Jutta Lindert

Depression and anxiety in labor migrants and refugees – A systematic review and meta-analysis

Prevalence rates of depression and anxiety among migrants (i.e. refugees, labor migrants) vary among studies and its been found that prevalence rates of depression and anxiety may be linked to financial strain in the country of immigration. Our aim is to review studies on prevalence rates of depression and/or anxiety (acknowledging that Post-traumatic Stress Disorder (PTSD) is within that class of disorders), and to evaluate associations between the Gross National Product (GNP) of the immigration country as a moderating factor for depression, anxiety and PTSD among migrants. We carried out a systematic literature review in the databases MEDLINE and EMBASE for population based studies published from 1990 to 2007 reporting prevalence rates of depression and/or anxiety and or PTSD according to DSM- or ICD- criteria in adults, and a calculation of combined estimates for proportions using the DerSimonian-Laird estimation. A total of 348 records were retrieved with 37 publications on 35 populations meeting our inclusion criteria. 35 studies were included in the final evaluation. Our meta-analysis shows that the combined prevalence rates for depression were 20 percent among labor migrants vs. 44 percent among refugees; for anxiety the combined estimates were 21 percent among labor migrants vs. 40 percent among (n=24,051) refugees. Higher GNP in the country of immigration was related to lower symptom prevalence of depression and/or anxiety in labor migrants but not in refugees. We conclude that depression and/or anxiety in labor migrants and refugees require separate consideration, and that better economic conditions in the host country reflected by a higher GNP appear to be related to better mental health in labor migrants but not in refugees.

Social Support, Socio-Economic Status, Health and Abuse among Older People in Seven European Countries

Background Social support has a strong impact on individuals, not least on older individuals with health problems. A lack of support network and poor family or social relations may be crucial in later life, and represent risk factors for elder abuse. This study focused on the associations between social support, demographics/socio-economics, health variables and elder mistreatment. Methods The cross-sectional data was collected by means of interviews or interviews/self-response during January-July 2009, among a sample of 4,467 not demented individuals aged 60–84 years living in seven European countries (Germany, Greece, Italy, Lithuania, Portugal, Spain, and Sweden). Results Multivariate analyses showed that women and persons living in large households and with a spouse/partner or other persons were more likely to experience high levels of social support. Moreover, frequent use of health care services and low scores on depression or discomfort due to physical complaints were indicators of high social support. Low levels of social support were related to older age and abuse, particularly psychological abuse. Conclusions High levels of social support may represent a protective factor in reducing both the vulnerability of older people and risk of elder mistreatment. On the basis of these results, policy makers, clinicians and researchers could act by developing intervention programmes that facilitate friendships and social activities in old age.

Enhancing the emotional and social skills of the youth to promote their wellbeing and positive development: a systematic review of universal school-based randomized controlled trials

Background: The acquisition of social and emotional skills is associated with positive youth development, character education, healthy lifestyle behaviours, reduction in depression and anxiety, conduct disorders, violence, bullying, conflict, and anger. School-based interventions aimed to enhance these skills go beyond a problem-focused approach to embrace a more positive view of health; they could also improve the youth’s wellbeing. Aim: To describe the main features and to establish the effectiveness of universal school-based RCTs for children and the youth, aimed to promote their psychosocial wellbeing, positive development, healthy lifestyle behaviours and/or academic performance by improving their emotional and social skills. Methods: Systematic review by searching for relevant papers in PubMed/Medline with the following key words: “mental health” OR “wellbeing” OR “health promotion” OR “emotional learning” OR “social learning” OR “emotional and social learning” OR “positive youth development” OR “life skills” OR “life skills training” AND “school”. Interval was set from January 2000 to April 2014. Results: 1,984 papers were identified through the search. Out of them 22 RCTs were included. While most interventions were characterized by a whole-school approach and SAFE practices, few studies only used standardized measures to assess outcomes, or had collected follow-up data after ≥ 6 months. The results of all these trials were examined and discussed. Conclusion: Universal school-based RCTs to enhance emotional and social skills showed controversial findings, due to some methodological issues mainly. Nevertheless they show promising outcomes that are relatively far-reaching for children and youth wellbeing and therefore are important in the real world.

