[Risk Factors for Secondary Traumatic Stress (STS) and Post-Traumatic Stress Disorder (PTSD) in Interpreters with Personal Trauma Experience]. / Risikofaktoren für sekundären traumatischen Stress (STS) und Posttraumatische Belastungsstörung (PTBS) bei Dolmetschenden mit eigener Traumaerfahrung.

BACKGROUND: Interpreters play a crucial role in the care of refugees. However, little attention has been paid to the mental health of interpreters. Despite increased levels of secondary traumatic stress (STS) and increased prevalence of post-traumatic stress disorder (PTSD) among interpreters in the refugee context, there has been little research on risk factors for STS and PTSD in this population. The aim of this study was to investigate potential risk factors for STS and PTSD symptom severity. METHODS: A Germany-wide online survey was conducted among interpreters for refugees in 2019. Only those who stated that they had experienced at least one traumatic event were included in the study. The final sample comprises N=83 interpreters. The examination of the potential risk factors (primary traumatic events, traumatic content, and personal refugee background) as well as the interaction between primary traumatic events and traumatic content was carried out using moderated multiple regression. RESULTS: There was exclusively found a positive association between the number of primary traumatic events for both STS (p=0.003) and PTSD symptom severity (p=0.042). DISCUSSION/CONCLUSION: In the present study, the number of primary traumatic events experienced was identified as a potential risk factor for STS and PTSD. The institutionalization of preventive measures such as regular supervision, follow-up talks, and interpreter-specific training could make an important contribution to protecting the mental health of interpreters. Further research is needed to gain a better understanding of risk factors for STS and PTSD in interpreters.

An internet-based cognitive behavioural intervention for adults with depression in Arabic-speaking countries: A randomized controlled trial.

Internet-based interventions have proven to be effective for the treatment of depression in different samples, but evidence from the Middle East and North Africa (MENA) region is scarce. The aim of this study was to investigate the acceptance and efficacy of an internet-based cognitive behavioural writing intervention for Arabic-speaking participants with depression living in the MENA region. A total of 259 participants (167 female, age in years: M = 25.58, SD = 6.39) with depressive symptoms indicative of clinical relevance were randomly allocated to a treatment group (TG; nTG = 128) or a waitlist control group (WG; nWG = 131). The TG received an internet-based intervention over a 6-week period. The primary outcome was depressive symptoms, and secondary outcomes were anxiety and quality of life (QoL). T-tests with change scores from pre- to post-treatment were used for data analyses. Intention-to-treat (ITT) as well as completer analyses were calculated. The ITT analysis revealed significant differences between the TG and WG in depression (T257 = -4.89, p < 0.001, d = 0.70) and QoL (T257 = 3.39, p < 0.001, d = 0.47). Significant differences regarding anxiety symptoms (T257 = 3.25, p < 0.05, d = 0.53) were identified for the completer sample. The general dropout rate was 39.9%. The results indicate the feasibility and efficacy of an internet-based cognitive behavioural writing intervention in adults from Arabic-speaking countries. The development and implementation of such interventions can be used to improve access to psychological help and adequate treatment.

Changes in trauma appraisal during brief internet-based exposure and cognitive restructuring treatment for Arabic-speaking people with PTSD.

Background: Maladaptive trauma appraisal plays an important role in the development and maintenance of posttraumatic stress disorder (PTSD). While studies have demonstrated the effectiveness of exposure and cognitive treatments for PTSD symptomatology, the effect of such treatments on specific trauma appraisals is still not well understood.Objective: The study investigated the effect of an exposure and a cognitive restructuring internet-based treatment on specific trauma appraisals in Arabic-speaking participants with PTSD.Method: 334 participants received either an exposure (n = 167) or a cognitive restructuring (n = 167) internet-based treatment. PTSD symptom severity (PCL-5) and specific trauma appraisals (TAQ) were assessed at pre- and post-treatment. Changes in specific trauma appraisals within and between the two treatments were analyzed using multi-group change modelling. Associations between changes in PTSD symptom severity and changes in trauma appraisals were evaluated using Pearson product-moment correlation. For both treatments, participants with versus without reliable improvement were compared regarding changes in specific trauma appraisals using Welch tests. Analyses were performed on 100 multiple imputed datasets.Results: Both treatments yielded significant changes in shame, self-blame, fear, anger, and alienation (all ps < .001). Changes in betrayal were only significant in the cognitive restructuring treatment (p < .001). There was no evidence of differences between treatments for any specific trauma appraisal. Changes in PTSD symptom severity were significantly associated with changes in trauma appraisals (all ps < .001). In both treatments, participants who experienced reliable improvement in PTSD symptom severity showed significantly larger pre- to post-treatment changes in specific trauma appraisals compared to those without reliable improvement. Again, differences in betrayal were only significant in the cognitive restructuring treatment.Conclusions: The findings indicate that both treatments are effective in reducing trauma appraisals in Arabic-speaking people with PTSD. Changes in trauma appraisal seem to be associated with changes in PTSD symptomatology.Trial registration: German Clinical Trials Register identifier: DRKS00010245.

