Background The COVID-19 pandemic exposed individuals to numerous psychosocial and health-related stressors associated with adjustment disorder (AjD) symptoms, yet it remains unclear which factors are most predictive.Methods Using mixed-effects regression random forests (MERF), a machine learning approach that combines random forests with mixed-effects regressions, we analyzed longitudinal data from 15,155 adults across 11 European countries collected at three time points between June 2020 and January 2022. We evaluated 245 candidate predictors, including sociodemographic, pandemic-related, and health-related factors, for their relative importance in predicting AjD symptoms (ADNM-8).Results The seven most influential predictors, ranked in descending order of importance, were uncertainty about the pandemic's duration and risks, poor health, social isolation, conflicts at home, loss of daily structure, fear of infection, and restricted personal contact with close others.Conclusions AjD symptoms were most strongly linked to factors related to lack of control (e.g., uncertainty, loss of daily structure, fear of infection), as well as current poor health and reduced social connectedness. Interventions that enhance a sense of control through clear communication, help individuals re-establish daily routines, and strengthen social connectedness may mitigate AjD symptoms during future public health crises. Our findings also highlight the potential of machine learning approaches for identifying complex patterns across high-dimensional predictors of clinical symptoms, which may improve prediction accuracy in mental health research.

Prolonged grief disorder (PGD) is a new diagnostic category included in global diagnostic classification systems for mental disorders. However, PGD can only be diagnosed if the severity and duration exceed socio-cultural norms. Here, we present a new supplementary module to the DSM-5 Cultural Formulation Interview: the Bereavement and Grief Cultural Formulation Interview (BG-CFI). The BG-CFI was developed to help clinicians provide a culturally informed diagnosis and guide treatment planning.We investigated the feasibility, acceptability, and clinical utility of the BG-CFI. Two participant groups (11 refugees, asylum seekers or migrants experiencing bereavement and 3 clinicians) took part in the study and were interviewed using open-ended questions on measures of feasibility, acceptability, and clinical utility. A step-by-step procedure was followed: (1) Clinicians and/or researchers conducted the BG-CFI with participants; (2) Debriefing interviews were conducted separately with clinicians and with bereaved participants.The BG-CFI was found to be a feasible, acceptable, and clinically useful tool for both bereaved participants and clinicians. Where clinicians found the interview difficult to conduct (i.e. lack of conceptual clarity or triggering emotional distress) specific changes were made to the interview format such as prompts for further questioning or recommendations for withholding or adapting questions. The BG-CFI would offer a useful complement for a reliable assessment of PGD in clinical settings working with cultural incongruity.

Due to the presumed high risk for prolonged grief disorder (PGD) in people bereaved during the COVID-19 pandemic, it is crucial to examine how grief develops over time in this population. This is the first study examining longitudinal symptom-profiles of PGD severity in people bereaved during the pandemic. We aimed to identify latent trajectories of DSM-5-TR PGD severity and predictors thereof in Dutch adults bereaved during the pandemic. Latent class growth modeling was employed to identify differential trajectories of PGD severity in 266 people bereaved on average 115 days prior when entering the study. Participants completed a PGD measure online (using the Traumatic Grief Inventory-Self Report-Plus) at three time-intervals six months apart. Associations between class-membership and socio-demographic, loss-related, health-related, and trauma-related characteristics were examined using multinomial logistic regression. Three trajectories were identified: Low/decreasing PGD symptoms (74%), Mild/stable PGD symptoms (18%), and High/decreasing PGD trajectory (8%). Closer kinship to the deceased, poorer self-rated health status, and having a mental disorder increased the likelihood of belonging to the Mild/stable PGD symptoms and High/decreasing PGD trajectories. This study provides insights in longitudinal PGD symptom-profiles in people bereaved during the pandemic. We found that PGD severity either remained low/mild or eventually decreased over time.

