .95, respectively). Convergent validity was established by theoretically expected and statistically significant positive correlations of DAAPGQ subscales with symptom severity of prolonged grief, depression, and anxiety and negative correlations with time since loss. Furthermore, the addition of depressive and anxious avoidance significantly improved the prediction of prolonged grief symptom severity over sociodemographic and loss-related information. In sum, our results suggest that the German-language DAAPGQ is a reliable and valid measure of depressive and anxious avoidance and a useful tool to improve our knowledge on the role of avoidance in prolonged grief. We also provide descriptive data to improve the applicability of the DAAPGQ for individual diagnostics.

Mental Health Self-Stigma of Syrian Refugees With Posttraumatic Stress Symptoms: Investigating Sociodemographic and Psychopathological Correlates.

Background: The high prevalence of mental disorders related to posttraumatic stress among Syrian refugees is often in contrast with their low utilization of mental health care in the host countries. Mental health self-stigma, i.e., internalized stigma of having a mental disorder, could prevent individuals from seeking mental health care. Therefore, we aimed to provide evidence on different aspects of mental health self-stigmatization among adult Syrian refugees with posttraumatic stress symptoms residing in Germany. Moreover, we investigated associations with sociodemographic and psychopathological variables in order to identify those at higher risk of self-stigmatization. Material and Methods: Overall, 133 participants with mild to moderate posttraumatic stress symptoms were recruited in the metropolitan areas of Leipzig, Dresden and Halle, Germany, using a multimodal approach. Mental health self-stigma was assessed using the Self-Stigma of Mental Illness Scale - Short Form (SSMIS-SF), consisting of four subscales (Stereotype awareness, Stereotype agreement, Application to self , Harm to self-esteem), each scoring from 5 (low) to 45 (high) points. Linear regression analysis was used to test associations of sociodemographic and psychopathological variables with self-stigma subscales. Results: On average, self-stigma ratings ranged from 16.5 (SD = 6.6) points on Application to self to 28.3 (SD = 7.5) points on Stereotype awareness. Results showed higher scores on Application to self for individuals who were younger (t = 2.65, p = 0.009) and single (F = 5.70, p = 0.004). Regression analyses yielded statistically significant associations between having multiple comorbidities and a higher Application to self stigma (ß = 0.18, p = 0.044), controlling for sociodemographic covariates. Discussion: Mental health self-stigma was increased among Syrian refugees in Germany. Correlates of increased self-stigma could inform efforts to improve access to mental health care among Syrian refugees with mental ill-health. Longitudinal studies following an intersectional approach by concurrently examining multiple forms of public and internalized stigma could provide helpful insights for developing tailored stigma reduction efforts in this context.

Pre-loss grief and preparedness for death among caregivers of terminally ill cancer patients: A systematic review.

BACKGROUND: Cancer is one of the most common causes of death. The period of time between receiving a terminal diagnosis of cancer and the death of a loved one has been operationalized as pre-loss grief and, more recently, as preparedness for death. Originally, grief before loss was thought to have positive effects on the bereavement outcome, but some studies have revealed contradictory findings. This systematic review investigates definitions and measurement tools of pre-loss grief and preparedness for death, as well as the associations of both constructs with caregiver characteristics, pre-loss psychological aspects and post-loss adjustment among caregivers of people living with terminal cancer. METHODS: PubMed/Medline, PsycINFO and Web of Science were searched for studies published up until October 2020. Quantitative empirical studies from peer reviewed journals were included if a measurement tool for pre-loss grief or preparedness for death was used and if they focused on adult caregivers of adult people with cancer in an end-of-life trajectory and were excluded when they were not written in English or were descriptive/qualitative studies. Quality assessment of all studies was performed. RESULTS: Most studies used convenience samples and had a mean number of 725 participants. Overall, 16,326 participants in 35 articles were included and narratively synthesized. High levels of pre-loss grief, as well as low levels of perceived preparedness for death, were associated with poor post-loss adjustment (e.g., prolonged grief, depressive symptoms, etc.). CONCLUSIONS: Caregivers with high levels of pre-loss grief and low levels of preparedness for the death of their loved one would benefit from targeted support for post-loss adjustment. Results are limited by an inconsistent operationalization of both constructs.