Exposure and cognitive restructuring treatment in Arabic-speaking individuals with PTSD yield significant changes in shame, self-blame, fear, anger, and alienation.Changes in PTSD symptoms are positively associated with changes in specific trauma appraisals.There is no evidence of differences between both treatments for any specific trauma appraisal.

Internet-based transdiagnostic treatment for emotional disorders in Arabic- and Farsi-speaking refugees: study protocol of a randomized controlled trial.

BACKGROUND: Refugee populations have an increased risk for mental disorders, such as depression, anxiety, and posttraumatic stress disorders. Comorbidity is common. At the same time, refugees face multiple barriers to accessing mental health treatment. Only a minority of them receive adequate help. The planned trial evaluates a low-threshold, transdiagnostic Internet-based treatment. The trial aims at establishing its efficacy and cost-effectiveness compared with no treatment. METHODS: N = 131 treatment-seeking Arabic- or Farsi-speaking patients, meeting diagnostic criteria for a depressive, anxiety, and/or posttraumatic stress disorder will be randomized to either the intervention or the waitlist control group. The intervention group receives an Internet-based treatment with weekly written guidance provided by Arabic- or Farsi-speaking professionals. The treatment is based on the Common Elements Treatment Approach (CETA), is tailored to the individual patient, and takes 6-16 weeks. The control group will wait for 3 months and then receive the Internet-based treatment. DISCUSSION: The planned trial will result in an estimate of the efficacy of a low-threshold and scalable treatment option for the most common mental disorders in refugees. TRIAL REGISTRATION: German Registry for Clinical Trials DRKS00024154. Registered on February 1, 2021.

Exposure Versus Cognitive Restructuring Techniques in Brief Internet-Based Cognitive Behavioral Treatment for Arabic-Speaking People With Posttraumatic Stress Disorder: Randomized Clinical Trial.

BACKGROUND: Cognitive behavioral interventions delivered via the internet are demonstrably efficacious treatment options for posttraumatic stress disorder (PTSD) in underserved, Arabic-speaking populations. However, the role of specific treatment components remains unclear, particularly in conflict-affected areas of the Middle East and North Africa. OBJECTIVE: This study aims to evaluate 2 brief internet-based treatments in terms of efficacy, including change in PTSD symptom severity during treatment. Both treatments were developed in line with Interapy, an internet-based, therapist-assisted cognitive behavioral therapy protocol for PTSD and adapted to the specific research question. The first treatment comprised self-confrontation and social sharing (exposure treatment; 6 sessions); the second comprised cognitive restructuring and social sharing (cognitive restructuring treatment; 6 sessions). The 2 treatments were compared with each other and with a waitlist control group. METHODS: In total, 365 Arabic-speaking participants from the Middle East and North Africa (mean age 25.49, SD 6.68 y) with PTSD were allocated to cognitive restructuring treatment (n=118, 32.3%), exposure treatment (n=122, 33.4%), or a waitlist control group (n=125, 34.2%) between February 2021 and December 2022. PTSD symptom severity, posttraumatic maladaptive cognitions, anxiety, depressive and somatoform symptom severity, and quality of life were assessed via self-report at baseline and after treatment or waiting time. PTSD symptom severity was also measured throughout treatment or waiting time. Treatment satisfaction was assessed after treatment completion. Treatment use and satisfaction were compared between the 2 treatment conditions using appropriate statistical tests (eg, chi-square and Welch tests). Multiple imputation was performed to address missing data and evaluate treatment-associated changes. These changes were analyzed using multigroup change modeling in the completer and intention-to-treat samples. RESULTS: Overall, 200 (N=240, 83.3%) participants started any of the treatments, of whom 123 (61.5%) completed the treatment. Treatment condition was not significantly associated with the proportion of participants who started versus did not start treatment (P=.20) or with treatment completion versus treatment dropout (P=.71). High treatment satisfaction was reported, with no significant differences between the treatment conditions (P=.48). In both treatment conditions, PTSD, anxiety, depressive and somatoform symptom severity, and posttraumatic maladaptive cognitions decreased, and quality of life improved significantly from baseline to the posttreatment time point (P≤.001 in all cases). Compared with the baseline assessment, overall PTSD symptom severity decreased significantly after 4 sessions in both treatment conditions (P<.001). Moreover, both treatment conditions were significantly superior to the waitlist control group regarding overall PTSD symptom severity (P<.001) and most other comorbid mental health symptoms (P<.001 to P=.03). Differences between the 2 conditions in the magnitude of change for all outcome measures were nonsignificant. CONCLUSIONS: Internet-based cognitive behavioral treatments for PTSD focusing primarily on either self-confrontation or cognitive restructuring are applicable and efficacious for Arabic-speaking participants. TRIAL REGISTRATION: German Clinical Trials Register DRKS00010245; https://drks.de/search/de/trial/DRKS00010245.

