Group problem management plus (PM+) to decrease psychological distress among Syrian refugees in Turkey: a pilot randomised controlled trial.

BACKGROUND: Syrian refugees resettled in Turkey show a high prevalence of symptoms of mental disorders. Problem Management Plus (PM+) is an effective psychological intervention delivered by non-specialist health care providers which has shown to decrease psychological distress among people exposed to adversity. In this single-blind pilot randomised controlled trial, we examined the methodological trial procedures of Group PM+ (gPM+) among Syrian refugees with psychological distress in Istanbul, Turkey, and assessed feasibility, acceptability, perceived impact and the potential cost-effectiveness of the intervention. METHODS: Refugees with psychological distress (Kessler Psychological Distress Scale, K10 > 15) and impaired psychosocial functioning (World Health Organization Disability Assessment Schedule, WHODAS 2.0 > 16) were recruited from the community and randomised to either gPM+ and enhanced care as usual (E-CAU) (n = 24) or E-CAU only (n = 22). gPM+ comprised of five weekly group sessions with eight to ten participants per group. Acceptability and feasibility of the intervention were assessed through semi-structured interviews. The primary outcome at 3-month follow-up was symptoms of depression and anxiety (Hopkins Symptoms Checklist-25). Psychosocial functioning (WHODAS 2.0), symptoms of posttraumatic stress disorder and self-identified problems (Psychological Outcomes Profiles, PSYCHLOPS) were included as secondary outcomes. A modified version of the Client Service Receipt Inventory was used to document changes in the costs of health service utilisation as well as productivity losses. RESULTS: There were no barriers experienced in recruiting study participants and in randomising them into the respective study arms. Retention in gPM+ was high (75%). Qualitative analyses of the interviews with the participants showed that Syrian refugees had a positive view on the content, implementation and format of gPM+. No adverse events were reported during the implementation. The study was not powered to detect an effect. No significant difference between gPM+ and E-CAU group on primary and secondary outcome measures, or in economic impacts were found. CONCLUSIONS: gPM+ delivered by non-specialist peer providers seemed to be an acceptable, feasible and safe intervention for Syrian refugees in Turkey with elevated levels of psychological distress. This pilot RCT sets the stage for a fully powered RCT. TRIAL REGISTRATION: ClinicalTrials.gov Identifier NCT03567083 ; date: 25/06/2018.

Treatment gap and mental health service use among Syrian refugees in Sultanbeyli, Istanbul: a cross-sectional survey.

AIMS: Syrian refugees may have increased mental health needs due to the frequent exposure to potentially traumatic events and violence experienced during the flight from their home country, breakdown of supportive social networks and daily life stressors related to refugee life. The aim of this study is to report evidence on mental health needs and access to mental health and psychosocial support (MHPSS) among Syrians refugees living in Sultanbeyli-Istanbul, Turkey. METHODS: A cross-sectional survey was conducted among Syrian refugees aged 18 years or over in Sultanbeyli between February and May 2018. We used random sampling to select respondents by using the registration system of the municipality. Data among 1678 Syrian refugees were collected on mental health outcomes using the Posttraumatic Stress Disorder (PTSD) Checklist (PCL-5) and the Hopkins Symptoms Checklist (HSCL-25) for depression and anxiety. We also collected data on health care utilisation, barriers to seeking and continuing care as well as knowledge and attitudes towards mental health. Descriptive analyses were used. RESULTS: The estimated prevalence of symptoms of PTSD, depression and anxiety was 19.6, 34.7 and 36.1%, respectively. In total, 249 respondents (15%) screened positive for either PTSD, depression or anxiety in our survey and self-reported emotional/behavioural problems since arriving in Sultanbeyli. The treatment gap (the proportion of these 249 people who did not seek care) was 89% for PTSD, 90% for anxiety and 88% for depression. Several structural and attitudinal barriers for not seeking care were reported, including the cost of mental health care, the belief that time would improve symptoms, fear of being stigmatised and lack of knowledge on where and how to get help. Some negative attitudes towards people with mental health problems were reported by respondents. CONCLUSIONS: Syrian refugees hardly access MHPSS services despite high mental health needs, and despite formally having access to the public mental health system in Turkey. To overcome the treatment gap, MHPSS programmes need to be implemented in the community and need to overcome the barriers to seeking care which were identified in this study. Mental health awareness raising activities should be provided in the community alongside the delivery of psychological interventions. This is to increase help-seeking and to tackle negative attitudes towards mental health and people with mental health problems.

