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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 E-mental health interventions may help to bridge the mental health treatment gap. Evidence on their effectiveness is compelling in high-income countries. Not enough evidence has been generated on their use with communities affected by adversity in low- and middle-income countries. The World Health Organization (WHO), the National Mental Health Programme (NMMP) at Ministry of Public Health (MoPH) in Lebanon and other partners have adapted a WHO intervention called Step-by-Step for use with Lebanese and displaced people living in Lebanon. Step-by-Step is a minimally guided, internet-based intervention for adults with depression. In this study, a feasibility randomised controlled trial (RCT) and a qualitative process evaluation were conducted to explore the feasibility and the acceptability of the research methods, and the intervention, in preparation for two fully powered trials to assess the effectiveness and cost-effectiveness of Step-by-Step in Lebanon. Method Participants were recruited through social media. Inclusion criteria were: being able to understand and speak Arabic or English; access to an internet connected device; aged over 18; living in Lebanon; scores above cut-off on the Patient Health Questionnaire and the WHO Disability Assessment Schedule 2.0. Participants were randomly assigned to the intervention or enhanced care as usual. They completed post-assessments eight weeks after baseline, and follow-up assessments another three months later. Primary outcomes were depression and level of functioning, secondary outcomes were anxiety, post-traumatic stress, and well-being. Qualitative interviews were conducted to evaluate the feasibility and acceptability of the research procedures and the intervention. Results A total of N = 138 participants, including 33 Syrians, were recruited and randomised into two equal groups. The dropout rate was higher in the control group (73% post- and 82% follow-up assessment) than in the intervention group (63% post- and 72% follow-up assessment). The intervention was perceived as relevant, acceptable and beneficial to those who completed it. Suggestions were made to further adapt the content and to make the intervention more engaging. Statistical analyses were conducted despite the small sample size. Complete cases analysis showed a statistically significant symptom reduction in depression, anxiety, disability, and post-traumatic stress, and statistically significant improvement in well-being and functioning. Intention-to-treat analysis revealed non-significant effects. Conclusion The research design, methods and procedures are feasible and acceptable in the context of Lebanon and can be applied in the RCTs. Preliminary findings suggest that Step-by-Step may be effective in reducing symptoms of depression and anxiety and improving functioning and well-being., Highlights • An e-intervention was tested among people affected by adversities in Lebanon. • The study showed that the intervention and methods can be applied in full RCTs. • The intervention may reduce symptoms of depression and improve functioning.

There is currently a high global demand for mental health professionals, including child and adolescent mental health professionals. In 2020, the World Health Organization (WHO) published “Enhancing mental health pre-service training with the mhGAP-Intervention Guide: experiences and lessons learned” to address the proposition of implementing Mental Health Gap Action Programme Intervention Guide (mhGAP-IG) materials and principles as a component of pre-service training. By integrating the mhGAP-IG within pre-service training, future healthcare providers will acquire theoretical knowledge and early exposure to practical knowledge and will be better prepared for their future work.Examples demonstrate that mhGAP-IG pre-service training can be successfully implemented in diverse settings and in various pre-service training programs. It can be used in small group learning activities and short courses, taught through lectures, used as a clinical tool to teach students (i.e. medical, nursing students) and medical doctors in training. We can enhance pre-service training with the mhGAP-IG and contribute to a learning environment, which nurtures knowledge and skills required to help people with mental health needs.

