Refugees and asylum seekers have often been exposed to multiple or complex traumas and are known to have a high rate of trauma-related disorders. Different therapeutic approaches have been used to treat this group with varying success. Narrative Exposure Therapy (NET) is one promising intervention for refugees and asylum seekers that are suffering from post-traumatic stress-disorder (PTSD). NET is a treatment given individually or in small groups in typically 12 sessions or less. In NET, memories are reorganized through a process involving imaginary exposure to trauma.

To review the literature on NET for refugees and asylum seekers suffering from PTSD.

The data bases PubMed, Medline, PsycInfo and Web of Science were searched using a selection of search terms, including ‘Narrative therapy’, ‘refugees’ and ‘stress disorders, post-traumatic’. The identified relevant articles were qualitatively assessed and effect sizes were compared. Methodological quality was assessed according to the GRADE-criteria.

Thirteen studies were assessed with a total study population of 745. Nine of the included studies were RCTs. Overall, the studies found medium to very high effects of NET. The quality of the studies varied from very low to high. More studies of NET for refugees and asylum seekers are needed, and in particular studies reporting long-term outcomes.

The review suggests that NET shows promise as a method for the treatment of PTSD in refugees and asylum seekers. However, the review is based on relatively few studies and more studies of long-term outcomes are particularly needed.

Evaluate the impact of the initial health assessment service for asylum seekers provided by the Asylum Practice Service.

Examine the inputs of Asylum practice service to asylum seekers. Investigate the activities and outputs of the Asylum practice service. Identify the outcomes of Asylum practice service to asylum seekers. Assess the impact of Asylum practice service to asylum seekers.

The conceptual framework for measuring impact at the asylum practice service was based on a Logic Model to engage stakeholders and service users in order to evaluate the impact of services provided by the service. Also the Refugee Health Screener – 15 (RHS15) was used to screen the emotional distress/trauma to identify those individuals who would benefit from further mental health evaluation and treatment. Both quantitative and qualitative data were used to articulate and evidence social value performance and to tell the story of change created.

The study shows that newly arrived asylum seekers benefit from the services of asylum practice, even though the impact could be marginal in some cases.

There is a need to revisit the current Initial Health Assessment tool, as in its current form, vital information on the causes of trauma such as rape, torture, human trafficking, and witnessing the death of parents, child, and close relatives which may underpin mental health problems, may not be captured, thus preventing access to appropriate interventions.

No significant relationships.

Post-traumatic stress disorder (PTSD) is commonly experienced by asylum seekers and refugees (ASR). Evidence supports the use of cognitive behavioural therapy-based treatments, but not in group format for this population. However, group-based treatments are frequently used as a first-line intervention in the UK.

This study investigated the feasibility of delivering a group-based, manualised stabilisation course specifically developed for ASR. The second aim was to evaluate the use of routine outcome measures (ROMs) to capture psychological change in this population.

Eighty-two participants from 22 countries attended the 8-session Moving On After Trauma (MOAT) group-based stabilisation treatment. PHQ-9, GAD-7, IES-R and idiosyncratic outcomes were administered pre- and post-intervention.

Seventy-one per cent of participants (n = 58) attended five or more of the treatment sessions. While completion rates of the ROMs were poor – measures were completed at pre- and post-intervention for 46% participants (n = 38) – a repeated-measures MANOVA indicated significant improvements in depression (p = .001, ηp2 = .262), anxiety (p = .000, ηp2 = .390), PTSD (p = .001, ηp2 = .393) and idiosyncratic measures (p = .000, ηp2 = .593) following the intervention.

Preliminary evidence indicates that ASR who attended a low-intensity, group-based stabilisation group for PTSD experienced lower mental health scores post-group, although the lack of a comparison group means these results should be interpreted with caution. There are significant challenges in administering ROMs to individuals who speak many different languages, in a group setting. Nonetheless, groups have benefits including efficiency of treatment delivery which should also be considered.

In total numbers, Germany has faced the largest number of refugees and asylum seekers (RAS) in Europe in the past decade. Although a considerable proportion have experienced traumatic and stressful life events, there is no systematic review to date examining the prevalence of depressive symptoms and post-traumatic stress disorder (PTSD) symptoms in RAS in Germany.

To calculate the prevalence of depressive symptoms and PTSD symptoms in the general population of RAS living in Germany after the year 2000 and explore the impact of study- and participant-related characteristics on prevalence estimates.

