Mental healthcare access among resettled Syrian refugees in Leipzig, Germany.

Our aim was to examine mental health needs and access to mental healthcare services among Syrian refugees in the city of Leipzig, Germany. We conducted a cross-sectional survey with Syrian refugee adults in Leipzig, Germany in 2021/2022. Outcomes included PTSD (PCL-5), depression (PHQ-9), anxiety (GAD-7) and somatic symptom (SSS-8). Descriptive, regression and effect modification analyses assessed associations between selected predictor variables and mental health service access. The sampling strategy means findings are applicable only to Syrian refugees in Leipzig. Of the 513 respondents, 18.3% had moderate/severe anxiety symptoms, 28.7% had moderate/severe depression symptoms, and 25.3% had PTSD symptoms. A total of 52.8% reported past year mental health problems, and 48.9% of those participants sought care for these problems. The most common reasons for not accessing mental healthcare services were wanting to handle the problem themselves and uncertainty about where to access services. Adjusted Poisson regression models (n = 259) found significant associations between current mental health symptoms and mental healthcare service access (RR: 1.47, 95% CI: 1.02-2.15, p = 0.041) but significance levels were not reached between somatization and trust in physicians with mental healthcare service access. Syrian refugees in Leipzig likely experience high unmet mental health needs. Community-based interventions for refugee mental health and de-stigmatization activities are needed to address these unmet needs in Leipzig.

Interdisciplinary perspectives on digital technologies for global mental health.

Digital Mental Health Technologies (DMHTs) have the potential to close treatment gaps in settings where mental healthcare is scarce or even inaccessible. For this, DMHTs need to be affordable, evidence-based, justice-oriented, user-friendly, and embedded in a functioning digital infrastructure. This viewpoint discusses areas crucial for future developments of DMHTs. Drawing back on interdisciplinary scholarship, questions of health equity, consumer-, patient- and developer-oriented legislation, and requirements for successful implementation of technologies across the globe are discussed. Economic considerations and policy implications complement these aspects. We discuss the need for cultural adaptation specific to the context of use and point to several benefits as well as pitfalls of DMHTs for research and healthcare provision. Nonetheless, to circumvent technology-driven solutionism, the development and implementation of DMHTs require a holistic, multi-sectoral, and participatory approach.

Effectiveness and cost-effectiveness of a transdiagnostic intervention for alcohol misuse and psychological distress in humanitarian settings: study protocol for a randomised controlled trial in Uganda.

BACKGROUND: The war in South Sudan has displaced more than four million people, with Uganda hosting the largest number of South Sudanese refugees. Research in Uganda has shown elevated levels of alcohol misuse and psychological distress among these refugees. The World Health Organization (WHO) has developed a trans-diagnostic scalable psychological intervention called Problem Management Plus (PM +) to reduce psychological distress among populations exposed to adversities. Our study aims to evaluate the effectiveness and cost-effectiveness of the CHANGE intervention, which builds on PM + , to also address alcohol misuse through problem-solving therapy and selected behavioural strategies for dealing with alcohol use disorders. We hypothesise that the CHANGE intervention together with enhanced usual care (EUC) will be superior to EUC alone in increasing the percentage of days abstinent. METHODS: A parallel-arm individually randomised controlled trial will be conducted in the Rhino Camp and Imvepi settlements in Uganda. Five hundred adult male South Sudanese refugees with (i) elevated levels of alcohol use (between 8 and 20 on the Alcohol Use Disorder Identification Test [AUDIT]); and (ii) psychological distress (> 16 on the Kessler Psychological Distress Scale) will be randomly assigned 1:1 to EUC or CHANGE and EUC. CHANGE will be delivered by lay healthcare providers over 6 weeks. Outcomes will be assessed at 3 and 12 months post-randomisation. The primary outcome is the percentage of days abstinent, measured by the timeline follow-back measure at 3 months. Secondary outcomes include percentage of days abstinent at 12 months and alcohol misuse (measured by the AUDIT), psychological distress (i.e. depression, anxiety, posttraumatic stress disorder), functional disability, perpetration of intimate partner violence, and health economic indicators at 3 and 12 months. A mixed-methods process evaluation will investigate competency, dose, fidelity, feasibility, and acceptability. Primary analyses will be intention-to-treat. DISCUSSION: CHANGE aims to address alcohol misuse and psychological distress with male refugees in a humanitarian setting. If it is proven to be effective, it can help fill an important under-researched gap in humanitarian service delivery. TRIAL REGISTRATION: ISRCTN ISRCTN10360385. Registered on 30 January 2023.

