Background Although several studies have examined climate change-related concerns affecting mental health, it remains unclear what specific cognitions are present in clinical samples. The present study examines (1) the thought content of patients with climate change-related concerns and (2) their cognitive styles, as reported by therapists. Methods This study is a secondary analysis of a nationwide survey of German therapists on climate change-related concerns in their patients. We qualitatively analysed reports from a subgroup of N = 214 therapists regarding patients' thought content and cognitive styles with structural content analysis. Results Therapists' reports revealed diverse themes of thought content as outlined in the literature, with the most prevalent categories reported by approximately half of therapists being the deadly threat posed by climate change (54.2%) and helplessness in face of collective inaction and individual inability (52.8%) as well as the paralysis and disengagement from life goals (48.1%) and the immediacy, celerity, and irreversibility of climate change (46.7%). The most commonly identified cognitive styles in the therapists' reports were rumination (50.0%), catastrophising (44.9%), and self- and other-blame (32.2%). Conclusions The findings indicate that recurring climate change-related cognitions in therapy correspond with established cognitive patterns and overarching themes such as loss and danger, commonly linked to depression and generalised anxiety. Preliminary associations with disorders like panic and adjustment disorder require further empirical validation. Clinically, assessing these cognitions may guide intervention adaptation and inform targeted psychotherapist training using relevant cognitive content.

BackgroundIn recent years, various risk factors for the development of prolonged grief disorder (PGD) have been discussed. While it is well established that child abuse increases the risk of various mental disorders in later life, the relationship between child abuse, including its subtypes, and PGD is barely examined.ObjectiveThe aim of this study was to assess the impact of child abuse and distinct abuse patterns on PGD symptoms in a population-based German sample.MethodsWe used self-reported data from 911 individuals (54.3 ± 17.9 years, 59.2% women) who had experienced the loss of a loved one. Participants completed demographic, loss-related and child abuse-related questions. To investigate PGD symptoms we utilized the Prolonged Grief Disorder-13+9 (PG13+9). The Childhood Trauma Questionnaire (CTQ) was employed to assess both overall child abuse severity as well as child abuse subtypes: child emotional abuse, child physical abuse, child sexual abuse. We used k-means cluster analysis to identify distinct child abuse patterns. Two hierarchical regression analyses were conducted to examine the associations between PGD symptom severity and child abuse and the identified child abuse clusters.ResultsThe prevalence rate for experiencing any child abuse was 13.5%. The occurrence of the child abuse subtypes was 7.9% for emotional abuse, 7.6% for physical abuse, and 5.9% for sexual abuse. A priori, we defined an “extreme abuse” cluster from the outliers and identified three clusters “no/low abuse”, “moderate abuse” and “high abuse” in our sample through the cluster analysis. Overall child abuse severity (ß=.13, p<0.001), “high abuse” cluster (ß=.12, p=0.001) and the a priori “extreme abuse” cluster (ß=.07, p=0.040) were significant predictors of PGD symptoms.ConclusionOur study indicates that child abuse impacts PGD symptoms. Possible hypotheses for this connection and their implications are discussed.

Background. Imminent threat does not only capture attention but also triggers defensive psychophysiological responses associated with fight-flight-freeze behavior. However, within-subject associations between central markers of attentional stimulus processing and peripheral components of early defensive activation (e.g., cardiac acceleration) are not well understood. These associations may be especially important in understanding dynamics of anxiety disorders that are characterized by cardiovascular symptoms such as panic disorder.Methods. We analyzed data from N = 90 participants with panic disorder (PD), social anxiety disorder (SAD), as well as healthy controls (CG) who completed a threat conditioning paradigm with face stimuli as conditioned stimuli (CS) and an aversive white noise burst as unconditioned stimulus (US). In addition to univariate analyses of ERPs and heartbeat, single-trial EEG evoked by the noise burst at centromedial sites and heart period were used to calculate intraindividual coupling of unconditioned cortico-cardiac responses.Results. The noise burst evoked strong cardiac acceleration and an event-related potential with a pronounced N100 component. Importantly, the magnitude of single-trial cardiac acceleration was predicted within individuals by the preceding single-trial N100 magnitude. This cortico-cardiac coupling, but not the N100 component or cardiac acceleration per se, was enhanced in individuals with panic disorder compared to social anxiety disorder, with intermediate levels of coupling observed in healthy controls.Conclusion. The present results suggest a central role of early attentional stimulus processing in subsequent cardiac defensive responses. Furthermore, they indicate that cortico-cardiac defensive responses may be altered in individuals with panic disorder specifically, rather than in anxiety disorders in general.

