Abstract Background Mental health care faces significant challenges, particularly in Arabic-speaking countries, where only a fraction of individuals with depression receive treatment. While internet-based interventions (IBIs) have shown promising results, how clients experience IBIs is not well known, highlighting the need for a deeper understanding of client experiences. Objective To better understand the impact of IBIs, qualitative interviews were conducted with participants from Arabic-speaking countries regarding perceived changes, causes of changes, and hindering and helpful aspects of IBIs. Method In total, 93 participants (68% female; M_age = 27.45) from various Arabic-speaking countries who completed either an internet-based cognitive (n = 49) or an internet-based interpersonal (n = 44) treatment for depression were interviewed via structured change interviews to understand perceived positive and negative changes after treatment as well as perceived causes of changes, as well as helpful and hindering aspects. The interviews were analyzed using qualitative content analysis. Results Most of the participants reported positive changes after treatment, which were categorized into the five following domains: Coping strategies, Personal Growth, Interpersonal Changes, Symptomatic Changes and Increase in Activity and Energy. Causes of changes were attributed mainly to the Program Structure, Personal Factors, Working Alliance, and External Reasons. However, negative changes were also reported and categorized into Short-term and Persistent Negative Changes. Hindering aspects were related to the Program Structure and Technical Difficulties, Standardization and External Reasons. Helpful aspects were related to the Program Structure. Conclusion Despite some hindering aspects and negative changes, the IBIs predominantly induced positive changes across multiple life domains, with the Program Structure being identified as both the main cause of positive effects and an obstacle, which indicates individual-dependent differences.

Background: The PTSD Checklist for DSM-5 (PCL-5) is widely used to assess posttraumatic stress disorder (PTSD), yet validation in Arabic-speaking populations remains limited, and no guideline-based cutoff scores have been established. This study evaluated the structural validity, reliability, and diagnostic performance of the Arabic PCL-5 in a large treatment-seeking sample. Methods: As part of a broader treatment study, a total of 1140 participants from across the Southwest Asia and North Africa (SWANA) region completed the Arabic PCL-5 among other measures. PTSD diagnoses were established via the SCID-5-CV interview. Exploratory and confirmatory factor analyses assessed dimensionality. Reliability, convergent validity, and diagnostic utility were evaluated along STARD guidelines, with emphasis on ROC analyses and cutoff performance. Results: The Anhedonia model fit the data acceptably, with good to excellent internal consistencies. ROC analyses indicated moderate diagnostic utility (AUC = 0.658), with no cutoff achieving both high sensitivity and specificity. Lower cutoffs (31-33) maximized sensitivity (0.87-0.89) and positive predictive values (0.78-0.81), while a cutoff of 38 offered a more balanced compromise (sensitivity: 0.799, specificity: 0.419). The PCL-5 algorithm performed worse than optimized cutoffs. Discussion: The Arabic PCL-5 shows strong structural validity and reliability and is suitable for screening within a stepped-care approach. Its limited diagnostic accuracy likely reflects effects of the spectrum bias, sample heterogeneity and methodological differences between self-report and interviews. Based on this study, the PCL-5 is recommended for symptom monitoring and screening with clinical follow-up rather than as a stand-alone diagnostic tool in Arabic-speaking treatment-seeking individuals.

Background Refugees, including Syrians, exhibit higher rates of posttraumatic mental disorders than non-refugee populations, partly due to traumatic events and stressors before, during, and after displacement. However, differences in symptom load cannot solely be attributed to being a refugee, as comparison groups vary in other characteristics, such as country of residence and origin. Using a cross-country comparative design, the present study examined mental health outcomes associated with being a refugee by contrasting Syrian refugees with Syrian residents. Methods Syrians residing in Syria (SRS) were compared with Syrian refugees in Germany (RSG) and Turkey (RST) regarding posttraumatic stress disorder (PTSD; using the PTSD Checklist for DSM-5), depression (using the Patient Health Questionnaire-9 (PHQ-9)), and traumatic event exposure (using a curated list of traumatic events). Participants (n = 689 total, n = 236 SRS, n = 254 RSG, n = 199 RST) were recruited from an open-label dissemination study between 2021 and 2024. Prevalence rates and trauma exposure were compared between groups, and mediation models examined trauma exposure as a potential mechanism underlying group differences, adjusting for employment, education, family status, age, and gender. Results Prevalence rates were calculated for depression (SRS: 90%, RSG: 91%, RST: 86%) and PTSD (SRS: 75%, RSG: 81%, RST: 72%), with no significant differences between refugees and Syrian residents. However, both refugee groups reported significantly more trauma load (SRS vs. RSG: t = -5.94, p < 0.001; SRS vs. RST: t = -4.87, p < 0.001). Mediation models indicated that trauma load partly explained existing differences in mental health outcomes between refugees and Syrian residents (Indirect effects - SRS vs. RSG for PTSD: β = 0.040, 95% CI [0.015, 0.065], p = 0.002; SRS vs. RST for depression: β = 0.028, 95% CI [0.003, 0.053], p < 0.03; SRS vs. RST for PTSD: β = 0.059, 95% CI [0.028, 0.090], p < 0.001). Conclusion PTSD and depression rates did not differ between refugees and Syrian residents from Syria, emphasizing the high mental health symptom burden in treatment-seeking Syrians regardless of their country of residence. Notably, though trauma exposure was higher among refugees and explained existing differences in symptom load, underscoring the need for psychosocial support across host countries.

