Background: Asylum seekers and refugees are at great risk for developing mental disorders. Afghan refugees are a particularly vulnerable group with a low average education and mental health literacy level. Traumatic experiences and hardship before and during migration are predictive of mental health problems. However, post-migration living difficulties (PMLDs) also account for a large proportion of mental distress in such populations, which, critically, are not sufficiently considered in treatment protocols and research investigations. Indeed, the evidence base for the treatment of refugees and asylum seekers is sparse and limited mainly to trauma-specific treatments, where refugees may likely suffer from other mental health problems such as depression or anxiety. Methods/design: This trial is the first evaluation of a short-term, transdiagnostic treatment protocol for treatmentseeking Afghan refugees which addresses mental health problems and PMLDs while using an adapted version of the Problem Management Plus (PM+) protocol. Here, we will investigate the efficacy of an intervention manual with a prospective, single-center, randomized, assessor-blind, two-group trial among refugees who are on a waiting list for professional mental health treatment. Furthermore, we will investigate participants' subjective experiences with the intervention manual via in-depth interviews. One hundred twenty people will be assessed and randomly allocated to either the intervention arm or a treatment-as-usual arm. Clinical psychologists will conduct the treatment, and the sessions will take place with a Dari interpreter. The protocol consists of six 90-min sessions. The primary endpoint is the general symptom distress measure, assessed with the General Health Questionnaire 28 (GHQ-28). Secondary endpoints are the Post-Migration Living Difficulties Checklist (PMLDC), the International Trauma Questionnaire (ITQ), the World Health Organization Quality of Life Questionnaire (WHOQOL-BREF), the Psychological Outcome Profile (PSYCHLOPS), service and health care use (assessed with several items), and the Immigrant Integration Index (IPL-12). Discussion: This trial may provide substantial evidence for a brief transdiagnostic psychological intervention. Here, we intend to contribute to the treatment of mental health problems among Afghan refugees. The assessment of subjective experience with this treatment manual, as well as the evaluation of its clinical applicability, may optimize treatment acceptance and outcomes across a wide range of mental health problems among refugees.

Background: Afghan refugees often face hardship and traumatic experiences before, during, and after migration and frequently suffer from mental health burdens. Evidence based psychological treatments for refugees mostly focus on symptoms of posttraumatic stress disorder (PTSD), however, refugees often suffer from a variety of general health problems as well as depression and anxiety. We thus aimed to evaluate the effectiveness of a transdiagnostic psychological intervention. Objective: To investigate the effectiveness of an adapted version of Problem Management Plus (aPM+) delivered by mental health professionals to adult Afghan refugees and asylum seekers. Methods: We randomly allocated 88 Afghan refugees either to aPM+ in addition to treatment as usual (aPM+/TAU) or TAU alone. APM+ comprises of six weekly 90-minute individual sessions including strategies of stress management, problem solving, behavioural activation, strengthening social support and either anger regulation or increasing self-efficacy. The primary outcome was general health (GHQ-28) post intervention. Secondary outcome measures included distress by PMLD, Complex PTSD symptoms, quality of life, self-identified problems, and integration. Results: Attrition was high: 42% of the randomized participants did not participate in the post-treatment assessment. A repeated measures per-protocol (completers only) ANCOVA evidenced a significant group × timepoint interaction for GHQ total scores [F(1, 47) =  14.80, p < .001, partial η 2 = 0.24]. Post-hoc analyses showed significantly lower symptoms in the aPM+/TAU arm ( n = 26) as compared to the TAU arm ( n = 25) for the GHQ total scores ( d z = 1.04). Most secondary outcomes significantly improved in the aPM+/TAU arm, but not in the TAU arm. Conclusion: APM+ was effective in reducing general health problems in Afghan refugees and might be considered as a first-line intervention. High drop-out rate limit the interpretations of our results, where future investigations should focus on possibilities to reduce these rates. Trial registration: . HIGHLIGHTS Refugees’ mental health can be strengthened with a brief psychological intervention that also focuses on skills in the context of post-migration stressors. High drop-out rates are a major challenge for future research and delivery of psychological interventions as part of health care systems to refugees and asylum seekers.