The death of a loved one has been identified as one of the most commonly reported traumatic experiences among refugees. This phenomenon can lead to the development of prolonged grief disorder (PGD), for which particularly elevated PGD rates were observed among refugees. Currently, there is no treatment specifically designed for refugees with PGD. Therefore, this study investigates the feasibility of a newly developed grief-focused cognitive behavioral group therapy (G-CBT) for this population. Four young refugees aged 16 to 18 and suffering from PGD were assessed pre, during and after treatment. We found a high comorbidity of PGD, posttraumatic stress disorder (PTSD) and depression at baseline. Among completers, clinician-rated PGD symptom severity decreased clinically significantly at posttreatment and remained stable at the three- and six-month follow-ups. The results indicate good feasibility in an outpatient setting with therapists providing positive feedback. However, larger and controlled studies are needed to prove its efficacy.

Background The number of refugees worldwide is at an all-time high with many being exposed to potentially traumatic events and the loss of loved ones. The 11th revision of the International Statistical Classification of Diseases and Related Health Problems now includes prolonged grief disorder and complex posttraumatic stress disorder and revised criteria for posttraumatic stress disorder. An overview of these stress-related disorders among people who have become refugees is therefore needed. Consequently, we conducted a systematic review to determine prevalence rates, comorbidities, and associated factors for each of the disorders.Method We systematically searched PubMed, Web of Science, and PsycArticles to identify studies that reported prevalence rates, predictors or associated factors, and/or comorbid mental disorders for either (1) prolonged grief disorder, (2) posttraumatic stress disorder, or (3) complex posttraumatic stress disorder among refugees. The selection process followed the PRISMA guidelines.Results A total of 36 studies met the inclusion criteria. Most of the studies were of high quality. There was substantial variation in prevalence rates by disorder, with prolonged grief ranging from 6 to 54%, posttraumatic stress disorder ranging from 0.4 to 80%, and complex posttraumatic stress disorder ranging from 3 to 74.6%. Pooled prevalence for posttraumatic stress disorder was estimated at 29.8% in treatment seeking samples and 9.92% in population samples. For complex posttraumatic stress disorder, it was estimated at 57.4% in treatment seeking samples and 7.8% in population samples. Posttraumatic stress disorder was among the most frequent comorbidities for prolonged grief disorder while depressive symptoms were the most frequently occurring co-morbidity across all three disorders. Sociodemographic variables, trauma exposure, and loss characteristics were associated with higher symptom severity. Postmigration living difficulties played an important role in prolonged grief and complex posttraumatic stress disorder.Conclusion The review revealed substantial differences in prevalence rates between the three studied disorders but underscored a very high prevalence of ICD-11 stress-related disorders among refugees. The identified associated factors point to subgroups that may be particularly at risk and establishes a foundational basis for targeted interventions and potential policy changes. Future research should incorporate longitudinal investigations and emphasize culturally sensitive assessments.

