Abstract
Background: The mental health of immigrants and refugees is an important issue, which may point at cultural differences, baseline mental health problems, and underlying mental states. Culturally adapted psychiatric interventions are designed to meet these problems in countries with different cultures.
Methods: This study is a systematic review. After searching relevant English and Persian papers with keywords of refugee, immigrant, psychotherapy, and Iran in Scopus, Medline, and Google Scholar databases besides IranDoc, ElmNet, Magiran, Iranmedex, SID, and Civilica, as databases indexing Iranian journals and Persian scientific articles until December 2022, the included papers screened by two independent reviewers and their data were extracted in previously-designed forms.
Results: After removing duplicate papers, 1742 papers were screened but only 14 papers met eligibility criteria and their full-texts were available or the corresponding author was available for asking for the full text. Majority of the studies focused on depression and post-traumatic stress disorder and various aspects of culturally-adapted psychiatric interventions, including interventions with similar comparing with different interviewer race, same-race group-therapy approaches, and various cognitive behavioral therapy (CBT).
Conclusion: There are few culturally-adapted interventions reported in the literature, which shows the importance of applying culture-related modifications on therapy methods. However, depression, post-traumatic stress disorder, and grief are three main mental health issues of Persian-speaking immigrants and refugees and face-to-face and internet-based CBT, psychodrama and trauma-focused group therapy were the main interventions among the reported culture-considered ones.
Keywords: Cognitive behavioral therapy, Depression, Grief, Iran, Post-traumatic stress disorders, Psychodrama, Psychotherapy, Refugees, Search engine 

Introduction
The mental health needs of immigrants and refugees, including Iranian and Persian speaking immigrants, are an important public health concern that requires attention from mental health professionals, policymakers, and the broader community. Culturally adapted psychiatric interventions hold promise in addressing the mental health needs of Iranian immigrants and other immigrant and refugee populations.
Iranian immigrants are a particularly important group to consider in the context of psychiatric intervention. Recent statistics show that an estimated three million Iranians live outside of Iran, with the majority residing in the United States, Canada, and Europe (1). Push factors such as political instability, economic challenges, and limited professional growth opportunities in the country of origin often compel individuals to seek better prospects abroad. On the other hand, pull factors like attractive salaries, advanced educational opportunities, superior work environments, and robust social welfare systems in destination countries serve as powerful motivators (2). Iranian immigrants, like other immigrants, experience a range of mental health problems, including anxiety, depression, and  Post-Traumatic Stress Disorder  (PTSD), which are often exacerbated by the challenges of adjusting to a new culture, including language barriers, discrimination, and social isolation (1).
Given the unique needs of Iranian immigrants, it is important to consider culturally adapted psychiatric interventions. Culturally adapted interventions are designed to take into account the specific cultural, linguistic, and social needs of the target population (3). For Iranian immigrants, this may involve integrating traditional Iranian healing practices and cultural values into Western psychiatric treatment approaches.
The development of culturally adapted psychiatric interventions requires an understanding of the cultural context of mental illness in Iran (3), the impact of migration and acculturation on mental health (4), and the incorporation of Iranian cultural values and beliefs into the therapeutic process. In Iranian culture, for instance, the role of family and community in supporting mental health is highly valued (3). Thus, it may be important to involve family members or community leaders in the therapeutic process to provide additional support and encouragement.
Moreover, collaboration between mental health professionals and members of the target population is essential to ensure that interventions are tailored to the specific needs of the population and are culturally sensitive. This collaboration can help to promote cultural sensitivity, understanding, and collaboration in the provision of mental health services (5).
Further research is needed to develop and evaluate these interventions and promote cultural sensitivity and collaboration in the provision of mental health services. This systematic review aims to review current literature about culturally-adapted psychiatric interventions among Iranian and other Persian speaking population whether inside or outside of the country. Studies among various Iranian races and studies comparing Iranian and Persian speaking immigrants or refugees among people in other countries were the interests of this study.

