Predictors of outcome of the culturally sensitive group psychotherapy Empowerment for refugees with affective disorders

Strupf, Michael (2022): Predictors of outcome of the culturally sensitive group psychotherapy Empowerment for refugees with affective disorders: a multicenter randomized controlled trial. Dissertation, LMU München: Medizinische Fakultät

Abstract

Theoretical background: Due to various pre-, peri-, and post-displacement stressors that are active in the context of forced migration, refugees are at significant risk of developing mental disorders in the post-migration environment. It is a major challenge for researchers and clinicians to provide effective, culturally sensitive, and accessible mental health interventions to cover the urgent need for psychosocial care in this population. First, this dissertation gives an overview on the existing mental health interventions for refugees and asylum seekers. Second, a systematic overview of available predictor studies in this field is provided. Predictor studies represent a key element in transcultural health care research as they target the question of which refugees benefit from specific treatment options and which ones do not. Data on outcome predictors can be used to allocate refugees to those interventions which they are most likely to benefit from or modify treatment for non-responders, finally providing an empirical foundation to structure the health care system in the most effective and pragmatic possible way. As the number of available predictor studies in the field of refugee treatment is scarce, this dissertation aims to provide a comprehensive predictor analysis of psychotherapeutic treatment for refugees based on a novel group intervention named Empowerment. Methods: This dissertation was conducted within the framework of the multicenter randomized controlled trial MEHIRA (Mental Health in Refugees and Asylum Seekers), investigating a stepped and collaborative care model (SCCM) for refugees with affective disorders. 149 participants who reported moderate depressive symptoms at baseline were allocated to level 3 of the SCCM and randomly assigned either to the Empowerment group therapy or Treatment-as-usual (TAU). Empowerment is a 12-week culturally sensitive group treatment that was developed to equip refugees with functional self-help skills to deal with depressive symptoms and post-migration stressors. Depressive symptoms were assessed at baseline (T0) and post-intervention (T1) using the self-rated Patient Health Questionnaire 9 (PHQ-9) as a primary outcome, and the clinician-rated Montgomery Asberg Depression Rating Scale (MADRS) as a secondary outcome. Predictor analysis was conducted using regression models with change scores (T1-T0) of PHQ-9 and MADRS. Predictors were selected following a mixed-method approach. First, hypothesis-guided hierarchical regression models were calculated with five literature-based predictors. These were baseline depression (PHQ-9, MADRS), post-migration context factors (residence status, employment, housing), and a comorbid PTSD. Second, explorative bivariate regression models were calculated with multiple further baseline variables. Third, final regression models were calculated integrating both findings from hypothesis-guided and explorative models. All analyses were applied both to the Intention-to-treat (ITT) and Per protocol (PP) sample and both to the treatment (Empowerment) and control (TAU) condition. Results: Primary evaluations showed that Empowerment was effective in reducing depressive symptoms (PHQ-9 and MADRS) compared to TAU. Concerning the ITT sample, baseline PHQ-9 (β=-0.35, t=-3.27, p=.002) and baseline self-efficacy (β=-0.24, t=-2.26, p=.027) predicted PHQ-9 change scores, and baseline MADRS (β=-0.71, t=-8.65, p<.001) predicted MADRS change scores, in Empowerment. Concordantly, baseline self-efficacy (β=-0.30, t=-2.41, p=.020) predicted PHQ-9 change scores, and baseline MADRS (β=-0.56, t=-5.50, p<.001) predicted MADRS change scores, in TAU. Thus, analyses were repeated in the pooled ITT sample of both conditions to identify general predictors of refugee treatment outcome. It was found that baseline PHQ-9 (β=-0.30, t=-3.82, p<.001) and baseline self-efficacy (β=-0.29, t=-3.65, p<.001) were predictors of change in PHQ-9, and baseline MADRS (β=-0.71, t=-10.36, p<.001) and housing (β=-0.17, t=-2.51, p=.013) were predictors of change in MADRS. Concerning the PP sample, concomitant psychotherapy (β=0.57, t=3.66, p=.001) and identification as a migrant (β=0.44, t=2.80, p=.010) were predictors of MADRS change scores in Empowerment. In TAU, baseline self-efficacy (β=-0.43, t=-2.89, p=.006) and baseline MADRS (β=-0.34, t=-2.65, p=.012) predicted change in PHQ-9 and MADRS, respectively. Discussion: High rates of baseline depression severity and perceived self-efficacy predicted symptom improvement in participants of both conditions. Although these factors seem to represent global predictors of successful refugee treatment, they may be of high practical relevance in implementing the Empowerment intervention under real-life conditions. Contrary to the hypotheses, post-migration context factors and comorbid PTSD did not predict outcomes in Empowerment. It appears that Empowerment represents a suitable low-threshold intervention to treat a broad and diversified population of refugees in different post-migration stages and settings. A widespread dissemination of the intervention into routine practice may contribute to significant improvements in culturally sensitive mental health care. Ultimately, the presented results may find application in the development of decision-making tools that allow for optimized treatment allocations and ensure a pragmatic health care delivery to refugees in need. To extend the database on relevant outcome predictors, future studies should examine further important socio-cultural variables, such as discrimination and racism, social participation, and strategies of acculturation in the context of culturally sensitive treatment.

• Dokumententyp: Dissertationen (Dissertation, LMU München)
• Themengebiete: 600 Technik, Medizin, angewandte Wissenschaften ; 600 Technik, Medizin, angewandte Wissenschaften > 610 Medizin und Gesundheit
• Fakultäten: Medizinische Fakultät
• Sprache der Hochschulschrift: Englisch
• Datum der mündlichen Prüfung: 16. November 2022
• 1. Bericht­erstatter:in: Padberg, Frank