The Modern Slavery Core Outcome Set: A Survivor-Driven Consensus on Priority Outcomes for Recovery, Wellbeing, and Reintegration.

There is no consensus on the outcomes needed for the recovery and reintegration of survivors of modern slavery and human trafficking. We developed the Modern Slavery Core Outcome Set (MSCOS) to address this gap. We conducted three English-language reviews on the intervention outcomes sought or experienced by adult survivors: a qualitative systematic review (4 databases, 18 eligible papers, thematic analysis), a rapid review of quantitative intervention studies (four databases, eight eligible papers, content analysis) and a gray literature review (2 databases, 21 websites, a call for evidence, 13 eligible papers, content analysis). We further extracted outcomes from 36 pre-existing interview transcripts with survivors, and seven interviews with survivors from underrepresented groups. We narrowed down outcomes via a consensus process involving: a three-stage E-Delphi survey (191 respondents); and a final consensus workshop (46 participants). We generated 398 outcomes from our 3 reviews, and 843 outcomes from interviews. By removing conceptual and literal duplicates, we reduced this to a longlist of 72 outcomes spanning 10 different domains. The E-Delphi produced a 14-outcome shortlist for the consensus workshop, where 7 final outcomes were chosen. Final outcomes were: "long-term consistent support," "secure and suitable housing," "safety from any trafficker or other abuser," "access to medical treatment," "finding purpose in life and self-actualisation," "access to education," and "compassionate, trauma-informed services." The MSCOS provides outcomes that are accepted by a wide range of stakeholders and that should be measured in intervention evaluation.

Serotonin and depression - a riposte to Moncrieff et al. (2022).

In their recently published systematic "umbrella" review, Moncrieff and colleagues conclude that there is no consistent evidence that depression is caused by decreased serotonin activity in the central nervous system (CNS). However, this paper - which was extensively publicized and received a lot of attention on the social media - can cause misunderstandings, since the serotonin hypothesis of depression in its original form (i.e. reduced serotonin activity in the CNS = depression) formulated more than 50 years ago has been considered outdated for several decades. It has long been known that depression is a heterogeneous disorder not only genetically, clinically and biologically but also from a pharmacotherapeutic perspective. The decreased activity of serotonin, which undoubtedly plays an essential role in the pathogenesis of depression, is characteristic of only a subgroup of depressed subjects whose clinical picture is mostly dominated by intensified negative emotions, agitation, anxiety, insomnia, decreased appetite, self-blame and suicidality and these individuals are primarily responsive to SSRIs. By contrast, depression cases with reduced positive affects (characterized by anhedonia, anergia, inhibition and reduced cognitive functions) are mainly caused by a disturbance in the metabolism of dopamine and/or noradrenaline. These patients are primarily responsive to dual-action (e.g. SNRI) antidepressants. Results of serotonin and catecholamine (dopamine, noradrenaline) depletion studies also suggest that that the dysregulation of serotonin and dopamine/noradrenaline in the CNS is characteristic of different subgroups of depressed patients. In addition to the serotonergic, dopaminergic and noradrenergic systems, many other neurotransmitter systems (e.g. cholinergic, glutamatergic, GABAergic) and other mechanisms (e.g. neuroinfl ammation) have also been proven to play a role in the development of the disorder. Knowledge of the data presented in our publication is important since the simplistic interpretation by Moncrieffetal. of the role of serotonin in the pathogenesis of depression may undermine confidence in SSRIs in many patients. (Neuropsychopharmacol Hung 2022; 24(3): 120-125).

Finding agency in limbo: A qualitative investigation into the impact of occupational engagement on the mental health and wellbeing of asylum seekers in the UK.