Elder abuse and socioeconomic inequalities: a multilevel study in 7 European countries.

OBJECTIVES To compare the prevalence of elder abuse using a multilevel approach that takes into account the characteristics of participants as well as socioeconomic indicators at city and country level. METHODS In 2009, the project on abuse of elderly in Europe (ABUEL) was conducted in seven cities (Stuttgart, Germany; Ancona, Italy; Kaunas, Lithuania, Stockholm, Sweden; Porto, Portugal; Granada, Spain; Athens, Greece) comprising 4467 individuals aged 60-84 years. We used a 3-level hierarchical structure of data: 1) characteristics of participants; 2) mean of tertiary education of each city; and 3) country inequality indicator (Gini coefficient). Multilevel logistic regression was used and proportional changes in Intraclass Correlation Coefficient (ICC) were inspected to assert explained variance between models. RESULTS The prevalence of elder abuse showed large variations across sites. Adding tertiary education to the regression model reduced the country level variance for psychological abuse (ICC=3.4%), with no significant decrease in the explained variance for the other types of abuse. When the Gini coefficient was considered, the highest drop in ICC was observed for financial abuse (from 9.5% to 4.3%). CONCLUSION There is a societal and community level dimension that adds information to individual variability in explaining country differences in elder abuse, highlighting underlying socioeconomic inequalities leading to such behavior.

Psychological abuse among older persons in Europe: a cross‐sectional study

Purpose – Elder abuse is an issue of great concern world-wide, not least in Europe. Older people are increasingly vulnerable to physical, psychological, financial maltreatment and sexual coercion. However, due to complexities of measurement, psychological abuse may be underestimated. The purpose of this study is to investigate the prevalence of psychological abuse toward older persons within a 12 month period.Design/methodology/approach – The study design was cross-sectional and data were collected during January-July 2009 in the survey “Elder abuse: a multinational prevalence survey, ABUEL”. The participants were 4,467 randomly selected persons aged 60-84 years (2,559 women, 57.3 per cent) from seven EU countries (Germany, Greece, Italy, Lithuania, Portugal, Spain, Sweden). The sample size was adapted to each city according to their population of women and men aged 60-84 years (albeit representative and proportional to sex-age). The participants answered a structured questionnaire either through a face-to-face interview or a mix of interview/self-response. The data were analysed using descriptive statistics and regression methods.Findings – The prevalence of overall psychological abuse was 29.7 per cent in Sweden, followed by 27.1 per cent in Germany; 24.6 per cent in Lithuania and 21.9 per cent in Portugal. The lowest prevalence was reported in Greece, Spain and Italy with 13.2 per cent, 11.5 per cent and 10.4 per cent, respectively. Similar tendencies were observed concerning minor/severe abuse. The Northern countries (Germany, Lithuania, Sweden) compared to Southern countries (Greece, Italy, Portugal, Spain) reported a higher mean prevalence (across countries) of minor/severe abuse (26.3 per cent/11.5 per cent and 12.9 per cent/5.9 per cent, respectively). Most perpetrators (71.2 per cent) were spouses/partners and other relatives (e.g. children). The regression analysis indicated that being from Greece, Italy, Portugal and Spain was associated with less risk of psychological abuse. Low social support, living in rented housing, alcohol use, frequent health care use, and high scores in anxiety and somatic complaints were associated with increased risk of psychological abuse.Social implications – Psychological abuse was more prevalent in Northern than Southern countries and factors such as low social support and high anxiety levels played an important role. Further studies are warranted to investigate the prevalence of psychological abuse and risk factors among older persons in other EU countries. Particular attention should be paid to severe abuse. Such research may help policy makers and health planers/providers in tailoring interventions to tackle the ever growing problem of elder abuse.Originality/value – The paper reports data from the ABUEL Survey, which collected population based data on elderly abuse.

