The effect of a low-level psychological intervention (PM+) on post-migration living difficulties - Results from two studies in Switzerland and in the Netherlands.

AIMS OF THE STUDY: After arriving in host countries, most refugees are confronted with numerous post-migration stressors (e.g., separation from family, discrimination, and employment difficulties). Post-migration living difficulties (PMLDs) significantly contribute to the development and persistence of mental disorders. Effective treatment approaches focusing on reducing post-migration stress are urgently needed. The aim of the present study was to examine the effect of a brief psychological intervention, Problem Management Plus (PM+), on PMLDs among Syrian refugees in two European countries. METHODS: We merged data from two single-blind feasibility trials with Syrian refugees experiencing elevated levels of psychological distress and impaired functioning in Switzerland (N = 59) and the Netherlands (N = 60). Participants were randomised to receive either five sessions of PM+ or an enhanced care-as-usual control condition. PMLDs were assessed at baseline and 3 months after the intervention. To estimate treatment effect on PMLD, linear mixed model analysis was performed. RESULTS: Three months after the intervention, participants in the PM+ condition reported significantly fewer PMLDs compared to the control condition. Further analyses at item-level showed that interpersonal and family related PMLDs, such as "worries about family back home" significantly improved over time in the PM+ condition. CONCLUSIONS: This exploratory study suggests that brief psychological interventions have the potential to reduce PMLDs in refugees and asylum seekers. The reduction of post-migration stress in turn may subsequently lead to an overall reduction in psychological distress. CLINICAL TRIAL NUMBERS: BASEC Nr. 2017-0117 (Swiss trial) and NL61361.029.17, 7 September 2017 (Dutch trial).

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.

Problems after flight: understanding and comparing Syrians' perspectives in the Middle East and Europe.

BACKGROUND: Syrian refugees and asylum seekers (SRAs) face multiple stressors after flight, which may vary due to different geographic, economic, cultural and socio-political contexts in the host countries. Past research has recognised the importance of participants' own perspectives. The aims of this multi-country study were to identify and compare self-reported problems of SRAs between various settings. METHODS: A semi-structured client-generated outcome measurement was used to collect data among adult SRAs in Jordan (N = 61), Turkey (N = 46) and Switzerland (N = 57) between September 2018 and November 2019. Answers were analysed following thematic analysis. RESULTS: Over half of the participants reported practical problems with an emphasis on camp-related problems (Jordan), finances (Turkey), employment (Jordan and Switzerland) and government regulations (Switzerland), followed by psychological, and social issues. CONCLUSION: This study highlights the impact of local contextual factors on wellbeing. The findings emphasise that planning preventative procedures and mental health care services for SRAs need to consider local challenges affecting the population in specific countries.

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.

Feasibility and acceptability of Problem Management Plus (PM+) among Syrian refugees and asylum seekers in Switzerland: a mixed-method pilot randomized controlled trial.

Background: Syrian refugees in Switzerland face several barriers in accessing mental health care. Cost-effective psychological interventions are urgently needed to meet the mental health needs of refugees. Problem Management Plus (PM+) is an evidence-based, psychological intervention delivered by trained non-specialist 'helpers'. Objective: To assess the feasibility and acceptability of PM+ among Syrian refugees in Switzerland. Methods: We conducted a single-blind pilot randomized controlled trial (RCT) with Syrian refugees impaired by psychological distress (K10 > 15 and WHODAS 2.0 > 16). Participants were randomized to PM+ or Enhanced Treatment As Usual (ETAU). Participants were assessed at baseline, and 1 week and 3 months after the intervention, and completed measures indexing mental health problems and health care usage. Semi-structured interviews were conducted with different stakeholders. Results: N = 59 individuals were randomized into PM+ (n = 31) or ETAU (n = 28). N = 18 stakeholders were interviewed about facilitators and barriers for the implementation of PM+. Retention rates in the trial (67.8%) and mean intervention attendance (M = 3.94 sessions, SD = 1.97) were high. No severe events related to the study were reported. These findings indicate that the trial procedures and PM+ were feasible, acceptable and safe. Conclusions: The findings support the conduct of a definitive RCT and show that PM+ might have the potential to be scaled-up in Switzerland. The importance, as well as the challenges, of implementing and scaling-up PM+ in high-income countries, such as Switzerland, are discussed.