ImportanceProlonged grief disorder (PGD) is included as a new diagnosis in international classification systems. Treatments following a cognitive behavioral model are most effective, but comparisons with active control treatments are scarce. ObjectiveTo examine whether integrative cognitive behavioral therapy for prolonged grief (PG-CBT) is superior to present-centered therapy (PCT). Design, Setting, and ParticipantsThis was a rater-blinded, multicenter, randomized clinical trial (stratified by center and relationship to the deceased) with enrollment from April 2017 to May 2022. The setting included 4 university outpatient clinics in Germany. Eligible participants were aged 18 to 75 years and had PGD based on the Prolonged Grief Disorder 13 (PG-13) interview. Participants were randomized 1:1 to PG-CBT and PCT. InterventionsPG-CBT focused on the exposure to the worst moment of the loss and cognitive restructuring of grief-related cognitions in combination with solution-focused and experiential methods (eg, walk to the grave exercise). PCT was adapted in session length and number to PG-CBT and focused on a supportive relationship and coping with daily problems that may have arisen from the loss or grief symptoms. Main Outcomes and MeasuresAll outcomes were assessed at baseline, after treatment, and 12 months after randomization at follow-up. The primary outcome was a blinded assessment of the PG-13 severity score at follow-up. Secondary outcomes were self-reported depressive, somatic, and overall psychopathological symptoms. ResultsOf 544 treatment-seeking individuals experiencing bereavement, 212 eligible participants (mean [SD] age, 51.8 [13.3] years; 173 female [82%]) with PGD based on the PG-13 interview were randomized to PG-CBT and PCT (n = 106 in each condition). In the intention-to-treat analysis, both treatments yielded high reductions in PGD severity at follow-up (PG-CBT: Cohen d = 1.64; 95% CI, 1.31-1.97; PCT: Cohen d = 1.38; 95% CI, 1.09-1.66). After treatment, participants receiving PG-CBT demonstrated significantly greater reductions in PGD severity than those receiving PCT (Cohen d = 0.31; 95% CI, 0.03-0.57). At follow-up, this effect was only visible on a trend level (Cohen d = 0.28; 95% CI, -0.02 to 0.57), whereas participants in the PG-CBT group had significantly less depressive and general psychopathological symptoms. Twenty-three participants (20%) discontinued PG-CBT treatment, and 17 participants (16%) discontinued PCT. Conclusion and RelevanceThis randomized clinical trial demonstrates that PG-CBT was superior to PCT after treatment and at follow-up with regard to comorbid symptoms. Both treatments were shown to be effective and acceptable, showing the potential for dissemination and increasing patient choice. Trial registrationGerman Clinical Trials Register (DRKS) identifier: DRKS00012317

Impactful research on refugee mental health is urgently needed. To mitigate the growing refugee crisis, researchers and clinicians seek to better understand the relationship between trauma, grief and post-migration factors with the aim of bringing better awareness, more resources and improved support for these communities and individuals living in host countries. As much as this is our intention, the prevailing research methods, that is, online anonymous questionnaires, used to engage refugees in mental health research are increasingly outdated and lack inclusivity and representation. With this perspective piece, we would like to highlight a growing crisis in global mental health research; the predominance of a Global North-centric approach and methodology. We use our recent research challenges and breakdowns as a learning example and possible opportunity to rebuild our research practice in a more ethical and equitable way.

BACKGROUND:While adverse impacts of climate change on physical health are well-known, research on its effects on mental health is still scarce. Thus, it is unclear whether potential impacts have already reached treatment practice. Our study aimed to quantify psychotherapists' experiences with patients reporting climate change-related concerns and their views on dealing with this topic in psychotherapy.METHODS:In a nationwide online survey, responses were collected from 573 psychotherapists from Germany. Therapists reported on the presence of such patients, their socio-demographic characteristics, and climate change-related reactions. Psychotherapists' views on dealing with this topic in psychotherapy were also assessed. Descriptive statistics were used to analyse the responses.RESULTS:About 72% (410/573) of psychotherapists indicated having had patients expressing concerns about climate change during treatment. Out of these therapists, 41% (166/410) stated that at least one patient sought treatment deliberately because of such concerns. Patients were mainly young adults with higher education. Most frequent primary diagnoses were depression, adjustment disorder, and generalized anxiety disorder. Psychotherapists having encountered such patients differed from those without such encounters in their views on potential functional impairment and the necessity to target the concerns in treatment. Although 79% (326/415) of all respondents felt adequately prepared by their current therapeutic skills, 50% (209/414) reported a lack of information on how to deal with such concerns in therapy.CONCLUSIONS:Results indicate that psychotherapists are frequently confronted with climate change-related concerns and regard the mental health impact of climate change on their patients as meaningful to psychotherapeutic care. Regular care could be improved by a continuous refinement of the conceptualization and knowledge of the mental health influences of climate change. This would allow providing tailored methods of assessing and addressing climate change-related concerns in practice.