Materials and Methods
Search strategy
A systematic review on English and Persian literature was conducted in order to collect every article, related to culturally adapted psychiatric interventions among Iranian and Persian speaking refugees or immigrants, including cross-sectional studies, reports, case controls, and clinical trials. The query (refug* OR migra* OR immigr*) AND (psychotherap* OR “cognitive therapy” OR “behavioural therapy” OR “cognitive behavioural therapy” OR “behavioural cognitive therapy”) AND (iran* OR persian) was searched among Scopus, Medline, and Google Scholar databases besides IranDoc, ElmNet, Magiran, Iranmedex, SID, and Civilica, as databases indexing Iranian journals and Persian scientific articles until December 2022.
The titles were all included and reviewed by two independent authors, separately. The inclusion criteria were as follows:
The study should evaluate the outcomes of at least one psychiatric intervention.
The study population should be Iranian immigrants or refugees, or they should make at least one separate group in the study population.
The disagreements among the researchers were resolved through consensus. 

Data extraction
After the title screening process, the articles were accessed and their required data were extracted in a pre-designed extraction sheet. Main variables included study method, population age- and sex-group, study groups and the comparison group, population size, the intervention, how the intervention is adapted to the culture, follow-up time, outcome measures, and cultural considerations in the study. Data were extracted and discussed by expert psychiatrists. inappropriateness, sole method reporting and not mentioning the study outcomes, and just reporting the complaints of the refugees and immigrants, rather than using a treatment approach, were the most important reasons of exclusion.

Results
Finally, 14 articles met the inclusion criteria and included in the study (Figure 1). Three of these articles were Persian and 11 were published in English. As shown in table 1, most of the studies have focused on depression, post-traumatic stress disorder, and grief, respectively. In addition, 7 studies have also focused on youth population.
It was explicitly noted in 12 studies that the psychiatrist was from a different race and culture from the patients. The follow-up period also ranged from 5 weeks to 10 years. It is noteworthy that most of the patients were evaluated using self-constructed questionnaires and a vast variety of standardized questionnaires, which made it impossible to pool the data for a quantitative analysis.
Main interventions were CBT and internet-based CBT, psychodrama, and trauma-focused group therapy. None of the included studies controlled the prescribed drugs but most of them reported use of serotonin selective reuptake inhibitors, anticonvulsants, and antipsychotics. Addressing specific cultural aspects, as well as respecting and considering trans-cultural differences were noted in all the interviews, performed to evaluate the treatment expectations (6-8). Not considering all of cultural components may yield to low adherence, even in the presence of care givers with the same race and language (9).

Table 1. The summary of the included studies

Post-Traumatic Stress Disorder (PTSD), Acceptance and Commitment Therapy (ACT), Cognitive Behavioral Therapy (CBT), Major Depressive Disorder (MDD), Prolonged Grief Discomfort (PGD).

Discussion
What Problems Do Immigrants Usually Experience?
The systematic review conducted in this study highlights that Iranian and Persian speaking immigrants are likely to experience various mental health challenges, including PTSD, depression, social avoidance, social discomfort, social phobia, acculturation stress, and grief. Research has shown that PTSD is a prevalent mental health condition among Iranian immigrants, with a prevalence rate ranging from 5.6 to 28.9% (10). Depression is another significant mental health problem among Iranian immigrants. Research has reported high rates of depression among Iranian immigrants, with a prevalence rate ranging from 17.3 to 55% (3). Depressive symptoms are associated with a variety of factors, including economic hardship, social isolation, discrimination, and acculturation stress. Iranian immigrants face numerous challenges that can contribute to depression, including cultural and linguistic barriers, limited social support, and difficulty accessing mental health services (11).
In addition to PTSD and depression, Iranian immigrants may experience other mental health problems, such as social avoidance, social discomfort, and social phobia. These difficulties are often linked to cultural and linguistic differences, as well as the challenge of adapting to a new social environment (12). Social isolation and loneliness are also common among Iranian immigrants, which can exacerbate mental health problems and lead to a reduced sense of well-being and depression.
Acculturation stress is another significant mental health challenge faced by Iranian immigrants. Acculturation refers to the process of adapting to a new culture, which can be accompanied by significant stress and anxiety (7,13,14) . Iranian immigrants may experience acculturation stress due to factors such as language barriers, discrimination, and difficulties in finding employment. This stress can manifest in a variety of mental health problems, including anxiety, depression, and PTSD (7,14). Grief is also a significant mental health issue among Iranian immigrants. Immigration often involves leaving behind loved ones and familiar cultural practices, which can lead to feelings of loss and grief (15). This grief can be further compounded by the challenges of adapting to a new culture and environment.
Overall, understanding the mental health challenges faced by Iranian immigrants is critical to developing culturally sensitive and appropriate interventions that can facilitate their adjustment and improve their mental health outcomes. PTSD and depression, in particular, can lead to significant impairments in functioning, including social, occupational, and academic functioning. More importantly, these mental health problems can interfere with the process of acculturation and assimilation, which can ultimately impact the health and well-being of the entire immigrant community. It is therefore essential to develop and implement culturally adapted interventions that take into account the unique challenges faced by Iranian immigrants, including their cultural beliefs, values, and practices.