Background: E-mental health is an established mode of delivering treatment for common mental disorders in many high income countries. However, evidence of its effectiveness in lower income countries is lacking. This mixed methods study presents lessons learned and preliminary data on the feasibility of a minimally guided e-mental health intervention in Lebanon. The aim was to pilot test Step-by-Step, a WHO guided e-mental health intervention, and research methods prior to future, controlled testing. Methods: Participants were recruited using social media and advertisements in primary care clinics. Participants completed baseline and post-intervention questionnaires on depression symptoms (primary outcome, PHQ-8), anxiety symptoms, well-being, disability and self-perceived problem severity, and a client satisfaction questionnaire. In addition, seven completers, four drop-outs, 11 study staff, and four clinic managers were interviewed with responses thematically analyzed. Website analytics were used to understand participant behavior when using the website. Results: A total of 129 participants signed up via the Step-by-Step website. Seventy-four participants started session 1 after completing pre-test questionnaires and 26 completed both baseline and post-intervention data. Among those who completed post-assessments, depression symptoms improved (PHQ-8 scores (t=5.62, p < 0.001 two-tailed, df = 25). Wilcoxon signed ranks tests showed a significant difference between baseline and post-Step-by-Step scores on all secondary outcome measures. Client satisfaction data was positive. Interview responses suggested that the intervention could be made more appropriate for younger, single people, more motivating, and easier to use. Those who utilized the support element of the intervention were happy with their relationship with the non-specialist support person (e-helper), though some participants would have preferred specialist support. E-helpers would have liked more training on complex cases. Website analytics showed that many users dropped out before intervention start, and that some re-entered screening data having been excluded from the study. Conclusion: Step-by-Step skills and techniques, model of service integration, and its non-specialist support element are acceptable. Though the sample was small and non-controlled and drop-out was high, results suggest that it may be effective in reducing depression and anxiety symptoms and increasing well-being. Lessons learned will inform content revision, the development of an app version of Step-by-Step, and the research methodology of upcoming effectiveness studies.

Summary Background Innovative solutions are required to provide mental health support at scale in low-resource humanitarian contexts. We aimed to assess the effectiveness of a facilitator-guided, group-based, self-help intervention (Self-Help Plus) to reduce psychological distress in female refugees. Methods We did a cluster randomised trial in rural refugee settlements in northern Uganda. Participants were female South Sudanese refugees with at least moderate levels of psychological distress (cutoff ≥5 on the Kessler 6). The intervention comprised access to usual care and five 2-h audio-recorded stress-management workshops (20–30 refugees) led by briefly trained lay facilitators, accompanied by an illustrated self-help book. Villages were randomly assigned to either intervention (Self-Help Plus or enhanced usual care) on a 1:1 basis. Within 14 villages, randomly selected households were approached. Screening of women in households continued until 20–30 eligible participants were identified per site. The primary outcome was individual psychological distress, assessed using the Kessler 6 symptom checklist 1 week before, 1 week after, and 3 months after intervention, in the intention-to-treat population. All outcomes were measured at the individual (rather than cluster) level. Secondary outcomes included personally identified problems, post-traumatic stress, depression symptoms, feelings of anger, social interactions with other ethnic groups, functional impairment, and subjective wellbeing. Assessors were masked to allocation. This trial was prospectively registered at ISRCTN, number 50148022. Findings Of 694 eligible participants (331 Self-Help Plus, 363 enhanced usual care), 613 (88%) completed all assessments. Compared with controls, we found stronger improvements for Self-Help Plus on psychological distress 3 months post intervention (β −1·20, 95% CI −2·33 to −0·08; p=0·04; d −0·26). We also found larger improvements for Self-Help Plus 3 months post-intervention for five of eight secondary outcomes (effect size range −0·30 to −0·36). Refugees with different trauma exposure, length of time in settlements, and initial psychological distress benefited similarly. With regard to safety considerations, the independent data safety management board responded to six adverse events, and none were evaluated to be concerns in response to the intervention. Interpretation Self-Help Plus is an innovative, facilitator-guided, group-based self-help intervention that can be rapidly deployed to large numbers of participants, and resulted in meaningful reductions in psychological distress at 3 months among South Sudanese female refugees. Funding Research for Health in Humanitarian Crises (R2HC) Programme.

