RE-DEFINE Project

RE-DEFINE aims to provide effective community-based health care implementation strategies to scale-up the delivery and uptake of psychosocial interventions for preventing the onset of mental disorders in refugees and asylum seekers resettled in middle-income and in high-income countries. The project focuses on adaptation, testing, and implementation of a novel transdiagnostic self-help preventive psychosocial intervention specifically developed by the World Health Organization (WHO) to respond to humanitarian crises. The intervention can be delivered by non-specialists to groups of up to 30 people at a time, which is particularly relevant for the refugee crisis in Europe and in bordering countries (i.e., Turkey), since the sudden increase in refugees seeking asylum poses a significant challenge to health systems’ capacity to adequately respond to the health needs of this population.

The number of people seeking refugee status has progressively increased in the last years, driven by the wars in Syria and Iraq, alongside conflicts and instability in Afghanistan, Eritrea, Somalia and elsewhere There is no evidence suggesting that numbers of refugees will decrease in the near future; indeed, the most recent data from the European Asylum Support Office suggest quite the opposite. The refugee crisis imposes highly challenging demands on health systems in Europe and bordering countries. The provision of services to address the psychological conditions of millions of refugees and asylum seekers is often conducted by non-government organisations (NGOs) and coordinated by international organisations, including the World Health Organization, the United Nations High Commissioner of Refugees, and the the International Federation of Red Cross and Red Crescent Societies. An effective, evidence-based response from health systems in countries inside and outside Europe is still incomplete and therefore an urgent issue.

Preventive psychosocial interventions

Refugees and asylum seekers often endure great physical and mental challenges either before or during displacement, and suffer continuing hardships after arrival. Refugees and asylum seekers are exposed to a constellation of stressors, i.e., poverty, violence, persecution, armed conflict, resettlement stressors. This cause them to be much more vulnerable than the general population to some common mental health conditions such as post-traumatic stress disorder, anxiety, depression and other forms of disabling psychological distress. Interventions to treat mental health problems exist, but services for refugees and asylum seekers in European mental health care systems vary in capacity. This is in part due to the lack of available professionals, which limits the availability of specialised mental health services available for refugees and asylum seekers. In some cases such services may be delivered by highly trained professionals, involving anti-depressants, Cognitive Behavioural Therapy (CBT) and interpersonal psychotherapy (IPT) for depression, or CBT, narrative exposure therapy or Eye Movement Desensitization and Reprocessing (EMDR) for Post-Traumatic Stress Disorder (PTSD). However, even though effective:

1) these approaches rely on professionals, which are a scare resource;

2) these interventions have often been developed according to the needs of Western populations, and intervention protocols usually need to be culturally adapted

3) These interventions are aimed at treating mental disorders, but are not focused on preventing mental health conditions in distressed refugees and asylum seekers exposed to a constellation of stressors.

According to a public mental health approach, preventive interventions may be categorised as follows:

In order to help large numbers of refugees and asylum seekers, urgent transformations of health systems are required to adequately scale-up evidence-based preventive psychosocial interventions in ways that are feasible (i.e., practical and affordable), sustainable and cost-effectiveness. This transformation has the potential of addressing individual quality of life and health of refugees and asylum seekers, enhancing protective underlying mechanism, and decreasing suffering. One important element of such a transformation is the inclusion of guided self-help approaches in routine care, which have been shown to be as effective as face to face psychological therapy in people with depression. This may have particular advantages for refugees and asylum seekers given the lack of services for these groups, the high level of need and that they can be delivered by non-professionals. Simultaneously, it would be beneficial for the scientific and clinical community as a whole, by reducing health costs and preventing an unprecedented social drift associated with mental health conditions.