Suicide, recession, and unemployment

www.thelancet.com Vol 381 March 2, 2013 721 Submissions should be made via our electronic submission system at http://ees.elsevier.com/ thelancet/ Aaron Reeves and colleagues suggest that the suicide rate in the USA has increased since 2007 in direct correlation to the increase in unemployment caused by economic recession. However, although this correlation seems strong, the cause and eff ect interpretation remains problematic. In the data Reeves and colleagues provide in their appendix, there is a temporal advance of the rise in suicides in relation to the rise in unemployment. Thus if a causative correlation really exists between the two, and since the cause should appear fi rst and the eff ect should follow, then the inevitable conclusion should be that suicides cause un employment and not vice versa. Of course such an assumption is irrational, but it points to the simple fact that, despite the widely believed theory that unemployment increases suicide, the data are inconclusive. Argentina experienced a severe crisis during 1999–2002, and, according to WHO data, suicide rates increased during 2000–08 (from 6·4–6·6 per 100 000 in 1985–95 to 7·5–7·7 per 100 000 in 2000–08); however, this increase was still lower than the rates reported for the years before 1980 (9·4–9·9 per 100 000). Con cerning eastern European countries, the data are confl icting. For example, Hungary saw an increase in suicide rates in the mid-1980s, before the fall of the Berlin wall, and a relative decrease a decade later, whereas Ukraine experienced a sharp increase only after the Berlin wall had fallen. Some data suggest an increase in suicides in east Asia because of the fi nancial crisis of the late 1990s. Premature overinterpretations are not only unwise but can also be harmful. Indeed, discussion of suicidality in the media is itself an independent risk factor for suicide.

Refugees mental health—A public mental health challenge

Mental health is central to health, and research has recognized the vulnerability of refugees, asylum seekers and internally displaced persons in relation to mental health.1 Escalating wars and continuous conflicts contributed to mass displacement of people during 2015. By the end of 2015 almost 60 million individuals were forcibly displaced. In 2015, one million refugees came to Europe, and almost 4000 have died in the Mediterranean. This situation requires a timely and effective Public Mental Health answer (Box 1). Box 1 Definition The 1951 United Nations Convention Relating to the Status of Refugees defines a refugee as a person who ‘owing to well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion, is outside the country of his nationality and is unable or, owing to such fear, is unwilling to avail himself of the protection of that country; or who, not having a nationality and being outside the country of his former habitual residence as a result of such events, is unable or, owing to such fear, is unwilling to return to it’. An asylum seeker is a person seeking international protection whose claim has not been determined …

Abuse of Older Men in Seven European Countries: A Multilevel Approach in the Framework of an Ecological Model.

Background Several studies on elder abuse indicate that a large number of victims are women, but others report that men in later life are also significantly abused, especially when they show symptoms of disability and poor health, and require help for their daily activities as a result. This study focused on the prevalence of different types of abuse experienced by men and on a comparison of male victims and non-victims concerning demographic/socio-economic characteristics, lifestyle/health variables, social support and quality of life. Additionally, the study identified factors associated with different types of abuse experienced by men and characteristics associated with the victims. Methods The cross-sectional data concerning abuse in the past 12 months were collected by means of interviews and self-response during January-July 2009, from a sample of 4,467 not demented individuals aged between 60–84 years living in seven European countries (Germany, Greece, Italy, Lithuania, Portugal, Spain and Sweden). We used a multilevel approach, within the framework of an Ecological Model, to explore the phenomenon of abuse against males as the complex result of factors from multiple levels: individual, relational, community and societal. Results Multivariate analyses showed that older men educated to higher levels, blue-collar workers and men living in a rented accommodation were more often victims than those educated to lower levels, low-rank white-collar workers and home owners, respectively. In addition, high scores for factors such as somatic and anxiety symptoms seemed linked with an increased probability of being abused. Conversely, factors such as increased age, worries about daily expenses (financial strain) and greater social support seemed linked with a decreased probability of being abused. Conclusions Male elder abuse is under-recognized, under-detected and under-reported, mainly due to the vulnerability of older men and to social/cultural norms supporting traditional male characteristics of stoicism and strength. Further specific research on the topic is necessary in the light of the present findings. Such research should focus, in particular, on societal/community aspects, as well as individual and family ones, as allowed by the framework of the Ecological Model, which in turn could represent a useful method also for developing prevention strategies for elder abuse.

