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Despite the increasing psychological distress during COVID-19, utilisation of face-to-face psychological interventions decreased profoundly. The aim of this study involving two parallel, two-armed pilot randomised controlled trials was to examine the effectiveness of a guided self-help intervention ""Doing What Matters in Times of Stress"" (DWM) in decreasing psychological distress in Turkish and Syrian participants. Seventy-four Turkish nationals and 50 Syrian refugee adults with psychological distress were randomly allocated to a DWM group or wait-list control group. The primary outcome measure was the Patient Health Questionnaire 9 postintervention. Secondary outcome measures were the Generalised Anxiety Disorder Scale, posttraumatic stress disorder (PTSD) Checklist for DSM-5, Generalized Self-Efficacy Scale and Acceptance and Action Questionnaire-II postintervention. Although this study was not powered to detect a significant effect for DWM postassessment between DWM and the control group, results showed a significant improvement in depression symptoms among Turkish participants in the DWM group (d = 0.46) and in PTSD symptoms among Syrian participants in the DWM group (d = 0.67) from pre- to postintervention assessment. These results indicate the potential of DWM to decrease mental health problems during the pandemic and importance of a fully powered, definitive controlled trial to examine its effectiveness both for the host community and refugees to reduce psychological distress during COVID-19., Scientific and Technical Research Council of Turkey (TÜBİTAK)

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 psi, European Union (EU); Horizon 2020; European Commission (EC); RE-DEFINE: Refugee Emergency DEFining and Implementing Novel Evidence-based psycho-social Interventions

Background: Türkiye hosts 4 million refugees and asylum seekers, with Syrians and Afghans being among the largest refugee groups in country. There are limited comparative data on the conflict- and displacement-related experiences of these groups and the relation with mental health status. Aims: to assess the mental health status of Syrians and Afghans in Türkiye, identify risk factors and explore to what extent differences in mental health conditions are related to potentially traumatic events and post-displacement stressors. Method: two parallel online survey studies were conducted between April and June 2021 among 798 Syrians and 785 Afghans in Türkiye. Data were collected on sociodemographic characteristics, traumatic events (Harvard Trauma Questionnaire), post-displacement stressors (Post-Migration Living Difficulties Checklist), symptoms of depression and anxiety (Hopkins Symptoms Checklist-25) and post-traumatic stress disorder (PTSD) (Post-Traumatic Stress Disorder Checklist for DSM-5, short form). Results: for Syrian and Afghan participants respectively, estimated prevalence rates were: 41.1% and 50.3% for depression; 39.6% and 41% for anxiety; and 41.6% and 46.5% for PTSD. In both groups, significant predictors were female gender, exposure to potentially traumatic events, and structural and socioeconomic post-displacement stressors. Additional risk factors were older age for Afghans and higher education for Syrians. Conclusions: self-reported symptoms of common mental health problems are highly prevalent among Syrian and Afghan refugees and associated with a wide range of risk factors. After controlling for conflict- and displacement-related experiences, Afghans reported higher anxiety symptoms than Syrians, which is likely related to their legal status in Türkiye., Koç University Seed Fund Program

Introduction: The World Health Organization's (WHO) scalable psychological interventions, such as Problem Management Plus (PM+) and Step-by-Step (SbS) are designed to be cost-effective non-specialist delivered interventions to reduce symptoms of common mental disorders, such as anxiety, depression and post-traumatic stress disorder (PTSD). The STRENGTHS consortium aims to evaluate the effectiveness, cost-effectiveness and implementation of the individual format of PM+ and?its group version (gPM+), as well as of the digital SbS intervention among Syrian refugees in seven countries in Europe and the Middle East. This is a study protocol for a prospective individual participant data (IPD) meta-analysis to evaluate (1) overall effectiveness and cost-effectiveness and (2) treatment moderators of PM+, gPM+ and?SbS with Syrian refugees. Methods and analysis: Five pilot randomised controlled trials (RCTs) and seven fully powered RCTs conducted within STRENGTHS will be combined into one IPD meta-analytic dataset. The RCTs include Syrian refugees of 18 years and above with elevated psychological distress (Kessler Psychological Distress Scale (K10>15)) and impaired daily functioning (WHO Disability Assessment Schedule 2.0 (WHODAS 2.0>16)). Participants are randomised into the intervention or care as usual control group, and complete follow-up assessments at 1-week, 3-month and 12-month follow-up. Primary outcomes are symptoms of depression and anxiety (25-item Hopkins Symptom Checklist). Secondary outcomes include daily functioning (WHODAS 2.0), PTSD symptoms (PTSD Checklist for DSM-5) and self-identified problems (PSYCHLOPS). We will conduct a one-stage IPD meta-analysis using linear mixed models. Quality of evidence will be assessed using the GRADE approach, and the economic evaluation approach will be assessed using the CHEC-list. Ethics and dissemination: Local ethical approval has been obtained for each RCT. This IPD meta-analysis does not require ethical approval. The re, European Union (EU); Horizon 2020; Framework Programme for Research and Innovation (2014–2020)