Blended-ALMAMAR app for inpatient mental health care for refugees: study protocol for a multicenter implementation study within the I-REACH consortium (Internet based REfugee mentAl healtH Care).

BACKGROUND: Refugees are at high risk for developing mental illnesses. Due to language and cultural barriers, there is need for specifically adapted therapeutic procedures for refugees in inpatient mental health care settings. Internet-based applications in refugee mother tongues have the potential to improve the outcomes of mental health care for this vulnerable population. The key research question of the present implementation study is whether the newly developed "blended ALMAMAR" app for Arabic and Farsi speaking refugees in Germany is used and accepted by patients and professionals in routine inpatient mental health care (blended care). METHODS: We present the design of an observational, prospective multicenter implementation study in eight psychiatric hospitals. We plan to recruit 100 Farsi or Arabic speaking refugees receiving in-patient treatment due to depression, anxiety disorder, posttraumatic stress disorder or substance use disorders. These patients will get access to the "blended ALMAMAR" app during their inpatient stay in a blended-care approach. We will assess the usage (e.g., duration and frequency of use of the app) as well as subjective acceptability and usability of the intervention. To identify sociodemographic and clinical factors associated with "blended ALMAMAR" usage, we will also perform clinical and questionnaire assessments. DISCUSSION: The newly developed "blended ALMAMAR" app may help to close communication gaps for the hard-to reach and vulnerable group of refugees in inpatient mental health care. It is the first blended-care intervention that addresses severely mentally ill refugees in an inpatient psychiatric setting in Germany. TRIAL REGISTRATION: The trial was registered in the German Clinical Trials Register on November 11, 2021 (DRKS00025972) and adapted on November 14, 2023.

Patterns of posttraumatic stress symptoms, their predictors, and comorbid mental health symptoms in traumatized Arabic-speaking people: A latent class analysis.

Many people from the Middle East and North Africa (MENA) have experienced traumatic events due to human rights abuses, violence, and conflict in the region, with potential psychological consequences including symptoms of posttraumatic stress and comorbid mental health problems. Yet, little is known about how different posttraumatic stress symptoms unfold in Arabic-speaking people who have experienced diverse traumatic events. This study examined latent classes based on posttraumatic stress symptoms, differences across classes concerning comorbid mental health symptoms and quality of life, and several predictors, including sociodemographic characteristics, social support, and trauma-related characteristics. Participants were 5,140 traumatized Arabic-speaking individuals who had registered for an online intervention. Latent class analysis was conducted to identify distinct classes based on DSM-5 posttraumatic stress symptoms. Multinomial logistic regression was used to analyze predictors of class membership. Differences between classes in severity of posttraumatic stress, depressive, anxiety, and somatoform symptoms, as well as quality of life were examined. Five different latent classes were identified: a general high posttraumatic stress symptom class (43.8%), a high posttraumatic stress symptom-low avoidance class (12.8%), a mixed posttraumatic stress symptom class (20.9%), a high dysphoric-low reexperiencing/avoidance class (14%), and a general low posttraumatic stress symptom class (8.4%). The classes differed in severity of posttraumatic stress, depressive, anxiety and somatoform symptoms, and quality of life. Consistent significant predictors of class membership were gender, social support, cumulative trauma exposure, sexual violence and direct exposure during the most distressing trauma, as well as time since the most distressing trauma. Distinct symptom classes with quantitative and qualitative differences can emerge following exposure to trauma among help-seeking Arabic-speaking people from the MENA region, with gender, social support, and trauma-related characteristics predicting symptom presentation. The results have implications for identifying distressed people and enhancing interventions based on an individual's symptom presentation.

Development and Validation of a Questionnaire to Assess Role Conflicts Among Interpreters Working With Refugee Clients: The Role Conflicts Questionnaire.

Objectives: The aim of this study was to develop and validate a questionnaire to assess interpreters' role conflicts and the challenging aspects within the triad of practitioner, interpreter and refugee client. Methods: A questionnaire was developed based on previous literature. Its factor structure and construct validity were assessed in an online survey of 164 interpreters working with refugee clients. Psychological distress (BSI-18), work-related exhaustion (CBI), and secondary traumatic stress (ProQOL) were measured to test the questionnaire's convergent validity. Results: Exploratory structural equation modeling for categorical variables resulted in 23 items across four subscales. The scores of all subscales had good or excellent reliability (ω = 0.81 to ω = 0.93) and correlation analyses indicated convergent validity. Conclusion: The final questionnaire (RoCo) showed four clearly interpretable subscales and may help to identify emotional distress due to role conflicts among interpreters. Future studies should validate the questionnaire in different samples.

With a little help from my friends? Acculturation and mental health in Arabic-speaking refugee youth living with their families.

