Mid Sweden University

Refugees often experience multiple losses. Despite this, and even though the loss is often due to unnatural causes and violent killings, the presence of Prolonged Grief (PG) among refugees may be obscured by other diagnoses such as depression and post-traumatic stress disorder (PTSD). In this cross-sectional study, we assessed the prevalence of PG and its comorbidity with depression and PTSD among 679 adult refugees in Sweden. Results showed that 401 (59.06 %) individuals had lost someone close to them, whom they were grieving intensely. Of these, 76 individuals (18.95 % of 401) fulfilled the criteria for PG. In the full sample, 304 individuals fulfilled the criteria for depression and 56 (18.42 % of 304) of these individuals also fulfilled the criteria for PG. Similarly, 315 fulfilled the criteria for PTSD. Among these individuals, 201 reported loss and 64 (20.32 % of 315) also fulfilled the criteria for PG. The results indicate that behind symptoms of depression and PTSD, there may be a layer of grief. This needs to be considered if we are to provide accurate and effective assessments and interventions for refugees. 

BACKGROUND: Many refugees suffer from mental health problems due to stressful and traumatic events before, during, and after migration. However, refugees are facing a wide variety of barriers, limiting their access to mental health care. Internet-based tools, available in several languages, could be one way to increase the availability of mental health services for refugees. The present study aimed to develop and test a screening tool to screen for clinically relevant symptoms of psychiatric disorders common among refugees (i.e. Depression, Anxiety, Post-traumatic stress disorder, and Insomnia). We, designed, translated, and adapted an internet-based tiered screening procedure suitable for use with the largest refugee populations residing in Sweden. The tool aims to accurately identify symptoms of mental distress (Tier 1), differentiate between symptoms of specific psychiatric disorders (Tier 2), and assess symptom severity (Tier 3). We tested the overall efficiency of using a tiered screening procedure. METHODS: Seven hundred fifty-seven refugees residing in Sweden, speaking any of the languages Arabic, Dari, Farsi, English, or Swedish, completed an online questionnaire following a three-tiered procedure with screening instruments for each tier. In this study, the Tier 3 scales were used as reference standards for clinically relevant symptoms, to evaluate screening efficiency in terms of accuracy and reduction of item burden in previous tiers. RESULTS: The results show that the tiered procedure could reduce the item burden while maintaining high accuracy, with up to 86% correctly assessed symptoms and few false negatives with moderate symptoms and above (at most 9%), and very few with severe symptoms (at most 1.3%). DISCUSSION: This study generated an accurate screening tool that efficiently identifies clinically relevant symptoms of common psychiatric disorders among refugees. Using an adapted online tiered procedure to screen for multiple mental health issues among refugees has the potential to facilitate screening and increase access to mental health services for refugees. We discuss the utility of the screening tool and the necessity of further evaluation. 

Background: Although post-traumatic stress is prevalent among unaccompanied refugee minors (URM), there are few evidence-based psychological interventions for this group. Teaching Recovery Techniques (TRT) is a brief, manualised intervention for trauma-exposed youth, which has shown promising results in exploratory studies. The aim of the present study was to assess the feasibility of conducting a randomised controlled trial (RCT) evaluating the use of TRT among URM by investigating key uncertainties relating to recruitment, randomisation, intervention delivery and data collection. Methods: A 3-month long non-blinded internal randomised pilot trial with a parallel-group design assessed the feasibility of a planned nationwide multi-site RCT. URM with or without granted asylum were eligible if they were 14 to 20 years old, had arrived in Sweden within the last 5 years and had screened positive for symptoms of post-traumatic stress disorder (PTSD). Quantitative data were collected pre- and post-intervention, and 18 weeks after randomisation. On-site individual randomisation (1:1) followed directly after pre-intervention assessment. Participants allocated to the intervention were offered seven weekly group-based TRT sessions. Quantitative pilot outcomes were analysed using descriptive statistics. Qualitative information was gathered through on-site observations and follow-up dialogue with group facilitators. A process for Decision-making after Pilot and feasibility Trials (ADePT) was used to support systematic decision-making in moving forward with the trial. Results: Fifteen URM (mean age 17.73 years) with PTSD symptoms were recruited at two sites. Three of the youths were successfully randomised to either TRT or waitlist control (TRT n = 2, waitlist n = 1). Fourteen participants were offered TRT for ethical reasons, despite not being randomised. Six (43%) attended ≥ 4 of the seven sessions. Seventy-three percent of the participants completed at least two assessments, with a response rate of 53% at both post-intervention and follow-up. Conclusions: The findings demonstrated a need for amendments to the protocol, especially with regard to the procedures for recruitment and randomisation. Upon refinement of the study protocol and strategies, an adequately powered RCT was pursued, with data from this pilot study excluded. Trial registration: ISRCTN47820795, prospectively registered on 20 December 2018 