Antecedentes: Los refugiados Sirios en Suiza enfrentan varias barreras para acceder a la atención en salud mental. Se necesitan con urgencia intervenciones psicológicas costo-efectivas, para satisfacer las necesidades de salud mental de los refugiados. Enfrentar Problemas Plus (PM + por sus siglas en inglés) es una intervención psicológica basada en la evidencia proporcionada por 'ayudantes' capacitados no especializados.Objetivo: Evaluar la viabilidad y aceptabilidad de PM + entre los refugiados sirios en Suiza.Métodos: Realizamos un ensayo controlado aleatorizado (ECA) piloto simple y ciego con refugiados sirios afectados por angustia psicológica (K10 > 15 y WHODAS 2.0 > 16). Los participantes fueron asignados al azar a PM + o Tratamiento usual mejorado (TUM). Los participantes fueron evaluados al inicio del estudio, 1 semana, y 3 meses después de la intervención, y completaron instrumentos que referencian problemas de salud mental y el uso de la atención médica. Se realizaron entrevistas semiestructuradas con diferentes partes relevantes.Resultados:N = 59 individuos fueron asignados al azar a PM + (n = 31) o TUM (n = 28). N = 18 partes relevantes fueron entrevistados sobre facilitadores y barreras para la implementación de PM +. Las tasas de retención en el ensayo (67,8%) y la asistencia media a la intervención (M = 3,94 sesiones, DE = 1,97) fueron altas. No se informaron eventos graves relacionados con el estudio. Estos hallazgos indican que los procedimientos del ensayo y PM + fueron factibles, aceptables y seguros.Conclusiones: Los hallazgos apoyan la realización de un ECA definitivo y muestran que PM + podría tener el potencial de ampliarse en Suiza. Se discute la importancia, así como los desafíos, de implementar y ampliar PM + en países de altos ingresos, como Suiza.

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.

An exploratory study of embitterment in traumatized refugees.

BACKGROUND: Refugees and asylum seekers are frequently exposed to violence, human rights violations and unstable living conditions before, during, and after their displacement. Elevated prevalence rates of psychiatric disorders in forcibly displaced persons are well documented. However, less is known about other problems related to common refugee experiences, such as embitterment, moral injury, and diminished self-efficacy, and how they are related to trauma exposure and post-migration living difficulties. METHODS: A cross-sectional sample of 71 refugees and asylum seekers in treatment were examined regarding exposure to potentially traumatic events, post-migration living difficulties, moral injury appraisals, self-efficacy, and embitterment. RESULTS: Elevated levels of embitterment were reported by 68% of participants. The regression analysis revealed that greater moral injury appraisals and low levels of self-efficacy were significantly associated with higher levels of embitterment. CONCLUSION: The results provide first insights into embitterment and associated factors in refugee populations. Furthermore, they highlight the significance of moral transgressions and low levels of self-efficacy emerging from displacement and traumatic experiences for the development of mental health problems in a clinical sample of refugees. The findings have implications for future research, policy development and clinical practice.

Prolonged Grief Disorder Among Refugees in Psychological Treatment-Association With Self-Efficacy and Emotion Regulation.

BACKGROUND: While Prolonged Grief Disorder (PGD) among refugees has recently started to attract scientific attention, knowledge regarding associated psychological factors remains limited. Given the multifactorial context of persecution, trauma, displacement, and exile-related difficulties, obtaining a better understanding of PGD in refugees is crucial because PGD may affect psychological well-being, level of functioning, and social integration. METHODS: In a sample of refugees receiving psychological treatment in Switzerland (N = 88), we examined the relationship between severity of PGD and potentially associated factors such as emotion regulation, perceived self-efficacy, as well as potentially traumatic events and post-migration living difficulties. RESULTS: In a regression analysis, difficulties in emotion regulation and lower perceived self-efficacy were associated with greater severity of PGD, while post-migration living difficulties and potentially traumatic events did not emerge as significant factors. CONCLUSION: These findings suggest that emotion regulation and perceived self-efficacy are associated with PGD in refugees in psychological treatment and are thus potential targets for treatment interventions.