from Evaluating Needs and Psychological Mechanisms to Culturally Sensitive Psychotherapy

The present habilitation project encompasses research on multiple and complex levels of mental health care preferences and expectations, support systems, psychological mechanisms, as well as novel and culturally sensitive treatment approaches for RAS who primarily stem from Arabic- and Farsi-speaking countries. Until today, there are still enormous mental health treatment gaps for RAS, regardless of the country of residence. The current investigations shed light on a variety of facets, including preferences and expectations on psychotherapy (Böge et al., 2021), the key role of perceived stress and social support on psychopathology (Böge et al., 2020), as well as the representation of symptoms and the influence of stigma in refugee populations (Lindheimer et al., 2020). Moreover, we could show that emotional regulation appears to be a vital psychological mechanism mediating the effect between early life stress and the development of psychiatric symptoms, suggesting a direction for personalized psychotherapeutic interventions in refugees (Demir et al., 2020). In a last step, we developed a novel stepped collaborative and care model, which proved the effectiveness and cost-effectiveness in alleviating depressive symptoms of adolescent and adult RAS compared to routine mental health care in Germany (Böge et al, 2022). Against this background, the outcomes of this habilitation project are relevant because they outline where cultural barriers lie, showcase possible ways of overcoming those and depict a suitable, scalable, and collaborative intervention approach. Our outcomes pave the way for resource-saving, cost-efficient, and tailored psychological interventions, specifically for humanitarian aid and international settings with low human and financial resources. In challenging times and impending decades, in which large-scale migration movements and pandemics significantly increase the relevance of global mental health, our findings are especially valuable. Consequently, outcomes of the present work make key contributions to and have implications and a meaningful influence on the immediate and long-term mental health and its provision for RAS worldwide

Multilevel assessment of public attitudes and stigma towards psychiatry and mental illness in Vietnam