IntroductionThis article describes two randomised controlled trials that will evaluate the effectiveness and cost-effectiveness of Self-Help Plus (SH+), a group self-help intervention developed by the WHO to reduce distress. In these trials SH+ is being tested as a preventative intervention to lower the incidence of mental disorders in asylum seekers and refugees with psychological distress resettled in Europe and Turkey.Methods and analysisTwo prospective, multicentre, randomised, rater-blinded, parallel-group studies will follow participants over a period of 12 months. One trial will be conducted in Europe and one in Turkey. In each trial, 600 asylum seekers and refugees screening positive on the General Health Questionnaire (≥3), but without a formal diagnosis of any mental disorders according to the Mini International Neuropsychiatric Interview, will be randomly allocated to SH+or to enhanced treatment-as-usual. The primary outcome will be a lower incidence of mental disorders at 6 month follow-up. Secondary outcomes will include the evaluation of psychological symptoms, functioning, well-being, treatment acceptability and indicators of intervention cost-effectiveness.Ethics and disseminationThe two trials received ethical clearance from the local Ethics Committees of the participating sites (seven sites), as well as from the WHO Ethics Committee. All participants will provide informed consent before screening and before study inclusion (a two-step procedure). The results of the trials will be disseminated in agreement with a dissemination plan that includes publication(s) in peer-reviewed journals and presentations at relevant national and international conferences and meetings.Trials registration numbersNCT03571347,NCT03587896.

AimsIn the past few years, there has been an unprecedented increase in the number of forcibly displaced migrants worldwide, of which a substantial proportion is refugees and asylum seekers. Refugees and asylum seekers may experience high levels of psychological distress, and show high rates of mental health conditions. It is therefore timely and particularly relevant to assess whether current evidence supports the provision of psychosocial interventions for this population. We conducted a systematic review and meta-analysis of randomised controlled trials (RCTs) assessing the efficacy and acceptability of psychosocial interventions compared with control conditions (treatment as usual/no treatment, waiting list, psychological placebo) aimed at reducing mental health problems in distressed refugees and asylum seekers.MethodsWe used Cochrane procedures for conducting a systematic review and meta-analysis of RCTs. We searched for published and unpublished RCTs assessing the efficacy and acceptability of psychosocial interventions in adults and children asylum seekers and refugees with psychological distress. Post-traumatic stress disorder (PTSD), depressive and anxiety symptoms at post-intervention were the primary outcomes. Secondary outcomes include: PTSD, depressive and anxiety symptoms at follow-up, functioning, quality of life and dropouts due to any reason.ResultsWe included 26 studies with 1959 participants. Meta-analysis of RCTs revealed that psychosocial interventions have a clinically significant beneficial effect on PTSD (standardised mean difference [SMD] = −0.71; 95% confidence interval [CI] −1.01 to −0.41; I2 = 83%; 95% CI 78–88; 20 studies, 1370 participants; moderate quality evidence), depression (SMD = −1.02; 95% CI −1.52 to −0.51; I2 = 89%; 95% CI 82–93; 12 studies, 844 participants; moderate quality evidence) and anxiety outcomes (SMD = −1.05; 95% CI −1.55 to −0.56; I2 = 87%; 95% CI 79–92; 11 studies, 815 participants; moderate quality evidence). This beneficial effect was maintained at 1 month or longer follow-up, which is extremely important for populations exposed to ongoing post-migration stressors. For the other secondary outcomes, we identified a non-significant trend in favour of psychosocial interventions. Most evidence supported interventions based on cognitive behavioural therapies with a trauma-focused component. Limitations of this review include the limited number of studies collected, with a relatively low total number of participants, and the limited available data for positive outcomes like functioning and quality of life.ConclusionsConsidering the epidemiological relevance of psychological distress and mental health conditions in refugees and asylum seekers, and in view of the existing data on the effectiveness of psychosocial interventions, these interventions should be routinely made available as part of the health care of distressed refugees and asylum seekers. Evidence-based guidelines and implementation packages should be developed accordingly.