Die Entscheidung für einen assistierten Suizid kann für Angehörige mit erheblichen emotionalen Belastungen einhergehen. Trotz der vielfältigen psychosozialen Herausforderungen finden Angehörige in Forschung, Versorgung sowie in ethischen und gesellschaftlichen Diskursen zu diesem Thema bislang nur unzureichende Beachtung. Der vorliegende Artikel bietet einen Überblick über die Rolle der Angehörigen im Kontext des assistierten Suizids. Bisherige Studien zeigen, dass Angehörige häufig mit moralischen Dilemmata, ambivalenten Emotionen sowie antizipatorischer Trauer konfrontiert sind. Darüber hinaus übernehmen sie oftmals organisatorische Aufgaben zur Unterstützung der sterbewilligen Person und erleben nicht selten Stigmatisierung sowie daraus resultierende soziale Isolation. Zudem deuten bisherige Studienergebnisse darauf hin, dass Angehörige ein erhöhtes Risiko für die Entwicklung psychischer Erkrankungen aufweisen können. Gleichzeitig können bestimmte Merkmale des assistierten Suizids entlastend auf Angehörige wirken und die Verarbeitung des Verlusts positiv beeinflussen. Hierzu zählen unter anderem die Möglichkeit zur Abschiednahme, offene Kommunikation sowie die Einbindung in den Prozess des assistierten Suizids. Diese Befunde unterstreichen die Notwendigkeit spezifischer psychosozialer Unterstützungsangebote für Angehörige sowie deren frühzeitige Einbindung in relevante Prozesse.

The decision to pursue physician-assisted dying can place a significant emotional burden on relatives. Despite the considerable psychosocial stress they often face, these individuals have received limited attention in research, clinical practice and ethical or societal debates surrounding this topic. This article provides an overview of the role of relatives in the context of physician-assisted dying.Previous studies indicate that relatives are frequently confronted with moral dilemmas, ambivalent emotions and anticipatory grief. In addition, they often take on organisational responsibilities in support of the person wishing to die and may experience stigma and subsequent social isolation. Research also suggests that relatives and close friends are at increased risk for mental health challenges.At the same time, certain aspects of the process, such as the opportunity to say goodbye, open communication and the active involvement of relatives, can have a positive effect and support a more adaptive grieving process. These findings highlight the importance of psychosocial support for relatives as well as the necessity of involving them at an early stage throughout the entire process.

THEORETICAL BACKGROUND:The PHQ-9 is a widely used international screening instrument for depressive disorders, but optimal cut-off values vary depending on population and geographical region. RESEARCH QUESTION:This study aims to evaluate the psychometric properties and diagnostic accuracy of the Arabic PHQ-9 and identify the threshold with the best discrimination of current major depressive episode (MDE). METHOD:In this prospective diagnostic accuracy study, 2298 individuals were included as a convenience sample as part of an intake screening for an Arabic-language therapy project. Participants completed questionnaires and underwent a telephone-based SCID-5-CV interview, which served as the reference standard; the PHQ-9 served as the index test. Psychometric properties were assessed using EFA and CFA, and diagnostic accuracy was evaluated using ROC analyses. RESULTS:Of the 2298 participants included in the analyses, 1967 met SCID-5-CV criteria for a current MDE, while 331 did not. The psychometric evaluation yielded satisfactory values overall. The AUC was 0.71 (95% CI = 0.69-0.75). The highest sensitivity was observed at a cut-off of 10 (Se = 0.93, Sp = 0.34), while the Youden Index indicated that a cut-off of 14 provided the best balance between sensitivity (0.76) and specificity (0.56). CONCLUSION:Given that high sensitivity is central in clinical studies, the Arabic PHQ-9 is suitable as a first step in a stepped screening procedure, but not for diagnostic decision-making. Cut-off values from other linguistic versions cannot be automatically transferred and must instead be validated specifically for each language version. REGISTRATION:DRKS00016652.

