Mental health and conflict: a pilot of an online eye movement desensitisation and reprocessing (EMDR) intervention for forcibly displaced Syrian women.

Background: The Syrian conflict has been ongoing since 2011. Practical and scalable solutions are urgently needed to meet an increase in need for specialised psychological support for post-traumatic stress disorder given limited availability of clinicians. Training forcibly displaced Syrians with a mental health background to remotely deliver specialised interventions increases the availability of evidence based psychological support. Little is known about the effectiveness of online therapy for forcibly displaced Syrian women provided by forcibly displaced Syrian women therapists. Purpose: To pilot an evidence-based trauma therapy, Eye Movement Desensitisation and Reprocessing (EMDR), carried out online by trained forcibly displaced Syrian women therapists for forcibly displaced Syrian women who require treatment for post-traumatic stress disorder (PTSD). Methods: 83 forcibly displaced Syrian women, living in Türkiye or inside Syria, with diagnosable PTSD, were offered up to 12 sessions of online EMDR over a period of 3 months. This was delivered by forcibly displaced Syrian women therapists who were trained in EMDR. Data were gathered, using Arabic versions, on PTSD symptoms using the Impact of Events Scale Revised, depression symptoms using the Patient Health Questionnaire-9 and anxiety symptoms using the Generalised Anxiety Disorder Assessment-7 at baseline, mid-point, and end of therapy. Results: PTSD scores, depression scores and anxiety scores all significantly reduced over the course of treatment, with lower scores at midpoint than baseline and lower scores at end of treatment than at midpoint. Only one participant (1%) exceeded the cutoff point for PTSD, and 13 (16%) exceeded the cutoff points for anxiety and depression at the end of treatment. Conclusion: In this pilot study up to 12 sessions of online EMDR were associated with reductions in PTSD, anxiety and depression symptoms in Syrian women affected by the Syrian conflict. The training of forcibly displaced Syrian mental health professionals to deliver online therapy is a relatively low cost, scalable, sustainable solution to ensure that those who are affected by the conflict can access specialised support. Further research is needed using a control group to confirm that the observed effects are due to EMDR treatment, as is research with post-treatment follow-up to ascertain that benefits are maintained.

'We are trying to live in a normal way, but nothing is normal about us anymore ': a qualitative study of women's lived experiences of healthcare in opposition-controlled areas of Syria.

INTRODUCTION: The Syrian conflict, which has included mass killings, displacement, infrastructure destruction and illegal targeting of health facilities and staff mainly by the Syrian government and allies, is in its 10th year. This study explored the lived experiences of women within healthcare, both as health workers and service users, in Syrian opposition-controlled areas (OCAs). METHODS: We chose a qualitative study design, with 20 in-depth interviews conducted remotely over WhatsApp and Messenger with purposively sampled Syrian women (ie, 15 health workers, 5 service users). We analysed data using interpretative phenomenological analysis. RESULTS: Anxiety, fear and horror affected women's everyday work and wellness. Excess workload and insecurity were major challenges for women health workers, who also had household and caring responsibilities. Coping mechanisms included: (1) normalising death; (2) acceptance of God's will; and (3) focusing on controllable issues such as health services provision while accepting the reality of insecurity and death. Conflict contributed to changing social norms and expectations, and women became key actors in healthcare provision, though this did not translate directly into greater decision-making authority. Structural biases (eg, lack of maternity leave) and gender-based violence (eg, increased harassment and child marriage) inordinately affected women. CONCLUSION: This is a first effort to amplify women's voices in health policy and systems research on the Syrian conflict. Women have become key healthcare providers in OCAs but remain under-represented in decision making. While the conflict-related social transformation, increasing the role of-and demand for-women health workers could be viewed positively for women's empowerment, the reality is complex and long-term implications are unclear.

Family functioning but not social capital is associated with better mental health in adolescents affected by violence and displacement by armed conflict in Colombia.