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, European Union (EU); Horizon 2020

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 immediat, European Commission

Background: Syrian refugees resettled in Turkey show a high prevalence of symptoms of mental disorders. Problem Management Plus (PM+) is an effective psychological intervention delivered by non-specialist health care providers which has shown to decrease psychological distress among people exposed to adversity. In this single-blind pilot randomised controlled trial, we examined the methodological trial procedures of Group PM+ (gPM+) among Syrian refugees with psychological distress in Istanbul,Turkey, and assessed feasibility, acceptability, perceived impact and the potential cost-effectiveness of the intervention. Methods: refugees with psychological distress (Kessler Psychological Distress Scale, K10 > 15) and impaired psychosocial functioning (World Health Organization Disability Assessment Schedule, WHODAS 2.0> 16) were recruited from the community and randomised to either gPM+ and enhanced care as usual (E-CAU) (n = 24) or E-CAU only (n = 22). gPM+ comprised of five weekly group sessions with eight to ten participants per group. Acceptability and feasibility of the intervention were assessed through semi-structured interviews. The primary outcome at 3-month follow-up was symptoms of depression and anxiety (Hopkins Symptoms Checklist-25). Psychosocial functioning (WHODAS 2.0), symptoms of posttraumatic stress disorder and self-identified problems (Psychological Outcomes Profiles, PSYCHLOPS) were included as secondary outcomes. A modified version of the Client Service Receipt Inventory was used to document changes in the costs of health service utilisation as well as productivity losses. Results: there were no barriers experienced in recruiting study participants and in randomising them into the respective study arms. Retention in gPM+ was high (75%). Qualitative analyses of the interviews with the participants showed that Syrian refugees had a positive view on the content, implementation and format of gPM+. No adverse events were reported during the implementati, European Union (EU); Horizon 2020; Research and Innovation Programme Societal Challenges

Given the increasing use of low-intensity psychological interventions in humanitarian mental health and psychosocial support work, more attention is needed to strengthen the intersection between evidence-based interventions and cultural contextualisation. Undertaking the process of cultural adaptation ensures the appropriateness and acceptability of psychological interventions in these contexts. We present the process and results of conducting a cultural adaptation for the Group Problem Management Plus (GroupPM+) intervention, for Syrian refugees across two contexts; Jordan in camp settings and Turkey in urban settings. The first step of the adaptation was to conduct a rapid qualitative assessment following the Design, Implementation, Monitoring and Evaluation model proceeded by cognitive interviews and a workshop designed to apply changes according to the Bernal framework. Based on the results, a total of 82 changes were proposed across the intervention manual, training, supervision and implementation protocols. Changes ranged from minor amendments to terminology to broader changes to how metaphors, stories and illustrations are presented during the intervention. Additionally, two substantial adaptations were suggested: (1) the addition of a session designed to enhance family engagement, and (2) the development of a male case study. Changes were incorporated prior to the implementation of the GroupPM+ intervention in Jordan and Turkey.

Introduction: Self-Help Plus (SH+) is a group-based psychological intervention developed by the World Health Organization for managing stress. Objective: to assess the effectiveness of SH+ in preventing mental disorders in refugees and asylum seekers in Western Europe. Methods: we conducted a randomized controlled trial in 5 European countries. Refugees and asylum seekers with psychological distress (General Health Questionnaire score >= 3), but without a Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) or ICD/10 diagnosis of mental disorder, as assessed with the Mini International Neuropsychiatric Interview (MINI), were randomized to SH+ or enhanced treatment as usual (ETAU). The primary outcome was the frequency of mental disorders with the MINI at 6 months. Secondary outcomes included the frequency of mental disorders at postintervention, self-identified problems, psychological symptoms, and other outcomes. Results: four hundred fifty-nine individuals were randomly assigned to SH+ or ETAU. For the primary outcome, we found no difference in the frequency of mental disorders at 6 months (Cramer V = 0.007, p = 0.90, RR = 0.96; 95% CI 0.52-1.78), while the difference significantly favored SH+ at after the intervention (secondary outcome, measured within 2 weeks from the last session; Cramer V = 0.13, p = 0.01, RR = 0.50; 95% CI 0.29-0.87). Conclusions: this is the first randomized indicated prevention study with the aim of preventing the onset of mental disorders in asylum seekers and refugees in Western Europe. As a prevention effect of SH+ was not observed at 6 months, but rather after the intervention only, modalities to maintain its beneficial effect in the long term need to be identified.