BackgroundRefugees often experience multiple traumatic events before and during forced migration, compounded by daily stressors in resettlement, which can erode resilience and increase the risk of serious mental disorders. Strengthening resilience in the aftermath of adversity may help prevent such outcomes. Mind-Spring (MS) is a low-threshold, group-based psychosocial intervention designed to enhance resilience and well-being. Intervention groups were organized by language, cultural background, and gender, and co-facilitated by a mental health professional and a peer educator with lived refugee experience, shared culture and language, and long-term settlement in the host country. This study assessed the feasibility of MS and its impact on four mental health domains among refugees and asylum seekers in the Netherlands presenting with early trauma-related symptoms.MethodsA convergent parallel mixed-methods study involved four MS groups with 37 participants (72.37% female; mean age 47.4 years, SD = 13.6). Feasibility was evaluated through attendance rates and thematic analysis of pre- and post-intervention interviews. Quantitative outcomes were measured using the Brief Resilience Scale-6 (resilience), WHO-5 Well-being Index (well-being), Cantril Ladder (life satisfaction), and Sense of Coherence-Kinderen (sense of coherence). Changes were analyzed using paired t-tests, reliable change indices, and multilevel modeling.ResultsHigh attendance and positive feedback indicated MS is both feasible and acceptable. Participants valued peer support, native-language delivery (Arabic, Dari, Tigrinya, Ukrainian), and the role of peer educators in fostering trust, engagement, and cultural relevance. The intervention’s adaptability and its potential to identify individuals needing additional care underscore its role as both a preventive and bridging approach. Topics considered most helpful included psychoeducation, coping with stress and emotions, and navigating cultural identity. Quantitative analyses revealed medium-to-large effects across domains, with particularly large gains in well-being (d = 1.22), and 62.5% demonstrating positive reliable change. Life satisfaction improved progressively during the program.ConclusionMS is a feasible, acceptable, and culturally meaningful intervention for resettling refugees, associated with improvements in resilience, well-being, life satisfaction, and sense of coherence. Despite limitations related to sample size and demographic skew, findings add to the evidence base for culturally adapted psychosocial interventions, supporting MS as a promising component within broader refugee integration and mental health services.

This short communication concerns recruitment issues in a multicenter randomized controlled trial. An overview of anticipated and unexpected recruitment issues at various organizational levels is discussed as encountered in this trial. These experiences are shared to assist researchers in avoiding similar experiences, prevent wasting valuable research resources, and justify the time and energy committed by enrolled participants.

BackgroundThe Cultural Formulation Interview (CFI) is designed to improve understanding of patients’ mental health care needs. The lack of empirical evidence on the impact and effectiveness of CFI use in clarifying people’s perspectives, experiences, context, and identity, and in preventing cultural misunderstandings between migrant patients and clinicians, inspired this study. The objective is to examine the effect of the CFI on the strength of therapeutic working alliances, and the potential mediating or moderating role of perceived empathy.Materials and methodsA multicenter randomized controlled trial will be conducted, involving migrant patients, their confidants, and clinicians. The CFI will be administered in the intervention group, but not in the control group. Validated questionnaires will be used to assess therapeutic working alliances and perceived empathy. T-tests and linear regression analyses will be conducted to investigate between-group differences and possible mediating or moderating effects.ResultsThis study will indicate whether or not the CFI strengthens the therapeutic working alliance between patients and clinicians, as moderated and/or mediated by perceived empathy.DiscussionResearch on the effect and impact of using the CFI in mental health care for migrant patients is important to clarify whether its use strengthens the therapeutic working alliance with clinicians. This can lead to a reduction in cultural misunderstandings and improve mental health care for migrant patients. The results may also be important for the implementation of the CFI as a standard of care.Ethics and disseminationThis research protocol was tailored to the needs of patients in collaboration with experts by experience. It was approved by the Ethical Review Board of the Tilburg Law School and registered in the Clinical Trials Register under number NCT05788315. Positive results may stimulate further implementation of the CFI in clinical practice, and contribute to improving the impact of the CFI on the therapeutic working alliances.