BACKGROUND: The effect of the Colombian armed conflict on the mental health of adolescents is still poorly understood. AIMS: Given social interventions are most likely to inform policy, we tested whether two potential intervention targets, family functioning and social capital, were associated with mental health in Colombian adolescents, and whether this was moderated by experience of violence and displacement. METHODS: We examined the cross-sectional association between family functioning, cognitive social capital, structural social capital and 12-month prevalence of Composite International Diagnostic Interview (CIDI) diagnosed psychiatric disorder, using data on 12 to 17-year-old adolescents (N = 1,754) from the 2015 National Mental Health Survey of Colombia, a nationally representative epidemiological study. We tested whether associations survived cumulative adjustment for demographic confounders, experience of non-specific violence and harm and displacement by armed conflict. RESULTS: Neither structural nor cognitive social capital were associated with better mental health. Better family functioning was associated with reduced risk of poor mental health in an unadjusted analysis (OR 0.90 [0.85-0.96]), and after cumulative adjustments for demographic confounders (OR 0.91 [0.86-0.97]), non-specific violence and harm (OR 0.91 [0.86-0.97]) and social capital variables (OR 0.91 [0.85-0.97]). In the final model, each additional point on the family APGAR scale was associated with a 9% reduced odds of any CIDI diagnosed disorder in the last 12 months. CONCLUSIONS: Better family functioning was associated with better mental health outcomes for all adolescents. This effect remained present in those affected by the armed conflict even after accounting for potential confounders.

Qualitative accounts from Syrian mental health professionals: shared realities in the context of conflict and forced displacement.

OBJECTIVES: To explore the impact of the provision of care of forcibly displaced Syrian mental health professionals (MHPs) to Syrian clients in the community given shared experiences and backgrounds with clients. DESIGN: A qualitative study using thematic analysis of in-depth semistructured interviews to explore shared realities, self-disclosure and the impact of providing therapy. SETTING: Syrian MHPs operating in Gaziantep and Istanbul, Turkey, were interviewed. PARTICIPANTS: Sixteen forcibly displaced Syrian MHPs (eight male, eight female) aged between 24 and 54 years (M=35, SD=8.3) who provided care to the displaced Syrian community in Turkey. RESULTS: All workers described having a shared reality with their clients as helpful in therapy and a smaller proportion described it as a vulnerability. All described their work with Syrian clients as fulfilling and most described it as distressing. Participants referred to self-care,supervision, peer-support and personal therapy as a means to cope. CONCLUSIONS: This study provides the first insight into the shared experiences of the ongoing trauma, loss and violations resulting from the ongoing Syrian conflict from the perspective of Syrian MHPs, adding to the literature of the professional issues and ethical duty to protect health workers in conflict settings.

Psychological, social, and welfare interventions for torture survivors: A systematic review and meta-analysis of randomised controlled trials.

BACKGROUND: Torture and other forms of ill treatment have been reported in at least 141 countries, exposing a global crisis. Survivors face multiple physical, psychological, and social difficulties. Psychological consequences for survivors are varied, and evidence on treatment is mixed. We conducted a systematic review and meta-analysis to estimate the benefits and harms of psychological, social, and welfare interventions for torture survivors. METHODS AND FINDINGS: We updated a 2014 review with published randomised controlled trials (RCTs) for adult survivors of torture comparing any psychological, social, or welfare intervention against treatment as usual or active control from 1 January 2014 through 22 June 2019. Primary outcome was post-traumatic stress disorder (PTSD) symptoms or caseness, and secondary outcomes were depression symptoms, functioning, quality of life, and adverse effects, after treatment and at follow-up of at least 3 months. Standardised mean differences (SMDs) and odds ratios were estimated using meta-analysis with random effects. The Cochrane tool was used to derive risk of bias. Fifteen RCTs were included, with data from 1,373 participants (589 females and 784 males) in 10 countries (7 trials in Europe, 5 in Asia, and 3 in Africa). No trials of social or welfare interventions were found. Compared to mostly inactive (waiting list) controls, psychological interventions reduced PTSD symptoms by the end of treatment (SMD -0.31, 95% confidence interval [CI] -0.52 to -0.09, p = 0.005), but PTSD symptoms at follow-up were not significantly reduced (SMD -0.34, 95% CI -0.74 to 0.06, p = 0.09). No significant improvement was found for PTSD caseness at the end of treatment, and there was possible worsening at follow-up from one study (n = 28). Interventions showed no benefits for depression symptoms at end of treatment (SMD -0.23, 95% CI -0.50 to 0.03, p = 0.09) or follow-up (SMD -0.23, 95% CI -0.70 to 0.24, p = 0.34). A significant improvement in functioning for psychological interventions compared to control was found at end of treatment (SMD -0.38, 95% CI -0.58 to -0.18, p = 0.0002) but not at follow-up from only one study. No significant improvement emerged for quality of life at end of treatment (SMD 0.38, 95% CI -0.28 to 1.05, p = 0.26) with no data available at follow-up. The main study limitations were the difficulty in this field of being certain of capturing all eligible studies, the lack of modelling of maintenance of treatment gains, and the low precision of most SMDs making findings liable to change with the addition of further studies as they are published. CONCLUSIONS: Our findings show evidence that psychological interventions improve PTSD symptoms and functioning at the end of treatment, but it is unknown whether this is maintained at follow-up, with a possible worsening of PTSD caseness at follow-up from one study. Further interventions in this population should address broader psychological needs beyond PTSD while taking into account the effect of multiple daily stressors. Additional studies, including social and welfare interventions, will improve precision of estimates of effect, particularly over the longer term.