The overall goal of this dissertation was to investigate the impact of public attitudes, perceptions and associated stigma towards psychiatry and mental illness on different societal levels in Vietnam. Currently, the mental health care infrastructure in Vietnam is on the verge of transformation, exhibiting the demand for access to effective and adequate mental health care services. Additionally, mental illness-related stigmatization and discrimination remain highly prevalent causing impairment in patients’ access to adequate, effective and reliable psychiatric care. Furthermore, public attitudes towards mental illness, as well as corresponding treatment options, influence help-seeking behaviours of patients and caregivers, ultimately affecting the course of the treatment. In Vietnam, depression and schizophrenia account for at least 75% of all psychiatric inpatients. The present study aims to assess public attitudes towards psychiatrists and treatment options for depression and schizophrenia in Vietnam. A secondary goal is to analyse the existing restrictions patients with a mental illness and the Vietnamese general publics’ desire for social distance from individuals labelled with a mental illness. To that end, for the first time in a Southeast Asian sample, socio-demographic factors will be included to explore their influence within the Vietnamese cultural context. The collected data stems from a general population-based survey that was carried out in the greater Hanoi area using self-report questionnaires. Data was stratified according to the latest Vietnamese census (2009) and micro-census (2013) with regards to socio-demographic factors. Respondents mostly endorsed evidence-based treatment recommendations, such as psychotherapy or psychotropic medication both for schizophrenia and depression. Moreover, negative attitudes towards psychiatrists were associated with religious beliefs and male gender among respondents, while public attitudes towards restrictions of mentally ill people were related to gender and age. Finally, three independent factors were found to influence perceptions regarding the course of mental illness. These include (1) loss of social integration and functioning, (2) lifelong dependency on others and (3) positive expectations towards treatment outcome, out of which two were associated with more desire for social distance. The results of this study will be interpreted in the context of the socio-cultural landscape in Vietnam and give insight into its role in help-seeking behaviour as well as any stigma associated with mental illness giving ground for developments in the mental health system and among care providers. Involving religious institutions in raising awareness about mental health issues while considering socio-cultural factors of the public might pave the way for adequate psychiatric care and destigmatize the mental health system.Das übergeordnete Ziel dieser Dissertationsschrift ist es, die Auswirkungen öffentlicher Einstellungen, Wahrnehmungen und die damit verbundenen Stigmata gegenüber Psychiatrien und psychischen Erkrankungen auf verschiedenen gesellschaftlichen Ebenen in Vietnam zu untersuchen. Derzeit steht die Infrastruktur der psychiatrischen Versorgung in Vietnam am Rande einer Transformation, bedingt durch eine steigende Nachfrage nach Zugang zu effektiven und angemessenen psychiatrischen Versorgungsdiensten. Nichtsdestotrotz sind Stigmatisierung und Diskriminierung im Zusammenhang mit psychischen Erkrankungen nach wie vor in weiten Teilen der Gesellschaft verbreitet und beeinträchtigen den Zugang der Patienten zu einer angebrachten, effektiven und zuverlässigen psychiatrischen Versorgung. Darüber hinaus beeinflusst die Einstellung der Öffentlichkeit gegenüber psychischen Erkrankungen und entsprechenden Behandlungsmöglichkeiten auch das Hilfesuchverhalten von Patienten und Pflegepersonal, was sich letztlich negativ auf den Behandlungsverlauf auswirkt. In Vietnam sind mindestens 75 % aller psychiatrischen stationären Aufenthalte auf Patienten mit Schizophrenien oder Depressionen verteilt. Die vorliegenden Studien zielen somit darauf ab, die öffentliche Einstellung gegenüber Psychiatern und Behandlungsmöglichkeiten bei Depressionen und Schizophrenie in Vietnam zu messen. Ein sekundäres Ziel ist es, bestehende soziale Restriktionen für psychisch Erkrankte sowie den Wunsch der vietnamesischen Bevölkerung nach sozialer Distanz zu Menschen mit psychischen Erkrankungen zu analysieren. Zu diesem Zweck werden erstmals in einer südostasiatischen Stichprobe soziodemographische Faktoren einbezogen um deren Einfluss eingebettet in den vietnamesischen kulturellen Kontext zu untersuchen. Die gesammelten Daten stammen aus einer allgemeinen bevölkerungsrepräsentativ stratifizierten Umfrage, die im Großraum Hanoi auf der Basis von Selbstbeurteilungsfragenbögen durchgeführt wurde. Die Daten wurden gemäß des letzten vietnamesischen Zensuses (2009) und des Mikrozensus (2013) in Bezug auf soziodemografische Faktoren stratifiziert. Die Befragten befürworteten größtenteils evidenzbasierte Behandlungsempfehlungen wie Psychotherapie oder pharmakologische Behandlungen zur Behandlung von Schizophrenie ebenso wie bei Depressionen. Darüber hinaus wurde ein Zusammenhang zwischen negativen Einstellungen gegenüber Psychiatern und religiösen Überzeugungen sowie männlichem Geschlecht festgestellt, während die öffentliche Einstellung gegenüber Einschränkungen für psychisch Erkrankte eher geschlechts- und altersbedingt war. Konklusiv wurden drei unabhängige Faktoren gefunden, die die Wahrnehmungen über den Verlauf einer psychischen Erkrankung beeinflussen: Dazu gehören (1) ein Verlust von sozialer Integration und Funktionalität, (2) eine erwartete lebenslange Abhängigkeit von Anderen und (3) positive Erwartungen an das Behandlungsergebnis, von denen die ersten zwei Faktoren mit einem stärkeren Wunsch nach sozialer Distanz verbunden waren. Die Ergebnisse dieser Studie werden im soziokulturellen Kontext Vietnams interpretiert und geben einen Einblick in ihre Rolle bei hilfesuchendem Verhalten sowie den vorherrschenden Stigmata gegenüber psychischen Erkrankungen. Darüber hinaus werden Implikationen für die Entwicklung im psychischen Gesundheits- und Pflegesystem in Vietnam diskutiert. Das Einbeziehen religiöser Institutionen und Praktiken hinsichtlich einer Sensibilisierung bezüglich Fragen der psychischen Gesundheit, im Kontext soziokultureller Faktoren der Öffentlichkeit, könnte einen Weg für eine adäquate psychiatrische Versorgung ebnen und die Inanspruchnahme des psychischen Gesundheitssystems langfristig entstigmatisieren

On Perceived Stress and Social Support: Depressive, Anxiety and Trauma-Related Symptoms in Arabic-Speaking Refugees in Jordan and Germany

