Course of Mental Health in Refugees—A One Year Panel Survey

Background: Cross-sectional studies indicate that a substantial proportion of refugees have psychiatric disorders. However, longitudinal studies on the course of psychiatric symptoms and on influencing factors are scarce. The current study investigates the development of symptoms in an untreated refugee sample in Germany and seeks to identify potential predictors.Methods: Over the course of 1 year, 57 refugees participated in monthly assisted self-reports on the phone assessing emotional distress. At the same time, semi-annual, semi-structured clinical interviews focusing on posttraumatic stress disorder (PTSD) and depression were conducted. The overall dropout rate for the year was 23% for the assisted self-reports and 33% for the clinical interviews.Results: Symptoms did not systematically change over the course of the year. On the individual level, a reliable change in PTSD symptoms was observed in 13% who showed improvement and 24% who showed worsening symptoms. Figures for depression symptoms were 24 and 16% respectively. A higher number of traumatic experiences was related to a greater intensity of PTSD symptoms. In addition, postmigrational stressors were associated with a worsening of PTSD symptoms over the course of the year. Emotional distress was associated with current negative life events, unemployment, and frequent visits to physicians.Conclusions: There is on average no improvement or worsening of symptoms over the period of 1 year. However, individual courses vary, and thus show the importance of risk factors. Accordingly, the identification of risk factors such as trauma load and postmigrational stressors can be useful to determine the need of further monitoring and to provide appropriate interventions when necessary

MyosinVIIa Interacts with Twinfilin-2 at the Tips of Mechanosensory Stereocilia in the Inner Ear

In vertebrates hearing is dependent upon the microvilli-like mechanosensory stereocilia and their length gradation. The staircase-like organization of the stereocilia bundle is dynamically maintained by variable actin turnover rates. Two unconventional myosins were previously implicated in stereocilia length regulation but the mechanisms of their action remain unknown. MyosinXVa is expressed in stereocilia tips at levels proportional to stereocilia length and its absence produces staircase-like bundles of very short stereocilia. MyosinVIIa localizes to the tips of the shorter stereocilia within bundles, and when absent, the stereocilia are abnormally long. We show here that myosinVIIa interacts with twinfilin-2, an actin binding protein, which inhibits actin polymerization at the barbed end of the filament, and that twinfilin localization in stereocilia overlaps with myosinVIIa. Exogenous expression of myosinVIIa in fibroblasts results in a reduced number of filopodia and promotes accumulation of twinfilin-2 at the filopodia tips. We hypothesize that the newly described interaction between myosinVIIa and twinfilin-2 is responsible for the establishment and maintenance of slower rates of actin turnover in shorter stereocilia, and that interplay between complexes of myosinVIIa/twinfilin-2 and myosinXVa/whirlin is responsible for stereocilia length gradation within the bundle staircase

Mental health of refugees : addressing and overcoming challenges in the identification and treatment of mental health problems