Introduction: Refugee youth are often faced with the compounding challenges of heightened exposure to traumatic events and acculturating to a new country during a developmental period when their sense of self is still forming. This study investigated whether refugee youth's acculturation orientation (separation, integration, marginalization, and assimilation) is associated with depressive and posttraumatic stress symptoms and aimed to identify additional indicators of acculturation that may contribute to mental health. Methods: A total of 101 Arabic-speaking refugee youths (aged 14-20 years), who were living with their families and attending school in Germany, took part in the study. They answered questions concerning traumatic exposure and posttraumatic stress symptoms, depressive symptoms, and several indicators of acculturation, including cultural orientation, positive and negative intra- and intergroup contact, language skills and friendship networks. All participants were categorized into one of four acculturation orientations using median splits. Results: Kruskal-Wallis rank sum tests revealed that acculturation orientation was not significantly associated with depressive symptoms [χ2 (3, 97) = 0.519, p = 0.915] or posttraumatic stress symptoms [χ2 (3, 97) = 0.263, p = 0.967]. Regression analysis revealed that German language skills were significantly associated with lower scores of depressive symptoms (p = 0.016) and number of friends in Germany was significantly associated with lower scores of depressive (p = 0.006) and posttraumatic stress symptoms (p = 0.002), respectively. Discussion: Policies that provide refugee youth with access to language classes and social activities with peers do not only enable them to actively participate in a new society but may also have a positive effect on their mental health.

Prolonged grief disorder in Arabic-speaking treatment-seeking populations: Relationship with socio-demographic aspects, loss- and trauma-related characteristics, and mental health support.

Introduction: Prolonged grief disorder (PGD) has been included as a new diagnosis in the ICD-11 and is set to be included in the DSM-5-TR. To better identify vulnerable individuals, different factors associated with PGD have to be taken into account, but results regarding these factors remain equivocal. Moreover, few studies on PGD are available from Arabic-speaking populations and from different countries dealing with conflicts and wars. The objective was thus to examine PGD prevalence and associated characteristics in these populations. Materials and methods: A total of N = 1,051 bereaved participants from Arabic-speaking populations completed the PG-13 as part of a screening procedure for an online mental health intervention. Multiple linear regression was conducted to examine associated factors for PGD symptom severity, and multiple logistic regression was applied to investigate associated factors for PGD according to PG-13 diagnostic criteria. Results: Of the participants, 18.8% (n = 198) met the PGD diagnostic criteria, at an average of about 6 years post-loss. The multiple linear regression yielded eight associated factors for PGD symptom severity (age, gender, number of losses, number of traumatic event types, relationship with the deceased, age at loss, impairment during first year post-loss, perceived social support), which explained 40.2% of the variance [F (17, N=1,033) = 40.82, p < 0.001, R 2 = 0.402]. The multiple logistic regression yielded five significant associations with PGD (gender, relationship with the deceased, number of lost persons, impairment during first year post-loss, perceived social support), which explained 33.0% (Nagelkerke R 2) of the variance in PGD according to PG-13 diagnostic criteria. Discussion: A substantial proportion of the participants met the PG-13 criteria for PGD, emphasizing that therapeutic services are indispensable in this population. The associated factors for PGD found in our Arab-speaking sample are largely consistent with those found in studies from other regions. The slightly differing numbers of associated factors between the linear and logistic regression underline that a continuous score reflects the continuum between normal and dysfunctional grieving, and therefore also a range of factors associated with PGD.

Do Gender and Country of Residence Matter? A Mixed Methods Study on Lay Causal Beliefs about PTSD.

Laypersons' causal beliefs about mental disorders can differ considerably from medical or psychosocial clinicians' models as they are shaped by social and cultural context and by personal experiences. This study aimed at identifying differences in causal beliefs about post-traumatic stress disorder (PTSD) by country and gender. A cross-sectional, vignette-based online survey was conducted with 737 participants from Germany, Greece, Ecuador, Mexico, and Russia. Participants were presented with a short unlabeled case vignette describing a person with symptoms of PTSD. Causal beliefs were assessed using an open-ended question asking for the three most likely causes. Answers were analyzed using thematic analysis. Afterwards, themes were transformed into categorical variables to analyze differences by country and by gender. Qualitative analyses revealed a wide range of different causal beliefs. Themes differed by gender, with women tending to mention more external causal beliefs. Themes also differed between the five countries but the differences between countries were more pronounced for women than for men. In conclusion, causal beliefs were multifaceted among laypersons and shared basic characteristics with empirically derived risk factors. The more pronounced differences for women suggest that potential gender effects should be considered in cross-cultural research.

A comparison of interpreters' wellbeing and work-related characteristics in the care of refugees across different work settings.