ImportanceProlonged grief disorder (PGD) is included as a new diagnosis in international classification systems. Treatments following a cognitive behavioral model are most effective, but comparisons with active control treatments are scarce.ObjectiveTo examine whether integrative cognitive behavioral therapy for prolonged grief (PG-CBT) is superior to present-centered therapy (PCT).Design, Setting, and ParticipantsThis was a rater-blinded, multicenter, randomized clinical trial (stratified by center and relationship to the deceased) with enrollment from April 2017 to May 2022. The setting included 4 university outpatient clinics in Germany. Eligible participants were aged 18 to 75 years and had PGD based on the Prolonged Grief Disorder 13 (PG-13) interview. Participants were randomized 1:1 to PG-CBT and PCT.InterventionsPG-CBT focused on the exposure to the worst moment of the loss and cognitive restructuring of grief-related cognitions in combination with solution-focused and experiential methods (eg, walk to the grave exercise). PCT was adapted in session length and number to PG-CBT and focused on a supportive relationship and coping with daily problems that may have arisen from the loss or grief symptoms.Main Outcomes and MeasuresAll outcomes were assessed at baseline, after treatment, and 12 months after randomization at follow-up. The primary outcome was a blinded assessment of the PG-13 severity score at follow-up. Secondary outcomes were self-reported depressive, somatic, and overall psychopathological symptoms.ResultsOf 544 treatment-seeking individuals experiencing bereavement, 212 eligible participants (mean [SD] age, 51.8 [13.3] years; 173 female [82%]) with PGD based on the PG-13 interview were randomized to PG-CBT and PCT (n = 106 in each condition). In the intention-to-treat analysis, both treatments yielded high reductions in PGD severity at follow-up (PG-CBT: Cohen d = 1.64; 95% CI, 1.31-1.97; PCT: Cohen d = 1.38; 95% CI, 1.09-1.66). After treatment, participants receiving PG-CBT demonstrated significantly greater reductions in PGD severity than those receiving PCT (Cohen d = 0.31; 95% CI, 0.03-0.57). At follow-up, this effect was only visible on a trend level (Cohen d = 0.28; 95% CI, −0.02 to 0.57), whereas participants in the PG-CBT group had significantly less depressive and general psychopathological symptoms. Twenty-three participants (20%) discontinued PG-CBT treatment, and 17 participants (16%) discontinued PCT.Conclusion and RelevanceThis randomized clinical trial demonstrates that PG-CBT was superior to PCT after treatment and at follow-up with regard to comorbid symptoms. Both treatments were shown to be effective and acceptable, showing the potential for dissemination and increasing patient choice.Trial registrationGerman Clinical Trials Register (DRKS) identifier: DRKS00012317

Background: Prolonged grief disorder (PGD) is now included as a diagnosis in international classification systems. Most research on PGD is based on Western populations, but first data from non -Western countries have recently become available. Little is still known about country-related effects on PGD's prevalence. Objective: Determining possible causes of variations in the prevalence of PGD as defined by DSM-5-TR and ICD-11 within and between countries. Methods: We retrieved data from 24 prevalence studies, the World Bank and the 2022 World Risk Report. Negative binomial regressions were used to explore methodological, loss-related and country context characteristics as predictors of PGD. The average rate of PGD was calculated using random effects models. Results: The included studies comprised 34 samples from 16 countries (20,347 participants). Non-probability sampling and older mean age of the sample as well as lower country vulnerability were associated with higher PGD rates. The average PGD prevalence was 13 % (95 % CI [11, 22]), varying from 5 % (95 % CI [3, 11]) in probability to 16 % (95 % CI [13, 25]) in non-probability samples. Limitations: Samples from Europe and North America were overrepresented. For about half of the countries, data were available from only one sample. Conclusions: While confirming the importance of studies' methodological quality, the results show that PGD is of public health relevance around the world, but especially common in less vulnerabled countries with better access to daily necessities and healthcare services, highlighting sociocultural impacts on grief processing. Further investigations of cross -national differences are needed.

