Mental Health and Quality of Life Among Individuals in Asylum Accommodations : Screening and Intervention

Refugees have often experienced traumatic events that could be classified as disasters before leaving their home countries. They are further distressed by difficult experiences while in flight and after reaching the new country. Since the experience of traumatic events is associated with an increased risk of subsequent mental health problems, recommendations regarding psychosocial support after disasters have been established. Two examples are the screen and treat approach, and active monitoring. According to these recommendations, individuals who have experienced a disaster ought to be screened for mental health problems one month after the disaster, and those with persisting symptoms of distress should be offered treatment.  The general aim of this thesis is to assess the possibility and appropriateness of applying a screen and treat approach to the mental health of refugees. Four studies are included in the thesis. The first study assessed the mental health and quality of life among individuals living in refugee housing facilities in Sweden. The results showed that the prevalence of symptoms of anxiety, depression and PTSD was high, and that the included participants rated their quality of life as low. Individuals without residence permits generally had worse outcomes than those who had received a residence permit. In the second study, the ability of the Refugee Health Screener (RHS, an instrument developed for assessment of emotional distress among newly arrived refugees) to distinguish between different levels of symptom severity was assessed. By comparing the scores on the RHS with scores on other established scales with cutoffs indicating symptom severity, we identified cutoff values for mild, moderate, and severe distress. In the third study, these cutoffs were further assessed by an investigation of the association between suicidal ideation and symptom severity. The odds of an individual having suicidal ideation increased notably at each severity level. More than half of the individuals with severe distress had suicidal ideation, indicating that they needed support. The fourth study is a pilot study assessing potential effectiveness, acceptability and feasibility of a group psychoeducational intervention delivered at asylum accommodations. The results showed that the intervention was promising in alleviating symptoms of distress and insomnia. It also seemed to be acceptable to both participants and staff, even though some sessions require further elaboration. To deliver the intervention in the midst of the asylum process was demanding, but feasible. This was an early evaluation but shows that the transition to an RCT is reasonable.  Taken together, the results of the four studies indicate that the mental health needs among newly arrived refugees are considerable, that the RHS can be used to identify individuals with differing needs of mental health care, and that high levels of distress are associated with suicidal ideation. The results also indicate that it is possible and meaningful to provide psychosocial interventions to individuals at asylum accommodations. This indicates that it could be possible to implement a screen and treat approach to the mental health of refugees. However, if access to treatment cannot be assured, only implementing the screening would neither be ethical nor appropriate.  Delfinansierad av Asyl, migration och integrationsfonden (AMIF)</p

A Pilot Study of a Psychoeducational Group Intervention Delivered at Asylum Accommodation Centers—A Mixed Methods Approach

Asylum seekers suffer high levels of distress but have restricted access to mental health care. This paper constitutes an evaluation of a psycho-educational group intervention, called AMIN, which was provided at two asylum accommodation centers in Sweden. A mixed-methods approach was used. To assess potential effectiveness, acceptability, and feasibility, quantitative outcome measures were combined with qualitative information from interviews with both intervention participants and staff providing the intervention. Potential effectiveness in reducing symptoms of distress and insomnia and in increasing physical quality of life was found, even though the intervention participants suffered from more severe distress than expected. In general, the intervention seemed to be acceptable to both participants and staff, with concrete strategies seeming more meaningful than abstract psychological techniques. Finally, regardless of the asylum process itself being a complicating factor, the intervention seemed feasible to deliver to individuals with different backgrounds and conditions. Taken together, these results indicate that some sessions may need further elaboration, but also that the transition to a randomized control trial is reasonable

Suicidal Ideation and Severity of Distress among Refugees Residing in Asylum Accommodations in Sweden

Refugees worldwide suffer high levels of distress and are at increased risk for death by suicide. The Refugee Health Screener (RHS) was developed to screen for emotional distress among refugees and can be used to assess distress severity. This paper examines the association between distress severity and suicidal ideation in a sample of refugees residing in asylum accommodations. Data from the RHS and item 9 on the Patient Health Questionnaire-9 (PHQ-9) was analyzed. Results showed that individuals at moderate and severe levels of distress were much more likely to exhibit suicidal ideation than individuals with low levels of distress. Even though we cannot conclude that individuals with low levels of distress do not have thoughts of ending their lives, further suicide assessment is warranted in asylum seekers with moderate to severe distress on the RHS

Suicidal ideation and severity of distress among refugees residing in asylum accommodations in Sweden

Refugees worldwide suffer high levels of distress and are at increased risk for death by suicide. The Refugee Health Screener (RHS) was developed to screen for emotional distress among refugees and can be used to assess distress severity. This paper examines the association between distress severity and suicidal ideation in a sample of refugees residing in asylum accommodations. Data from the RHS and item 9 on the Patient Health Questionnaire-9 (PHQ-9) was analyzed. Results showed that individuals at moderate and severe levels of distress were much more likely to exhibit suicidal ideation than individuals with low levels of distress. Even though we cannot conclude that individuals with low levels of distress do not have thoughts of ending their lives, further suicide assessment is warranted in asylum seekers with moderate to severe distress on the RHS.