Using theory of change to plan for the implementation of a psychological intervention addressing alcohol use disorder and psychological distress in Uganda.

In conflict-affected settings, prevalence of alcohol use disorders (AUDs) can be high. However, limited practical information exists on AUD management in low-income settings. Using a theory of change (ToC) approach, we aimed to identify pathways influencing the implementation and maintenance of a new transdiagnostic psychological intervention ("CHANGE"), targeting both psychological distress and AUDs in humanitarian settings. Three half-day workshops in Uganda engaged 41 stakeholders to develop a ToC map. ToC is a participatory program theory approach aiming to create a visual representation of how and why an intervention leads to specific outcomes. Additionally, five semi-structured interviews were conducted to explore experiences of stakeholders that participated in the ToC workshops. Two necessary pathways influencing the implementation and maintenance of CHANGE were identified: policy impact, and mental health service delivery. Barriers identified included policy gaps, limited recognition of social determinants and the need for integrated follow-up care. Interviewed participants valued ToC's participatory approach and expressed concerns about its adaptability in continuously changing contexts (e.g., humanitarian settings). Our study underscores ToC's value in delineating context-specific outcomes and identifies areas requiring further attention. It emphasizes the importance of early planning and stakeholder engagement for sustainable implementation of psychological interventions in humanitarian settings.

[Digital technologies to improve mental health]. / Digitale Technologien zur Verbesserung der psychischen Gesundheit.

The burden of mental diseases is enormous and constantly growing worldwide. The resulting increase in demand for psychosocial help is also having a negative impact on waiting times for psychotherapy in Germany. Digital interventions for mental health, such as interventions delivered through or with the help of a website (e.g. "telehealth"), smartphone, or tablet app-based interventions and interventions that use text messages or virtual reality, can help. This article begins with an overview of the functions and range of applications of digital technologies for mental health. The evidence for individual digital forms of interventions is addressed. Overall, it is shown that digital interventions for mental health are likely to be cost-effective compared to no therapy or a non-therapeutic control group. Newer approaches such as "digital phenotyping" are explained in the article. Finally, individual papers from the "Leibniz ScienceCampus Digital Public Health" are presented, and limitations and challenges of technologies for mental health are discussed.

Implementing a Non-Specialist Delivered Psychological Intervention for Young Adolescents in a Protracted Refugee Setting: a Qualitative Process Evaluation in Lebanon.

There has been an increase in the evaluation and implementation of non-specialist delivered psychological interventions to address unmet mental health needs in humanitarian emergencies. While randomized controlled trials (RCTs) provide important evidence about intervention impact, complementary qualitative process evaluations are essential to understand key implementation processes and inform future scaling up of the intervention. This study was conducted as part of an RCT of the Early Adolescents Skills for Emotions (EASE) psychological intervention for young adolescents with elevated psychological distress (predominantly with a Syrian refugee background) in Lebanon. Our aims were firstly to conduct a qualitative process evaluation to understand stakeholder experiences and perceived impact of the intervention and identify barriers and facilitators for implementation, and secondly to explore considerations for scaling up. Eleven key informant interviews and seven focus groups were conducted with 39 respondents including adolescent and caregiver participants, trainers, providers, outreach workers, and local stakeholders. Data were analyzed using inductive and deductive thematic analysis. Respondents perceived the intervention to be highly needed and reported improvements in adolescent mental health and wellbeing. Key implementation factors that have potential to influence engagement, adherence, and perceived impact included the socio-economic situation of families, mental health stigma, coordination within and between sectors (particularly for scaling up), embedding the intervention within existing service pathways, having clear quality and accountability processes including training and supervision for non-specialists, and sustainable funding. Our findings provide important context for understanding effectiveness outcomes of the RCT and highlights factors that need to be considered when implementing a mental health intervention on a larger scale in a complex crisis.

Understanding the protective effect of social support on depression symptomatology from a longitudinal network perspective.