BACKGROUND: Interpreters in the care of refugees work in various different settings. Qualitative studies suggest that interpreters are confronted with a variety of demands depending on the context in which they work, which may in turn influence their wellbeing. To date, no larger-scale study has investigated differences between work settings regarding interpreters' work-related characteristics or wellbeing. OBJECTIVE: The aim of this study was to compare the work-related characteristics and possible changes in the wellbeing of interpreters between four main work settings (psychotherapy, counselling, medical setting, and authorities) in the care of refugees. METHOD: Interpreters in refugee care were recruited for a nationwide online survey in Germany with two measurement time points. Participants provided socio-demographic data and answered questions about the working conditions in their respective main work setting. In addition, psychological distress (Brief Symptom Inventory, BSI-18), work-related exhaustion (Copenhagen Burnout Inventory, CBI), and compassion satisfaction (Professional Quality of Life, ProQOL) were assessed. RESULTS: Overall, 158 interpreters were included at t1, of whom 63 were also included at t2. Significantly more traumatic content was interpreted in counselling settings and psychotherapy than in medical and authorities settings (H (3) = 26.09, p < .001). The highest proportion of interpreters with an interpreting degree worked in the authorities setting (Fisher's exact test, p = .002). Significant differences between the four settings were found for psychological distress (Kruskal-Wallis-test, H (3) = 12.02, p = .01) and work-related exhaustion (Kruskal-Wallis-test, H (3) = 8.10, p = .04) but not for compassion satisfaction. CONCLUSION: The presented results indicate differences regarding working conditions, psychological distress, and work-related exhaustion between different work settings of interpreters. Future studies may explore each setting in greater detail and include a larger sample size to reach a better understanding of the relationship between setting-specific challenges and interpreters' wellbeing.

Psychological distress, exhaustion, and work-related correlates among interpreters working in refugee care: results of a nationwide online survey in Germany.

Background: Due to language barriers, interpreters are crucial for refugee care in the countries of resettlement. However, interpreters are often faced with distressing working conditions, such as precarious work circumstances, lack of supervision, or exposure to their clients' traumatic experiences. Recent studies examining interpreters' mental health focussed primarily on secondary traumatic stress. The present study aimed to gain a better understanding of psychological distress and exhaustion among interpreters in refugee care by examining these factors in the work context as well as their possible work-related correlates. Method: An online survey was carried out in Germany, which included several standardized questionnaires regarding distress, work- and client-related exhaustion, job satisfaction, and trauma exposure (BSI-18, CBI, JSS, HTQ, PCL-5). Interpreters were recruited primarily through psychosocial treatment centres and interpreter pools in Germany. Results: In total, 164 interpreters were included in the analyses. The participants showed increased psychological distress, and around 7% screened positive for posttraumatic stress disorder (PTSD). In an exploratory regression analysis, younger age (ß = -.25, p = .004) emerged as correlate of psychological distress, whereas dissatisfaction with payment (ß = -.21, p = .04) and a higher amount of traumatic content (ß = .22, p = .001) were associated with work-related exhaustion, and dissatisfaction with recognition was associated with client-related exhaustion (ß = -.35, p = .001). Conclusion: The results point to increased stress levels among interpreters for refugees. Moreover, they indicate that interpreters' distress is primarily correlated with work-related circumstances, thus suggesting the need for a greater work-related support structure for interpreters.

Antecedentes: Debido a las barreras del lenguaje, los intérpretes tienen un rol crucial en la atención de refugiados en los países que les proporcionan refugio. Sin embargo, los intérpretes se enfrentan a menudo con condiciones de trabajo estresantes, tales como circunstancias laborales precarias, carencia de supervisión, o exposición a las experiencias traumáticas de sus clientes. Estudios recientes que han examinado la salud mental de los intérpretes se centran principalmente en el estrés traumático secundario. El presente estudio busca ganar un mejor entendimiento del malestar psicológico y el agotamiento en los intérpretes en la atención de refugiados al examinar estos factores en el contexto laboral, así como sus posibles correlatos relacionados con el trabajo.Método: Una encuesta en línea fue llevada a cabo en Alemania, la cual incluyó varios cuestionarios estandarizados relacionados a la angustia, al agotamiento relacionado con el trabajo y el cliente, satisfacción laboral, y exposición al trauma (BSI-18, CBI, JSS, HTQ, PCL-5, en sus siglas en inglés). Los intérpretes fueron reclutados principalmente a través de centros de tratamiento psicosocial y bases de datos de intérpretes en Alemania.Resultados: En total, 164 intérpretes fueron incluidos en el análisis. Los participantes mostraron mayor malestar psicológico, y alrededor del 7% fueron identificados como positivos para el trastorno de estrés postraumático (TEPT). En un análisis de regresión exploratoria, la menor edad (b = −.25, p = .004) surgió como un correlato de malestar psicológico, mientras que la insatisfacción con el pago (b = −.21, p = .04), y una mayor cantidad de contenido traumático (b = .22, p = .001) se asociaron con agotamiento relacionado al trabajo, y la insatisfacción con el reconocimiento se asoció con agotamiento relacionado con el cliente (b = −.35, p = .001).Conclusión: Los resultados apuntan a un aumento de los niveles de estrés entre los intérpretes de refugiados. Además, indican que la angustia de los intérpretes se correlaciona principalmente con las circunstancias relacionadas con el trabajo, lo que sugiere la necesidad de una mayor estructura de apoyo relacionada con el trabajo para los intérpretes.