Background.Exposure to armed conflict and forced displacement constitute significant risks for mental health. Existing evidence-based psychological interventions have limitations for scaling-up in low-resource humanitarian settings. The WHO has developed a guided self-help intervention, Self Help Plus (SH+), which is brief, implemented by non-specialists, and designed to be delivered to people with and without specific mental disorders. This paper outlines the study protocol for an evaluation of the SH+ intervention in northern Uganda, with South Sudanese refugee women.Methods.A two-arm, single-blind cluster-randomised controlled trial will be conducted in 14 villages in Rhino Camp refugee settlement, with at least 588 women experiencing psychological distress. Villages will be randomly assigned to receive either SH+ with enhanced usual care (EUC), or EUC alone. SH+ is a five-session guided self-help intervention delivered in workshops with audio-recorded materials and accompanying pictorial guide. The primary outcome is reduction in overall psychological distress over time, with 3 months post-treatment as the primary end-point. Secondary outcomes are self-defined psychosocial concerns, depression and post-traumatic stress disorder symptoms, hazardous alcohol use, feelings of anger, interethnic relations, psychological flexibility, functional impairment and subjective wellbeing. Psychological flexibility is a hypothesised mediator, and past trauma history and intervention attendance will be explored as potential moderators.Discussion.This trial will provide important information on the effectiveness of a scalable, guided self-help intervention for improving psychological health and wellbeing among people affected by adversity.Trial Registration:ISRCTN50148022; registered 13/03/2017.

The crisis in Syria has resulted in vast numbers of refugees seeking asylum in Syria's neighbouring countries as well as in Europe. Refugees are at considerable risk of developing common mental disorders, including depression, anxiety, and posttraumatic stress disorder (PTSD). Most refugees do not have access to mental health services for these problems because of multiple barriers in national and refugee specific health systems, including limited availability of mental health professionals. To counter some of challenges arising from limited mental health system capacity the World Health Organization (WHO) has developed a range of scalable psychological interventions aimed at reducing psychological distress and improving functioning in people living in communities affected by adversity. These interventions, including Problem Management Plus (PM+) and its variants, are intended to be delivered through individual or group face-to-face or smartphone formats by lay, non-professional people who have not received specialized mental health training, We provide an evidence-based rationale for the use of the scalable PM+ oriented programmes being adapted for Syrian refugees and provide information on the newly launched STRENGTHS programme for adapting, testing and scaling up of PM+ in various modalities in both neighbouring and European countries hosting Syrian refugees.La crisis en Siria ha dado lugar a un gran número de refugiados que buscan asilo en países vecinos a Siria, así como en Europa. Los refugiados corren un riesgo considerable de desarrollar trastornos mentales comunes, como depresión, ansiedad y trastorno por estrés postraumático (TEPT). La mayoría de los refugiados no tienen acceso a servicios de salud mental para estos problemas debido a las múltiples barreras existentes en los sistemas de salud nacionales y específicos para refugiados, incluida una limitada disponibilidad de profesionales de salud mental. Para contrarrestar algunos de los retos derivados de la limitada capacidad del sistema de salud mental, la Organización Mundial de la Salud (OMS) ha desarrollado una gama de intervenciones psicológicas escalables dirigidas a reducir la angustia psicológica y mejorar el funcionamiento de las personas afectadas por la adversidad. Estas intervenciones, que incluyen叙利亚危机导致了海量的难民到周边国家和欧洲寻求避难所。难民们发展出常见心理障碍的风险非常大，其中包括抑郁，焦虑，创伤后应激障碍（PTSD）。大多数难民没有渠道向心理健康机构寻求帮助，这主要是因为国家医疗和难民健康系统的种种阻碍，包括心理健康专家的数量不足。为了应对心理健康系统容量有限所产生的问题，世界卫生组织（WHO）发展出了一系列的可量化心理干预方法，用来减少心理障碍和提高社区中处于逆境里的人们的生活功能。这些干预方法中就有《问题应对量表Plus》（PM+）和它的其他变型，用来给未经过专业心理健康训练的非专业新手以面对面的或智能手机的形式向个人或群体使用。我们为针对叙利亚难民改良的可量化的PM+为基础的项目提供了有证据支持的原理，并且提供了关于新近运行的STRENGTHS项目的信息，该项目旨在在接受叙利亚难民的周边国家和欧洲国家中适应、测试、扩大PM+的多种形式。.