BACKGROUND: Higher social support protects people from developing mental disorders. Limited evidence is available on the mechanism through which social support plays this protective role. OBJECTIVE: To investigate the stress-buffering process of social support on depressive symptoms using a novel longitudinal dynamic symptom network approach. METHODS: A total of 4242 adult participants who completed the first two waves (from May to October 2020) of the International Covid Mental Health Survey were included in the study. Cross-lagged panel network modelling was used to estimate a longitudinal network of self-reported social support, loneliness and depressive symptoms. Standardised regression coefficients from regularised cross-lagged regressions were estimated as edge weights of the network. FINDINGS: The results support a unidirectional protective effect of social support on key depressive symptoms, partly mediated through loneliness: A higher number of close confidants and accessible practical help was associated with decreased anhedonia (weight=-0.033) and negative self-appraisal symptoms (weight=-0.038). Support from others was also negatively associated with loneliness, which in turn associated with decreased depressed mood (weight=0.086) and negative self-appraisal (weight=0.077). We identified a greater number of direct relationships from social support to depressive symptoms among men compared with women. Also, the edge weights from social support to depression were generally stronger in the men's network. CONCLUSIONS: Reductions in negative self-appraisal might function as a bridge between social support and other depressive symptoms, and, thus, it may have amplified the protective effect of social support. Men appear to benefit more from social support than women. CLINICAL IMPLICATIONS: Building community-based support networks to deliver practical support, and loneliness reduction components are critical for depression prevention interventions after stressful experiences.

Predictors of spontaneous remission and recovery among women with untreated perinatal depression in India and Pakistan.

Background: Mothers with perinatal depression can show different symptom trajectories and may spontaneously remit from depression, however, the latter is poorly understood. This is the first study which sought to investigate predictors of spontaneous remission and longer-term recovery among untreated women with perinatal depression. Methods: We analysed data from two randomised controlled trials in women with perinatal depression in India and Pakistan. Analyses were restricted to women in the control groups who did not receive active treatment. Generalised estimating equations and logistic regressions were used to estimate odds ratios (ORs) and 95% confidence intervals (CIs), adjusting for within-person correlation. Results: In multivariable analyses, remission was associated with a husband who is not working (adjusted OR, aOR = 2.04, 95% CI 1.02-4.11), lower Patient Health Questionnaire-9 score at baseline (aOR = 0.43, 95% CI 0.20-0.90 for score of ≥20 vs. 10-14) and better social support at baseline (aOR = 2.37, 95% CI 1.32-4.27 for high vs. low social support). Conclusions: Women with low baseline severity may remit from perinatal depression with adequate social support from family and friends. These factors are important contributors to the management of perinatal depression and the prevention of clinical worsening, and should be considered when designing low-threshold psychological interventions.

Community-based counselling programme for pregnant women with alcohol problems in Cape Town, South Africa: a qualitative study of the views of pregnant women and healthcare professionals.

Introduction: South Africa lacks services to detect and address alcohol use during pregnancy, particularly outside of health-care facilities. This study aimed to explore pregnant women and healthcare providers' perceptions of the acceptability, feasibility and appeal of a community-based counselling programme for pregnant women with alcohol problems. Methods: Twenty-eight in-depth interviews with pregnant women who drink, Community Health Workers (CHWs) and antenatal service providers were conducted. Transcribed interviews were analyzed thematically using a combined deductive and inductive approach. Results: Women reported feeling uncomfortable seeking help for their alcohol use at antenatal clinics, limiting usefulness of current support services. All stakeholders perceived a community-based intervention to be acceptable and feasible as it could be integrated with other CHW-delivered services. Participants thought an intervention should facilitate early linkage to antenatal services and should include partners or family members. The feasibility of an intervention may depend on the relationship between CHWs and clinic-based antenatal staff, and their relationships with pregnant women. Clinic and community challenges to implementation were raised. Clinic-level challenges included shortage of space, staff capacity, high number of pregnant women, long waiting times, financial burden of having to travel to a clinic, lack of comfort and privacy and staff attitudes. Community-level challenges included crime, lack of privacy, lack of attention given competing interests in the home, fear due to abuse, and stigma and discrimination from other community members. Suggestions for overcoming these challenges were provided. Conclusion: Findings provide essential information to facilitate the adaptation of a community-based alcohol counselling programme for greater acceptability, feasibility and cultural appropriateness for the South African context. Intensive training, supervision and support is required to ensure the programme is delivered as planned.

