Research Project: Refugee Emergency: DEFining and Implementing Novel Evidence-based psychosocial interventions
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Contributors
Funders
ID
EC.00123
Authors
Acartürk, Ceren
Faculty Member
Publications
Long-term effectiveness of Self-Help Plus in refugees and asylum seekers resettled in Western Europe: 12-month outcomes of a randomised controlled trial
(Cambridge University Press (CUP), 2022) Acartürk, Ceren; Turrini, G.; Purgato, M.; Tedeschi, F.; Anttila, M.; Au, T.; Carswell, K.; Churchill, R.; Cuijpers, P.; Friedrich, F.; Gastaldon, C.; Klein, T.; Kosters, M.; Lantta, T.; Nose, M.; Ostuzzi, G.; Papola, D.; Popa, M.; Sijbrandij, M.; Tarsitani, L.; Todini, L.; Uygun, E.; Valimaki, M.; Walker, L.; Wancata, J.; White, R. G.; Zanini, E.; van Ommeren, M.; Barbui, C.; Department of Psychology; Yes; College of Social Sciences and Humanities
Aims: as refugees and asylum seekers are at high risk of developing mental disorders, we assessed the effectiveness of Self-Help Plus (SH + ), a psychological intervention developed by the World Health Organization, in reducing the risk of developing any mental disorders at 12-month follow-up in refugees and asylum seekers resettled in Western Europe. Methods: refugees and asylum seekers with psychological distress (General Health Questionnaire-12 > 3) but without a mental disorder according to the Mini International Neuropsychiatric Interview (M.I.N.I.) were randomised to either SH + or enhanced treatment as usual (ETAU). The frequency of mental disorders at 12 months was measured with the M.I.N.I., while secondary outcomes included self-identified problems, psychological symptoms and other outcomes. Results: of 459 participants randomly assigned to SH + or ETAU, 246 accepted to be interviewed at 12 months. No difference in the frequency of any mental disorders was found (relative risk [RR] = 0.841; 95% confidence interval [CI] 0.389-1.819; p-value = 0.659). In the per protocol (PP) population, that is in participants attending at least three group-based sessions, SH + almost halved the frequency of mental disorders at 12 months compared to ETAU, however so few participants and events contributed to this analysis that it yielded a non-significant result (RR = 0.528; 95% CI 0.180-1.544; p-value = 0.230). SH + was associated with improvements at 12 months in psychological distress (p-value = 0.004), depressive symptoms (p-value = 0.011) and wellbeing (p-value = 0.001). Conclusions: the present study failed to show any long-term preventative effect of SH + in refugees and asylum seekers resettled in Western European countries. Analysis of the PP population and of secondary outcomes provided signals of a potential effect of SH + in the long-term, which would suggest the value of exploring the effects of booster sessions and strategies to increase SH + adherence.
Risk factors for mental disorder development in asylum seekers and refugees resettled in Western Europe and Turkey: Participant-level analysis of two large prevention studies
(Sage Publications Ltd, 2023) Acartürk, Ceren; Barbui, Corrado; Tedeschi, Federico; Anttila, Minna; Au, Teresa; Baumgartner, Josef; Carswell, Ken; Churchill, Rachel; Cuijpers, Pim; Karyotaki, Eirini; Klein, Thomas; Koesters, Markus; Lantta, Tella; Nosè, Michela; Ostuzzi, Giovanni; Pasquini, Massimo; Prina, Eleonora; Sijbrandij, Marit; Tarsitani, Lorenzo; Turrini, Giulia; Uygun, Ersin; Välimäki, Maritta; Walker, Lauren; Wancata, Johannes; White, Ross G.; Purgato, Marianna; Department of Psychology; Yes; College of Social Sciences and Humanities
Background: In asylum seekers and refugees, the frequency of mental disorders, such as depression, anxiety and post-traumatic stress disorder, is higher than the general population, but there is a lack of data on risk factors for the development of mental disorders in this population. Aim: This study investigated the risk factors for mental disorder development in a large group of asylum seekers and refugees resettled in high- and middle-income settings. Methods: Participant-level data from two randomized prevention studies involving asylum seekers and refugees resettled in Western European countries and in Turkey were pooled. The two studies randomized participants with psychological distress, but without a diagnosis of mental disorder, to the Self-Help Plus psychological intervention or enhanced care as usual. At baseline, exposure to potentially traumatic events was measured using the Harvard Trauma Questionnaire-part I, while psychological distress and depressive symptoms were assessed with the General Health Questionnaire and the