Current literature points toward several challenges in the access to sufficient and effective psychosocial care for Syrian refugees in host settings. This study is a comparative investigation into the relationship between “perceived social stress” and “perceived social support” on three of the most prevalent symptom dimensions in Syrian refugees across two host capitals, Berlin and Amman. Eighty nine Syrians refugees were recruited between January 2017 and March 2018. Participants were contacted through local institutions and organizations collaborating with the Charité—Universitätsmedizin Berlin. Assessments include the PHQ-9, GAD-7, HTQ, MSPSS, and PSS. Primary analyses consist of non- or parametric tests and multiple linear regression analyses. Subsample analyses showed relevant depressive, anxiety and trauma-related symptoms. Significant differences in PTSD symptoms (p < 0.04) were found. Participants reported high perceived stress and moderate to high social support. Linear regressions revealed that perceived stress had a significant negative effect (p < 0.01) on clinical outcomes in both subsamples. Perceived social support had a positive influence on depressive (p = 0.02) and PTSD symptoms (p = 0.04) for participants in Berlin. Analyses revealed significant positive effects of “significant others” (p = 0.05) on depressive- in Berlin and “family” (p = 0.03) support for PTSD symptoms in Amman. Study results show that levels of “perceived stress” appear to be the same across different host countries, whereas types of social support and their effect onmental health differ significantly depending on the host setting. Outcomes may guide future comparative study designs and investigations to promote well-being, integration, and the development of effective social support structures for the diverse needs of Arabic-speaking refugees

Psychotherapy in Jordan: An Investigation of the Host and Syrian Refugee Community's Perspectives

Little is known about patient satisfaction, bias, stigma, and the effects of psychotherapy within the Kingdom of Jordan or the Arab world in general. The purpose of this study was to explore the perceptions of both the Jordanian host and refugee community members from the psychotherapeutic services offered at various mental health care settings in Jordan. A sample of 100 patients who received psychosocial expert interventions was recruited between October and December 2017 in Amman, Jordan. Participants were either from the host or Syrian refugee community or contacted through multiple organizations working in the mental health field. The Patient Satisfaction Questionnaire, which consists of four subscales covering 1) patient satisfaction, 2) bias toward therapy, 3) effects of therapy, and 4) stigma, was administered. As a means of investigation and exploration, descriptive statistics of participant responses are displayed. Results revealed overall high rates of satisfaction with provided services and perceived benefits of psychotherapeutic interventions. However, respondents showed ambivalence regarding bias and stigma. Subsample analyses indicated no significant differences between both communities. These findings give an understanding of perceptions surrounding psychotherapy in Jordan and some insights on therapeutic processes that may be useful for clinical applications and future research

Mechanisms of action and processes of yoga-based group intervention for inpatients with schizophrenia spectrum disorders–A longitudinal qualitative study

Background: Research exploring the effects of yoga therapy (YT) on individuals with schizophrenia spectrum disorders (SSD) is scarce. Therefore, the current study aimed to explore possible mechanisms of actions and processes, as well as adverse effects of a novel yoga-based group intervention (YoGI) for in-patients with SSD in a German university hospital setting. Material and methods: A longitudinal qualitative study was integrated into a rater-blinded randomized controlled trial, exploring the impact of a 4-week YoGI as add-on treatment. In-depth interviews were conducted with participants receiving YoGI (n = 19) in addition to treatment as usual (TAU) and a control group (n = 14) which only received TAU. Interviews were conducted at baseline (n = 33) and 4 weeks post-intervention (N = 28) to assess the participant's experiences and how they changed over time. The interviews (N = 61) were audio-taped, translated, coded, and analyzed by means of inductive thematic analysis. Separate case summaries were prepared for each participant to analyze longitudinal changes within subjects. The research team members collaboratively discussed the final list of themes and subcodes. Rater-based questionnaires, such as the Positive and Negative Syndrome Scale (PANSS), Calgary Depression Scale for Schizophrenia (CDSS), and Personal and Social Performance Scale (PSP) were administered at baseline to assess clinical outcomes. Results: At baseline, participants reported a desire to improve their stress- and symptom management. A minority of participants expressed reservations toward yoga, and several psychosocial barriers were named, including worries about symptom exacerbation. At post-intervention, four mechanisms of change became evident from the interviews: (1) acquiring competence in relaxation, (2) increased interoceptive awareness, (3) feeling connected, and (4) a sense of spiritual wellbeing. A small number of participants reported difficulties with YoGI. Conclusion: Generally, YoGI positively influenced participants' experiences of their inpatient stay, regarding distress, self- and body awareness, social connectedness, and spiritual wellbeing. However, participants also illuminated necessary adjustments to improve the intervention. YoGI will therefore be adapted and further developed in an iterative process based on a participant involvement approach. The efficacy regarding outcomes and processes needs to be investigated in a future larger-scaled randomized controlled trial