Lay causal beliefs about PTSD and cultural correlates in five countries.

Background: To date, cultural clinical research has primarily focused on differences between ethnic groups when investigating causal beliefs about mental disorders. While individual as well as contextual factors are considered important for gaining a better understanding of cultural influences, research on causal beliefs about post-traumatic stress disorder (PTSD) and cultural correlates in laypersons is scarce. Objective: This study aimed at gain a better understanding of the association between causal beliefs about PTSD and cultural aspects, as well as other contextual and individual correlates of causal beliefs. Method: We conducted a cross-sectional, vignette-based online survey with 737 laypersons from Mexico, Ecuador, Germany, Greece, and Russia. Participants completed the illness perception questionnaire revised (IPQ-R) and reported several cultural and sociodemographic (e.g. country of residence, gender, personal values) as well as mental health-related variables (e.g. PTSD symptoms, previous seeking of help). Latent class analysis (LCA) was performed to identify subgroups of individuals expressing similar causal beliefs for PTSD. Multinomial logistic regression was used to analyse covariates of class membership. Results: LCA resulted in a three-class solution of casual beliefs: a traumatic event-focused class (41.1%); an intrapersonal causes class (40.1%); and a multiple causes class (18.0%). Multinomial logistic regression analysis revealed country of residence, gender, personal value of security, PTSD symptoms, and mental health literacy as significant covariates of class membership. Conclusions: Integrating a more diverse concept of culture into cultural clinical research can be a valuable addition to group comparisons based on nationality or ethnicity. Cultural clinical research needs to move towards a more integrated approach that accounts for the complexity of culture. Including additional contextual and sociodemographic factors can help to reach a more accurate understanding of the cultural influences on the development of causal beliefs and mental health.

Antecedentes:Hasta la fecha, la investigación clínica cultural se ha centrado principalmente en las diferencias entre grupos étnicos al investigar las creencias causales sobre los trastornos mentales. Si bien los factores individuales y contextuales se consideran importantes para obtener una mejor comprensión de las influencias culturales, la investigación sobre las creencias causales sobre el trastorno de estrés postraumático (TEPT) y los correlatos culturales en las personas legas es escasa.Objetivo:Este estudio tuvo como objetivo obtener una mejor comprensión de la asociación entre las creencias causales sobre el TEPT y los aspectos culturales, así como otros correlatos contextuales e individuales de las creencias causales.Método:Realizamos una encuesta en línea transversal basada en viñetas con 737 legos de México, Ecuador, Alemania, Grecia y Rusia. Los participantes completaron el cuestionario de percepción de la enfermedad revisado (IPQ-R en su sigla en inglés) y reportaron varias variables culturales y sociodemográficas (e.g. país de residencia, género, valores personales) así como variables relacionadas con la salud mental (e.g. síntomas de TEPT, búsqueda previa de ayuda). Se realizó un análisis de clases latentes (LCA en su sigla en inglés) para identificar subgrupos de individuos que expresan creencias causales similares sobre el TEPT. Se utilizó la regresión logística multinomial para analizar las covariables de pertenencia a una clase.Resultados:El LCA resultó en una solución de tres clases de creencias causales: una clase centrada en un evento traumático (41,1%); una clase de causas intrapersonales (40,1%); y una clase de causas múltiples (18,0%). El análisis de regresión logística multinomial reveló el país de residencia, el género, el valour personal de la seguridad, los síntomas del TEPT y el conocimiento en salud mental como covariables importantes de la pertenencia a una clase.Conclusiones:La integración de un concepto de cultura más diverso en la investigación clínica cultural puede ser una valiosa adición a las comparaciones de grupos basadas en la nacionalidad o la etnia. La investigación clínica cultural debe avanzar hacia un enfoque más integrado que dé cuenta de la complejidad de la cultura. La inclusión de factores contextuales y sociodemográficos adicionales puede ayudar a alcanzar una comprensión más precisa de las influencias culturales en el desarrollo de las creencias causales y la salud mental.

Mental Health and Work Experiences of Interpreters in the Mental Health Care of Refugees: A Systematic Review.

Background: Interpreters often play a crucial role in the health care of refugees. Although interpreters working with refugees are regularly confronted with emotionally stressful content, little is known about their work-related stress and psychological well-being. Primarily qualitative studies indicate increased emotional stress in interpreters, and difficulties in handling the traumatic content from their clients. Additionally, the working conditions of interpreters appear to be demanding, due to low payment and a lack of supervision or adequate preparation. Objective: The presented systematic review aimed to identify and summarise quantitative and qualitative research on the mental health of interpreters in the mental health care of refugees. Method: A systematic search was performed in five databases, and specific interpreting journals were searched. After removal of duplicates, 6,920 hits remained. Eligible studies included quantitative, qualitative, and mixed-methods studies as well as case studies and grey literature. The studies aimed to examine mental health aspects or work experiences of spoken language interpreters in mental health care settings for adult refugees. Results: Altogether, 25 studies were identified, including six quantitative and 19 qualitative studies. Studies were analysed and presented narratively. In the analysis of the qualitative studies, three themes emerged: "Emotions, behaviour, and coping strategies," "Working in a triad," and "Working environment." In the quantitative studies, interpreters showed heightened levels of emotional stress and anxiety, and secondary traumatic stress reactions. In several qualitative studies, interpreters described a devaluing health care system and stressful working conditions with a lack of support structures. Conclusion: Overall, the results indicate a high level of stress among interpreters working with refugees. Quantitative data are sparse, and studies employ heterogeneous assessments in diverse study settings. Therefore, future quantitative research is necessary to consistently investigate interpreters' mental health in different mental health care settings. Systematic Review Registration: https://www.crd.york.ac.uk/PROSPERO/, identifier: CRD42019117948.