Previous self-report measures of attachment have used different assessment approaches, and a common conceptualization is using a dimensional perspective in which attachment is measured with two factors: attachment anxiety and attachment avoidance. The Experiences in Close Relationships—Relationship Structures Questionnaire (ECR-RS) has, prior to this study, been assessed for psychometric properties regarding specific relationships, but not in a shorter version for close relationships in general. In this paper, we present a Swedish translation of the ECR-RS Global nine-item version assessed for factor structure and psychometric properties by using a cross-validation approach with two separate adult samples. In Study 1 (N = 492), participants were randomly split into two subsamples. Using an exploratory factor analysis (EFA), the first subsample was used for finding the best-fitting model while the second subsample was used to test the a priori model using confirmatory factor analysis (CFA). In Study 2 (N = 806), we set out to validate the factor structure yet again by using CFA. Results from the EFA supported a two-factor structure with six items for attachment avoidance and three items for attachment anxiety. In the validation of the factor structure using CFA, both studies showed that all model-fit indices were good only after some modification, including removal of one avoidance item. Methodological reasoning and implications are discussed. The final eight-item model showed good internal consistency, as well as good convergent and discriminant validity, and multi-group invariance tests for gender and age showed no violations to invariance. Findings are encouraging to use this short global attachment self-report instrument, but further validation is advised. 

In this cross-sectional study we aimed to assess symptoms of depression and anxiety at an early stage of the COVID-19 pandemic, and to explore factors predictive of these mental health outcomes. A sample of 1,503 participants, recruited from the general Swedish population, completed an online survey distributed through social media. In this sample, 22.2% reported clinically significant levels of depressive symptoms (PHQ-9 >= 10) and 10.9% indicated possible major depression using the PHQ-9 algorithm. Moreover, 28.3% reported clinically significant levels of anxiety (GAD-7 >= 8) and 9.7% severe anxiety and possible GAD (GAD-7 >= 15). Multiple linear regression analyses identified some common predictors for both outcomes. Age, having a stable income, and sufficient social stimulation, sleep, and recovery showed negative associations, whereas worry about the economy and overall burden showed positive associations. These results suggest an impact on mental health already at an early stage of the COVID-19 pandemic.

Research indicates that subgroups of refugees may be at increased risk for suicidal ideation, but further knowledge on this topic is needed. This study aimed to assess both prevalence and factors associated with suicidal ideation among newly arrived refugees in Sweden. Assessing suicidal ideation was part of a larger project, aiming to develop a model for assessment and treatment of mental health problems among refugees. The included data were based on a cross-sectional survey among 510 asylum seekers and refugees, all under the care of the Swedish Migration Agency. The project group visited 12 asylum accommodations and 9 other locations, asking potential participants to answer a survey with questions on mental health, suicidal ideation and quality of life. Data were analysed using logistic regression. Symptoms of depression, anxiety and posttraumatic stress disorder, low physical and psychological quality of life, and being of young age were all independently associated with suicidal ideation. This study points to the importance of identifying refugees with mental health problems and of providing them with adequate care. It also indicates the importance of assuring a decent quality of life at asylum accommodations, and it shows that the young may constitute an especially vulnerable group. 