Scaling-up problem management plus for refugees in Switzerland - a qualitative study.

BACKGROUND: Refugees are at an increased risk of developing symptoms of mental disorders but face various structural and socio-cultural barriers to accessing mental health care. The SPIRIT project (Scaling-up Psychological Interventions in Refugees In SwiTzerland) seeks to promote the resilience of refugees and improve their access to mental health care. For this purpose, Problem Management Plus (PM+), an evidence-based low-intensity psychological intervention delivered by trained non-specialist "helpers", is being scaled-up in Switzerland. OBJECTIVE: To identify factors influencing the process of the large-scale implementation of PM + for refugees in Switzerland and to develop recommendations to guide the implementation process. METHODS: 22 semi-structured interviews were conducted with key informants (Syrian refugees who previously participated in PM+, PM + helpers, health professionals working with refugees and decision-makers from the migration, integration, social, and health sectors). The data were analyzed using thematic analysis, combining an inductive and deductive approach. RESULTS: The data revealed three major themes, which might have an impact for the longer-term implementation of PM + in Switzerland. First, preconditions for successful integration in the health system prior to scaling-up such as sustainable funding or the introduction of a stepped care approach. Second, the requirements for the PM + intervention supporting scale-up such as quality control during PM + delivery, PM + modality, time and setting when PM + is offered or the views on task sharing. Third, the perceived benefits of scaling-up PM + in Switzerland. CONCLUSIONS: Our results have shown that PM + must be scaled-up within a stepped care approach, including a functioning triage system and sustainable funding. Rather than selecting one modality or setting, it seemed preferable to offer a variety of formats and settings to achieve maximum reach and benefits. A successful scale-up of PM + in Switzerland might have various benefits. Communicating them to policy-makers and health providers, might enhance their acceptability of the intervention and their willingness to adopt PM + in regulatory structure and promote it.

The global burden of perinatal common mental health disorders and substance use among migrant women: a systematic review and meta-analysis.

BACKGROUND: There are one billion migrants globally, of whom 82 million are forced migrants. Pregnant migrants face pre-migration stressors such as conflict, transit stressors including poverty, and post-migration stressors including navigating the immigration system; these stressors can make them vulnerable to mental illness. We aimed to assess the global prevalence of and risk factors for perinatal mental health disorders or substance use among women who are migrants. METHODS: In this systematic review and meta-analysis, we searched OVID MEDLINE, Embase, PsycINFO, CENTRAL, Global Health, Scopus, and Web of Science for studies published from database inception until July 8, 2022. Cohort, cross-sectional, and interventional studies with prevalence data for any mental illness in pregnancy or the postnatal period (ie, up to a year after delivery) or substance use in pregnancy were included. The primary outcome was the prevalence of perinatal common mental health disorders among women who are migrants, globally. Data for study quality and risk factors were also extracted. A random-effects meta-analysis was used to calculate pooled prevalence estimates, when appropriate. Sensitivity analyses were conducted according to study quality, sample representativeness, and method of outcome assessment. Risk factor data were synthesised narratively. This study is registered with PROSPERO, CRD42021226291. FINDINGS: 18 650 studies were retrieved, of which 135 studies comprising data from 621 995 participants met the inclusion criteria. 123 (91%) of 135 studies were conducted in high-income host countries. Five (4%) of 135 studies were interventional, 40 (30%) were cohort, and 90 (66%) were cross-sectional. The most common regions of origin of participants were South America, the Middle East, and north Africa. Only 26 studies presented disaggregated data for forced migrants or economic migrants. The pooled prevalence of perinatal depressive disorders was 24·2% (range 0·5-95·5%; I2 98·8%; τ2 0·01) among all women who are migrants, 32·5% (1·5-81·6; 98·7%; 0·01) among forced migrants, and 13·7% (4·7-35·1; 91·5%; 0·01) among economic migrants (p<0·001). The pooled prevalence of perinatal anxiety disorders was 19·6% (range 1·2-53·1; I2 96·8%; τ2 0·01) among all migrants. The pooled prevalence of perinatal post-traumatic stress disorder (PTSD) among all migrant women was 8·9% (range 3·2-33·3; I2 97·4%; τ2 0·18). The pooled prevalence of perinatal PTSD among forced migrants was 17·1% (range 6·5-44·3; I2 96·6%; τ2 0·32). Key risk factors for perinatal depression were being a recently arrived immigrant (ie, approximately within the past year), having poor social support, and having a poor relationship with one's partner. INTERPRETATION: One in four women who are migrants and who are pregnant or post partum experience perinatal depression, one in five perinatal anxiety, and one in 11 perinatal PTSD. The burden of perinatal mental illness appears higher among women who are forced migrants compared with women who are economic migrants. To our knowledge, we have provided the first pooled estimate of perinatal depression and PTSD among women who are forced migrants. Interpreting the prevalence estimate should be observed with caution due to the very wide range found within the included studies. Additionally, 66% of studies were cross-sectional representing low quality evidence. These findings highlight the need for community-based routine perinatal mental health screening for migrant communities, and access to interventions that are culturally sensitive, particularly for forced migrants who might experience a higher burden of disease than economic migrants. FUNDING: UK National Institute for Health Research (NIHR); March of Dimes European Preterm Birth Research Centre, Imperial College; Imperial College NIHR Biomedical Research Centre; and Nuffield Department of Population Health, University of Oxford.