Patient Health Questionnaire. After 3 and 6 months of follow-up, the proportion of participants who developed a mental disorder was calculated using the Mini International Neuropsychiatric Interview. Results: A total of 1,101 participants were included in the analysis. At 3- and 6-month follow-up the observed frequency of mental disorders was 13.51% (115/851) and 24.30% (207/852), respectively, while the frequency estimates after missing data imputation were 13.95% and 23.78%, respectively. After controlling for confounders, logistic regression analysis showed that participants with a lower education level (p =.034), a shorter duration of journey (p =.057) and arriving from countries with war-related contexts (p =.017), were more at risk of developing mental disorders. Psychological distress (p =.004), depression (p =.001) and exposure to potentially traumatic events (p =.020) were predictors of mental disorder development. Conclusions: This study identified several risk factors for the development of mental disorders in asylum seekers and refugees, some of which may be the target of risk reduction policies. The identification of asylum seekers and refugees at increased risk of mental disorders should guide the implementation of focused preventative psychological interventions.
Effectiveness of a WHO self-help psychological intervention for preventing mental disorders among Syrian refugees in Turkey: a randomized controlled trial
(Wiley, 2022) İlkkurşun, Zeynep; Kurt, Gülşah; Acartürk, Ceren; Öztürk, Sevde Eskici; Uygun, E.; Carswell, K.; Tedeschi, F.; Batu, M.; Anttila, M.; Au, T.; Baumgartner, J.; Churchill, R.; Cuijpers, P.; Becker, T.; Koesters, M.; Lantta, T.; Nosè, M.; Ostuzzi, G.; Popa, M.; Purgato, M.; Sijbrandij, M.; Turrini, G.; Välimäki, M.; Walker, L.; Wancata, J.; Zanini, E.; White, R.G.; van Ommeren, M.; Barbui C.; Department of Psychology; Graduate School of Social Sciences and Humanities; Yes; College of Social Sciences and Humanities; GRADUATE SCHOOL OF SOCIAL SCIENCES AND HUMANITIES
Refugees are at high risk of developing mental disorders. There is no evidence from randomized controlled trials (RCTs) that psychological interventions can prevent the onset of mental disorders in this group. We assessed the effectiveness of a self-help psychological intervention developed by the World Health Organization, called Self-Help Plus, in preventing the development of mental disorders among Syrian refugees experiencing psychological distress in Turkey. A two-arm, assessor-masked RCT was conducted in two Turkish areas. Eligible participants were adult Syrian refugees experiencing psychological distress (General Health Questionnaire ?3), but without a diagnosis of mental disorder. They were randomly assigned either to the Self-Help Plus arm (consisting of Self-Help Plus combined with Enhanced Care as Usual, ECAU) or to ECAU only in a 1:1 ratio. Self-Help Plus was delivered in a group format by two facilitators over five sessions. The primary outcome measure was the presence of any mental disorder assessed by the Mini International Neuropsychiatric Interview at six-month follow-up. Secondary outcome measures were the presence of mental disorders at post-intervention, and psychological distress, symptoms of post-traumatic stress disorder and depression, personally identified psychological outcomes, functional impairment, subjective well-being, and quality of life at post-intervention and six-month follow-up. Between October 1, 2018 and November 30, 2019, 1,186 refugees were assessed for inclusion. Five hundred forty-four people were ineligible, and 642 participants were enrolled and randomly assigned to either Self-Help Plus (N=322) or ECAU (N=320). Self-Help Plus participants were significantly less likely to have any mental disorders at six-month follow-up compared to the ECAU group (21.69% vs. 40.73%; Cramer's V = 0.205, p<0.001, risk ratio: 0.533, 95% CI: 0.408-0.696). Analysis of secondary outcomes suggested that Self-Help Plus was not effective immediately post-intervention, but was associated with beneficial effects at six-month follow-up in terms of symptoms of depression, personally identified psychological outcomes, and quality of life. This is the first prevention RCT ever conducted among refugees experiencing psychological distress but without a mental disorder. Self-Help Plus was found to be an effective strategy for preventing the onset of mental disorders. Based on these findings, this low-intensity self-help psychological intervention could be scaled up as a public health strategy to prevent mental disorders in refugee populations exposed to ongoing adversities.
