Mental health treatment for refugees in Germany: need and barriers (TREAT)

自2015年以来抵达德国的大量难民对德国精神卫生保健系统构成了挑战。虽然总的来说，难民的患病率并不比东道国人口高，但具体的心理障碍，特别是创伤后应激障碍的发病率却大大增加。根据目前的指南，PTSD的一线治疗是以创伤为中心的心理治疗。然而，由于在德国，少数民族很难获得心理治疗，因此很可能只有少数难民得到了充分的循证治疗。TREAT项目的目的是查明难民心理保健的障碍，特别侧重于心理治疗。根据目前的文献中难民的医疗保健利用，我们预计，获得心理保健是有限的，主观和客观因素。TREAT将与PH-LENS NEXUS项目密切合作，对第二波NEXUS调查的N = 200名参与者进行深入访谈，这些参与者对心理障碍筛查呈阳性。使用经过验证的工具，我们的目标是确定PTSD或抑郁症的初步诊断。在精神卫生保健访问的过程模型中，我们将确定不同步骤的精神卫生保健利用率和预测因素，从治疗的需要，以帮助寻求，最后，充分的循证治疗的利用。作为可能与利用率相关的因素，我们将评估心理健康信念、对卫生保健系统的了解、各种治疗的预期疗效以及寻求帮助的态度，包括感知的耻辱。在回归和中介分析的过程中，精神卫生保健利用率将进行探讨，使用主观和客观的参数作为利用率的预测。在这项调查的前一个筹备阶段，我们将与ENSURE项目密切合作，调整和评估研究工具，特别是一份调查表，以评估难民的科学和传统心理健康信念。此外，我们将告知LARGE项目在他们的小组研究中这项研究的关键参数，以便评估德国难民的代表性样本中的精神卫生保健利用情况。TREAT不仅可以具体说明难民获得精神保健的障碍，而且可以利用难民的情况作为放大一般人群的过程的透镜，揭示现有精神保健系统的局限性。在PH-LENS研究单位的背景下，TREAT将有助于了解卫生系统的弹性，通过确定主观的个人层面的因素如何与卫生系统因素相互作用，影响获得护理。

The high number of refugees who have arrived in Germany since 2015 has posed a challenge to the German Mental Health care system. While, in general, refugees do not present with higher rates of diseases than the host population, rates of specific psychological disorders, in particular posttraumatic stress disorder (PTSD), are substantially increased. According to current guidelines, the first-line treatment for PTSD is trauma-focused psychotherapy. However, since access to psychotherapy for ethnic minorities has ever been difficult in Germany, it is likely that only a small minority of the refugees have received adequate evidence-based treatment. The aim of the TREAT project is to identify barriers to mental health care for refugees, with a specific focus on psychotherapy. Based on the current literature on health care utilization among refugees, we expect that access to mental health care is limited by both, subjective as well as objective factors. In close collaboration with the PH-LENS NEXUS project, TREAT will carry out in-depth interviews with sub-sample of N = 200 participants of the second wave of the NEXUS survey who screen positive for a psychological disorder. Using validated instruments, we aim to determine a tentative diagnosis of PTSD or depression. Within a process model of mental health care access, we will determine rates and predictors of mental health care utilization on different steps, ranging from the perceived need for treatment to help seeking and, finally, the utilization of adequate evidence-based treatment. As factors that may be associated with utilization we will assess mental health beliefs, knowledge about the health care system, the expected efficacy of various types of treatment as well as attitudes to help seeking including perceived stigmatization. In regression and mediator analyses the process of mental health care utilization will be explored, using both, subjective as well as objective parameters as predictors of utilization. In a preceding preparatory phase of this survey we will adapt and evaluate the study instruments, in particular a questionnaire to assess scientific and traditional mental health beliefs among refugees, in close collaboration with the ENSURE project. Furthermore, we will inform the LARGE project about the key parameters of this study in their panel study to allow the assessment of mental health care utilization in a representative sample of refugees in Germany. TREAT will not only allow to specify the barriers to mental health care access for refugees, but, using the situation of refugees as a magnifying lens of processes in the general population, reveal limitations of the existing mental health care system. In the context of the PH-LENS research unit, TREAT will contribute to the understanding of health system resilience, by determining how subjective individual-level factors interact with health system factors in affecting access to care.