The process of seeking asylum is complex and often leads to extended periods of uncertainty and liminality for people awaiting decisions on their status. Occupational engagement-defined as meaningful activities and roles that bring purpose and agency to one's life-may be a key driver for mental health recovery for marginalized populations, including asylum seekers with traumatic experiences pre- and post-migration. This study aimed to clarify how occupational engagement impacts on mental health and wellbeing and how asylum seekers maintain engagement in occupation in the context of socio-political constraints of the asylum process. We explored the occupational experiences of 12 clients of one human-rights charity, utilizing community-based participatory research methods. Participants completed group mapping sessions where they depicted routine journeys taken to perform occupations in London, which included discussion around the significance of their journeys. Four participants also completed additional "walking maps"-semi-structured interviews which occurred along a selected "occupational journey" they identified as meaningful to their wellbeing. All data were analyzed using thematic network analysis. Findings revealed that engagement in routine occupations within safe, social spaces positively affects the mental wellbeing of asylum seekers by promoting competence, agency, and feelings of belonging. The liminal space of the asylum process meant that participants' occupational engagement was limited to 'leisure' activities but was still critical to establishing forms of agency associated with their wellbeing. Implications for programs and interventions responding to the needs of asylum seekers are discussed.

The mass release of migrants from UK immigration detention during the COVID-19 pandemic: what can be learned?

Convincing international evidence demonstrates that immigration detention adversely affects mental health. During the COVID-19 outbreak, additional concerns were raised about the safety and appropriateness of immigration detention. Consequently, several hundred migrants were released en masse from UK immigration detention centres, and few new detentions took place. Over 70% fewer migrants were held in detention centres in June 2020 compared with December 2019. This large 'natural experiment' has demonstrated that detaining fewer migrants is possible and it provides an opportunity to review the necessity for large-scale detention for the purpose of immigration control, as well as its impact on health inequalities. Additionally, given that detainee release arrangements had already been considered unsafe prior to the pandemic, clinicians and service providers should take into consideration that many of those released may not be receiving adequate post-release continuity of care.

Prevalence of complex post-traumatic stress disorder in refugees and asylum seekers: systematic review.

BACKGROUND: Refugees and asylum seekers often report having experienced numerous complex traumas. It is important to understand the prevalence of complex post-traumatic stress disorder (CPTSD), which can follow complex traumas. AIMS: This systematic review aims to summarise the available literature reporting the prevalence in refugees and asylum seekers of three operationalised definitions of CPTSD: the ICD-11 diagnostic criteria, the ICD-10 criteria (for enduring personality change after catastrophic experience) and the DSM-IV criteria (for disorders of extreme stress not otherwise specified). METHOD: Six electronic databases were searched for studies reporting the prevalence of CPTSD in adult refugee and/or asylum-seeking samples. Owing to heterogeneity between the studies, a narrative synthesis approach was used to summarise studies. Methodological quality was assessed using the Joanna Briggs Critical Appraisal Checklist for Prevalence Studies. This systematic review has been registered with PROSPERO (registration number CRD42020188422, https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=188422). RESULTS: Systematic searches identified 15 eligible studies, with 10 examining treatment-seeking samples and five using population samples. CPTSD prevalence in treatment-seeking samples was between 16 and 38%. Prevalence in population samples ranged from 2.2 to 9.3% in four studies, with the fifth reporting a much higher estimate (50.9%). CONCLUSIONS: This review highlights both the high prevalence of CPTSD in treatment samples and the lack of research aiming to establish prevalence of CPTSD in refugee and asylum-seeking populations. Understanding the prevalence of these disabling disorders has implications for policy and healthcare services for the appropriate promotion, planning and provision of suitable treatment and interventions for this highly traumatised population.

Complex post-traumatic stress disorder in asylum seekers and victims of trafficking: treatment considerations.

Asylum-seekers experience high levels of traumatic events pre-, post- and during migration. Poly-traumatisation is associated with complex post-traumatic stress disorder (CPTSD), which has not yet been extensively explored in this population. CPTSD is a prevalent and highly disabling disorder in the present population requiring culturally sensitive diagnostic and treatment approaches. In this service evaluation, we evidence the high prevalence of CPTSD in an asylum-seeking sample and its association with greater distress compared with PTSD. We outline the treatment needs of asylum seekers with CPTSD.

Mental health in immigration detention: A comparison of foreign national ex-prisoners and other detainees.