Cost-effectiveness of the Self-Help Plus intervention for adult Syrian refugees hosted in Turkey
(American Medical Association (AMA), 2022) İlkkurşun, Zeynep; Acartürk, Ceren; Park, A.L.; Waldmann, T.; Kösters, M.; Tedeschi, F.; Nose, M.; Ostuzzi, G.; Purgato, M.; Turrini, G.; Valimaki, M.; Lantta, T.; Anttila, M.; Wancata, J.; Friedrich, F.; Uygun, E.; Cuijpers, P.; Sijbrandij, M.; White, R.G.; Popa, M.; Carswell, K.; Au, T.; Kilian, R.; Barbui, C.; Department of Psychology; Yes; College of Social Sciences and Humanities
Importance: the cost-effectiveness of the Self-Help Plus (SH+) program, a group-based, guided, self-help psychological intervention developed by the World Health Organization for people affected by adversity, is unclear. Objective: to investigate the cost-utility of providing the SH+ intervention combined with enhanced usual care vs enhanced usual care alone for Syrian refugees or asylum seekers hosted in Turkey. Design, setting, and participants: this economic evaluation was performed as a prespecified part of an assessor-blinded randomized clinical trial conducted between October 1, 2018, and November 30, 2019, with 6-month follow-up. A total of 627 adults with psychological distress but no diagnosed psychiatric disorder were randomly assigned to the intervention group or the enhanced usual care group. Interventions: the SH+ program was a 5-session (2 hours each), group-based, stress management course in which participants learned self-help skills for managing stress by listening to audio sessions. The SH+ sessions were facilitated by briefly trained, nonspecialist individuals, and an illustrated book was provided to group members. Th intervention group received the SH+ intervention plus enhanced usual care; the control group received only enhanced usual care from the local health care system. Enhanced usual care included access to free health care services provided by primary and secondary institutions plus details on nongovernmental organizations and freely available mental health services, social services, and community networks for people under temporary protection of Turkey and refugees. Main outcomes and measures: the primary outcome measure was incremental cost per quality-adjusted life-year (QALY) gained from the perspective of the Turkish health care system. An intention-to-treat analysis was used including all participants who were randomized and for whom baseline data on costs and QALYs were available. Data were analyzed September 30, 2020, to July 30, 2021. Results: of 627 participants (mean [SD] age, 31.3 [9.0] years; 393 [62.9%] women), 313 were included in the analysis for the 51-1+ group and 314 in the analysis for the enhanced usual care group. An incremental cost-utility ratio estimate of T 6068 pound ($1147) per QALY gained was found when the SH+ intervention was provided to groups of 10 Syrian refugees. At a willingness to pay per QALY gained of T 14 pound 831 ($2802), the SH+ intervention had a 97.5% chance of being cost-effective compared with enhanced usual care alone. conclusions and relevance: this economic evaluation suggests that implementation of the SH+ intervention compared with enhanced usual care alone for adult Syrian refugees or asylum seekers hosted in Turkey is cost-effective from the perspective of the Turkish health care system when both international and country-specific willingness-to-pay thresholds were applied.