Context. There are limited studies and few theoretical models addressing the interaction between pain and symptoms of post-traumatic stress disorder, with none concerning this interaction in survivors of torture, who frequently report persistent pain. Objectives. We aimed to explore the relationship between persistent pain and re-experiencing of traumatic events in survivors of torture. Methods. Nine torture survivors were interviewed about their experiences of pain and re-experiencing, and the results analyzed using interpretative phenomenological analysis. Levels of pain and post-traumatic stress were assessed. Results. Four superordinate themes emerged, namely ‘‘pain is the enemy,’’ ‘‘pain and intrusive memories are connected,’’ ‘‘changed identity,’’ and ‘‘resilience and resources.’’ These themes showed a complex relationship between torture, pain, re-experiencing, and other aspects of individual experience, such as the multiple losses experienced by torture survivors. Both pain and post-traumatic stress disorder symptoms were shown to have profound impacts on the everyday lives of participants. Conclusion. The results suggest that the relationship between pain and reexperiencing requires a broad model that considers the impact of a range of individual, social, and environmental factors on the interaction between pain and traumatic stress symptoms in survivors of torture. The study has clinical implications, most notably the need to attempt more integrated treatment of pain and traumatic symptoms where they occur together, and to consider the meaning and impact of pain when treating survivors of torture. Further investigation of the relationship between pain and traumatic stress symptoms in torture survivors is needed, as are studies of combined treatment for pain and trauma. J Pain Symptom Manage 2013;46:546e555. 2013 U.S. Cancer Pain Relief Committee.

Peters E, Landau S, McCrone P, Cooke M, Fisher P, Steel C, Evans R, Carswell K, Dawson K, Williams S, Howard A, Kuipers E. A randomised controlled trial of cognitive behaviour therapy for psychosis in a routine clinical service. Objective: To evaluate cognitive behaviour therapy for psychosis (CBTp) delivered by non-expert therapists, using CBT relevant measures. Method: Participants (N = 74) were randomised into immediate therapy or waiting list control groups. The therapy group was offered 6 months of therapy and followed up 3 months later. The waiting list group received therapy after waiting 9 months (becoming the delayed therapy group). Results: Depression improved in the combined therapy group at both the end of therapy and follow-up. Other significant effects were found in only one of the two therapy groups (positive symptoms; cognitive flexibility; uncontrollability of thoughts) or one of the two time points (end of therapy: general symptoms, anxiety, suicidal ideation, social functioning, resistance to voices; follow-up: power beliefs about voices, negative symptoms). There was no difference in costs between the groups. Conclusion: The only robust improvement was in depression. Nevertheless, there were further encouraging but modest improvements in both emotional and cognitive variables, in addition to psychotic symptoms.

Background: There is growing evidence of the impact of post-migration factors on the mental health of refugees. To date, few UK studies have been conducted. Aims: The study investigated the relationship between trauma, post-migration problems, social support and the mental health of refugees and asylum seekers. Methods: Refugees and asylum seekers ( n = 47) were recruited mainly from clinical settings. Self-report measures of post-migration problems, mental health problems and social support were completed in an interview. Results: Bivariate associations were identified between increased symptoms and number of traumas, adaptation difficulties, loss of culture and support and confidant support. In multivariate analyses post-migration problems were significantly associated with post-traumatic stress disorder symptoms and emotional distress. There was no significant association of symptoms and number of traumas or social support. Conclusions: The results suggest that clinical services should provide holistic interventions within a phased approach when working with refugees and asylum seekers. At a policy level, the results suggest the need for asylum policies that reduce post-migration problems and provide support for refugees and asylum seekers.