Peer-provided psychological intervention for Syrian refugees: results of a randomised controlled trial on the effectiveness of Problem Management Plus.

BACKGROUND: The mental health burden among refugees in high-income countries (HICs) is high, whereas access to mental healthcare can be limited. OBJECTIVE: To examine the effectiveness of a peer-provided psychological intervention (Problem Management Plus; PM+) in reducing symptoms of common mental disorders (CMDs) among Syrian refugees in the Netherlands. METHODS: We conducted a single-blind, randomised controlled trial among adult Syrian refugees recruited in March 2019-December 2021 (No. NTR7552). Individuals with psychological distress (Kessler Psychological Distress Scale (K10) >15) and functional impairment (WHO Disability Assessment Schedule (WHODAS 2.0) >16) were allocated to PM+ in addition to care as usual (PM+/CAU) or CAU only. Participants were reassessed at 1-week and 3-month follow-up. Primary outcome was depression/anxiety combined (Hopkins Symptom Checklist; HSCL-25) at 3-month follow-up. Secondary outcomes included depression (HSCL-25), anxiety (HSCL-25), post-traumatic stress disorder (PTSD) symptoms (PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition; PCL-5), impairment (WHODAS 2.0) and self-identified problems (PSYCHLOPS; Psychological Outcomes Profiles). Primary analysis was intention-to-treat. FINDINGS: Participants (n=206; mean age=37 years, 62% men) were randomised into PM+/CAU (n=103) or CAU (n=103). At 3-month follow-up, PM+/CAU had greater reductions on depression/anxiety relative to CAU (mean difference -0.25; 95% CI -0.385 to -0.122; p=0.0001, Cohen's d=0.41). PM+/CAU also showed greater reductions on depression (p=0.0002, Cohen's d=0.42), anxiety (p=0.001, Cohen's d=0.27), PTSD symptoms (p=0.0005, Cohen's d=0.39) and self-identified problems (p=0.03, Cohen's d=0.26), but not on impairment (p=0.084, Cohen's d=0.21). CONCLUSIONS: PM+ effectively reduces symptoms of CMDs among Syrian refugees. A strength was high retention at follow-up. Generalisability is limited by predominantly including refugees with a resident permit. CLINICAL IMPLICATIONS: Peer-provided psychological interventions should be considered for scale-up in HICs.

Scaling up task-sharing psychological interventions for refugees in Jordan: a qualitative study on the potential barriers and facilitators.