A Pilot Study of a Psychoeducational Group Intervention Delivered at Asylum Accommodation Centers-A Mixed Methods Approach

Asylum seekers suffer high levels of distress but have restricted access to mental health care. This paper constitutes an evaluation of a psycho-educational group intervention, called AMIN, which was provided at two asylum accommodation centers in Sweden. A mixed-methods approach was used. To assess potential effectiveness, acceptability, and feasibility, quantitative outcome measures were combined with qualitative information from interviews with both intervention participants and staff providing the intervention. Potential effectiveness in reducing symptoms of distress and insomnia and in increasing physical quality of life was found, even though the intervention participants suffered from more severe distress than expected. In general, the intervention seemed to be acceptable to both participants and staff, with concrete strategies seeming more meaningful than abstract psychological techniques. Finally, regardless of the asylum process itself being a complicating factor, the intervention seemed feasible to deliver to individuals with different backgrounds and conditions. Taken together, these results indicate that some sessions may need further elaboration, but also that the transition to a randomized control trial is reasonable

Assessing Severity of Psychological Distress Among Refugees With the Refugee Health Screener, 13-Item Version

The recent inflow of refugees to Sweden has put pressure on health care as well as revealing a need for methods regarding assessment of refugees' mental health status. The present study investigated the use of the Refugee Health Screener (RHS; Hollifield et al., 2013) to distinguish among severity levels of symptoms of psychological distress in refugees. Refugees residing in asylum accommodations (n = 510) were screened with RHS-13, together with screeners for depression, anxiety, and posttraumatic stress disorder (PTSD). Risk for mild, moderate, or severe levels of depression, anxiety, or/and PTSD was used as screening proxy. Receiver operating characteristic analysis rendered cutoff scores of 11, 18, and 25, for mild, moderate, and severe symptoms, respectively. Evaluated against each symptom scale separately, cutoffs performed well. Cutoff 11, previously identified by Hollifield et al. (2016), was also confirmed. However, utilization of additional cutoffs could improve refugee mental health by guiding clinical decision making

An online tiered screening procedure to identify mental health problems among refugees

Background: Many refugees suffer from mental health problems due to stressful and traumatic events before, during, and after migration. However, refugees are facing a wide variety of barriers, limiting their access to mental health care. Internet-based tools, available in several languages, could be one way to increase the availability of mental health services for refugees. The present study aimed to develop and test a screening tool to screen for clinically relevant symptoms of psychiatric disorders common among refugees (i.e. Depression, Anxiety, Post-traumatic stress disorder, and Insomnia). We, designed, translated, and adapted an internet-based tiered screening procedure suitable for use with the largest refugee populations residing in Sweden. The tool aims to accurately identify symptoms of mental distress (Tier 1), differentiate between symptoms of specific psychiatric disorders (Tier 2), and assess symptom severity (Tier 3). We tested the overall efficiency of using a tiered screening procedure.Methods: Seven hundred fifty-seven refugees residing in Sweden, speaking any of the languages Arabic, Dari, Farsi, English, or Swedish, completed an online questionnaire following a three-tiered procedure with screening instruments for each tier. In this study, the Tier 3 scales were used as reference standards for clinically relevant symptoms, to evaluate screening efficiency in terms of accuracy and reduction of item burden in previous tiers.Results: The results show that the tiered procedure could reduce the item burden while maintaining high accuracy, with up to 86% correctly assessed symptoms and few false negatives with moderate symptoms and above (at most 9%), and very few with severe symptoms (at most 1.3%).Discussion: This study generated an accurate screening tool that efficiently identifies clinically relevant symptoms of common psychiatric disorders among refugees. Using an adapted online tiered procedure to screen for multiple mental health issues among refugees has the potential to facilitate screening and increase access to mental health services for refugees. We discuss the utility of the screening tool and the necessity of further evaluation

Feasibility of a randomised trial of Teaching Recovery Techniques (TRT) with refugee youth : results from a pilot of the Swedish UnaccomPanied yOuth Refugee Trial (SUPpORT)

Background Although post-traumatic stress is prevalent among unaccompanied refugee minors (URM), there are few evidence-based psychological interventions for this group. Teaching Recovery Techniques (TRT) is a brief, manualised intervention for trauma-exposed youth, which has shown promising results in exploratory studies. The aim of the present study was to assess the feasibility of conducting a randomised controlled trial (RCT) evaluating the use of TRT among URM by investigating key uncertainties relating to recruitment, randomisation, intervention delivery and data collection. Methods A 3-month long non-blinded internal randomised pilot trial with a parallel-group design assessed the feasibility of a planned nationwide multi-site RCT. URM with or without granted asylum were eligible if they were 14 to 20 years old, had arrived in Sweden within the last 5 years and had screened positive for symptoms of post-traumatic stress disorder (PTSD). Quantitative data were collected pre- and post-intervention, and 18 weeks after randomisation. On-site individual randomisation (1:1) followed directly after pre-intervention assessment. Participants allocated to the intervention were offered seven weekly group-based TRT sessions. Quantitative pilot outcomes were analysed using descriptive statistics. Qualitative information was gathered through on-site observations and follow-up dialogue with group facilitators. A process for Decision-making after Pilot and feasibility Trials (ADePT) was used to support systematic decision-making in moving forward with the trial. Results Fifteen URM (mean age 17.73 years) with PTSD symptoms were recruited at two sites. Three of the youths were successfully randomised to either TRT or waitlist control (TRT n = 2, waitlist n = 1). Fourteen participants were offered TRT for ethical reasons, despite not being randomised. Six (43%) attended ≥ 4 of the seven sessions. Seventy-three percent of the participants completed at least two assessments, with a response rate of 53% at both post-intervention and follow-up. Conclusions The findings demonstrated a need for amendments to the protocol, especially with regard to the procedures for recruitment and randomisation. Upon refinement of the study protocol and strategies, an adequately powered RCT was pursued, with data from this pilot study excluded