Background:Refugees are a particularly vulnerable target group in healthcare. Innovative digital treatment options offer the opportunity to reduce or even close gaps in care for this particular group. Despite promising evidence, only a few digital interventions have been used in inpatient psychiatric care in Germany to date. The I-REACH project investigated the implementation of "blended care" (the use of a digital support in addition to face-to-face (F2F) routine care services) in inpatient psychiatric care for refugees. The aim was to describe the factors promoting and hindering implementation from the perspective of professionals in order to support implementation efforts. Methodology:As part of the I-REACH project, a qualitative survey was conducted to explore support factors and barriers to the implementation of a blended care application ("blended Almamar-App" in combination with face-to-face diagnostics and therapy). Between August and November 2024, 15 guided interviews were conducted with eight healthcare professionals and seven local study coordinators from the participating study centres. The interviews were coded and evaluated using a qualitative content analysis according to Kuckartz. Results:Key promoting factors and barriers were identified deductively and inductively in accordance with the interview guide from the perspective of professionals involved in the project. Technical, patient-related, practitioner-related, organizational, and structural factors were described. Conclusion:In order to integrate digital interventions such as the "blended Almamar-App" into routine care, technical requirements such as existing devices and reliable network connectivity, continuous information and training for users, and structured organization are particularly important. It is advisable to integrate data into existing digital hospital information systems wherever possible and to provide resource-oriented support to practitioners in implementing digital treatment options.

Background Politically and economically unstable contexts have been associated with increased prevalence rates of depression. Despite high demand, the availability of mental health experts and care systems is limited in Arabic-speaking countries. Internet-based interventions might provide an opportunity to treat patients independently of location. Therefore, we investigated the efficacy of internet-based cognitive behavioral treatment (iCBT) and interpersonal treatment (iIPT) for depression in Arabic-speaking countries. Methods In total, 743 Arabic-speaking adults with depression were randomly allocated to iCBT (n = 243), iIPT (n = 247), or waitlist (n = 253). Depressive, anxiety, and somatoform symptoms, perceived social support and quality of life (QoL) were assessed at pre-, and post-treatment and at three months follow-up. Multiple imputation was performed for missing data. Changes associated with treatment were analyzed using regression in the completer and intention-to-treat sample. Results Participants in both treatment groups showed lower depressive and anxiety symptom severity, higher QoL, and perceived social support compared to the waitlist group (p < .001). Somatoform symptom severity was significantly lower in participants receiving iIPT compared to waitlist (p < .001). Differences between the two treatments in all outcomes were non-significant (p > .05). Three-month follow-up treatment effects regarding depressive symptoms were indicated. Limitations The sample mainly consists of educated, single, female adults. Three- month follow-up results rely on a small subsample and must be interpreted with caution. Conclusions This is the first randomized controlled trial to demonstrate the efficacy of iCBT and iIPT for depression in Arabic-speaking countries. It provides first indications that internet-based interventions might help specific individuals in this region.

Following the ruling of the Federal Constitutional Court, the number of assisted suicides in Germany has been increasing. However, the psychological and psychosocial burden experienced by relatives in this context remains insufficiently explored. This study aims to examine specific stress factors and the motivations for seeking support from a specialized counseling center for relatives of individuals who are considering or have undergone assisted suicide.This cross-sectional study analyzes baseline data from relatives (N=23). In addition to sociodemographic characteristics, the study examines psychological stress factors, decision-making processes, and concerns of the relatives, as well as the illnesses and motives for assisted suicide of the individuals seeking to end their lives. Depressive symptoms were assessed using the Patient Health Questionnaire. Data were collected through structured questionnaires and qualitative free-text responses, which were analyzed using qualitative content analysis.The majority of relatives (83%) sought support during the period preceding the assisted suicide, particularly when a fixed date for the death had already been set. Among the participants, 30.4% exhibited moderate depressive symptoms, while 47.8% showed mild depressive symptoms. Key stress factors included ambivalent feelings between offering support and maintaining distance, moral conflicts, uncertainty about one's own role, anticipatory grief, and navigating the planning process leading up to the assisted suicide, including the day of death. Additionally, relatives reported experiencing social stigmatization and difficulties discussing assisted suicide with others. The most commonly cited reasons for assisted suicide among the individuals seeking to end their lives were the desire for control over their own death, fear of dying in an undignified manner, and loss of autonomy.The results showed that family members of individuals who choose assisted suicide are exposed to significant emotional distress. In particular, anticipatory grief and the awareness of a predetermined time of death led to a complex emotional experience marked by feelings of guilt and helplessness. Moreover, there is a high need for counseling, especially regarding emotional processing, legal uncertainties, and social support after the loss.These findings highlight the considerable emotional burden experienced by those close to individuals who undergo assisted suicide and emphasize the need for targeted psychosocial support. Future research should further explore effective counseling approaches to address anticipatory grief, moral conflicts, and social stigmatization in this context.