The culture, mental health and psychosocial wellbeing of Rohingya refugees: a systematic review.

AIMS: Despite the magnitude and protracted nature of the Rohingya refugee situation, there is limited information on the culture, mental health and psychosocial wellbeing of this group. This paper, drawing on a report commissioned by the United Nations High Commissioner for Refugees (UNHCR), aims to provide a comprehensive synthesis of the literature on mental health and psychosocial wellbeing of Rohingya refugees, including an examination of associated cultural factors. The ultimate objective is to assist humanitarian actors and agencies in providing culturally relevant Mental Health and Psychosocial Support (MHPSS) for Rohingya refugees displaced to Bangladesh and other neighbouring countries. METHODS: We conducted a systematic search across multiple sources of information with reference to the contextual, social, economic, cultural, mental health and health-related factors amongst Rohingya refugees living in the Asia-Pacific and other regions. The search covered online databases of diverse disciplines (e.g. medicine, psychology, anthropology), grey literature, as well as unpublished reports from non-profit organisations and United Nations agencies published until 2018. RESULTS: The legacy of prolonged exposure to conflict and persecution compounded by protracted conditions of deprivations and displacement is likely to increase the refugees' vulnerability to wide array of mental health problems including posttraumatic stress disorder, anxiety, depression and suicidal ideation. High rates of sexual and gender-based violence, lack of privacy and safe spaces and limited access to integrated psychosocial and mental health support remain issues of concern within the emergency operation in Bangladesh. Another challenge is the limited understanding amongst the MHPSS personnel in Bangladesh and elsewhere of the language, culture and help-seeking behaviour of Rohingya refugees. While the Rohingya language has a considerable vocabulary for emotional and behavioural problems, there is limited correspondence between these Rohingya terms and western concepts of mental disorders. This hampers the provision of culturally sensitive and contextually relevant MHPSS services to these refugees. CONCLUSIONS: The knowledge about the culture, context, migration history, idioms of distress, help-seeking behaviour and traditional healing methods, obtained from diverse sources can be applied in the design and delivery of culturally appropriate interventions. Attention to past exposure to traumatic events and losses need to be paired with attention for ongoing stressors and issues related to worries about the future. It is important to design MHPSS interventions in ways that mobilise the individual and collective strengths of Rohingya refugees and build on their resilience.

Mental health capacity building in refugee primary health care settings in Sub-Saharan Africa: impact, challenges and gaps.

BACKGROUND: In 2015, the United Nations High Commissioner for Refugees started a process of mental health capacity building in refugee primary health care settings in seven countries in Sub-Saharan Africa, ultimately aiming to decrease the treatment gap of mental, neurological and substance use (MNS) conditions in these operations. In 2015 and 2016, a specialized non-governmental organization, the War Trauma Foundation, trained 619 staff with the mental health gap action programme (mhGAP) Humanitarian Intervention Guide (HIG), a tool designed to guide clinical decision making in humanitarian settings. METHODS: This paper describes the results of a process evaluation of a real-life implementation project by an external consultant, one and a half years after starting the programme. RESULTS: The mhGAP-HIG capacity building efforts had various effects contributing to the integration of mental health in refugee primary health care. Facility-and community-based staff reported strengthened capacities to deliver mental health and psychosocial support interventions as well as changes in their attitude towards people suffering from MNS conditions. Service delivery and collaboration amongst different intervention levels improved. The scarcity of specialized staff in these settings was a major barrier, hindering the setting-up of supervision mechanisms. CONCLUSION: Mental health training of non-specialized staff in complex humanitarian settings is feasible and can lead to increased competency of providers. However, capacity building is a 'process' and not an 'event' and mhGAP trainings are only one element in a spectrum of activities aimed at integrating mental health into general health care. Regular supervision and continuing on-the-job training are in fact critical to ensure sustainability.

Translation, adaptation, and pilot of a guided self-help intervention to reduce psychological distress in South Sudanese refugees in Uganda.