How Ethics Failed — The Role of Psychiatrists and Physicians in Nazi Programs from Exclusion to Extermination, 1933–1945

Background: Disregard of Hippocratic medical ethics by major leaders in the Public Health establishment and the leadership role played by physicians during the Nazi era in Germany (1933–1945) pose continuing challenges for later generations to investigate and disclose. Aims: We review the history of evolution from humiliation of mental patients, other ill and disabled individuals and targeted ethnic groups to humiliation, sterilization, and “involuntary euthanasia” (a euphemism for medical murder). We focus on the role played by psychiatrists and neurologists during the Nazi period in Germany; we discuss the ethical norms of universal dignity, compassion and responsibility and we propose concrete steps to prevent recurrence of medically supported genocide. Methods: We explored the history of psychiatry of the period leading up to, including and immediately after the Nazi era in order to analyze the ethical standards and practices of psychiatrists and neurologists. Results: Psychiatrists, and neurologists, were guilty leaders and participants in the implementation of the Nazi programs, which escalated from humiliation and classification of their victims to the exclusion of the mentally ill and disabled, to devaluation and forced sterilization, to medical murder, then finally to the industrialized mass murder of millions, named the “Final Solution”. Discussion: This process was driven by a dangerous mix of failure of medical ethics, racist ideology and individual ambition. Radicalized myths of racial and genetic purity and 19th century technology of industrial production transformed into a technology driven industry of mass murder; motivated by calculated ambitions and desire for individual career advancement. Post war, the Nuremberg Trials and later The Universal Declaration of Human Rights defined standards of ethical framework for the medical profession everywhere. Outlook: Each generation should be made aware of these events through awareness, education and communication to prevent recurrence of medical professional criminality.

Angst, Depressionen und posttraumatische Belastungsstörungen bei Flüchtlingen – eine Bestandsaufnahme

Anxiety, depression and posttraumatic stress disorder are the main psychopathological symptoms shown by refugees. We conducted a systematic review. First, we identified key-words for a systematic search in PUBMED. We included original articles since 2009 with 1) a non-clinical sample of refugees, 2) refugees living at maximum 5 years in the host country, 4) with the outcomes anxiety, depression, and PTSD and 5) a sample with >100 participants. Then we read titles, abstracts and fulltexts. We identified 1 877 studies. Based on this screening procedure, we included in our review 15 studies. 52% of the refugees are from Africa (Somalia, Congo, Rwanda, Liberia, Sierra-Leon and Togo), 33% from Asia (Syria, Bhutan, Vietnam, Cambodia, Iraq) and 16% are from more than one continent. In those studies n=6 769 refugees participated in the studies. The number of participants varied from n=117 to n=1,422 (Median: n=366 refugees). Prevalence rates for PTBS varied from 5-71% (mean prevalence rate: 32%) rates for depression varied from 11-54% (mean prevalence rate: 35%). Sensitivity analyses suggest that refugees, which come from countries with intense human rights violations according to the Political Terror Scale, have an increased rate of psychopathological symptoms. Heterogeneity of prevalence rate is related both 1) to methodological and 2) to difference in the refugee populations according to the human rights violations in the countries of origin of refugees. It is necessary to include further databases in a systematic review. There is an urgent need for representative studies on refugees needs for psychosocial and medical care, especially for those refugees coming from countries with intense human rights violations. Psychosocial and medical services for these refugees are urgently needed to enhance and enable a perspective in the host country Germany.