Social media use and postpartum body image dissatisfaction: The role of appearance-related social comparisons and thin-ideal internalization.

OBJECTIVES: For many women, the postpartum period is a particularly vulnerable time to experience body image dissatisfaction. We aimed to examine the impact of social media usage frequency in the context of postpartum body image dissatisfaction and eating disorder psychopathology. We therefore empirically tested a hypothetical model assuming that social media usage influences postpartum body image dissatisfaction and eating disorder psychopathology via multiple mediation through appearance-related social comparisons and thin ideal internalization. DESIGN: Cross-sectional online-survey. SETTING: Online forums, social media groups, community groups PARTICIPANTS: Two-hundred-fifty-two new mothers who had given birth within the last 26 weeks prior to the assessment. MEASUREMENTS: Social media use was assessed by the average frequency of using Facebook, Instagram, Youtube or other per week. Body image dissatisfaction was assessed with the Body Shape Questionnaire and eating disorder psychopathology with the Eating Disorder Examination-Questionnaire. Path analyses using SPSS Amos were conducted to examine whether the hypothetical model fitted our data. RESULTS: After minor modification, the final model revealed a good fit to the data, CFI = .977, TLI = .964, SRMR = .061, RMSEA = .056 (90%CI .027, .084), and as expected the indirect multiple mediation pathway via appearance-related social comparisons and thin ideal idealization was significant, IE = 4.395; 95%BCaCI 2.969, 7.394; p = .001. The number of target groups for appearance-related social comparisons did not moderate the results. KEY CONCLUSIONS: Our results provide first evidence that social media use may play an important role in postpartum body dissatisfaction and eating disorder psychopathology. Mediational pathways proposed by socio-cultural theories of body image also hold for the postpartum period. IMPLICATIONS FOR PRACTICE: Practitioners in the field should be aware of the association between social media use and body image dissatisfaction and mediating factors among new mothers and sensitive when directing new mothers to those media.

Traumatized Syrian Refugees with Ambiguous Loss: Predictors of Mental Distress.

Refugees from war zones often have missing significant others. A loss without confirmation is described as an ambiguous loss. This physical absence with simultaneous mental persistence can be accompanied by economic, social or legal problems, boundary ambiguity (i.e., uncertainty about who belongs to the family system), and can have a negative impact on mental health. The aim of this study was to identify sociodemographic and loss-related predictors for prolonged grief, anxiety, depression, post-traumatic stress disorder (PTSD) and somatization in treatment-seeking Syrian refugees with post-traumatic stress symptoms in Germany experiencing ambiguous loss. For the present study, data were based on the treatment-seeking baseline sample of the "Sanadak" randomized-controlled trial, analyzing a subsample of 47 Syrian refugees with post-traumatic stress symptoms in Germany experiencing ambiguous loss. Sociodemographic and loss-related questions were applied, along with standardized instruments for symptoms of prolonged grief (ICG), anxiety (GAD-7), depression (PHQ-9), PTSD (PDS-5) and somatization (PHQ-15). Linear regression models were used to predict mental health outcomes. Having lost a close family member and higher boundary ambiguity showed a statistically significant association with higher severity in prolonged grief. The overall model for somatization reached statistical significance, while no predictor independently did. Boundary ambiguity showed a statistically significant positive association with depression, while the overall model showed no statistically significant associations. Boundary ambiguity and missing family members seemed to be important predictors for prolonged grief. These findings support the importance of reunification programs and suggest an inclusion of the topic into psychosocial support structures, e.g., including psychoeducational elements on boundary ambiguity in support groups for traumatized individuals and families experiencing ambiguous loss. Further research is needed for a more detailed understanding of the impact of ambiguous loss on refugee populations.

Health Care Services Utilization and Health-Related Quality of Life of Syrian Refugees with Post-Traumatic Stress Symptoms in Germany (the Sanadak Trial).