Training nonspecialists in providing evidence-based psychological interventions (i.e. task-sharing) can effectively increase community access to psychological support. However, task-sharing interventions for this purpose are rarely used at scale. The aim of this study was to examine the factors influencing the potential for scaling up (i.e. scalability) of a task-sharing psychological intervention called Problem Management Plus (PM+) for Syrian refugees in Jordan. Semi-structured individual (n = 17) and group interviews (n = 20) were conducted with stakeholders knowledgeable about PM+ and the mental health system for Syrian refugees in Jordan. Using 'system innovation perspective', this study conceptualized the context as landscape developments, and systemic considerations were divided into culture (shared ways of thinking) and structure (ways of organizing). Political momentum was identified as a landscape trend likely facilitating scaling up, while predicted reductions in financial aid was regarded as a constraint. In terms of culture, the medicalized approach to mental health, stigma and gender were reported barriers for scaling up PM+. Using non-stigmatizing language and offering different modalities, childcare options and sessions outside of working hours were suggestions to reduce stigma, accommodate individual preferences and increase the demand for PM+. In relation to structure, the feasibility of scaling up PM+ largely depends on the ability to overcome legal barriers, limitations in human and financial resources and organizational challenges. We recommend sustainable funding to be made available for staff, training, supervision, infrastructure, coordination, expansion and evaluation of 'actual' scaling up of PM+. Future research may examine the local feasibility of various funding, training and supervision models. Lessons learned from actual scaling up of PM+ and similar task-sharing approaches need to be widely shared.

Common strategies in empirically supported psychological interventions for alcohol use disorders: A meta-review.

ISSUES: Despite the large number of effective psychological interventions for alcohol use disorders (AUD), there is still a lack of clarity concerning the strategies that make these interventions effective. APPROACH: The overall goal of this review was to identify, examine and synthesise the information about common strategies from evidence-based psychological interventions for AUDs by conducting a review of systematic reviews, that is, a meta-review. We isolated the relevant primary studies from eligible systematic reviews and extracted information about the interventions from these studies to understand the strategies used. Analysis was restricted to narrative summaries. KEY FINDINGS: Thirteen reviews were eligible for inclusion in our meta-review. Of these, eight demonstrated the effectiveness of a range of psychological interventions-behavioural couples therapy, cognitive behaviour therapy combined with motivational interviewing, brief interventions, contingency management, psychotherapy plus brief interventions, Alcoholics Anonymous and 12-step treatment programs, family-therapy or family-involved treatment, and community reinforcement approach. The most commonly used component strategies in effective interventions for AUDs included assessment, personalised feedback, motivational interviewing, goal setting, setting and review of homework, problem solving skills and relapse prevention/management. IMPLICATIONS: Evidence about commonly used strategies in evidence-based psychological interventions for AUDs offer the possibility of creating menu-driven interventions that can be tailored to respond to individual client needs and preferences in different contexts.

Health system responsiveness to the mental health needs of Syrian refugees: mixed-methods rapid appraisals in eight host countries in Europe and the Middle East.

Background: Syrian refugees have a high burden of mental health symptoms and face challenges in accessing mental health and psychosocial support (MHPSS). This study assesses health system responsiveness (HSR) to the MHPSS needs of Syrian refugees, comparing countries in Europe and the Middle East to inform recommendations for strengthening MHPSS systems. Methods: A mixed-methods rapid appraisal methodology guided by an adapted WHO Health System Framework was used to assess HSR in eight countries (Egypt, Germany, Jordan, Lebanon, Netherlands, Sweden, Switzerland, and Türkiye). Quantitative and qualitative analysis of primary and secondary data was used. Data collection and analysis were performed iteratively by multiple researchers. Country reports were used for comparative analysis and synthesis. Results: We found numerous constraints in HSR: i) Too few appropriate mental health providers and services; ii) Travel-related barriers impeding access to services, widening rural-urban inequalities in the distribution of mental health workers; iii) Cultural, language, and knowledge-related barriers to timely care likely caused by insufficient numbers of culturally sensitive providers, costs of professional interpreters, somatic presentations of distress by Syrian refugees, limited mental health awareness, and stigma associated to mental illness; iv) High out-of-pocket costs for psychological treatment and transportation to services reducing affordability, particularly in middle-income countries; v) Long waiting times for specialist mental health services; vi) Information gaps on the mental health needs of refugees and responsiveness of MHPSS systems in all countries. Six recommendations are provided to address these issues. Conclusions: All eight host countries struggle to provide responsive MHPSS to Syrian refugees. Strengthening the mental health workforce (in terms of quantity, quality, diversity, and distribution) is urgently needed to enable Syrian refugees to receive culturally appropriate and timely care and improve mental health outcomes. Increased financial investment in mental health and improved health information systems are crucial.