Development of a culturally sensitive Arabic version of the Mini International Neuropsychiatric Interview (M.I.N.I.-AR) and validation of the depression module

Background: Arabic represents one of the most frequently spoken languages worldwide, especially among refugee populations. There is a pressing need for specialized diagnostic tools corresponding to the DSM-5 criteria in Modern Standard Arabic, which can be administered on Arabic speakers in the West and Arab region alike. Objectives: To develop and validate the culturally-adapted version of the most recent M.I.N.I. 7.0.2 into Modern Standard Arabic-a form of Arabic commonly used across all Arab countries. Methods: 102 participants were recruited between April 2019 to March 2020 at the Charite - Universitatsmedizin in Berlin. Symptoms were assessed with Arabic versions of rater-based and self-rated measures, including Mini International Neuropsychiatric Interview (M.I.N.I.), Patient Health Questionnaire (PHQ-9), and Harvard Trauma Questionnaire (HTQ). Arabic-speaking psychiatrists saw participants for diagnostic assessment. Results: Cohen's kappa (kappa) values were moderate for major depression, and slight for post-traumatic stress disorder, as well as generalized anxiety disorder. Moreover, kappa values indicated moderate agreement between M.I.N.I.-AR and PHQ-9 for depression, as well as HTQ for post-traumatic stress disorder, respectively. Conclusion: The translated and culturally adapted version of the M.I.N.I. addresses an existing need for a reliable, efficient, and effective comprehensive diagnostic tool using the most recent DSM-5 criteria in Modern Standard Arabic (MSA). Based on the obtained results, only a validation of the depression module (Module A) of the M.I.N.I-AR was possible. Study outcomes also show evidence for the validation of Module H covering Post-Traumatic Stress Disorder. Potential valuable contributions can be extended to this translation and validation

Exploring the Representation of Depressive Symptoms and the Influence of Stigma in Arabic-Speaking Refugee Outpatients

The number of distressed refugees from the Arab world is relatively high in Germany and other host countries worldwide. For this specific population, substantial challenges and barriers have already been identified that hamper access to Germany's health care system. This study aims to contribute to this line of research by exploring the representation of depressive symptoms, both somatic and psychological, in order to inform clinicians about the most prevalent symptoms reported by Arabic-speaking refugee outpatients. Furthermore, this paper investigates the longstanding claim that mental health stigma fosters the expression of bodily distress. For these purposes, a total of 100 Arabic-speaking refugee outpatients, mostly Syrians, were recruited in Berlin, Germany. Somatic and psychological symptoms were assessed with the Patient Health Questionnaire (PHQ) 15 and 9, while stigma was assessed with the Brief Version of the Internalized Stigma of Mental Illness Scale (ISMI-10). Study results show that both somatic and psychological symptom severity was moderate while sleeping problems and energy loss were the most reported symptoms across both scales. Stigma was low and showed no association with somatic complaints in a multiple regression analysis, but was associated with more psychological symptoms. A principal factor extraction on the PHQ-15 items revealed five independent, somatic symptom clusters that were interpreted considering the rich poetic resources of the Arabic language. In conclusion, both somatic and psychological symptoms were commonly reported by Arabic-speaking refugees with symptoms of depression. Whereas, stigma does not seem to influence the expression of somatic symptoms, the present results provide first empirical indications for the relationship of symptom expression with the use of explanatory models and conceptualizations of mental illness within the Arabic culture and language. Future research efforts should be dedicated to enhancing our understanding of mental health care needs in this population as well as to exploring other mediators that might help explain the varying degree of somatic symptoms in depression across cultures

Prevalence, predictors and types of unpleasant and adverse effects of meditation in regular meditators: international cross-sectional study