COVID-19 does not leave behind refugees. They are disproportionately affected during the current pandemic. The present study aimed to investigate the psychological impacts of COVID-19 related stressors -resource loss and perceived discrimination during the COVID-19 pandemic- on Syrian refugees in Turkey. Further, the buffering role of perceived social support against the detrimental impacts of such stressors was examined. An online cross-sectional study was conducted between September-October 2020. A sample of 345 Syrian refugees in Turkey completed the questions about demographic characteristics, resource loss and perceived discrimination during the pandemic, perceived social support, and depressive and anxiety symptoms. A high level of depressive and anxiety symptoms was reported in our sample. Resource loss and perceived discrimination during the pandemic significantly and positively predicted depressive and anxiety symptoms. Perceived social support acted as a buffer against the detrimental effect of resource loss on mental health. For those with higher perceived social support, resource loss during the pandemic did not significantly predict depressive and anxiety symptoms. The results indicate the detrimental role of COVID-19 related stressors on refugee mental health. Social support is an important protective factor for mental health amidst the pandemic. Our findings highlight the importance of considering the precarious conditions of refugees in all COVID-19 responses and communications., Scientific and Technological Research Council of Turkey (TÜBİTAK)

Introduction: Self-Help Plus (SH+) is a group-based psychological intervention developed by the World Health Organization for managing stress. Objective: to assess the effectiveness of SH+ in preventing mental disorders in refugees and asylum seekers in Western Europe. Methods: we conducted a randomized controlled trial in 5 European countries. Refugees and asylum seekers with psychological distress (General Health Questionnaire score >= 3), but without a Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) or ICD/10 diagnosis of mental disorder, as assessed with the Mini International Neuropsychiatric Interview (MINI), were randomized to SH+ or enhanced treatment as usual (ETAU). The primary outcome was the frequency of mental disorders with the MINI at 6 months. Secondary outcomes included the frequency of mental disorders at postintervention, self-identified problems, psychological symptoms, and other outcomes. Results: four hundred fifty-nine individuals were randomly assigned to SH+ or ETAU. For the primary outcome, we found no difference in the frequency of mental disorders at 6 months (Cramer V = 0.007, p = 0.90, RR = 0.96; 95% CI 0.52-1.78), while the difference significantly favored SH+ at after the intervention (secondary outcome, measured within 2 weeks from the last session; Cramer V = 0.13, p = 0.01, RR = 0.50; 95% CI 0.29-0.87). Conclusions: this is the first randomized indicated prevention study with the aim of preventing the onset of mental disorders in asylum seekers and refugees in Western Europe. As a prevention effect of SH+ was not observed at 6 months, but rather after the intervention only, modalities to maintain its beneficial effect in the long term need to be identified., European Union (EU); Horizon 2020; European Commission (EC); RE-DEFINE: Refugee Emergency: DEFining and Implementing Novel Evidence-based Psychosocial Interventions

Background: Syrian refugees and asylum seekers (SRAs) face multiple stressors after flight, which may vary due to different geographic, economic, cultural and socio-political contexts in the host countries. Past research has recognised the importance of participants’ own perspectives. The aims of this multi-country study were to identify and compare self-reported problems of SRAs between various settings. Methods: a semi-structured client-generated outcome measurement was used to collect data among adult SRAs in Jordan (N = 61), Turkey (N = 46) and Switzerland (N = 57) between September 2018 and November 2019. Answers were analysed following thematic analysis. Results: over half of the participants reported practical problems with an emphasis on camp-related problems (Jordan), finances (Turkey), employment (Jordan and Switzerland) and government regulations (Switzerland), followed by psychological, and social issues. Conclusion: this study highlights the impact of local contextual factors on wellbeing. The findings emphasise that planning preventative procedures and mental health care services for SRAs need to consider local challenges affecting the population in specific countries., Swiss State Secretariat for Education, Research and Innovation (SERI); National Health and Medical Research Council-European Union Grant; European Union (EU); Horizon 2020; Research and Innovation Pro Innovation Programme Societal Challenges