Background: People who experience war often have increased mental health problems. Those who are forced to flee abroad frequently struggle to access adequate mental health and psychosocial support services. As a result, many refugees often do not seek or use such services.Researchers of the Syrian REfuGees MeNTal HealTH Care Systems (STRENGTHS) consortium carried out rapid appraisals to assess the responsiveness of health systems to the mental health and psychosocial needs of Syrian refugees in eight countries: Egypt, Germany, Jordan, Lebanon, the Netherlands, Sweden, Switzerland, and Türkiye. They used quantitative and qualitative data, including primary and secondary data. This paper summarises and compares findings from the eight countries. What is health system responsiveness?: The ability of a health system to meet the expectations and needs of its people with regards to access, coverage, quality, and safety of services. What are our main findings and recommendations?: We found that all eight host countries struggle to provide responsive mental health and psychosocial support to Syrian refugees. We identified the following key challenges: Insufficient mental health providers and services, including uneven rural-urban distribution;Cultural, language, and knowledge-related barriers to timely care, caused by insufficient culturally sensitive providers and mental health stigma among Syrian refugee communities;Out-of-pocket costs for psychological treatment and transportation to services;Long waiting times for specialist mental health services;Information gaps on the mental health needs of Syrian refugees;We recommend increasing national funding for mental health to help Syrian refugees to receive more culturally appropriate and timely care. Increased funding can reduce out-of-pocket payments by refugees, improve national health information systems, and strengthen the mental health workforce (in terms of quantity, quality, diversity, and distribution). We also recommend investment in cultural competency and mental health training for community-based workers and primary care providers.

Resilience of people with chronic medical conditions during the COVID-19 pandemic: a 1-year longitudinal prospective survey.

BACKGROUNDS: Individuals with chronic medical conditions are considered highly exposed to COVID-19 pandemic stress, but emerging evidence is demonstrating that resilience is common even among them. We aimed at identifying sustained resilient outcomes and their predictors in chronically ill people during the first year of the pandemic. METHODS: This international 4-wave 1-year longitudinal online survey included items on socio-demographic characteristics, economic and living situation, lifestyle and habits, pandemic-related issues, and history of mental disorders. Adherence to and approval of imposed restrictions, trust in governments and in scientific community during the pandemic were also investigated. The following tools were administered: the Patient Health Questionnaire, the Generalized Anxiety Disorder scale, the PTSD Checklist DSM-5, the Oslo Social Support Scale, the Padua Inventory, and the Portrait Values Questionnaire. RESULTS: One thousand fifty-two individuals reporting a chronic condition out of 8011 total participants from 13 countries were included in the study, and 965 had data available for the final model. The estimated probability of being "sustained-resilient" was 34%. Older male individuals, participants employed before and during the pandemic or with perceived social support were more likely to belong to the sustained-resilience group. Loneliness, a previous mental disorder, high hedonism, fear of COVID-19 contamination, concern for the health of loved ones, and non-approving pandemic restrictions were predictors of not-resilient outcomes in our sample. CONCLUSIONS: We found similarities and differences from established predictors of resilience and identified some new ones specific to pandemics. Further investigation is warranted and could inform the design of resilience-building interventions in people with chronic diseases.

The impact of employment programs on common mental disorders: A systematic review.

BACKGROUND: While employment programs were not created with the intent to improve common mental disorders (CMDs), they may have a positive impact on the prevalence, incidence, and severity of CMD by reducing poverty and increasing access to economic mobility. AIM: To examine and synthesize the available quantitative evidence of the impact of employment programs on outcomes of CMD. METHODS: Embase, Econlit, Global Health, MEDLINE, APA PsychINFO, and Social Policy and Practice were searched for experimental and quasi-experimental studies which investigated the impact of employment programs on primary and secondary outcomes of a CMD. A narrative synthesis according to Popay was conducted. The methodological quality of studies was assessed with the Cochrane Risk of Bias tool and the Newcastle-Ottawa Assessment Scale. RESULTS: Of the 1,327 studies retrieved, two randomized controlled trials, one retrospective cohort, one pilot study with a non-randomized experimental design, and one randomized field experiment were included in the final review. Employment programs generally included multiple components such as skills-based training, and hands-on placements. Depression and anxiety were the CMDs measured as primary or secondary outcomes within included studies. Findings regarding the impact of employment programs on CMD were mixed with two studies reporting significantly positive effects, two reporting no effects, and one reporting mixed effects. The quality among included studies was good overall with some concerns regarding internal validity. CONCLUSION: Employment programs may support a decrease in the prevalence, incidence, and severity of CMDs. However, there is high heterogeneity among study effects, designs, and contexts. More research is needed to gain further insight into the nature of this association and the mechanisms of impact. This review highlights the potential for employment programs and other poverty-reduction interventions to be utilized and integrated into the wider care, prevention, and treatment of common-mental disorders.

