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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, European Commission

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 Refugees and asylum seekers face various stressors due to displacement and are especially vulnerable to common mental disorders. To effectively manage psychological distress in this population, innovative interventions are required. The World Health Organization (WHO) Self-Help Plus (SH+) intervention has shown promising outcomes in reducing symptoms of common mental disorders among refugees and asylum seekers. However, individual participant differences in response to SH+ remain largely unknown. The Individual Participant Data (IPD) meta-analysis synthesizes raw datasets of trials to provide cutting-edge evidence of outcomes that cannot be examined by conventional meta-analytic approaches. Objectives This protocol outlines the methods of a series of IPD meta-analyses aimed at examining the effects and potential moderators of SH+ in (a) reducing depressive symptoms at post-intervention and (b) preventing the six-month cumulative incidence of mental disorders in refugees and asylum seekers. Method RCTs on SH+ have been identified through WHO and all authors have agreed to share the datasets of the trials. The primary outcomes of the IPD meta-analyses are (a) reduction in depressive symptoms at post-intervention, and (b) prevention of six-month cumulative incidence of mental disorders. Secondary outcomes include post-traumatic stress disorder symptoms, well-being, functioning, quality of life, and twelve-month cumulative incidence of mental disorders. One-stage IPD meta-analyses will be performed using mixed-effects linear/logistic regression. Missing data will be handled by multiple imputation. Conclusions These results will enrich current knowledge about the response to SH+ and will facilitate its targeted dissemination. The results of these IPD meta-analyses will be published in peer-reviewed journals., HIGHLIGHTS Refugees and asylum seekers face enormous challenges and, thus, are at risk of mental disorders. Low-intensity psychotherapeutic interventions are needed to effectively address symptoms and prevent the full-blown onset of mental disorders in refugees and asylum seekers.

The need for psychiatric patients and their family members to have access to quality user-friendly services has been studied for decades, yet few improvements have been made in treatment services. This study aims to explain how patients and family members have experienced facilitators of improvements, and their thoughts about barriers in the implementation of changes. An explanatory qualitative design was adopted. Data were collected using semi-structured interviews with eight focus groups made up of a total of 35 participants from mental health associations in Finland. The Theoretical Domains Framework guided the deductive data analysis. The Consolidated Criteria for Reporting Qualitative Studies (COREQ) was followed in the study. Participants in patient and family member associations had similar experiences and thoughts about facilitators of improvements in psychiatric services and barriers in the implementation of changes. For example, both participant groups experienced that promoting more positive roles of professionals could facilitate improvements in psychiatric care. On the other hand, a lack of theoretical competence and interpersonal skills of professionals could hinder change. We conclude that many of the facilitators that patients and families suggested could be addressed by enhancing collaboration and communication, having a more person-centred approach, focusing on recovery throughout the course of care, and acknowledging staff's well-being at work. Second, the barriers to implementing changes centre around the limited knowledge and skills of staff, and a paternalistic system that focuses on managing risk and administering treatment.

Background: Moral distress occurs when one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action. Moral distress was found to cause negative feelings, burnout, and/or resignation. Not only external factors such as lack of staff but also internal ones affect moral distress. Moral sensitivity, which is thought of as an advantage of nurses, could effect moral distress, as nurses being unaware of existing ethical problems must feel little distress. Objectives: To examine the impact of moral sensitivity on moral distress among psychiatric nurses, and affirm the hypothesis that nurses with higher moral sensitivity will suffer moral distress more than nurses with less moral sensitivity in two different samples. Ethical consideration: The study obtained ethical approval from the Research Ethics Committee of the Faculty of Medicine at Mie University (# 1111, 20.4.2010), and by the Turku University Ethics Board (29.5.2012). Permissions to undertake the study was obtained from the in two hospital districts and in one city (§ 48/4.10.2012, § 63/4.9.2012, 51/2012 27.8.2012). Informed consent was not formally obtained, because the questionnaire was anonymously reported by the participants who volunteered to answer. The participants responded voluntarily and anonymously. Methods: An anonymous questionnaire containing the Revised Moral Sensitivity Questionnaire and the Moral Distress Scale for Psychiatric nurses was conducted to 997 nurses in 12 hospitals in Japan, and 974 nurses in 10 hospitals in Finland after obtaining of approval by research ethics committees. Data were analyzed using a multi-group structural equation model analysis. Findings: A set of analyses imply that the association of moral sensitivity with moral distress is significant and similar between Japan and Finland, whereas the factor structures of moral sensitivity and moral distress may be partially different. Discussion: The result of this study may indicate that nurses with high moral sensitivity can sense and identify moral problems, but not resolve them. Therefore, supporting nurses to solve ethical problems, not benumbing them, can be important for better nursing care and prevention of nurses’ resignation. Conclusion: Moral sensitivity and moral distress were positively correlated among psychiatric nurses in both Japan and Finland, although the participating nurses from the two countries were different in qualification, age, and cultural background. Nurses with high moral sensitivity suffer from moral distress.