The mindful eye: Smooth pursuit and saccadic eye movements in meditators and non-meditators.

BACKGROUND: This study examined the effects of cultivated (i.e. developed through training) and dispositional (trait) mindfulness on smooth pursuit (SPEM) and antisaccade (AS) tasks known to engage the fronto-parietal network implicated in attentional and motion detection processes, and the fronto-striatal network implicated in cognitive control, respectively. METHODS: Sixty healthy men (19-59years), of whom 30 were experienced mindfulness practitioners and 30 meditation-naïve, underwent infrared oculographic assessment of SPEM and AS performance. Trait mindfulness was assessed using the self-report Five Facet Mindfulness Questionnaire (FFMQ). RESULTS: Meditators, relative to meditation-naïve individuals, made significantly fewer catch-up and anticipatory saccades during the SPEM task, and had significantly lower intra-individual variability in gain and spatial error during the AS task. No SPEM or AS measure correlated significantly with FFMQ scores in meditation-naïve individuals. CONCLUSIONS: Cultivated, but not dispositional, mindfulness is associated with improved attention and sensorimotor control as indexed by SPEM and AS tasks.

Acoustic prepulse inhibition: one ear is better than two, but why and when?

We examined whether monaural prepulses produce more prepulse inhibition (PPI) because they might be more attention capturing (unambiguous to locate) than binaural prepulses. Monaural and binaural PPI was tested under normal and verbal and visuospatial attention manipulation conditions in 55 healthy men, including 29 meditators. Attention manipulations abolished monaural PPI superiority, similarly in meditators and meditation-naïve individuals, and this was most strongly evident for right ear PPI under visuospatial attention manipulation. Meditators performed better than meditation-naïve individuals on attention tasks (verbal: more targets detected; visuospatial: faster reaction time). Spatial attention processes contribute to monaural PPI, particularly with the right ear. Better attentional performance, with similar attentional modulation of PPI, may indicate a stronger attentional capacity in meditators, relative to meditation-naïve individuals.

The relationship between awareness of intellectual disability, causal and intervention beliefs and social distance in Kuwait and the UK.

Evidence on lay beliefs and stigma associated with intellectual disability in an Arab context is almost non-existent. This study examined awareness of intellectual disability, causal and intervention beliefs and social distance in Kuwait. These were compared to a UK sample to examine differences in lay conceptions across cultures. 537 university students in Kuwait and 571 students in the UK completed a web-based survey asking them to respond to a diagnostically unlabelled vignette of a man presenting with symptoms of mild intellectual disability. They rated their agreement with 22 causal items as possible causes for the difficulties depicted in the vignette, the perceived helpfulness of 22 interventions, and four social distance items using a 7-point Likert scale. Only 8% of Kuwait students, yet 33% of UK students identified possible intellectual disability in the vignette. Medium to large differences between the two samples were observed on seven of the causal items, and 10 of the intervention items. Against predictions, social distance did not differ. Causal beliefs mediated the relationship between recognition of intellectual disability and social distance, but their mediating role differed by sample. The findings are discussed in relation to cultural practices and values, and in relation to attribution theory. In view of the apparent positive effect of awareness of the symptoms of intellectual disability on social distance, both directly and through the mediating effects of causal beliefs, promoting increased awareness of intellectual disability and inclusive practices should be a priority, particularly in countries such as Kuwait where it appears to be low.