Most studies examining prolonged grief disorder (PGD) in people bereaved during the COVID-19 pandemic are focused on psychopathology. However, mental health encompasses both absence of psychopathology and presence of well-being. This is the first study examining symptom profiles of early PGD and subjective mental well-being in 266 Dutch adults recently bereaved during the pandemic. Early PGD and well-being indicators were assessed with the Traumatic Grief Inventory-Self Report Plus and the World Health Organization-Five Well-Being Index, respectively. Latent class analysis identified four classes: low PGD/high well-being (32%), low PGD/moderate well-being (24%), moderate PGD/high well-being (23%) and high PGD/low well-being class (21%). People in the poorer mental health classes were more likely to be female, lower educated, suffering from a mental disorder, have a poor health status, closer kinship to the deceased, and higher risk of severe COVID-19. Classifying adults according to symptom profiles of negative and positive outcomes provides a more complete picture of mental health in bereaved people and offers potential intervention targets.

Background Recognition that the loss of a loved one may result in prolonged grief disorder (PGD) has gained broad attention recently. PGD may disturb daily functioning to such a degree that mental health treatment is required. Because PGD symptoms often resemble symptoms of common mental disorders (CMD) such as anxiety, depressive, and post-traumatic stress disorder, clinicians may not consider a PGD diagnosis. Moreover, cultural varieties in expression of PGD may complicate recognition. This study explores the prevalence of PGD among both natives and refugees with anxiety, depressive, or trauma- and/or stressor-related disorders as well as clinicians' awareness and knowledge of PGD symptoms. In addition, a psychoeducation module on PGD symptoms is developed through patient expert collaboration. Methods Prevalence of PGD symptoms is investigated among 50 participants who are referred to outpatient clinics for anxiety, depression, or post-traumatic stress, using the Traumatic Grief Inventory—Self Report Plus (TGI-SR+) and the Bereavement and Grief—Cultural Formulation Interview (BG-CFI). Clinicians will be interviewed on knowledge (gaps) with respect to PGD symptoms. Finally, focus groups with patient experts are held to develop a psychoeducation module tailored to the patients' needs, norms and values. Results This study will show prevalence of PGD among patients who are referred for anxiety, depression, and post-traumatic stress, awareness and knowledge of clinicians on PGD symptoms, and will offer patient expert informed psychoeducation. Discussion Research on prevalence and recognition of PGD is vital. Study results of the prevalence of PGD will be compared to previous studies. Recognition of PGD as distinct disorder from CMDs requires clinicians' awareness of symptoms related to the loss of a loved one. Thereby, clinicians need to take cultural aspects related to death, bereavement and mourning into consideration. Ethics and dissemination The study protocol will be carried out in accordance with relevant guidelines and regulations. Exploratory research to assess the prevalence of PGD in patients suffering from CMDs will facilitate adequate diagnosis by increasing clinician's awareness of PGD symptoms. Tailored PGD psychoeducation, co-created by culturally diverse patient experts and clinicians will be made publicly available.

Background A growing body of literature shows profound effects of the COVID-19 pandemic on mental health, among which increased rates of post-traumatic stress disorder (PTSD) and adjustment disorder (AD). However, current research efforts have largely been unilateral, focusing on psychopathology and not including well-being, and are dominated by examining average psychopathology levels or on disorder absence/presence, thereby ignoring individual differences in mental health. Knowledge on individual differences, as depicted by latent subgroups, in the full spectrum of mental health may provide valuable insights in how individuals transition between health states and factors that predict transitioning from resilient to symptomatic classes. Our aim is to (1) identify longitudinal classes (ie, subgroups of individuals) based on indicators of PTSD, AD and well-being in response to the pandemic and (2) examine predictors of transitioning between these subgroups. Methods and analysis We will conduct a three-wave longitudinal online survey study of n≥2000 adults from the general Dutch population. The first measurement occasion takes place 6 months after the start of the pandemic, followed by two follow-up measurements with 6 months of intervals. Latent transition analysis will be used for data analysis. Ethics and dissemination Ethical approval has been obtained from four Dutch universities. Longitudinal study designs are vital to monitor mental health (and predictors thereof) in the pandemic to develop preventive and curative mental health interventions. This study is carried out by researchers who are board members of the Dutch Society for Traumatic Stress Studies and is part of a pan-European study (initiated by the European Society for Traumatic Stress Studies) examining the impact of the pandemic in 11 countries. Results will be published in peer-reviewed journals and disseminated at conferences, via newsletters, and media appearance among (psychotrauma) professionals and the general public.