Katriina I Anttila,1,2 Minna J Anttila,1 Marjo H Kurki,1 Maritta A Välimäki1,3,4 1Department of Nursing Science, University of Turku, Turku, 2Helsinki University Hospital, Children and Adolescents, Child Psychiatry, Helsinki, 3Turku University Hospital, Development Unit, Turku, Finland; 4School of Nursing, Hong Kong Polytechnic University, Kowloon, Hong Kong, People’s Republic of China Abstract: Social relationships among adolescents with mental disorders are demanding. Adolescents with depressive symptoms may have few relationships and have difficulties sharing their problems. Internet may offer reliable and easy to use tool to collect real-time information from adolescents. The aim of this study is to explore how adolescents describe their social relationships with an electronic diary. Mixed methods were used to obtain a broad picture of adolescents’ social relationships with the data gathered from network maps and reflective texts written in an electronic diary. Adolescents who visited an outpatient clinic and used an intervention (N=70) designed for adolescents with signs of depression were invited to use the electronic diary; 29 did so. The quantitative data gathered in the electronic diary were summarized with descriptive statistics, and the qualitative data were categorized using a thematic analysis with an inductive approach. We found that social relationships among adolescents with signs of depression can vary greatly in regards to the number of existing relationships (from lacking to 21) and the quality of the relationships (from trustful to difficult). However, the relationships may change, and the adolescents are also willing to build up their social relationships. Professionals need to be aware of the diversity of adolescents’ social relationships and their need for personalized support. Keywords: adolescent, depression, electronic diary, internet, social relationship

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.

PURPOSE: This study aimed to explore relatives' perceptions of violent episodes and their suggestions on managing violence. DESIGN AND METHODS: Qualitative design with focus groups including relatives (n = 8) was carried out. Data were analyzed using inductive content analysis. FINDINGS: The relatives described patient violence in different contexts: at home, in a psychiatric hospital, and after discharge from the psychiatric hospital. They suggested interventions to achieve safer and more humane management of violent episodes. PRACTICE IMPLICATIONS: Relatives are a valuable source of information in developing strategies to manage patient violence humanely. Their views on developing the quality of psychiatric care merit more attention. Language: en

The purpose of this study was to describe the use of an Internet delivered question and answer column among patients with schizophrenia. The column was developed for research purposes. The study sample consisted of patients (N = 100) admitted to acute inpatient psychiatric care in two hospital districts. Descriptive data were collected from the column to which a nurse replied within 3 days and analysed using qualitative content analysis. The column had four to five questions weekly. The most common age of users was 18-24 years, and the gender distribution was almost equal. Column use was heaviest among students (44%) and least among unemployed people (19%). Out of 85 questions or comments sent to the column, 25 (29%) were related to program training and the remaining 60 (71%) were related to medication (31%), illness and tests (25%), other questions or comments (9%), daily life and coping with it (4%), and places to receive treatment (2%). An Internet delivered question and answer column can be included in the care of patients with schizophrenia. However, it requires a new type of basic and additional education in the field of mental health care in order for nurses to be able to provide nursing via the Internet forum.

PURPOSE: To explore service users' (n = 9) delayed perceptions of and suggestions for improvement of management of aggression/violence in psychiatry. DESIGN AND METHOD: Focus group interviews, inductive content analysis. FINDINGS: Participants reported aggression/violence-related negative perceptions (including loneliness, boredom, excessive control, and fear) but also memories of humane and caring personnel. The suggestions included meaningful activities and humane, interactive nursing. PRACTICE IMPLICATIONS: Delayed perceptions and proposals resembled the proximate ones. Perceptions may persist for years. Such perceptions and proposals, if taken into account from the beginning of treatment, may prevent negative long-term consequences of witnessed or experienced aggression/violence. Humane, interactive nursing models should be studied and disseminated. Language: en

