Depression and anxiety are among the most common mental health conditions treated in primary care. They frequently co-occur and involve recommended treatments that overlap. Evidence from randomised controlled trials (RCTs) shows specific stepped care interventions to be cost-effective in improving symptom remission. However, most RCTs have focused on either depression or anxiety, which limits their generalisability to routine primary care settings. This study aimed to evaluate the cost-effectiveness of a collaborative stepped care (CSC) intervention to treat depression and/or anxiety among adults in Australian primary care settings.

A quasi-decision tree model was developed to evaluate the cost-effectiveness of a CSC intervention relative to care-as-usual (CAU). The model adapted a CSC intervention described in a previous Dutch RCT to the Australian context. This 8-month, cluster RCT recruited patients with depression and/or anxiety (n = 158) from 30 primary care clinics in the Netherlands. The CSC intervention involved two steps: (1) guided self-help with a nurse at a primary care clinic; and (2) referral to specialised mental healthcare. The cost-effectiveness model adopted a health sector perspective and synthesised data from two main sources: RCT data on intervention pathways, remission probabilities and healthcare service utilisation; and Australia-specific data on demography, epidemiology and unit costs from external sources. Incremental costs and incremental health outcomes were estimated across a 1-year time horizon. Health outcomes were measured as disability-adjusted life years (DALYs) due to remitted cases of depression and/or anxiety. Incremental cost-effectiveness ratios (ICERs) were measured in 2019 Australian dollars (A$) per DALY averted. Uncertainty and sensitivity analyses were performed to test the robustness of cost-effectiveness findings.

The CSC intervention had a high probability (99.6%) of being cost-effective relative to CAU. The resulting ICER (A$5207/DALY; 95% uncertainty interval: dominant to 25 345) fell below the willingness-to-pay threshold of A$50 000/DALY. ICERs were robust to changes in model parameters and assumptions.

This study found that a Dutch CSC intervention, with nurse-delivered guided self-help treatment as a first step, could potentially be cost-effective in treating depression and/or anxiety if transferred to the Australian primary care context. However, adaptations may be required to ensure feasibility and acceptability in the Australian healthcare context. In addition, further evidence is needed to verify the real-world cost-effectiveness of the CSC intervention when implemented in routine practice and to evaluate its effectiveness/cost-effectiveness when compared to other viable stepped care interventions for the treatment of depression and/or anxiety.

Socio-cultural integration of refugees has received scant attention in the academic literature. Türkiye hosts the largest number of refugees, including Afghans, as the second largest asylum-seeking group in Türkiye. There is a dearth of research into the mental health and integration of Afghan refugees in Türkiye. The aim of the present study was to investigate socio-cultural integration outcomes among Afghan refugees in Türkiye by considering the role of traumatic events and post-displacement stressors. The role of mental health in integration outcomes was further examined.

A cross-sectional, web-based survey study with 785 Afghan refugees in Türkiye was conducted between April and June 2021. Data were collected on socio-demographic characteristics, potentially traumatic events (PTEs) (Harvard Trauma Questionnaire), post-displacement stressors (Post-Migration Living Difficulties Checklist), mental health symptoms (Hopkins Symptoms Checklist-25), social integration- social bonds (contact with co-ethnic group members) and social bridges (contact with the host community)- and cultural integration (Vancouver Index of Acculturation). Structural equation modelling was conducted to test the hypothesized relationship between conflict and displacement-related stressors, mental health and socio-cultural integration.

Findings showed that conflict-related traumatic events and post-displacement stressors significantly predicted higher mental health symptoms. Experiencing traumatic events significantly predicted higher levels of social bridges, adopting destination culture and lower level of maintaining heritage culture. Mental health problems predicted the relationship between stressors related to forced displacement and integration outcomes-social bridges and adopting destination culture. These findings highlight the role of mental health as an indispensable resource for socio-cultural integration. Further, conflict and displacement-related stressors are important determinants of socio-cultural integration among Afghan refugees in Türkiye.

Exposure to PTEs and post-displacement stressors were significant risk factors for the mental health and socio-cultural integration of Afghan refugees in Türkiye. These stressful experiences deteriorate refugees’ mental health, which hinders their integration into the host society.

Among asylum seekers in a high-risk unstable post-displacement context, we aimed to investigate the prevalence of and risk for suicidal ideation (study 1), and then to test whether and how Mindfulness-Based Trauma Recovery for Refugees (MBTR-R) may prevent or treat suicidal ideation (study 2).

Study 1 was conducted among a community sample of N = 355 (31.8% female) East African asylum seekers in a high-risk urban post-displacement setting in the Middle East (Israel). Study 2 was a secondary analysis of a randomised waitlist-control trial of MBTR-R among 158 asylum-seekers (46.2% female) from the same community and post-displacement setting.

Prevalence of suicidal ideation was elevated (31%). Post-migration living difficulties, as well as posttraumatic stress, depression, anxiety and their multi-morbidity were strongly associated with suicidal ideation severity. Likewise, depression and multi-morbidity prospectively predicted the onset of suicidal ideation. Relative to its incidence among waitlist-control (23.1%), MBTR-R prevented the onset of suicidal ideation at post-intervention assessment (15.6%) and 5-week follow-up (9.8%). Preventive effects of MBTR-R on suicidal ideation were mediated by reduced posttraumatic stress, depression, anxiety and their multi-morbidity. MBTR-R did not therapeutically reduce current suicidal ideation present at the beginning of the intervention.

Findings warn of a public health crisis of suicidality among forcibly displaced people in high-risk post-displacement settings. Although preliminary, novel randomised waitlist-control evidence for preventive effects of MBTR-R for suicidal ideation is promising. Together, findings indicate the need for scientific, applied and policy attention to mental health post-displacement in order to prevent suicide among forcibly displaced people.