Background: Meditation is commonly implemented in psychological therapies since the ‘third wave’ of cognitive–behavioural therapy has increased the focus on mindfulness-based interventions. Although extensive research literature demonstrates its benefits, little is known about potential adverse effects. Aims: The aim of this study is to report the prevalence, type and severity of particularly unpleasant meditation-related experiences in the largest cross-sectional study on this topic to date, with 1370 regular meditators. Method: The participants were asked whether they ever encountered particularly unpleasant experiences as a result of their meditation experience. For the first time, the type and severity of those experiences were assessed and the association with several predictors, such as pre-existing mental disorders, were explored via logistic and linear regression. Results: Similar to previous studies, 22% of participants (95% CI 20–24) reported having encountered unpleasant meditation-related experiences, and 13% of participants (95% CI 3–5) reported experiences that were categorised as adverse. Those were mostly of affective, somatic and cognitive nature. Unpleasant meditation-related experiences were more likely to occur in participants with pre-existing mental illnesses (P = 0.000, 95% CI 1.25–2.12). Conclusions: This study demonstrates that unpleasant meditation-related experiences are prevalent among meditators and, to a relevant extent, severe enough to warrant further scientific inquiry. Longitudinal studies are needed to examine whether the unpleasant meditation-related experiences are merely negative and thus should be avoided, or are an inherent part of the contemplative path

Compassion-based approaches:a systematic review of their effectiveness and acceptability in schizophrenia spectrum disorders

The purpose of this systematic literature review is to provide an exhaustive summary of current research to explore the prospects of compassion-based approaches in treating persons with Schizophrenia Spectrum Disorders (SSD). Thereby, studies investigating the relationship between clinical parameters and self-compassion in SSD, as well as the acceptability, feasibility, and effects of compassion-based approaches for individuals with SSD were considered. The review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and checklist. Eight studies were included for qualitative synthesis. The results indicate an important role of self-compassion for several clinical parameters, including negative associations to positive symptoms, negative symptoms, cognitive disorganization, and emotional distress. All studies reported good acceptability and feasibility. Regarding the clinical effectiveness of compassion-based approaches, a variety of clinical benefits, such as improvements of mood, affect regulation, positive symptoms, negative symptoms, cognitive disorganization, and variables relating to psychological recovery were found in individuals with SSD. It is concluded that compassion-based approaches are a promising form of intervention in the treatment of SSD. However, further research, especially randomized controlled trials, in this field is needed to understand the full potential of compassion-based approaches for individuals with SSD.</p

Mindfulness-Based Interventions for In-Patients With Schizophrenia Spectrum Disorders-A Qualitative Approach

In recent years, mindfulness-based interventions (MBI) have gained clinical relevance in the treatment of patients with schizophrenia spectrum disorders (SSDs). High symptom burden, long durations of hospitalization and high rehospitalization rates demonstrate the severity and cost-intensity of these disorders. MBIs have shown promising treatment outcomes in a small number of trials, primarily taking place in English-speaking countries. The current study aims to explore mechanisms and processes as well as adverse effects of MBIs on in-patients with SSDs in a German university hospital setting. A qualitative design based on inductive thematic analysis accompanied by quantitative assessments was chosen. A semi-structured interview guide was developed by psychiatrists and psychologists to assess patient experiences, perceptions, thoughts, and feelings during and after taking part in a MBI. Twenty-seven interviews were conducted between September 2017 and October 2018 with in-patients who are diagnosed with schizophrenia or schizoaffective disorder. Rater-based questionnaires, such as the Positive and Negative Syndrome Scale (PANSS), Montgomery Asberg Depression Rating Scale (MADRS), and Psychotic Symptom Rating Scales-Auditory Hallucination (PSYRATS-AH) were administered at baseline to collect clinical outcomes. Qualitative analysis revealed two domains: content and function. In the first domain related to content with the core elements "detachment and rumination", "presence and getting lost", "non-judgment and judgment", and effects with "emotions", "cognition", and "symptom changes". A second domain related to function was extracted, including the relevance of perception of context and transfer to everyday life. Overall, improvements concerning cognition, distress, and psychopathology were detected, while no adverse effects, such as increased psychotic symptoms, were revealed. As the first study of its kind, mechanisms, processes, and the safety of MBIs were explored and confirmed in a sample of German in-patients with SSDs. The results of this qualitative study are in line with recent findings on MBIs amongst patients with psychotic disorders from other countries. Results lay the ground for future research to focus on the systematic study of MBIs in large samples, its treatment processes, outcomes, and effectiveness for in-patients with SSDs