Is only one cognitive technique also effective? Results from a randomized controlled trial of two different versions of an internet-based cognitive behavioural intervention for post-traumatic stress disorder in Arabic-speaking countries.

Background: Internet-based cognitive-behavioural interventions seem to be effective for the treatment of posttraumatic stress disorder (PTSD) in Arabic-speaking countries in the MENA region. However, due to high prevalence rates of trauma-related mental disorders in this region, it is important to scale up existing Internet-based interventions in order to increase the number of clients. Objective: The aim of the study was to examine whether a brief Internet-based intervention with one cognitive technique (TF-short, 6 assignments) results in the same PTSD symptom change and lower dropouts compared to a longer intervention with two cognitive techniques (TF-reg, 10 assignments). Method: A total of 224 Arab participants (67.4% female; M = 25.3 years old) with PTSD were randomly assigned to Internet-based CBT with either a TF-reg protocol (n = 110) or a TF-short protocol (n = 114). Symptoms of PTSD and secondary outcomes (anxiety, depression, somatic complaints, quality of life) were self-assessed online at baseline and post-treatment. Treatment-associated changes were estimated using multigroup latent difference score models. Results: The overall PTSD score assessed with the PDS decreased by about 15 points in both conditions. The between-group differences (TF-reg vs. TF-short) at post-assessment were non-significant, Δ = 0.29, p = .896, d = 0.02, 95% CI [-0.30, 0.34]. Like the primary outcome, all within-group changes for the secondary outcomes throughout the intervention were statistically significant and all between-group effects were non-significant. Overall, the dropout rates did not differ between the two conditions, χ2 (1/N = 175) = 0.83, p = .364. Conclusions: The findings suggest that the shorter condition results in the same symptom change and dropout rate as the longer condition. This highlights the potential of shorter, more scalable Internet-based interventions in socially restricted and (post-)conflict societies. ClinicalTrialsgov ID: NCT01508377.

Antecedentes: Las intervenciones cognitivo-conductuales basadas en Internet parecen ser efectivas para el tratamiento del trastorno de estrés postraumático (TEPT) en los países de habla árabe de la región MENA. Sin embargo, debido a las altas tasas de prevalencia de trastornos mentales relacionados con el trauma en esta región, es importante escalar las intervenciones existentes basadas en Internet para aumentar el número de clientes.Objetivo: El propósito del estudio fue examinar si una intervención breve basada en Internet con una técnica cognitiva (TF-corta, 6 asignaciones) da como resultado el mismo cambio sintomático del TEPT y menos abandonos en comparación con una intervención más prolongada con dos técnicas cognitivas (TF -reg, 10 asignaciones).Método: Un total de 224 participantes árabes (67,4% mujeres; M = 25,3 años) con TEPT fueron asignados aleatoriamente a TCC basada en Internet con un protocolo TF-reg (n = 110) o un protocolo TF-corta (n = 114). Los síntomas del TEPT y los resultados secundarios (ansiedad, depresión, quejas somáticas, calidad de vida) fueron autoevaluadas en línea al inicio y al finalizar el tratamiento. Los cambios asociados al tratamiento se estimaron utilizando modelos de puntuación de diferencia latente multigrupo.Resultados: El puntaje general de TEPT evaluado con la PDS disminuyó aproximadamente 15 puntos en ambas condiciones. Las diferencias entre grupos (TF-reg vs. TF-corta) en la evaluación posterior no fueron significativas, Δ = 0,29, p = .896, d = 0,02, IC del 95% [-0,30, 0,34]. Al igual que el resultado primario, todos los cambios dentro del grupo para los resultados secundarios a lo largo de la intervención fueron estadísticamente significativos y todos los efectos entre los grupos no fueron significativos. En general, las tasas de abandono no difirieron entre las dos condiciones, χ2 (1/N = 175) = 0.83, p = .364.Conclusiones: Los hallazgos sugieren que la condición más corta da como resultado el mismo cambio de síntomas y la misma tasa de abandono que la condición más larga. Esto resalta el potencial de intervenciones más breves y escalables basadas en Internet en sociedades socialmente restringidas y (post) conflicto.

