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