Process evaluations of mental health and psychosocial support interventions for populations affected by humanitarian crises.

BACKGROUND: Randomised controlled trials (RCTs) have been increasingly used to test the effectiveness of mental health and psychosocial support(MHPSS) interventions for populations affected by humanitarian crises. Process evaluations are often integrated within RCTs of psychological interventions to investigate the implementation of the intervention, the impact of context, and possible mechanisms of action. We aimed to explore limitations and strengths of how process evaluations are currently conceptualised and implemented within MHPSS RCTs specifically. METHODS: In April-June 2021 we conducted semi-structured interviews with 24 researchers involved in RCTs of MHPSS interventions in 23 different countries. Participants were selected based on systematic reviews of MHPSS interventions, funders' databases, and personal networks. Data were analysed using codebook thematic analysis. RESULTS: The conduct of process evaluations was characterized by high heterogeneity in perceived function, implementation outcomes assessed, and methods used. While process evaluations were overwhelmingly considered as an important component of an RCT, there were different opinions on their perceived quality. This could be explained by the varying prioritization of effectiveness data over implementation data, confusion around the nature of process evaluations, and challenges in the collection and analysis of process data in humanitarian settings. Various practical recommendations were made by participants to improve future process evaluations in relation to: (i) study design (e.g., embedding process evaluations in study protocol and overall study objectives); (ii) methods (e.g., use of mixed methods); and (iii) increased financial and human resources dedicated to process evaluations. CONCLUSION: The current state of process evaluations in MHPSS RCTs is heterogeneous. The quality of process evaluations should be improved to strengthen implementation science of the growing number of evidence-informed MHPSS interventions.

Scalable psychological interventions for Syrian refugees in Europe and the Middle East: STRENGTHS study protocol for a prospective individual participant data meta-analysis.

INTRODUCTION: The World Health Organization's (WHO) scalable psychological interventions, such as Problem Management Plus (PM+) and Step-by-Step (SbS) are designed to be cost-effective non-specialist delivered interventions to reduce symptoms of common mental disorders, such as anxiety, depression and post-traumatic stress disorder (PTSD). The STRENGTHS consortium aims to evaluate the effectiveness, cost-effectiveness and implementation of the individual format of PM+ and its group version (gPM+), as well as of the digital SbS intervention among Syrian refugees in seven countries in Europe and the Middle East. This is a study protocol for a prospective individual participant data (IPD) meta-analysis to evaluate (1) overall effectiveness and cost-effectiveness and (2) treatment moderators of PM+, gPM+ and SbS with Syrian refugees. METHODS AND ANALYSIS: Five pilot randomised controlled trials (RCTs) and seven fully powered RCTs conducted within STRENGTHS will be combined into one IPD meta-analytic dataset. The RCTs include Syrian refugees of 18 years and above with elevated psychological distress (Kessler Psychological Distress Scale (K10>15)) and impaired daily functioning (WHO Disability Assessment Schedule 2.0 (WHODAS 2.0>16)). Participants are randomised into the intervention or care as usual control group, and complete follow-up assessments at 1-week, 3-month and 12-month follow-up. Primary outcomes are symptoms of depression and anxiety (25-item Hopkins Symptom Checklist). Secondary outcomes include daily functioning (WHODAS 2.0), PTSD symptoms (PTSD Checklist for DSM-5) and self-identified problems (PSYCHLOPS). We will conduct a one-stage IPD meta-analysis using linear mixed models. Quality of evidence will be assessed using the GRADE approach, and the economic evaluation approach will be assessed using the CHEC-list. ETHICS AND DISSEMINATION: Local ethical approval has been obtained for each RCT. This IPD meta-analysis does not require ethical approval. The results of this study will be published in international peer-reviewed journals.