BACKGROUND: In this period of unprecedented levels of displacement, scalable interventions are needed to address mental health concerns of forced migrants in low-resource settings. This paper describes the adaptation and piloting of a guided, multi-media, self-help intervention, Self-Help Plus (SH+), which was developed to reduce psychological distress in large groups of people affected by adversity. METHODS: Using a phased approach that included community consultations, cognitive interviewing, facilitator training, pilot implementation, and a qualitative process evaluation, we adapted SH+ for use among South Sudanese refugees in a refugee settlement in northern Uganda. RESULTS: The SH+ materials, including audio-recorded sessions and an accompanying illustrated manual, were translated into Juba Arabic. Cognitive interviewing primarily resulted in adaptations to language with some minor adaptations to content. Facilitator training and supervision led to further suggested changes to delivery methods. An uncontrolled pilot study (n = 65) identified changes in the expected direction on measures of psychological distress, functional impairment, depression, wellbeing, and psychological flexibility. The process evaluation resulted in further adaptations to intervention materials and the decision to focus future effectiveness evaluations of the intervention in its current form on South Sudanese female refugees. CONCLUSIONS: We found that this potentially scalable, guided self-help intervention could be adapted for and feasibly implemented among female South Sudanese refugees in northern Uganda. These findings lay the groundwork for a future rigorous evaluation of SH+ in this context.

Self Help Plus: study protocol for a cluster-randomised controlled trial of guided self-help with South Sudanese refugee women in Uganda.

BACKGROUND: Exposure to armed conflict and forced displacement constitute significant risks for mental health. Existing evidence-based psychological interventions have limitations for scaling-up in low-resource humanitarian settings. The WHO has developed a guided self-help intervention, Self Help Plus (SH+), which is brief, implemented by non-specialists, and designed to be delivered to people with and without specific mental disorders. This paper outlines the study protocol for an evaluation of the SH+ intervention in northern Uganda, with South Sudanese refugee women. METHODS: A two-arm, single-blind cluster-randomised controlled trial will be conducted in 14 villages in Rhino Camp refugee settlement, with at least 588 women experiencing psychological distress. Villages will be randomly assigned to receive either SH+ with enhanced usual care (EUC), or EUC alone. SH+ is a five-session guided self-help intervention delivered in workshops with audio-recorded materials and accompanying pictorial guide. The primary outcome is reduction in overall psychological distress over time, with 3 months post-treatment as the primary end-point. Secondary outcomes are self-defined psychosocial concerns, depression and post-traumatic stress disorder symptoms, hazardous alcohol use, feelings of anger, interethnic relations, psychological flexibility, functional impairment and subjective wellbeing. Psychological flexibility is a hypothesised mediator, and past trauma history and intervention attendance will be explored as potential moderators. DISCUSSION: This trial will provide important information on the effectiveness of a scalable, guided self-help intervention for improving psychological health and wellbeing among people affected by adversity. TRIAL REGISTRATION: ISRCTN50148022; registered 13/03/2017.

Mental health and psychosocial wellbeing of Syrians affected by armed conflict.

AIMS: This paper is based on a report commissioned by the United Nations High Commissioner for Refugees, which aims to provide information on cultural aspects of mental health and psychosocial wellbeing relevant to care and support for Syrians affected by the crisis. This paper aims to inform mental health and psychosocial support (MHPSS) staff of the mental health and psychosocial wellbeing issues facing Syrians who are internally displaced and Syrian refugees. METHODS: We conducted a systematic literature search designed to capture clinical, social science and general literature examining the mental health of the Syrian population. The main medical, psychological and social sciences databases (e.g. Medline, PubMed, PsycInfo) were searched (until July 2015) in Arabic, English and French language sources. This search was supplemented with web-based searches in Arabic, English and French media, and in assessment reports and evaluations, by nongovernmental organisations, intergovernmental organisations and agencies of the United Nations. This search strategy should not be taken as a comprehensive review of all issues related to MHPSS of Syrians as some unpublished reports and evaluations were not reviewed. RESULTS: Conflict affected Syrians may experience a wide range of mental health problems including (1) exacerbations of pre-existing mental disorders; (2) new problems caused by conflict related violence, displacement and multiple losses; as well as (3) issues related to adaptation to the post-emergency context, for example living conditions in the countries of refuge. Some populations are particularly vulnerable such as men and women survivors of sexual or gender based violence, children who have experienced violence and exploitation and Syrians who are lesbian, gay, bisexual, transgender or intersex. Several factors influence access to MHPSS services including language barriers, stigma associated with seeking mental health care and the power dynamics of the helping relationship. Trust and collaboration can be maximised by ensuring a culturally safe environment, respectful of diversity and based on mutual respect, in which the perspectives of clients and their families can be carefully explored. CONCLUSIONS: Sociocultural knowledge and cultural competency can improve the design and delivery of interventions to promote mental health and psychosocial wellbeing of Syrians affected by armed conflict and displacement, both within Syria and in countries hosting refugees from Syria.