The ever-increasing numbers of refugees worldwide present mental health care systems with major challenges (Schauer, 2016; Silove, Ventevogel, & Rees, 2017; United Nations High Commissioner for Refugees [UNHCR], 2018). Mental health disorders such as posttraumatic stress disorder (PTSD), depression, and anxiety are highly prevalent in refugees, but only few have access to mental health care (e.g. Nickerson et al., 2017; Porter & Haslam, 2005). Researchers and stakeholders call for an improvement in mental health care for refugees in order to reduce the mental health burden and thereby facilitate integration in the host communities (Giacco & Priebe, 2018; Nationale Akademie der Wissenschaften Leopoldina [Leopoldina; National academy of sciences Leopoldina], 2018; Schneider, Bajbouj, & Heinz, 2017). For this, an appropriate and timely identification and treatment of mental health disorders is vital. However, at this point in time, research on an efficient identification of mental health problems for the current refugee populations in Europe is scarce. Treatment options for PTSD are available with good evidence for the effectiveness of exposure-based therapy approaches (Nosè et al., 2017; Thompson, Vidgen, & Roberts, 2018), yet such approaches are rarely used in practice due to therapists’ concerns regarding symptom aggravation and dropout. Moreover, preventive interventions reducing additional stressors and traumatic experiences such as child maltreatment are essential in affected populations worldwide.The present thesis addresses the challenge of identifying and treating mental health problems in refugees and aims to close some of the current research gaps of this field to contribute to a better provision of care. The following objectives will be addressed in detail: (1) to assess the extent of mental health problems in a sample of refugees in Germany as well as to examine the feasibility, validity, and reliability of the mental health screening instrument Refugee Health Screener (RHS; Hollifield et al., 2013) as a self-rating and interview instrument; (2) to analyze the course of mental health symptoms in refugees not undergoing psychological treatment over one year and to find influencing factors; (3) to investigate PTSD symptom trajectories of refugees receiving trauma-focused therapy, namely Narrative Exposure Therapy (NET), as well as the influence of imaginal exposure to traumatic experiences and of therapy-unrelated life events; (4) to examine the feasibility of the preventive approach Interaction Competencies with Children (ICC) which aims to reduce violent disciplining in highly burdened populations – tested on a sample of Tanzanian teachers inflicting corporal punishment on a regular basis.Article 1 found mental health problems to be prevalent in a refugee sample in Germany, with clinically significant PTSD, depression, anxiety, and somatization symptoms being present in 35% of the same population. Furthermore, article 1 shows a good feasibility, validity, and reliability of the RHS in detecting common mental health problems for refugees residing in Germany. A shorter version, the RHS-13, shows equally good psychometric properties and is easier to administer. In addition, the RHS can be used both as a self-rating and an interview instrument.In article 2 the course of mental health symptoms in refugees was examined by combining monthly assisted self-reports on the phone with half-yearly clinical interviews. Over the course of one year, the average of symptoms did not systematically change. However, on the individual level, about 40% showed a significant symptom improvement or worsening. Higher PTSD symptoms were related to more experiences of past traumatic stress, while a worsening of PTSD symptoms over time was associated with reporting more current postmigrational stressors (PMS). Furthermore, current emotional distress was associated with negative life events, unemployment, and frequent visits to physicians.Article 3 analyzed symptom trajectories during NET on the basis of the PTSD Checklist, which was filled in before each therapy session as well as during follow-up interviews. Overall, symptoms decreased during and after treatment – with some showing fast (27%), slow (31%), or no immediate symptom response (42%) during therapy. Persistent symptom worsening was not observed. Imaginal exposure to the most distressing traumatic experiences was not associated with symptom aggravation. However, therapy-unrelated negative life events were related to increases in PTSD symptoms.Aiming to reduce additional ongoing and potentially traumatic stressors that could contribute to a high trauma load, article 4 describes the preventive approach ICC which intends to reduce violent disciplining. This approach was tested on a Tanzanian teacher sample, showing a good feasibility and acceptance despite challenging conditions. Future studies should test adapted versions in other affected populations such as refugee families.The current thesis highlights the need to provide better care for refugees presenting mental health problems. It further discusses a potential mental health care model by incorporating the findings of this thesis into the currently suggested scalable care approaches (Adorjan et al., 2017; Elbert, Wilker, Schauer, & Neuner, 2017; Leopoldina, 2018; Schneider, Bajbouj, & Heinz, 2017). Given that mental health problems in refugees are prevalent and often persistent, we recommend the inclusion of a mental health screening, such as the RHS for all refugees. Refugees with a positive screening result should be referred to appropriate mental health services, which can range from low-threshold interventions conducted by supervised peer counselors up to specialized mental health professionals for those with a complex symptomatology. The collaboration with other professionals working with refugees such as medical staff, social workers, teachers, and potentially also volunteers should be strengthened to identify mental health problems that arise at later stages and warrant a timely referral. Furthermore, training centers that offer qualifications, training, and regular supervision for the different actors within such a care system are vital to provide good care. Training for evidence-based treatments for PTSD such as NET should be offered, with therapists’ concerns of symptom aggravation and dropout being addressed and resolved. Such an integrative mental health care model has not yet been tested nor been implemented into the mental health care system – future studies should accordingly examine its feasibility and efficacy with the aim to reduce the mental health burden of refugees in order to improve their quality of life and functionality, thereby facilitating integration.publishe

Improving care quality and preventing maltreatment in institutional care – a feasibility study with caregivers

Hermenau K, Kaltenbach E, Mkinga G, Hecker T. Improving care quality and preventing maltreatment in institutional care – a feasibility study with caregivers. Frontiers in Psychology. 2015;6:937

A systematic review of socio-ecological factors contributing to risk and protection of the mental health of refugee children and adolescents

Scharpf F, Kaltenbach E, Nickerson A, Hecker T. A systematic review of socio-ecological factors contributing to risk and protection of the mental health of refugee children and adolescents. Clinical Psychology Review. 2020;83: 101930

Improving Interaction Competencies With Children—A Pilot Feasibility Study to Reduce School Corporal Punishment

Kaltenbach E, Hermenau K, Nkuba M, Gößmann K, Hecker T. Improving Interaction Competencies With Children—A Pilot Feasibility Study to Reduce School Corporal Punishment. Journal of Aggression, Maltreatment & Trauma. 2018;27(1):35-53

Efficient identification of mental health problems in refugees in Germany: the Refugee Health Screener

Background: A substantial number of refugees present with mental disorders. This appears particularly acute in the currently increasing refugee populations in Europe. Although EU guidelines demand the identification and support of vulnerable individuals such as survivors of trauma, no adequately validated and comprehensive mental health screening instruments for refugees residing in Europe currently exist. Objective: We studied the feasibility, validity, and reliability of the Refugee Health Screener-15 (RHS-15) – a time-efficient and easy-to-implement screening developed by Hollifield et al. (2013) – as a self-rating and interview instrument. Methods: A sample of refugees from different countries (N = 86), representative of those who had arrived around the turn of the year 2015/2016 in Germany, filled in the RHS-15 on their own. A semi-structured clinical interview was later conducted with a random subsample (n = 56). Results: Fifty-two percent of the refugees examined screened positive in the RHS-15, thus indicating current mental health problems. The RHS-15 showed a good feasibility, reliability, and validity in both the self-rating and the interview version. It detected clinically relevant mental health problems when PTSD, depression, anxiety, or somatization problems were present. A shorter 13-item version proved to be equally valid. Conclusions: Together with previous research on the RHS in refugees living in the US, this suggests that the RHS is a time-efficient and accurate instrument that is able to detect common mental health problems in a wide range of refugees. Prospectively, the RHS could be used as an instrument for identifying vulnerable refugees, for example, by integrating it in the initial medical examination in the host community, thereby initiating support