Background: a large mental health treatment gap exists among conflict-affected populations, and Syrian refugees specifically. Promising brief psychological interventions for conflict-affected populations exist such as the World Health Organization's Problem Management Plus (PM+) and the Early Adolescent Skills for Emotions (EASE) intervention, however, there is limited practical guidance for countries of how these interventions can be taken to scale. The aim of this study was to unpack pathways for scaling up PM+ and EASE for Syrian refugees. Methods: we conducted three separate Theory of Change (ToC) workshops in Turkey, the Netherlands, and Lebanon in which PM+ and EASE are implemented for Syrian refugees. ToC is a participatory planning process involving key stakeholders, and aims to understand a process of change by mapping out intermediate and long-term outcomes on a causal pathway. 15-24 stakeholders were invited per country, and they participated in a one-day interactive ToC workshop on scaling up. Results: a cross-country ToC map for scale up brief psychological interventions was developed which was based on three country-specific ToC maps. Two distinct causal pathways for scale up were identified (a policy and financing pathway, and a health services pathway) which are interdependent on each other. A list of key assumptions and interventions which may hamper or facilitate the scaling up process were established. Conclusion: ToC is a useful tool to help unpack the complexity of scaling up. Our approach highlights that scaling up brief psychological interventions for refugees builds on structural changes and reforms in policy and in health systems. Both horizontal and vertical scale up approaches are required to achieve sustainability. This paper provides the first theory-driven map of causal pathways to help support the scaling-up of evidence-based brief psychological interventions for refugees and populations in global mental health more broadly., STRENGTHS (Syrian REfuGees MeNTal HealTH Care Systems) Project; European Union (European Union); Horizon 2020

Background: a large proportion of Syrians have been exposed to potentially traumatic events, multiple losses, and breakdown of supportive social networks and many of them have sought refuge in host countries where they also face post-migration living difficulties such as discrimination or integration problems or both. These adversities may put Syrian refugees at high risk for common mental disorders. In response to this, the World Health Organization (WHO) developed a trans-diagnostic scalable psychological intervention called Problem Management Plus (PM+) to reduce psychological distress among populations exposed to adversities. PM+ has been adapted for Syrian refugees and can be delivered by non-specialist peer lay persons in the community. Methods: a randomized controlled trial (RCT) will be conducted with 380 Syrian refugees in Turkey. After providing informed consent, participants with high levels of psychological distress (scoring above 15 on the Kessler-10 Psychological Distress Scale (K10)) and functional impairment (scoring above 16 on the WHO Disability Assessment Schedule 2.0, or WHODAS 2.0) will be randomly assigned to Group PM+/enhanced care as usual (Group PM+/E-CAU) (n = 190) or E-CAU (n = 190). Outcome assessments will take place 1 week after the fifth session (post-assessment), 3 months after the fifth session and 12 months after baseline assessment. The primary outcome is psychological distress as measured by the Hopkins Symptom Checklist (HSCL-25). Secondary outcomes include functional impairment, post-traumatic stress symptoms, self-identified problems, and health system and productivity costs. A process evaluation will be conducted to explore the feasibility, challenges and success of the intervention with 25 participants, including participants, facilitators, policy makers and mental health professionals. Discussion: the treatment manual of the Syrian-Arabic Group PM+ and training materials will be made available through the WHO once the effect, European Union (European Union); Horizon 2020; Research and Innovation Programme, Societal Challenges

Purpose: the war in Syria has created the greatest refugee crisis in the 21st century. Turkey hosts the highest number of registered Syrian refugees, who are at increased risk of common mental disorders because of their exposure to war, violence and post-displacement stressors. The aim of this paper is to examine the prevalence and predictors of anxiety, depression, and post-traumatic stress disorder (PTSD) symptoms among Syrian refugees living in Turkey. Methods: a cross-sectional survey of adult Syrian refugees was conducted between February and May 2018 in Istanbul (Sultanbeyli district). Participants (N=1678) were randomly selected through the registration system of the district municipality. The Hopkins Symptoms Checklist (HSCL-25) was used to measure anxiety and depression and the Posttraumatic Stress Disorder (PTSD) Checklist (PCL-5) assessed posttraumatic stress. Descriptive and multivariate regression analyses were used. Results: the prevalence of symptoms of anxiety, depression and PTSD were 36.1%, 34.7% and 19.6%, respectively. Comorbidity was high. Regression analyses identified several socio-demographic, health and post-displacement variables that predicted common mental disorders including: being female, facing economic difficulties, previous trauma experience, and unmet need for social support, safety, law and justice. A lifetime history of mental health treatment and problems accessing adequate healthcare were associated with depression and anxiety but not with PTSD. Conclusions: mental disorder symptoms are highly prevalent among Syrian refugees in Turkey. The association with post-displacement factors points to the importance of comprehensive health and social services that can address these social, economic and cultural stressors., STRENGTHS (Syrian REfuGees MeNTal HealTH Care Systems) Project; European Union (European Union); Horizon 2020; Framework Programme for Research and Innovation (2014-2020)