Trajectories of psychosocial symptoms and wellbeing in asylum seekers and refugees exposed to traumatic events and resettled in Western Europe, Turkey, and Uganda
(Taylor _ Francis, 2022) İlkkurşun, Zeynep; Acartürk, Ceren; Purgato, Marianna; Tedeschi, Federico; Turrini, Giulia; Anttila, Minna; Augustinavicious, Jura; Baumgartner, Josef; Bryant, Richard; Churchill, Rachel; Karyotaki, Eirini; Klein, Thomas; Koesters, Markus; Lantta, Tella; Leku, Marx R.; Nose, Michela; Ostuzzi, Giovanni; Popa, Mariana; Prina, Eleonora; Sijbrandij, Marit; Uygun, Ersin; Valimaki, Maritta; Walker, Lauren; Wancata, Johannes; White, Ross G.; Cuijpers, Pim; Tol, Wietse; Barbui, Corrado; Department of Psychology; Graduate School of Social Sciences and Humanities; Yes; College of Social Sciences and Humanities; GRADUATE SCHOOL OF SOCIAL SCIENCES AND HUMANITIES
Background: longitudinal studies examining mental health trajectories in refugees and asylum seekers are scarce. Objectives: to investigate trajectories of psychological symptoms and wellbeing in refugees and asylum seekers, and identify factors associated with these trajectories. Method: 912 asylum seekers and refugees from the control arm of three trials in Europe (n = 229), Turkey (n = 320), and Uganda (n = 363) were included. We described trajectories of psychological symptoms and wellbeing, and used trauma exposure, age, marital status, education, and individual trial as predictors. Then, we assessed the bidirectional interactions between wellbeing and psychological symptoms, and the effect of each predictor on each outcome controlling for baseline values. Results: symptom improvement was identified in all trials, and for wellbeing in 64.7% of participants in Europe and Turkey, versus 31.5% in Uganda. In Europe and Turkey domestic violence predicted increased symptoms at post-intervention (ss = 1.36, 95% CI 0.17-2.56), whilst murder of family members at 6-month follow-up (ss = 1.23, 95% CI 0.27-2.19). Lower wellbeing was predicted by murder of family member (ss = -1.69, 95% CI -3.06 to -0.32), having been kidnapped (ss = -1.67, 95% CI -3.19 to -0.15), close to death (ss = -1.38, 95% CI -2.70 to -0.06), and being in the host country >= 2 years (ss = -1.60, 95% CI -3.05 to -0.14). In Uganda at post-intervention, having been kidnapped predicted increased symptoms (ss = 2.11, 95% CI 0.58-3.65), and lack of shelter (ss = -2.51, 95% CI -4.44 to -0.58) and domestic violence predicted lower wellbeing (ss = -1.36, 95% CI -2.67 to -0.05). Conclusion: many participants adapt to adversity, but contextual factors play a critical role in determining mental health trajectories. / Antecedentes: estudios longitudinales que examinan las trayectorias de la salud mental en losrefugiados y solicitantes de asilo son escasos. Objetivos: investigar las trayectorias de los síntomas psicológicos y el bienestar en refugiadosy solicitantes de asilo, e identificar factores asociados a estas trayectorias.Métodos:Se incluyeron 912 solicitantes de asilos y refugiados del brazo control de tresensayos clínicos en Europa (n= 229), Turquía (n= 320) y Uganda (n= 363). Describimos las trayectorias psicológicas de los síntomas y el bienestar, y utilizamos la exposición traumática, laedad, el estado marital, la educación y el juicio individual como predictores. Después,evaluamos las interacciones bidireccionales entre el bienestar y los síntomas psicológicos, yel efecto de cada uno de los predictores en cada resultado controlando por los valores iniciales.Resultados: se identificó una mejoría en los síntomas en todos los ensayos, y del bienestar en el64.7% de los participantes en Europa y Turquía, versus el 31.5% en Uganda. En Europa y en Turquía,la violencia doméstica predijo el incremento de síntomas de después de la intervención (ß= 1.36,95% CI 0.17 a 2.56), mientras que el homicidio de algún miembro familiar a los 6 meses deseguimiento (ß= 1.23, 95% CI 0.27 a 2.19). Un menor bienestar fue predicho por el homicidio dealgún miembro de la familia (ß=−1.69, 95% CI−3.06 a−0.32), haber sido secuestrado (ß=−1.67, 95% CI−3.19 a−0.15), haber estado próximo a la muerte (ß=−1.38, 95% CI−2.70 a−0.06), y estar en el país de acogida≥2años(ß=−1.60, 95% CI−3.05 a−0.14). En Uganda,después de la intervención, haber sido secuestrado predijo un aumento de los síntomas(ß=2.11, 95% CI 0.58 a 3.65), y la falta de refugio (ß=−2.51, 95% CI−4.44 a−0.58) y laviolencia doméstica predijo un menor bienestar (ß=−1.36, 95% CI−2.67 a−0.05).Conclusión: muchos participantes se adaptan a la adversidad, pero los factores contextualesjuegan un papel crítico en determinar las trayectorias de la salud mental.