Background: Refugees and asylum seekers (ASRs) are frequently exposed to loss in addition to a variety of other stressors and often display high levels of various psychological symptoms. Objective: The study aimed to primarily determine clusters of prolonged grief disorder (PGD), posttraumatic stress disorder (PTSD), and depression symptoms in bereaved ASRs and secondly identify predictors of cluster membership. Sociodemographic- and flight-related variables were investigated in exploratory analyses. Method: ASRs in Germany (N = 92) with interpersonal loss exposure, i.e. at least one missing or deceased relative or friend, were assessed with interview-based questionnaires for PGD, PTSD, and depressive symptoms. We used k-means cluster analysis to distinguish symptom profiles and logistic regression analyses to identify predictors of cluster membership. Results: We found a three-cluster-solution. The PGD-cluster (30%) was characterized predominantly by PGD symptoms, while the PGD/PTSD-cluster (32%) had high PGD and PTSD and moderate depressive symptoms. The resilient cluster (38%) showed low symptoms overall. Insecure residence status predicted membership in the PGD and PGD/PTSD clusters relative to the resilient cluster, whilst higher attachment anxiety predicted membership in the PGD/PTSD cluster relative to the other clusters. Explorative analysis revealed duration of stay as a significant predictor. Conclusion: Findings can extend the current knowledge about different symptom profiles among bereaved ASRs in Europe. Insights to attachment- and migration-related variables distinguishing between these profiles offer starting points for interventions.

Background Most individuals seeking asylum in Germany live in collective housing and are thus exposed to a higher risk of contagion during the COVID-19 pandemic. Objective In this study, we aimed to test the feasibility and efficacy of a culture-sensitive approach combining mobile app–based interventions and a face-to-face group intervention to improve knowledge about COVID-19 and promote vaccination readiness among collectively accommodated Arabic-speaking adolescents and young adults. Methods We developed a mobile app that consisted of short video clips to explain the biological basis of COVID-19, demonstrate behavior to prevent transmission, and combat misconceptions and myths about vaccination. The explanations were provided in a YouTube-like interview setting by a native Arabic-speaking physician. Elements of gamification (quizzes and rewards for solving the test items) were also used. Consecutive videos and quizzes were presented over an intervention period of 6 weeks, and the group intervention was scheduled as an add-on for half of the participants in week 6. The manual of the group intervention was designed to provide actual behavioral planning based on the health action process approach. Sociodemographic information, mental health status, knowledge about COVID-19, and available vaccines were assessed using questionnaire-based interviews at baseline and after 6 weeks. Interpreters assisted with the interviews in all cases. Results Enrollment in the study proved to be very challenging. In addition, owing to tightened contact restrictions, face-to-face group interventions could not be conducted as planned. A total of 88 participants from 8 collective housing institutions were included in the study. A total of 65 participants completed the full-intake interview. Most participants (50/65, 77%) had already been vaccinated at study enrollment. They also claimed to comply with preventive measures to a very high extent (eg, “always wearing masks” was indicated by 43/65, 66% of participants), but practicing behavior that was not considered as effective against COVID-19 transmission was also frequently reported as a preventive measure (eg, mouth rinsing). By contrast, factual knowledge of COVID-19 was limited. Preoccupation with the information materials presented in the app steeply declined after study enrollment (eg, 12/61, 20% of participants watched the videos scheduled for week 3). Of the 61 participants, only 18 (30%) participants could be reached for the follow-up interviews. Their COVID-19 knowledge did not increase after the intervention period (P=.56). Conclusions The results indicated that vaccine uptake was high and seemed to depend on organizational determinants for the target group. The current mobile app–based intervention demonstrated low feasibility, which might have been related to various obstacles faced during the delivery. Therefore, in the case of future pandemics, transmission prevention in a specific target group should rely more on structural aspects rather than sophisticated psychological interventions.