Maritta Välimäki,1–3 Lauri Kuosmanen,1,4,5 Heli Hätönen,1 Marita Koivunen,1,6 Anneli Pitkänen,7 Christina Athanasopoulou,1 Minna Anttila1 1Department of Nursing Science, Faculty of Medicine, University of Turku, Finland; 2Development Unit, Turku University Hospital, Turku, Finland; 3School of Nursing, Hong Kong Polytechnic University, Kowloon, Hong Kong, SAR, China; 4University of Helsinki and Helsinki University Hospital, Helsinki, Finland; 5Social and Healthcare Department, City of Vantaa, Vantaa, Finland; 6Administrative Centre, Research and Development, Satakunta Hospital District, Pori, Finland; 7Administration Centre, Pirkanmaa Hospital District, Tampere, Finland Purpose: Information and communication technologies have been developed for a variety of health care applications and user groups in the field of health care. This study examined the connectivity to computers and the Internet among patients with schizophrenia spectrum disorders (SSDs).Patients and methods: A cross-sectional survey design was used to study 311 adults with SSDs from the inpatient units of two psychiatric hospitals in Finland. The data collection lasted for 20 months and was done through patients’ medical records and a self-reported, structured questionnaire. Data analysis included descriptive statistics.Results: In total, 297 patients were included in this study (response rate =96%). More than half of them (n=156; 55%) had a computer and less than half of them (n=127; 44%) had the Internet at home. Of those who generally had access to computers and the Internet, more than one-fourth (n=85; 29%) used computers daily, and >30% (n=96; 33%) never accessed the Internet. In total, approximately one-fourth of them (n=134; 25%) learned to use computers, and less than one-third of them (n=143; 31%) were known to use the Internet by themselves. Older people (aged 45–65 years) and those with less years of education (primary school) tended not to use the computers and the Internet at all (P

Background Mental disorders affect the well-being of adolescents. This study aims to describe adolescents' concerns and hopes from their own perspective when referred to adolescent psychiatric outpatient treatment. Method The qualitative data consisted of adolescents' (n = 70) short essays gathered using the Depis.Net Internet program and analyzed with inductive thematic analysis. Results The adolescents described their concerns and hopes regarding their relationships, daily actions, identity, and well-being. Conclusions Adolescents share their concerns and find solutions if they find a safe channel to do so. Professionals should find new ways to help adolescents share their life experiences and information technology may be a promising tool.

Background Over 64% of nurses are exposed to violent assaults by patients worldwide. This creates costs for organisations and effect on nurses’ health. To prevent assaults, the causes should be known. It has been suggested, that patient characteristics explain only a proportion of assaults, while nurses’ wellbeing related factors might contribute to assaults. However, little is known about the specific wellbeing related factors exposing nurses to assaults. The objective of the abstract is to describe these factors exposing nurses to violent assaults by patients in healthcare. Methods Review of the literature with search terms violence, assaults, aggression, nurse and patient was conducted. Databases used were Cinahl, Pubmed, PsychInfo and Cochrane (2004–2015). Also manual searches were used. Studies were excluded if: they were conducted in other setting than healthcare, perpetrators were not patients or something else than quantitative research design was used. Searches resulted in 2368 citations, from which 14 studies met the inclusion criteria. Results Nurses’ anxiety, depression, fatigue, psychological distress, burn-out, stress and decreased psychological quality of life seem to expose them to assaults. Also nurses’ experiences of increased job demands, poor job control, job strain, time pressure, physical strain and excessive amount of work seem to be their exposing factor to violent assaults by patients. Further, nurses’ feelings of fear and guilt, as well as lowered job satisfaction might expose them to assaults. Conclusions Several wellbeing-related factors seem to expose nurses’ to violent assaults realised by patients. These are related to both psychological health and working conditions. Nurses’ psychological health and working conditions should be evaluated, monitored and supported as to reduce assaults towards them by patients. Longitudinal research is also needed to verify the results due to mainly cross-sectional nature of the studies.

The aim of this explorative study was to describe nurses' opportunities to integrate computer and Internet-based programmes in psychiatric out-patient care among adolescents with depression. Therefore, nurses' daily computer use and possible problems related to it were investigated. The data were collected by conducting focus group interviews with Finnish registered nurses (n =12) working at the out-patient clinics of two university central hospitals. The data were analysed using inductive content analysis. The analysis showed that nurses used the computer and Internet in their daily work for data transmission and informal interaction with adolescents. Findings revealed that nurses have good computer skills, a positive attitude towards using the computer and Internet and were motivated to make use of both on a daily basis. Problems faced in daily computer use were a lack of instructions and education, and lack of help and support. We can conclude that nurses have good opportunities to implement computer and Internet-based programmes in adolescent out-patient care. These results are encouraging keeping in mind that adolescents are the most active Internet users in society.