Refugees who have fled from the ongoing civil war in Syria that arrived in Germany often develop post-traumatic stress symptoms (PTSS). The aim of this study was to determine health care services utilization (HCSU), health care costs and health-related quality of life (HrQoL) of Syrian refugees with mild to moderate PTSS without current treatment in Germany. The study was based on the baseline sample of a randomized controlled trial of a self-help app for Syrian refugees with PTSS (n = 133). HCSU and HrQoL based on the EQ-5D-5L and its visual analogue scale (EQ-VAS) were assessed with standardized interviews. Annual health care costs were calculated using extrapolated four-month HCSU and standardized unit costs. Associations between health care costs, HrQoL and PTSS severity were examined using generalized linear models. Overall, 85.0% of the sample utilized health care services within four months. The mean total annual health care costs were EUR 1920 per person. PTSS severity was not associated with health care costs. The EQ-5D-5L index score and the EQ-VAS score was 0.82 and 73.6, respectively. For Syrian refugees with higher PTSS severity, the EQ-5D-5L index score was lower (-0.17; p < 0.001). The HCSU and the resulting health care costs of Syrian refugees with mild to moderate PTSS without current treatment are low and those with a higher PTSS severity had a lower HrQoL.

Correction: A Self-Help App for Syrian Refugees With Posttraumatic Stress (Sanadak): Randomized Controlled Trial.

[This corrects the article DOI: 10.2196/24807.].

A Self-Help App for Syrian Refugees With Posttraumatic Stress (Sanadak): Randomized Controlled Trial.

BACKGROUND: Syrian refugees residing in Germany often develop posttraumatic stress as a result of the Syrian civil war, their escape, and postmigration stressors. At the same time, there is a lack of adequate treatment options. The smartphone-based app Sanadak was developed to provide cognitive behavioral therapy-based self-help in the Arabic language for Syrian refugees with posttraumatic stress. OBJECTIVE: The aim of this study was to evaluate the effectiveness and cost-effectiveness of the app. METHODS: In a randomized controlled trial, eligible individuals were randomly allocated to the intervention group (IG; app use) or control group (CG; psychoeducational reading material). Data were collected during structured face-to-face interviews at 3 assessments (preintervention/baseline, postintervention/after 4 weeks, follow-up/after 4 months). Using adjusted mixed-effects linear regression models, changes in posttraumatic stress and secondary outcomes were investigated as intention-to-treat (ITT) and per-protocol (PP) analysis. Cost-effectiveness was evaluated based on adjusted mean total costs, quality-adjusted life years (QALYs), and cost-effectiveness acceptability curves using the net benefit approach. RESULTS: Of 170 screened individuals (aged 18 to 65 years), 133 were eligible and randomized to the IG (n=65) and CG (n=68). Although there was a pre-post reduction in posttraumatic stress, ITT showed no significant differences between the IG and CG after 4 weeks (Posttraumatic Diagnostic Scale for DSM-5, Diff -0.90, 95% CI -0.24 to 0.47; P=.52) and after 4 months (Diff -0.39, 95% CI -3.24 to 2.46; P=.79). The same was true for PP. Regarding secondary outcomes, ITT indicated a treatment effect for self-stigma: after 4 weeks (Self-Stigma of Mental Illness Scale/SSMIS-stereotype agreement: d=0.86, 95% CI 0.46 to 1.25; stereotype application: d=0.60, 95% CI 0.22 to 0.99) and after 4 months (d=0.52, 95% CI 0.12 to 0.92; d=0.50, 95% CI 0.10 to 0.90), the IG showed significantly lower values in self-stigma than the CG. ITT showed no significant group differences in total costs and QALYs. The probability of cost-effectiveness was 81% for a willingness-to-pay of €0 per additional QALY but decreased with increasing willingness-to-pay. CONCLUSIONS: Sanadak was not more effective in reducing mild to moderate posttraumatic stress in Syrian refugees than the control condition nor was it likely to be cost-effective. Therefore, Sanadak is not suitable as a standalone treatment. However, as the app usability was very good, no harms detected, and stigma significantly reduced, Sanadak has potential as a bridging aid within a stepped and collaborative care approach. TRIAL REGISTRATION: German Clinical Trials Register DRKS00013782; https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00013782. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.1186/s12888-019-2110-y.

Efficacy of an Internet-based cognitive-behavioural grief therapy for people bereaved by suicide: a randomized controlled trial.