An increasing number of techniques are emerging in the literature describing single-incision laparoscopic cholecystectomy (SILC). The advent of a new surgical approach is a reminder of the increase in bile duct injuries in the past when laparoscopic cholecystectomy was first introduced. With this in mind, the authors describe a safe and reproducible approach to SILC.Between August 2008 and August 2009, 20 patients with symptomatic gallbladder disease underwent SILC using a totally transumbilical fundus-first approach with an intraoperative cholangiogram. Data including pain scores were collected prospectively.In this initial series, the median operative time was 103 min (range, 55-177 min), including the time for two patients undergoing additional procedures at the time of surgery. Intraoperative cholangiograms were completed for 18 of 19 patients. Additional ports were required in four patients for safe completion of the procedure. The mean pain score 12 h postoperatively was 2.5 on a visual analogue scale with a range of 0-10. There was no morbidity or mortality.According to the findings, SILC with an intraoperative cholangiogram can be performed safely using a fundus-first approach. However, for SILC to become the operation of choice for the treatment of gallbladder disease, evidence is required to demonstrate its advantage over laparoscopic cholecystectomy.

To date, assessments of the prevalence of mental health problems in young offenders have largely focused on incarcerated samples. This paper describes a quantitative study of a sample of 47 male young offenders under the supervision of an inner city Youth Offending Team. A semi-structured interview, modified from previous studies, was used to investigate the type and frequency of psychosocial and health problems they experienced. The results were compared with data from a random community sample of 38 male adolescents interviewed in a comparable way. Young offenders reported more psychosocial problems at a statistically significant level (including depression/misery, excessive worry and problematic substance use), as well as higher life-time rates of head injury, than adolescents in the community sample. Levels of problematic substance use and exposure to head injury continued to differentiate the groups when offenders in custody were removed from the analyses. The findings are discussed in relation to previous research and implications for service delivery.

Background: Innovative solutions are required to provide mental health support at scale in low-resource humanitarian contexts. We aimed to assess the effectiveness of a guided self-help intervention (Self-Help Plus; SH+) to reduce psychological distress in female refugees. Methods: We conducted a cluster randomized trial in rural refugee settlements in northern Uganda. Participants were female South Sudanese refugees with at least moderate levels of psychological distress (cut-off ≥5 on the Kessler 6). Intervention comprised access to usual care and five 2-hour audio-recorded stress management workshops (20-30 refugees) led by briefly trained lay facilitators, accompanied by an illustrated self-help book. Villages were randomized on a 1:1 basis. Within 14 villages, randomly selected households were approached. Screening of women in households continued until 20-30 eligible participants were identified. The primary outcome was individual psychological distress, assessed using the Kessler 6 one-week before, one-week after, and three-months after intervention. Secondary outcomes included: personally-identified problems; posttraumatic stress; depression symptoms; feelings of anger; social interactions with other ethnic groups; functional impairment; and subjective well-being. Assessors were masked to allocation. Findings: Of 694 eligible participants (331 SH+, 363 EUC), 613 (88.3%) completed all assessments. We found stronger improvements for SH+ on psychological distress three months post-intervention (β = -1.20; p =0.04; 95% CI= -2.33, -.08, d= -0.26). We also found larger improvements for SH+ three months post-intervention for five of eight secondary outcomes (effect size range d=-0.30 to d=-0.36). Refugees with different trauma exposure, length of time in settlements, and initial psychological distress benefited similarly. Interpretation: An innovative guided self-help intervention that can be rapidly deployed to large numbers of participants resulted in meaningful reductions in psychological distress at three months among South Sudanese female refugees. Trial Registration: Prospectively registered at ISRCTN50148022 Funding Statement: This study was funded by the Research for Health in Humanitarian Crises (R2HC) Program, managed by Elhra (grant#12934). Declaration of Interests: None of the authors have conflicts of interests to disclose. Ethics Approval Statement: The project was approved by the MildMay Uganda Research Ethics Committee, the Uganda National Council for Science and Technology, and the WHO Ethical Review Committee and all participants provided informed consent.