∗De Evenaar, Centre for Transcultural Psychiatry, GGZ Drenthe Mental Health Care, Beilen †De Hemisfeer, Den Bosch, the Netherlands. Send reprint requests to Simon P.N. Groen, PhD, De Evenaar, Centre for Transcultural Psychiatry, GGZ Drenthe Mental Health Care, P.O. Box 30007, 9400 RA Assen, the Netherlands. E-mail: [email protected].

Although there is ample empirical evidence that traumatic events, postmigration stress, and acculturation problems have a great impact on the mental health of refugees, so far no studies have included cultural identity after migration in the equation. This mixed-methods study conducted among Afghan and Iraqi refugee and asylum-seeker psychiatric patients aims to fill this gap. Associations between postmigration stress, symptoms of anxiety and depression disorders, and symptoms of posttraumatic stress disorder were significant. When differentiated for the two groups, associations with postmigration stress were no longer significant for Afghan patients, who were predominantly younger and more often single, lower educated, and without resident status compared with Iraqi patients. Qualitative results indicate that, in addition to psychopathology and postmigration stress, acculturation problems contribute to confusion of cultural identity. The findings suggest that reduction of postmigration stress and acculturation problems may clarify cultural identity and as such may contribute to posttraumatic recovery.

Background: Migrants and refugees are at increased risk of traumatic loss of loved ones that may cause specific psychopathology. Ways of dealing with bereavement and grief are influenced by the norms of one’s cultural identity. Cultural assessment of bereavement and grief is therefore needed for a comprehensive evaluation of grief-related psychopathology and for negotiating appropriate treatment (Smid et al., 2018). Objective: To evaluate the risk of psychopathology related to traumatic and multiple loss in refugees and to describe a culturally sensitive assessment of traumatic grief. Method: We evaluated the effects of traumatic and multiple losses of family members and friends on psychopathology, disability and quality of life in Iraqi asylum seekers in the Netherlands (Hengst et al., 2018). To facilitate clinical exploration of cultural aspects of bereavement and grief, we developed a set of brief, person-centred and open-ended questions as a draft supplementary module to the DSM-5 Cultural Formulation Interview (CFI; Smid et al., 2018).> Results: The loss of a loved one was reported by 87.6% of the sample. Traumatic and multiple losses of family members independently predicted psychopathology (Hengst et al., 2018). Cultural ways of dealing with bereavement and grief include cultural traditions related to death, bereavement and mourning as well as help-seeking and coping (Smid et al., 2018). Conclusions: Clinicians need to assess psychopathology related to traumatic loss in a culturally sensitive way, especially when working with migrants and refugees. The proposed supplementary module bereavement and grief to the DSM-5 CFI supports such assessment.

Ways of dealing with bereavement and grief are influenced by the norms of ones cultural identity. Cultural assessment of bereavement and grief is therefore needed for a comprehensive evaluation of grief-related psychopathology and for negotiating appropriate treatment. Cultural aspects of bereavement and grief include cultural traditions related to death, bereavement, and mourning as well as help seeking and coping. To facilitate clinical exploration of cultural aspects of bereavement and grief, the authors propose a set of brief, person-centered, and open-ended questions as a draft supplementary module to the DSM-5 Cultural Formulation Interview.

Background There is a need for clinical tools to identify cultural issues in diagnostic assessment. Aims To assess the feasibility, acceptability and clinical utility of the DSM-5 Cultural Formulation Interview (CFI) in routine clinical practice. Method Mixed-methods evaluation of field trial data from six countries. The CFI was administered to diagnostically diverse psychiatric out-patients during a diagnostic interview. In post-evaluation sessions, patients and clinicians completed debriefing qualitative interviews and Likert-scale questionnaires. The duration of CFI administration and the full diagnostic session were monitored. Results Mixed-methods data from 318 patients and 75 clinicians found the CFI feasible, acceptable and useful. Clinician feasibility ratings were significantly lower than patient ratings and other clinician-assessed outcomes. After administering one CFI, however, clinician feasibility ratings improved significantly and subsequent interviews required less time. Conclusions The CFI was included in DSM-5 as a feasible, acceptable and useful cultural assessment tool.