Background: The loss of a loved one due to suicide can be a traumatic event associated with prolonged grief and psychological distress. Objective: This study examined the efficacy of an Internet-based cognitive-behavioural grief therapy (ICBGT) specifically for people bereaved by suicide. Methods: In a randomized controlled trial, 58 participants with prolonged grief disorder (PGD) symptoms who had lost a close person to suicide were randomly allocated either to the intervention group (IG) or waitlist-control group (WCG). The 5-week intervention comprised ten writing assignments in three phases: self-confrontation, cognitive restructuring, and social sharing. Symptoms of PGD, common grief reactions after suicide, depression, and general psychopathology were assessed at pre-, post-test and follow-up. Results: Between-group effect sizes were large for the improvement of PGD symptoms in treatment completers (dppc2 = 1.03) and the intent-to-treat analysis (dppc2 = 0.97). Common grief reactions after suicide and depressive symptoms also decreased in the IG compared to the WCG (moderate to large effects). The results are stable over time. Only for general psychopathology, there was no significant time by group interaction effect found. Conclusions: The ICBGT represents an effective treatment approach for people suffering from PGD symptoms after bereavement by suicide. Considering the effect sizes, the small treatment dose, duration, and the stability of the results, the ICBGT constitutes an appropriate alternative to face-to-face grief interventions.

Antecedentes: La pérdida de un ser querido por suicidio puede ser un evento traumático asociado con el duelo prolongado y el malestar psicológico.Objetivo: Este estudio examinó la eficacia de una terapia cognitivo conductual de duelo basada en el internet (ICBGT en su sigla en inglés), específicamente para las personas en duelo por suicidio.Métodos: En un ensayo controlado aleatorizado, 58 participantes con síntomas de trastorno de duelo prolongado (PGD en su sigla en inglés) que han perdido una persona cercana por suicidio fueron asignados al grupo de intervención (IG en su sigla en inglés) o grupo de control de lista de espera (WCG en su sigla en inglés). La intervención de 5 semanas incluye diez tareas escritas en tres etapas: auto-confrontación, reestructuración cognitiva, y compartir social. Fueron evaluados antes y después de la intervención y al seguimiento, los síntomas de PGD, reacciones de duelo comunes luego de un suicidio, depresión, y psicopatología general.Resultados: Los tamaños de los efectos entre los grupos fueron grandes para la mejoría de los síntomas de PGD en quienes completaron el tratamiento (dppc2=1.03) y el análisis del intento-de-tratar (dppc2=0.97). Las reacciones de duelo comunes luego de suicidio y los síntomas depresivos también disminuyeron en IG en comparación con WCG (efectos moderados a grandes). Los resultados fueron estables a lo largo del tiempo. Solo en psicopatología general no se encontró un efecto significativo de tiempo por grupo.Conclusiones: ICBGT representa una forma de tratamiento efectiva para las personas que sufren de síntomas PGD luego de una pérdida por suicidio. Considerando los tamaños de los efectos, la dosis pequeña de tratamiento, la duración, y la estabilidad de los resultados, ICBGT constituye una alternativa apropiada para las intervenciones en duelo presenciales.

Syrian refugees in Germany: Perspectives on mental health and coping strategies.

OBJECTIVE: Syrians have been the largest group among asylum seekers in Germany since 2014. Refugees are exposed to various risks along the migration process, indicating the need for adequate psychosocial support. Following the advice of the United Nations High Commissioner for Refugees to consult the target group, this is the first study qualitatively investigating the perspectives on mental health and coping strategies of Syrian refugees in Germany. METHODS: A qualitative design with semi-structured focus group discussions was applied. Three focus groups with a total of N = 20 participants were conducted. Focus group discussions were analyzed using content-structuring content analysis. RESULTS: Hopelessness, fear, and worries were reported most frequently as emotional consequences of war, fleeing, and resettlement, along with cognitive, physical, social, and behavioral consequences. Among the reported consequences, symptoms of PTSD were identified. Contrary to depression and schizophrenia, PTSD was not explicitly mentioned. Possibilities of coping and support referred to meeting basic needs (e.g., mental health care), fostering participation and personal coping, with the social network stated as most important source of support. Barriers of accessing mental health and psychosocial support (MHPSS) services included poor information, stigma, and language difficulties. CONCLUSION: In contrast to earlier research, Syrian refugees reported numerous emotional symptoms as well as mental disorders as consequences of war, fleeing, and resettlement, indicating awareness of mental health sequelae. However, PTSD was not reported as possible consequence. The findings indicate the need for adequate psychoeducation, matching the participants' wish for improved information on mental health to reduce barriers accessing MHPSS.