BACKGROUND: People held in immigration removal centres have a range of vulnerabilities relating both to disappointment at imminent removal from the country of hoped-for residence and various antecedent difficulties. An important subgroup in the UK is of foreign national ex-prisoners who have served a period of incarceration there. Prisoners generally have higher rates of mental disorders than the general population. It is, however, not clear whether foreign national ex-prisoners in UK immigration removal centres have higher rates of mental disorders than other detainees. AIMS: To compare the screened prevalence of mental disorders, levels of unmet needs and time in detention between foreign national ex-prisoners and others in Immigration Removal Centres in England. METHODS: We conducted a secondary analysis of cross-sectional survey data from a previously published study in one Immigration Removal Centre. RESULTS: The 28 foreign national ex-prisoners had been in immigration detention for longer and reported greater levels of unmet needs than the other 66 detainees. The highest levels of unmet needs among the foreign national ex-prisoners were in the areas of psychological distress and intimate relationships. After adjusting for time spent in detention, there was evidence to suggest that foreign national ex-prisoners had a higher screened prevalence of substance use disorders, autism spectrum disorders and attention-deficit hyperactivity disorder than the other detainees. CONCLUSIONS/IMPLICATIONS FOR CLINICAL PRACTICE: This study supports the view that foreign national ex-prisoners are a vulnerable group within immigration detention who have needs for enhanced and specialist service provision, including appropriate arrangements for health screening and active consideration to alternatives to their detention.

Mental health of forced migrants recently granted leave to remain in the United Kingdom.

BACKGROUND: Asylum seekers who are granted leave to remain in the United Kingdom are required to make a rapid transition to housing and welfare benefits. The challenges facing new refugees during this 'transition period' can affect their mental health, but this has not been quantified. AIMS: To assess the impact of the transition period on new refugees' mental health in the 12 months after being granted leave to remain in the United Kingdom. METHOD: A longitudinal survey design was used to measure the mental health of 30 newly recognised refugees at monthly intervals in the first 6 months and again at 1 year after receiving leave to remain in the United Kingdom. There were five outcome measures for symptoms of anxiety, depression, distress, post-traumatic stress disorder (PTSD), post-migration living difficulties (PMLD) and a life events calendar to record key changes in housing and welfare. RESULTS: The results showed that the trajectory of scores across all measures fluctuates, but overall they all improve from baseline to Month 12. Scores for depression and PMLD showed significant improvement at Month 5, and scores for anxiety, depression, distress and PMLD showed significant improvement at Month 12. PTSD scores did not show significant improvement at any month. In months with a high number of stressful life events, participants had worse PMLD and PTSD scores. CONCLUSION: Overall improvement in mental health could partly be explained by the stability of being granted leave to remain in the United Kingdom, but may also be due to the high level of practical support these participants received. Recommendations are made for those working with clients during the transition period.

The texture of narrative dilemmas: qualitative study in front-line professionals working with asylum seekers in the UK.

AIMS AND METHOD: Asylum seekers are required to narrate past experiences to the UK Home Office, doctors, lawyers and psychologists as part of their claims for international protection. The Home Office often cites perceived inconsistencies in asylum interviews as grounds for refusal of their claims. A number of processes affect asylum seekers' abilities to narrate past experiences fully to the professionals interviewing them. The dilemmas around disclosure that asylum seekers face have received little attention to date. This work aims to explore the perspectives of UK-based medico-legal report-writing doctors, lawyers and psychologists whose work involves eliciting narratives from asylum seekers on the processes that affect asylum seekers' abilities to disclose sensitive personal information in interview settings. Eighteen professionals participated in semi-structured interviews in individual or focus group settings to discuss, from their perspectives of extensive collective professional experience, the narrative dilemmas experienced by asylum seekers with whom they have worked. RESULTS: Professionals identified a number of processes that made disclosure of personal information difficult for asylum seekers. These included asylum seekers' lack of trust towards the professionals conducting the interview, unclear ideas around pertinence of information for interviewers, feelings of fear, shame and guilt related to suspicions around collusions between UK and their country-of-origin's authorities, sexual trauma and, occasionally, their own involvement or collusion in crimes against others. CLINICAL IMPLICATIONS: Recommendations are made on how to improve the interview environment to encourage disclosure. These have important implications for future research and policy initiatives.