Mental health and psychosocial support in humanitarian emergencies.

Armed conflicts and natural disasters impact negatively on the mental health and well-being of affected populations in the short- and long-term and affect the care of people with pre-existing mental health conditions. This paper outlines specific actions for mental health and psychosocial support by the health sector in the preparedness, response and recovery phases of emergencies. Broad recommendations for ministries of health are to: (1) embed mental health and psychosocial support in national health and emergency preparedness plans; (2) put in place national guidelines, standards and supporting tools for the provision of mental health and psychosocial support during emergencies; (3) strengthen the capacity of health professionals to identify and manage priority mental disorders during emergencies; and (4) utilize opportunities generated by the emergency response to contribute to development of sustainable mental health-care services.

Mental health and psychosocial support in humanitarian emergencies

Armed conflicts and natural disasters impact negatively on the mental health and well-being of affected populations in the short- and long-term and affect the care of people with pre-existing mental health conditions. This paper outlines specific actions for mental health and psychosocial support by the health sector in the preparedness, response and recovery phases of emergencies. Broad recommendations for ministries of health are to: [1]embed mental health and psychosocial support in national health and emergency preparedness plans; [2]put in place national guidelines, standards and supporting tools for the provision of mental health and psychosocial support during emergencies; [3]strengthen the capacity of health professionals to identify and manage priority mental disorders during emergencies;and [4]utilize opportunities generated by the emergency response to contribute to development of sustainable mental health-care services

Les conflits armés et les catastrophes naturelles ont des répercussions négatives sur la santé mentale et le bien-être des populations touchées à court et long termes et affectent la prise en charge des personnes atteintes de troubles de santé mentale préexistants. Le présent article détaille les actions spécifiques en matière de santé mentale et de soutien psychosocial menées par le secteur de la santé dans les phases de préparation aux situations d'urgence, d'organisation des secours et de relèvement. Les recommandations générales destinées aux ministères de la Santé sont les suivantes: 1]intégrer la santé mentale et le soutien psychosocial dans les plans nationaux de santé et de préparation aux situations d'urgence ; 2]mettre en place des directives et des normes nationales, et des outils d'appui pour la santé mentale et le soutien psychosocial en situations d'urgence ; 3]renforcer les capacités des professionnels de santé à identifier et prendre en charge les troubles de santé mentale prioritaires en situations d'urgence ; et 4]exploiter les opportunités générées par la riposte aux situations d'urgence pour contribuer à la mise en place de services de soins de santé mentale pérennes

[The effectiveness of mental health care in developing countries. Intervention and policy options at several levels]. / De effectiviteit van de geestelijke gezondheidszorg in ontwikkelingslanden. Interventiemogelijkheden en beleidsopties op verschillende niveaus.

BACKGROUND: In developing countries psychiatric disorders are a major cause of disability and reduced economic productivity. AIM: To present an overview of intervention and policy options in mental health care in developing countries. METHOD: We searched the literature using PubMed, supplementing our finding with what we have learned from experience in the field. RESULTS: Research data, though very limited, indicate that psychiatric disorders can be treated effectively in developing countries. Mental health care can be provided at three different levels: at the level of the existing health care system, at primary care level and at community level. We discuss interventions at each of these levels on the basis of three cases. CONCLUSION: More research is needed into the efficacy and cost-effectiveness of mental health care interventions in developing countries; research must be accompanied by the actual implementation of mental health programmes in these countries.

Career perspectives of women and men medical students.

In spite of the increasing number of women medical students, in many specialties the number of women actually working as doctors still lags behind the number of men working in the same profession. To define factors contributing to this discrepancy 646 medical students at the Vrije Universiteit in Amsterdam were surveyed. A questionnaire was used to obtain information about the difference between women and men medical students concerning their outlook on a future career as combined with domestic responsibilities. The questionnaire covered the items motives and career preference, barriers to reaching the profession of first choice, career planning and the combination of domestic responsibilities and a medical career. The results of this survey indicate that there are still important differences between women and men students in career perspectives. These differences need attention from medical students as well as teaching staff.