The association between breastfeeding and attachment: A systematic review.

OBJECTIVE: In the popular and scientific literature an association between breastfeeding and attachment is often supposed although this has not been systematically investigated. This is the first review that provides a systematic overview of the current state of research on the association between breastfeeding and attachment. The objective is to determine whether breastfeeding is associated with child attachment as well as if maternal attachment is associated with breastfeeding behaviour. DESIGN: A systematic electronic literature search for English language articles published from 1963 to 2019 using the databases Web of Science, PubMed, PsycInfo, and PsycArticles was conducted. Studies were included if (1) the association between breastfeeding and attachment of the child or maternal attachment style and breastfeeding was investigated, (2) participants were mothers or mother-child dyads, and (3) quantitative measures of breastfeeding and attachment were used. Study quality was rated using the NIH Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. PARTICIPANTS: Studies examining mothers or mother-child dyads were reviewed. Sample sizes varied between N = 60 and N = 8900 participants. On average, mothers were between 27.56 and 32.50 years old. FINDINGS: Eleven studies were eligible for inclusion. Of seven studies examining breastfeeding and child attachment, four found that a longer duration of breastfeeding was significantly associated with higher levels of attachment security after controlling for various covariates. No significant differences in attachment security between breastfeeding and bottle-feeding were reported, but one study found higher levels of attachment disorganization for bottle-feeding, although mean levels were below a clinically relevant level. The initiation of breastfeeding directly after childbirth was not related to child attachment. Of four studies examining maternal attachment and breastfeeding, three found a significant association between secure attachment of the mother and breastfeeding behaviour. Secure attached mothers initiated breastfeeding more often and preferred breast- over bottle-feeding than insecure attached mothers. Mixed results were found for breastfeeding duration. Most studies had limitations regarding adequate sample size, and valid and reliable measurement of breastfeeding. KEY CONCLUSIONS: The findings provide some evidence that breastfeeding might contribute to child attachment security. Furthermore, maternal attachment style might play a role in breastfeeding behaviour. However, more prospective studies are needed to draw a solid conclusion. IMPLICATIONS FOR PRACTICE: With regard to breastfeeding recommendations, health professionals should be aware of and communicate towards clients that the effect of breastfeeding on child attachment might be rather small. Screening of maternal attachment style as a part of maternity practice could be useful to support insecure attached mothers experiencing breastfeeding difficulties.

Associations of postpartum mother-infant bonding with maternal childhood maltreatment and postpartum mental health: a cross-sectional study.

BACKGROUND: After delivery, some women experience impairment of their mother-infant bonding (MIB), which can lead to long-term disturbances of the mother-child relationship and the child's social-emotional development. Little is known about the association between early maternal bonding problems and mothers' own adverse childhood experiences, even though the hypothesis of the intergenerational transmission of caregiving indicates continuity in parenting quality across generations. Therefore, the current study aimed at examining the relationship between maternal childhood maltreatment and postpartum MIB, controlling for the role of postpartum mental health. METHODS: From February 2014 to March 2015, 725 women completed self-report measures 2 months postpartum. Maternal childhood maltreatment was assessed with the Childhood Trauma Questionnaire, postpartum depression with the Revised Beck Depression Inventory, postpartum anxiety with the Symptom Checklist-90-Revised, and postpartum MIB with the abridged version of the Postpartum Bonding Questionnaire. Data were analysed using a hierarchical regression analysis. RESULTS: Almost 46% of the included women reported at least one type of childhood maltreatment with emotional neglect being most prevalent. 13% displayed at least mild postpartum depressive symptomatology and 20% scored above the 75th percentile for postpartum anxiety. In the final regression model, which explained 29% of variance, higher severity of maternal emotional neglect in childhood, higher levels of postpartum depression and higher education were significantly related to more postpartum MIB impairment. In contrast, higher severity of maternal physical neglect was significantly associated with less postpartum MIB impairment. CONCLUSIONS: This study is the first to explore the relationship between diverse types of maternal childhood maltreatment and postpartum MIB, adjusting for postpartum mental health. Maternal experiences of emotional neglect and postpartum depressive symptoms could serve as indicators to identify and support mothers with heightened risk for bonding problems, but results need to be validated in longitudinal studies.