We systematically searched PubMed, CINAHL, PsycINFO, PSYNDEX, Academic Search Complete, Science Direct and Web of Science from January 2000 to May 2020 to identify articles reporting prevalence of depressive symptoms and PTSD in RAS in Germany (PROSPERO registration number: CRD42020182796).

In total, 31 different surveys met inclusion criteria with 20 surveys reporting prevalence estimates of depressive symptoms and 25 surveys symptoms of PTSD. Based on screening tools, the pooled prevalence estimate of PTSD symptoms was 29.9% (95% CI 20.8–38.7%) and of depressive symptoms 39.8% (95% CI 29.8–50.1%). Heterogeneity was large within and between subgroups. In multivariate meta-regressions on depressive symptoms, heterogeneity was largely explained by survey period, length of field period and study quality.

Prevalence rates of depressive symptoms and PTSD symptoms in RAS are notably large. They exceed the prevalence in the general German population. As a result of high heterogeneity, however, pooled prevalence rates should be interpreted with caution.

This editorial introduces and reflects on a Praxis article in the trainees' section of this issue. The article, 'Assessing asylum seekers, refugees and undocumented migrants' by Waterman et al, begins with a clinical scenario describing an emergency presentation at a ‘place of safety’. The authors are to be congratulated for navigating a compassionate path through the complexities of law, health and new diagnostic categories. The resources found in the article, drawing on the principles of trauma-informed care and the work of Judith Herman, can help trainees to be more confident in promoting the basic rights of survivors of trauma, which might form a first step in the re-establishment of trust and empowerment.

All over the world, migration is affecting millions of people who either choose or are forced to leave their countries of origin. Health is considered to be one of the important aspects of migration that is highly influenced by the circumstances created by mobility within or across countries. In the context of forced migration, it is well-established that refugees are susceptible to various diseases and other health conditions which might occur or deteriorate based on the health systems and health care provision in receiving countries. There is a considerable amount of research on the challenges encountered by refugees in receiving countries, in terms of health care systems and services. However, there seems to be little focus on the health care providers’ perspectives of the challenges in health care provision in refugee settings. This review aims to explore some of the articles discussing the challenging issues surrounding refugee health from a provider’s perspective.

A systematic review was conducted through five main online databases: Medline (US National Library of Medicine, National Institutes of Health; Bethesda, Maryland USA); Science Direct (Elsevier; Amsterdam, Netherlands); Scopus (Elsevier; Amsterdam, Netherlands); Sage (Sage Publications; Thousand Oaks, California USA); and Google Scholar (Google Inc.; Mountain View, California USA), including only the articles published in English. In addition, grey literature resources available online were used.

Forty-eight articles were included in this review, mainly based on the amount of emphasis they placed on providers’ viewpoints in refugee health settings. Most of the articles were retrieved based on their availability in the databases which Hacettepe University (Ankara, Turkey) is subscribed to. Almost all of the articles mentioned the challenges caused by linguistic and cultural barriers, and some focused on providers’ limited knowledge and skills, as well as inefficient health care systems. There was little emphasis on ethical discussions, and the physical and emotional impact of caring for refugees on health care professionals. In the few articles discussing ethical and personal dimensions, issues concerning stress, burnout, and safety risks were found to be the recurring themes.

Evidence gathered suggests that the challenges faced by health care providers involve a variety of factors that are specific to health care settings involving refugees, such as linguistic and cultural barriers, and a lack of proper support and training. It seems that the challenges that health care providers face in refugee settings could be further investigated both from professional and personal aspects for a better understanding of refugee health care.

Kavukcu N, Altıntaş KH. The challenges of the health care providers in refugee settings: a systematic review. Prehosp Disaster Med. 2019;34(2):188–196

We sought to identify and review published studies that discuss the ethical considerations, from a physician’s perspective, of managing a hunger strike in a prison setting.

A database search was conducted to identify relevant publications. We included case studies, case series, guidelines and review articles published over a 20-year period. Non-English language publications were translated.

The review found 23 papers from 12 jurisdictions published in five languages suitable for inclusion.

Key themes from included publications are identified and summarised in the context of accepted guidelines from the World Medical Association. Whilst there seems to be an overall consensus favouring autonomy over beneficence, tensions along this fine balance are magnified in jurisdictions where legislation leads to a dual loyalty conflict for the physician.