Refugee mental health research: challenges and policy implications.

Mental illness is common among forced migrant populations, and ongoing mental illness can hinder refugees' ability to negotiate the asylum process. This editorial rehearses the challenges of undertaking research among forced migrant populations, exploring how they could be addressed in future research, and outlines differences between forced migrant groups. It points to the growing body of evidence that can be called on in advocating for systemic change in government policy and mental health services, with significant support for a sensitive and objective inquisitorial approach to gathering evidence in support of asylum claims.

Cost-effectiveness of psychological treatments for post-traumatic stress disorder in adults.

BACKGROUND: Post-traumatic stress disorder (PTSD) is a severe and disabling condition that may lead to functional impairment and reduced productivity. Psychological interventions have been shown to be effective in its management. The objective of this study was to assess the cost-effectiveness of a range of interventions for adults with PTSD. METHODS: A decision-analytic model was constructed to compare costs and quality-adjusted life-years (QALYs) of 10 interventions and no treatment for adults with PTSD, from the perspective of the National Health Service and personal social services in England. Effectiveness data were derived from a systematic review and network meta-analysis. Other model input parameters were based on published sources, supplemented by expert opinion. RESULTS: Eye movement desensitisation and reprocessing (EMDR) appeared to be the most cost-effective intervention for adults with PTSD (with a probability of 0.34 amongst the 11 evaluated options at a cost-effectiveness threshold of £20,000/QALY), followed by combined somatic/cognitive therapies, self-help with support, psychoeducation, selective serotonin reuptake inhibitors (SSRIs), trauma-focused cognitive behavioural therapy (TF-CBT), self-help without support, non-TF-CBT and combined TF-CBT/SSRIs. Counselling appeared to be less cost-effective than no treatment. TF-CBT had the largest evidence base. CONCLUSIONS: A number of interventions appear to be cost-effective for the management of PTSD in adults. EMDR appears to be the most cost-effective amongst them. TF-CBT has the largest evidence base. There remains a need for well-conducted studies that examine the long-term clinical and cost-effectiveness of a range of treatments for adults with PTSD.

Psychological treatments for post-traumatic stress disorder in adults: a network meta-analysis.

BACKGROUND: Post-traumatic stress disorder (PTSD) is a potentially chronic and disabling disorder affecting a significant minority of people exposed to trauma. Various psychological treatments have been shown to be effective, but their relative effects are not well established. METHODS: We undertook a systematic review and network meta-analyses of psychological interventions for adults with PTSD. Outcomes included PTSD symptom change scores post-treatment and at 1-4-month follow-up, and remission post-treatment. RESULTS: We included 90 trials, 6560 individuals and 22 interventions. Evidence was of moderate-to-low quality. Eye movement desensitisation and reprocessing (EMDR) [standardised mean difference (SMD) -2.07; 95% credible interval (CrI) -2.70 to -1.44], combined somatic/cognitive therapies (SMD -1.69; 95% CrI -2.66 to -0.73), trauma-focused cognitive behavioural therapy (TF-CBT) (SMD -1.46; 95% CrI -1.87 to -1.05) and self-help with support (SMD -1.46; 95% CrI -2.33 to -0.59) appeared to be most effective at reducing PTSD symptoms post-treatment v. waitlist, followed by non-TF-CBT, TF-CBT combined with a selective serotonin reuptake inhibitor (SSRI), SSRIs, self-help without support and counselling. EMDR and TF-CBT showed sustained effects at 1-4-month follow-up. EMDR, TF-CBT, self-help with support and counselling improved remission rates post-treatment. Results for other interventions were either inconclusive or based on limited evidence. CONCLUSIONS: EMDR and TF-CBT appear to be most effective at reducing symptoms and improving remission rates in adults with PTSD. They are also effective at sustaining symptom improvements beyond treatment endpoint. Further research needs to explore the long-term comparative effectiveness of psychological therapies for adults with PTSD and also the impact of severity and complexity of PTSD on treatment outcomes.