Objective To evaluate the use of web-based patient education sessions in the psychiatric inpatient care. Methods The qualitative and quantitative data was collected from 93 patients’ evaluation reports in two psychiatric hospitals in Finland completed by 83 nurses. Results The web-education included six patient education sessions which were used over a period lasting between 1 and 70 days and took 10–360 min per patient. Out of 508 sessions, 464 had no interruptions or disturbances, 37 sessions had disturbances and seven sessions were interrupted. Three fourths of the sessions were used successfully. Factors associated with use were patients’ vocational education level, mental status, diagnoses, number of nurses involved and hospital. Conclusion It is important to invest effort in web-based patient education during patients’ hospitalization and to use it even with patients suffering from serious mental health disorders. This is meant to provide more alternatives in nursing.

Title. Information technology-based standardized patient education in psychiatric inpatient care Aim. This paper is a report of a study to describe nurses’ experiences of information technology-based standardized patient education in inpatient psychiatric care. Background. Serious mental health problems are an increasing global concern. Emerging evidence supports the implementation of practices that are conducive to patient self-management and improved patient outcomes among chronically ill patients with mental health problems. In contrast, the attitude of staff towards information technology has been reported to be contradictory in mental health care. Method. After 1 year of using an Internet-based portal (Mieli.Net) developed for patients with schizophrenia spectrum psychosis, all 89 participating nurses were asked to complete questionnaires about their experiences. The data were collected in 2006. Fifty-six participants (63%) returned completed questionnaires and the data were analysed using content analysis. Findings. Nurses’ experiences of the information technology-based standardized patient education were categorized into two major categories describing the advantages and obstacles in using information technology. Nurses thought that it brought the patients and nurses closer to each other and helped nurses to provide individual support for their patients. However, the education was time-consuming. Conclusion. Systematic patient education using information technology is a promising method of patient-centred care which supports nurses in their daily work. However, it must fit in with clinical activities, and nurses need some guidance in understanding its benefits. The study data can be used in policy-making when developing methods to improve the transparency of information provision in psychiatric nursing.

Schizophrenia is a serious mental illness requiring self-management skills and information about the illness, its treatment, and where to get help with daily routines. Despite the systematic development of computer-based approaches in mental health, less systematic development of such methods can be found for patients with schizophrenia or psychosis.The aim is to describe the design and development process of patient-centered computer-based support system (Mieli.Net portal) for patients with schizophrenia spectrum psychoses.The process with a mixed methods approach includes four phases: analysis of users' needs, development of key patient information areas, development of a software prototype and to pilot the portal, and user evaluation by health care staff.The computer-based patient support system is a promising health-promoting service to schizophrenic patients. It is important, that users of technology are involved in the development process, which will ensure that sites are user-friendly, information can be personalized, and mental patients' voices are heard in the development of patient education.The effectiveness needs to be evaluated carefully in future clinical trials. This will offer valuable information for policymakers, organizations and health care practitioners about the usability of web-based patient education in the area of mental health care.

Background: Patient violence against nurses in their work environments is a widespread global concern, particularly in the field of mental health care. A high prevalence of violent events impacts the well-being of nurses and may also impair overall ward climate. However, it has been proposed that nurses' use limited techniques to prevent patient violence, and, therefore, more comprehensive methods for dealing with patient violence are needed. There is still restricted understanding of the ward climate during the occurrence of a violent event as well as how these incidents could be more effectively prevented. This study aimed to explore nurses' experiences of violent events in psychiatric wards, give insight into ward climates and examine suggestions for violence prevention. Methods: This study employed a descriptive, exploratory design including focus groups (n = 5) and open-ended questions. The participants were registered and enrolled nurses (n = 22) working on three closed psychiatric inpatient wards in one Finnish hospital district. Focus groups were tape-recorded, transcribed and analyzed with inductive content analysis. Results: Nurses' experiences of violent events included a variety of warning signs and high-risk situations which helped them to predict forthcoming violence. Patient-instigated violent events were described as complicated situations involving both nurses and patients. When the wards were overloaded with work or emotions, or if nurses had become cynical from dealing with such events, well-being of nurses was impaired and nursing care was complicated. Suggestions for violence prevention were identified, and included, for example, more skilled interaction between nurses and patients and an increase in contact between nurses and patients on the ward. Conclusions: This study revealed the complexity of violent events on psychiatric wards as well as the implications of these events on clinical practice development and training, administration and policy. A routine process is needed through which nurses' experiences and ideas concerning prevention of violent events are acknowledged.