Improving Interaction Competencies With Children : A Pilot Feasibility Study to Reduce School Corporal Punishment

High prevalence rates of corporal punishment in schools worldwide and the associated negative mental health issues show the need for interventions addressing this problem. Yet, so far there are very few intervention studies aimed at altering corporal punishment administered by teachers, particularly in low- or middle-income countries. To conduct a feasibility study of the newly developed intervention approach, Interaction Competencies with Children for Teachers (ICC-T)—a training workshop designed to prevent corporal punishment and improve the teacher-student relationship. The 1-week ICC-T intervention was conducted with 30 teachers in a Tanzanian primary school. Participants filled out a survey before, directly after, and 3 months following the intervention. The widespread use of corporal punishment indicated strong demand for a preventive intervention. The feasibility of ICC-T was good: Despite challenging conditions, implementation of the training and participants’ acceptance was high. Further, participants reported a good integration of the training’s core elements in their daily working routine, improvements in the teacher-student relationships, and in the students’ behavior. ICC-T shows a promising feasibility in the Tanzanian teacher sample. These encouraging results highlight the need for further studies testing the efficacy, sustainability, and effects of ICC-T on the students’ well-being.publishe

Trajectories of posttraumatic stress symptoms during and after Narrative Exposure Therapy (NET) in refugees

BackgroundTrauma-focused therapy approaches are recommended as treatment for posttraumatic stress disorder (PTSD). This includes the treatment of trauma-related suffering in refugee populations. However, there is a lack of knowledge about symptom trajectories in refugees living in volatile conditions. This has led to fear of “retraumatisation” and general skepticism in clinicians concerning the use of exposure therapy.MethodsTo test the relevance of this concern, we investigated PTSD symptom trajectories and potentially influencing factors during the course of Narrative Exposure Therapy (NET) in a refugee sample living in Germany. Refugees filled out the PTSD Checklist prior to each treatment session and also during follow-up interviews. Therapists continuously documented positive and negative life events as well as the content of the treatment sessions. Additionally, structured clinical interviews were conducted pre-treatment and at follow-up time points.ResultsOn average, clients presented with substantial decreases in PTSD symptoms already during and after NET. However, symptom trajectories differed and ranged from fast responders to slow responders to no immediate response during treatment. Importantly, a persistent worsening of symptoms was not observed, also not after exposure to the most distressing events. In contrast, stressful life experiences seemed to aggravate PTSD symptoms.ConclusionsConsistent with earlier studies, NET leads to clinically and behaviorally relevant reductions in PTSD symptoms both throughout and following treatment in refugees living in volatile conditions. Concerns about imaginal exposure in refugees were not substantiated. While stressful life events contributed to transient symptom increases, they weren’t found to prevent the overall effectiveness of NET.publishe

Terapia de exposición narrativa en línea para padres de niños con discapacidades del neurodesarrollo que padecen de síntomas de estrés postraumático : Protocolo de estudio de un ensayo clínico aleatorizado

BackgroundParents of children with intellectual and neurodevelopmental disorders (IDD) often experience traumatic events in the care of their children. This leads to comparatively high numbers of mental health problems such as posttraumatic stress disorder (PTSD) in those parents. Intervention approaches for parents of children with IDD are scarce and many parents remain without support.ObjectiveThis study aims to test the feasibility and efficacy of online Narrative Exposure Therapy (eNET) with parents of children with IDD.MethodsThe study follows a randomized waitlist-control design. eNET is an exposure-based PTSD intervention and includes 8–12 90-minute sessions. All sessions will be conducted via video calls with trained paraprofessionals. We aim to include 50 parents, approximately 25 in the immediate intervention group and 25 in the waitlist group. Waitlist participants will receive the same intervention after a three-month wait period. All participants need to either fulfill full or subclinical PTSD symptoms according to DSM-5. Feasibility and efficacy of the intervention will be measured with pre, post, and 2 and 6 months follow-up surveys focusing on PTSD symptoms. Secondary outcomes include other health-related outcomes such as physical symptoms, depression symptoms, anxiety symptoms and functionality.ConclusionsThe proposed study allows us to test the feasibility and efficacy of eNET in a sample of parents of children with IDD. There are so far no published studies on the evidence of eNET; this study is one of the first randomized controlled trials investigating the feasibility and efficacy of eNET and therefore will have implications on further research and practice.publishe