Posttraumatic stress in adult civilians exposed to violent conflict, war and associated human rights abuses in the Eastern Mediterranean Region: A systematic review and meta-analysis.

BACKGROUND: The Eastern Mediterranean Region (EMR) is the stage of the world's most violent conflicts and the origin of the largest refugee population worldwide. These conflicts can result in symptoms of posttraumatic stress (PTS). To date, no comprehensive meta-analysis on proportions of PTS in civilians from the EMR has been conducted. Sample characteristics, methodological, conflict-related and displacement-related factors might affect rates of PTS. METHODS: A systematic literature search for studies investigating PTS in adult civilians from the EMR was conducted until March 2020 and resulted in 118 individual study samples that were suitable for inclusion. A quality assessment was conducted. A random effects meta-analysis on proportions and sensitivity analyses were performed, and a 95% prediction interval was calculated. Subgroup analyses to identify moderators (e.g. diagnostic instruments, displacement) were conducted. RESULTS: The quality of the included study samples varied. The pooled estimate of proportions from all 118 study samples was 0.31 (95% CI: 0.27 - 0.35). Heterogeneity was considerable (Q = 10151.58, p < .0001; I2 = 98.64%). The prediction interval was 0.01 to 0.76. The results remained unchanged after excluding nine outlier study samples. Heterogeneity remained high in all subgroups (range of I2: 87.91 to 99.62). LIMITATIONS: Due to heterogeneity the pooled estimate cannot be interpreted. Moderators contributing to heterogeneity could not be detected. CONCLUSIONS: The proportion of symptoms of PTS in civilians from the EMR varies considerably. The prediction interval indicates that the true rate falls between 1% and 76%. Future studies need to identify variables that affect heterogeneity.

Associations of Depressive Symptoms, COVID-19-Related Stressors, and Coping Strategies. A Comparison Between Cities and Towns in Germany.

BACKGROUND: The COVID-19 pandemic has led to a wide range of stressors related to depressive symptoms. Prevention measures like physical distancing have burdened the general population, especially in highly urbanized areas. However, little is known about the associations between pandemic-related stressors, coping strategies, and depressive symptoms in highly urbanized vs. less urbanized environments. METHODS: Participants were recruited in a cross-sectional online survey in Germany. Propensity score matching yielded a matched sample of city (n = 453) and town (n = 453) inhabitants. Depressive symptoms, COVID-19-related stressors, and coping strategies were compared between cities and towns. Multiple regression analysis was performed to determine associations between pandemic-related stressors and depressive symptoms for the two groups separately. RESULTS: City inhabitants showed significantly higher depression scores than town inhabitants (t = 2.11, df = 897.95, p = 0.035). Seven coping strategies were more often used by the city sample. Depressive symptoms were associated with "restricted physical social contact" and "difficult housing conditions" (adjusted R 2= 0.19, F [9,443] = 12.52, p < 0.001) in city inhabitants, and with "fear of infection" and "difficult housing conditions" (adjusted R 2= 0.20, F [9,443] = 13.50, p < 0.001) in town inhabitants. LIMITATIONS: The data were collected at the end of the first wave and represent a snapshot without causal inferences. Pandemic-related stressors were measured with a newly developed scale. CONCLUSION: Depressive symptoms, perceived stressors, and approach/avoidance coping strategies differed between city vs. town inhabitants. These differences should be considered in policy-making and mental health care.

From Formative Research to Cultural Adaptation of a Face-to-Face and Internet-Based Cognitive-Behavioural Intervention for Arabic-Speaking Refugees in Germany.

Background: This study aims to provide a transparent and replicable documentation approach for the cultural adaptation of a cognitive-behavioural transdiagnostic intervention (Common Elements Treatment Approach, CETA) for Arabic-speaking refugees with common mental disorders in Germany. Method: A mixed-methods approach was used, including literature review, interviews, expert decisions and questionnaires, in order to adapt the original CETA as well as an internet-based guided version (eCETA). The process of cultural adaptation was based on a conceptual framework and was facilitated by an adaptation monitoring form as well as guidelines which facilitate the reporting of cultural adaptation in psychological trials (RECAPT). Results: Consistent with this form and the guidelines, the decision-making process of adaptation proved to be coherent and stringent. All specific CETA treatment components seem to be suitable for the treatment of Arabic-speaking refugees in Germany. Adaptations were made to three different elements: 1) Cultural concepts of distress: a culturally appropriate explanatory model of symptoms was added; socially accepted terms for expressing symptoms (for eCETA only) and assessing suicidal ideation were adapted; 2) Treatment components: no adaptations for theoretically/empirically based components of the intervention, two adaptations for elements used by the therapist to engage the patient or implement the intervention (nonspecific elements), seven adaptations for skills implemented during sessions (therapeutic techniques; two for eCETA only) and 3) Treatment delivery: 21 surface adaptations (10 for eCETA only), two eCETA-only adaptations regarding the format. Conclusion: The conceptual framework and the RECAPT guidelines simplify, standardise and clarify the cultural adaptation process.