Unfinished business in bereavement is associated with symptoms of prolonged grief, grief-related distress and poorer adjustment to the loss. To date, no study has examined unfinished business exclusively in suicide loss survivors. The aim of this study is to address this gap by exploring unfinished business and its impact on psychopathological symptoms in individuals bereaved by suicide loss. A total of 127 suicide bereaved individuals completed a questionnaire that assessed unfinished business (UBBS), symptoms of prolonged grief (TGI-SR+), symptoms of (complex) post-traumatic stress (ITQ), depression (PHQ-9), and guilt (GEQ). Significant positive correlations were found between unfinished business and all assessed outcomes. Unfinished business as well as unresolved conflicts and unfulfilled wishes were significant predictors for symptoms of PGD, PTSD, cPTSD, depression and guilt. Including unfinished business in clinical interventions could be an essential component in the care of suicide loss survivors.

Physician-assisted suicide (PAS) is increasingly being legalized in a growing number of countries and is the focus of societal and ethical debates. However, there is limited knowledge regarding the perception and acceptance of PAS across different physical and mental health conditions. This study aimed to explore emotional responses, understanding, and willingness to support individuals with the wish for PAS. Participants from the general German population (N = 512) were presented with four case vignettes of PAS depicting individuals in an online study: one with cancer, one with depression, one with schizophrenia, and one healthy individual. Participants were asked to evaluate the emotional reactions elicited by the desire for PAS, the extent of their understanding of this wish, and their willingness to support each individual. The study revealed significant differences in reactions to the case vignettes. Pro-social emotions were lowest and anger highest when considering the healthy individual. Participants demonstrated the greatest understanding and highest willingness to support the individual with cancer, while the least understanding and support were observed for the healthy person. The differential levels of support for PAS across various conditions underscore the complex interplay between societal values, perceived quality of life, and ethical considerations, particularly when mental health is involved.

High prevalences of mental disorders have been found among people from Arabic-speaking countries. Perceived social support has often been identified as a significant factor in the development of mental disorders, and the social environment is especially important with respect to treatment-seeking. However, the extent to which different sources of perceived social support are associated with mental health remains unclear. This cross-sectional study examined latent profiles based on perceived social support from different sources, and examined their relationship with sociodemographic characteristics, psychopathological symptom severity, and quality of life (QoL). The sample consisted of N = 5,977 treatment-seeking adults from different Arabic-speaking countries. Latent profile analysis was performed to identify subgroups of individuals based on perceived social support from family, friends, and significant others. Multinomial logistic regression was used to analyze predictors of profile membership. Differences between profiles regarding depressive, posttraumatic stress, somatoform symptom severity, and QoL, were examined using tests for equality of means. We identified a five-profile class-invariant unrestricted solution. Marital status, sex, age, education, and country of origin were significant predictors of profile membership. The profiles differed significantly regarding depressive, posttraumatic stress, and somatoform symptom severity, and QoL. Participants perceiving moderate to high social support from different sources indicated lower psychopathological symptom levels. The low perceived social support profile showed lower QoL compared to all other profiles (p < .05). Individuals who perceive low social support from different sources appear to show higher psychopathological symptom severity and lower QoL. Our key finding reveals that individuals with multi-source support profiles showed significantly lower psychopathological symptom severity and higher quality of life compared to those with limited support profiles. Social support perception varies systematically between participants from different Arabic-speaking countries, with individuals from more stable countries reporting higher perceived support. Therefore, clinical interventions should integrate family members and community networks as integral components to enhance therapeutic outcomes. At a systemic level, policy initiatives should focus on strengthening societal-level support infrastructure, with approaches tailored to the local political and economic contexts of the target populations. Enhancing perceived social support must be prioritized not only within psychotherapy but also through diverse societal levels, to promote sustained mental health in Arabic-speaking countries.