Measuring body image during pregnancy: psychometric properties and validity of a German translation of the Body Image in Pregnancy Scale (BIPS-G).

BACKGROUND: This study aimed to provide a German translation of the Body Image in Pregnancy Scale (BIPS) - a measure tailored to pregnancy-specific aspects of body image while being consistent to the multifaceted theoretical framework of body image - and to test its psychometric properties and validity. METHODS: The English-language original version of the BIPS was translated into German language using a forward-backward translation rationale. Face validity of the items was tested in cognitive interviews (n = 5). An online survey was conducted among 291 pregnant women. After conducting standard item analyses, factorial validity was tested using principal-axis factor analysis (PAF). Convergent and incremental validity with measures of body dissatisfaction (FFB), depression (EPDS), anxiety (GAD-7), self-esteem (RSE), and eating disorder psychopathology (EDE-Q) was tested by bivariate correlations and multiple linear hierarchical regression analyses. RESULTS: The PFA revealed a 32 item and 6-factor solution resembling the dimensions preoccupation with appearance, dissatisfaction with strength-related aspects, dissatisfaction with body parts, dissatisfaction with complexion, prioritization of appearance over function, and concerns about sexual attractiveness. Internal consistency on a subscale level was good to excellent (.79 ≤ Cronbach's α ≤ .91). Consistent with theoretical assumptions, we found significant positive correlations of BIPS-G subscales with depression, anxiety and eating disorder psychopathology and negative correlations of BIPS-G subscales with self-esteem. BIPS-G subscales substantially improved the prediction of depression, anxiety, self-esteem and eating disorder psychopathology over demographic factors and body dissatisfaction (.03 ≤ ΔR2 ≤ .15, all p-values < 0.05). CONCLUSIONS: The German version of the BIPS appeared to be a reliable and valid measure which has the capacity to enhance future research on body image during pregnancy in German-speaking populations.

HELP@APP: development and evaluation of a self-help app for traumatized Syrian refugees in Germany - a study protocol of a randomized controlled trial.

BACKGROUND: Syrians represent the largest group among refugees in Germany. Many of them were exposed to sequential traumatizing events including war, escape and post-migration stressors, which significantly increase the risk to develop symptoms of posttraumatic stress and other mental disorders. However, there is a lack of adequate treatment options for traumatized refugees in Germany. Moreover, their access to psychosocial care is often restricted due to legal regulation, language barriers, and unclear cost coverage. We therefore aim to develop a low-threshold supportive self-help app for Syrian refugees with posttraumatic stress symptoms. By conducting a randomized controlled trial, we further aim to evaluate the apps' efficacy, usability, acceptance, and economic health benefit/cost-effectiveness. METHODS: We will develop a modular, interactive self-help app in Arabic, which will be grounded on cognitive-behavioral models for the treatment of posttraumatic stress. Subsequently, screened positive (i.e., Syrian refugees, 18-65 years old, mild to moderate posttraumatic stress symptomatology as quantified by the Posttraumatic Stress Diagnostic Scale for DSM-5/PDS-5) participants (ideally up to n = 234) will be randomly allocated to an intervention (IG) and control group (CG), respectively. Participants in the IG will gain access to the self-help app for one month, while participants in the CG will receive psychoeducational reading material in form of a comprehensive brochure on traumatization and posttraumatic stress. Measurements are scheduled before the intervention (T0), directly after the intervention (T1, one month later) and three months after the intervention (T2). Using linear mixed effect models, we will investigate change in posttraumatic symptomatology. We will also test for changes in secondary outcomes such as depression, anxiety, and quality of life. Moreover, we will inspect the usability and user acceptance of the app. To evaluate the app in terms of its economic health benefit, the incremental cost-effectiveness ratio will be calculated. DISCUSSION: We plan to make the app freely available to the general public after evaluation. Thus, the app can help to add-on to routine care, which currently lacks sufficient and appropriate treatment options for Syrian refugees. TRIAL REGISTRATION: German Clinical Trials Register/Deutsches Register Klinischer Studien (DRKS). Registration ID: DRKS00013782 . Registered: 06th of July 2018.