Background Numerous traumatic experiences and post-migration living difficulties (PMLDs) increase the risk of developing symptoms of complex post-traumatic stress disorder (CPTSD) among Afghan refugees and asylum seekers, living in Austria. Research has repeatedly associated higher levels of CPTSD with higher levels of PMLDs. Summarizing PMLDs into empirically derived factors might facilitate a further understanding of their interaction with symptom presentation within distinct clusters of CPTSD. Objective The current study aimed to investigate homogeneous subgroups of ICD-11 CPTSD and their association with demographic variables, traumatic experiences, and empirically derived factors of PMLDs. Method Within a randomized controlled trail (RCT) CPTSD, PMLDs, and traumatic experiences were assessed in a sample of 93 treatment-seeking Afghan refugees and asylum seekers through a fully structured face-to-face and interpreter-assisted interview using the ITQ, the PMLDC, and a trauma checklist. Underlying clusters of CPTSD, superior factors of PMLDs, and their associations were investigated. Results In total, 19.4% of the sample met the diagnostic criteria for PTSD and 49.5% for CPTSD. We identified a 2-cluster solution consisting of two distinct subgroups as best fitting: (1) a CPTSD cluster and (2) a PTSD cluster. The multitude of PMLDs was summarized into four superior factors. CPTSD cluster membership was associated with childhood potentially traumatic experience types, and one of four PMLD factors, namely ‘language acquisition & barriers’. Conclusions The results suggest that not PMLDs in general, but rather specific types of PMLDs, are associated with CPTSD. An assumed bidirectional relationship between these PMLD factors and CPTSD symptoms might lead to a downward spiral of increasing distress, and could be considered in treatment strategies.

Background Psychological distress due to the ongoing war, violence, and persecution is particularly common among Afghan asylum seekers and refugees. In addition, individuals face a variety of post-migration living difficulties (PMLDs). Complex posttraumatic stress symptoms are among the most common mental health problems in this population, and were associated with the overall burden of PMLDs. The complex interplay of posttraumatic symptoms has been investigated from a network perspective in previous studies. However, individuals are embedded in and constantly react to the environment, which makes it important to include external factors in network models to better understand the etiology and maintaining factors of posttraumatic mental health problems. PMLDs are a major risk factor for posttraumatic distress and considering their impact in interventions might improve response rates. However, the interaction of these external factors with posttraumatic psychopathological distress is not yet fully understood. Thus, we aimed to illuminate the complex interaction between PMLDs and CPTSD symptom clusters. Objective The main objective is the exploration of the network structure and the complex interplay of ICD-11 CPTSD symptom clusters and distinct forms of PMLDs. Method The symptom clusters of CPTSD and PMLDs were collected within a randomised controlled trial among 93 treatment-seeking Afghan asylum seekers and refugees via a fully structured face-to-face and interpreter assisted interview. Using a network analytical approach, we explored the complex associations and network centrality of the CPTSD symptom clusters and the PMLD factors: discrimination & socio-economical living conditions, language acquisition & barriers, family concerns, and residence insecurity. Results The results suggest direct links within and between the constructs (CPTSD, PMLD). Almost all PMLD factors were interrelated and associated to CPTSD, family concerns was the only isolated variable. The CPTSD symptom cluster re-experiencing and the PMLD factor language acquisition & barriers connected the two constructs. Affective dysregulation had the highest and avoidance the lowest centrality. Conclusions Re-experiencing and affective dysregulation have the strongest ties to PMLDs. Thus, these domains might explain the strong association of posttraumatic psychopathology with PLMDs and, consequently, prioritization of these domains in treatment approaches might both facilitate treatment response and reduce burden caused by PMLDs.

Background: While many elaborated treatment protocols focus on post-traumatic stress symptoms, a large number of refugees suffer from a range of mental health problems. Thus, brief and transdiagnostic psychological interventions may be helpful first interventions for help-seeking refugees and asylum seekers in a stepped-care approach. Critically, there is limited research on how transdiagnostic interventions are received in general practice in non-specialized mental healthcare settings in high-income countries, where often only mental health professionals (MHPs) are legally allowed to treat people with mental disorders. MHPs may thus deliver such interventions, but their perspective towards them has not yet been investigated. Objective: We aimed to investigate MHPs’ perception of the usability of adapted Problem Management Plus (aPM+), a brief transdiagnostic psychological intervention for refugees, which we adapted to address distress caused by post-migration living difficulties (PMLDs). Method: Employing an e-learning tool, we introduced the aPM+ intervention to 59 MHPs and assessed their perspective towards the intervention. We then used an inductive approach to analyse their perspective towards the intervention with open-ended questions. Results: Altogether, 59 MHPs enrolled in the webinar and 29 provided feedback on the intervention. MHPs had a positive view on the intervention but emphasized the importance of situation-specific adaptations to the structure of the manual. The most favoured specific strategies were ‘managing stress/slow-breathing’, the ‘tree of capabilities’, and the ‘riding the anger’ exercise. The last two were additionally developed to reduce distress caused by PMLDs by either enhancing self-efficacy or reducing anger regulation difficulties. Conclusions: An adaptation to aPM+ regarding more flexibility of the manual may enhance the likelihood of MHPs implementing the intervention in their daily practice. Strategies addressing coping with PMLDs could be particularly helpful. Trial registration: . HIGHLIGHTS Mental health professionals had a positive view on a brief transdiagnostic psychological intervention for refugees but emphasized the importance of situation-specific adaptations to the structure of the manual. Low -intensity interventions may be useful not only in low- and middle-income countries but also in high-income countries as part of a stepped-care approach, even if distributed by MHPs instead of trained laypersons.