Road hazard perception is considered the most prominent higher-order cognitive skill related to traffic-accident involvement. Regional cultures and social rules that govern acceptable behavior may influence drivers’ interpretation of a traffic situation and, consequently, the correct identification of potentially hazardous situations. Here, we aimed to compare hazard perception skills among four European countries that differ in their traffic culture, policies to reduce traffic risks, and fatal crashes: Ukraine, Italy, Spain, and Sweden. We developed a static hazard perception test in which driving scenes with different levels of braking affordance were presented while drivers’ gaze was recorded. The test required drivers to indicate the action they would undertake: to brake vs. to keep driving. We assessed 218 young adult drivers. Multilevel models revealed that the scenes’ levels of braking affordance (i.e., road hazard) modulated drivers’ behavior. As the levels of braking affordance increased, drivers’ responses became faster and their gaze entropy decreased (i.e., visual search strategy became less erratic). The country of origin influenced these effects. Ukrainian drivers were the fastest and Swedish drivers were the slowest to respond. For all countries, the decrement in response times was less marked in the case of experienced drivers. Also, Spanish drivers showed the most structured (least erratic) visual search strategy, whereas the Italians had the most rigid (most constant) one. These results suggest that road hazard perception can be defined cross-culturally, with cultural factors (e.g., traffic climate, legislation) modulating response times and visual search strategies. Our results also support the idea that a multimodal assessment methodology is possible for mass testing of road hazard perception and its outcomes would be relevant to understand how different traffic cultures shape driving behavior. 

Asylum seekers suffer high levels of distress but have restricted access to mental health care. This paper constitutes an evaluation of a psycho-educational group intervention, called AMIN, which was provided at two asylum accommodation centers in Sweden. A mixed-methods approach was used. To assess potential effectiveness, acceptability, and feasibility, quantitative outcome measures were combined with qualitative information from interviews with both intervention participants and staff providing the intervention. Potential effectiveness in reducing symptoms of distress and insomnia and in increasing physical quality of life was found, even though the intervention participants suffered from more severe distress than expected. In general, the intervention seemed to be acceptable to both participants and staff, with concrete strategies seeming more meaningful than abstract psychological techniques. Finally, regardless of the asylum process itself being a complicating factor, the intervention seemed feasible to deliver to individuals with different backgrounds and conditions. Taken together, these results indicate that some sessions may need further elaboration, but also that the transition to a randomized control trial is reasonable.

BACKGROUND: Refugee children have often experienced traumas and are at significant risk of developing mental health problems, such as symptoms of post-traumatic stress disorder (PTSD), depression and anxiety, which can continue for years after resettlement. The Accompanied refugeeS In Sweden Trial (ASsIST) aims to evaluate a community-based intervention, called 'Teaching Recovery Techniques' (TRT), for accompanied refugee minors experiencing PTSD symptoms. METHODS/DESIGN: A cluster randomised controlled trial will be conducted in which participants will be randomly allocated to one of the two possible arms: the intervention arm (n=113) will be offered the TRT programme and the waitlist-control arm (n=113) will receive services as usual, followed by the TRT programme around 20 weeks later. Outcome data will be collected at three points: pre-intervention (T1), post-intervention (T2; c.8 weeks after randomisation) and follow-up (T3; c.20 weeks after randomisation). ETHICS AND DISSEMINATION: Ethical approval was granted by the Regional Ethical Review Board in Uppsala (Ref. 2018/382) (24th February 2019). Results will be published in scientific journals. TRIAL REGISTRATION DETAILS: ISRCTN17754931. Prospectively registered on 4th June 2019. 

BACKGROUND: In 2015, 162,877 persons sought asylum in Sweden, 35,369 of whom were unaccompanied refugee minors (URMs). Refugee children, especially URMs, have often experienced traumas and are at significant risk of developing mental health problems, such as symptoms of post-traumatic stress disorder (PTSD), depression and anxiety, which can continue years after resettlement. The Swedish UnaccomPanied yOuth Refugee Trial (SUPpORT) aims to evaluate a community-based intervention, called Teaching Recovery Techniques (TRT), for refugee youth experiencing PTSD symptoms.

METHODS/DESIGN: A randomised controlled trial will be conducted in which participants will be randomly allocated to one of two possible arms: the intervention arm (n = 109) will be offered the TRT programme, and the waitlist-control arm (n = 109) will receive services as usual, followed by the TRT programme around 20 weeks later. Outcome data will be collected at three points: pre-intervention (T1), post-intervention (T2; about 8 weeks after randomisation) and follow-up (T3; about 20 weeks after randomisation).

DISCUSSION: This study will provide knowledge about the effect and efficiency of a group intervention for URMs reporting symptoms of PTSD in Sweden. TRIAL REGISTRATION: ISRCTN, ISRCTN47820795. Prospectively registered on 20 December 2018.