Cognitive behavior therapy
Cognitive-Behavioral Therapy (CBT) is a form of psychotherapy that aims to change negative thoughts, beliefs, and behaviors. It has been found to be effective in treating a range of mental health problems, including depression, anxiety, PTSD, and trauma-related disorders. CBT usually involves weekly face-to-face sessions with a therapist and homework assignments between sessions. The effectiveness of CBT has been demonstrated in numerous studies, including meta-analyses (16). However, research has shown that the standard form of CBT may not be culturally appropriate for some populations, including immigrants and refugees. Spanhel and Lechner-Meichsner studies demonstrated that the refugees from Eastern countries expect more concentration on their difference from the Western population, especially on their habits, goals, diseases and their current stressors. They prefer religious and social support to explicit psychiatric meeting, due to their concerns about stigmas (8,17) .
Internet-based CBT is a newer approach to delivering CBT interventions remotely, using technology. Studies have shown that internet-based CBT can be as effective as traditional face-to-face CBT in treating depression, anxiety, and PTSD (13). This approach may be particularly useful for individuals who have limited access to mental health services due to location, transportation, or other barriers. However, there is less research on the effectiveness of internet-based CBT specifically for immigrant and refugee populations. However, this approach should meet the immigrants’ special condition. As reported by Lindegaard, young Iranian immigrants had low adherence to culturally-adapted internet-based CBT due to low human contact, difficult concentration, and their low energy level (9).
Culturally adapted CBT involves modifying traditional CBT interventions to better fit the cultural and linguistic backgrounds of the individuals receiving the treatment. This approach has been found to be effective in improving mental health outcomes for a range of populations, including immigrants and refugees. Culturally adapted CBT may include modifications to the language used in therapy sessions, as well as adaptations to the content of therapy materials to better align with cultural values and beliefs. By making CBT interventions more culturally sensitive and appropriate, culturally adapted CBT can improve access to mental health care for immigrant and refugee populations, who may face additional barriers to accessing traditional forms of therapy (18). Culturally adapted CBT has been shown to have the potential to decrease psychopathological distress and enhance the quality of life by improving emotion regulation strategies. However, it is important to note that due to uncertainties associated with asylum status and housing conditions, additional support may be required (19).

Trauma-focused group therapy
Trauma-focused group therapy is a form of psychotherapy that focuses on addressing the psychological effects of trauma by providing support and guidance to individuals who have experienced traumatic events. It is typically delivered in a group setting and involves a structured series of sessions that aim to promote healing, recovery, and resilience (20). The goal of trauma-focused group therapy is to help individuals develop coping skills and strategies that enable them to better manage the psychological symptoms associated with trauma (21) there is inadequate research identifying differential symptom profiles related to bereavement and trauma exposure in these groups. The objective of this study were to (1.
Research has shown that trauma-focused group therapy can be an effective intervention for individuals who have experienced trauma, including refugees and immigrants (22). The group setting provides a supportive environment where individuals can share their experiences, connect with others who have similar experiences, and receive validation and understanding. In addition, group therapy can provide a sense of community and belonging, which is especially important for refugees and immigrants who may feel isolated or disconnected from their new environment (20).
Culturally adapted trauma-focused group therapy may be particularly effective for refugees and immigrants. The experience of trauma and the cultural background of refugees and immigrants can impact the presentation and experience of psychological symptoms, as well as the types of coping strategies that are effective (21) there is inadequate research identifying differential symptom profiles related to bereavement and trauma exposure in these groups. The objective of this study were to culturally adapted group therapy can take into account the unique cultural beliefs, values, and experiences of the individuals participating in the therapy, and tailor the therapy to their specific needs (29). This may include incorporating culturally specific practices and traditions into the therapy, as well as addressing issues related to acculturation, discrimination, and identity (20). Overall, trauma-focused group therapy is a valuable treatment option for individuals who have experienced trauma, and it can play an important role in promoting healing and recovery. The effectiveness of trauma-focused group therapy can be enhanced through cultural adaptation and a focus on addressing the unique needs of refugees and immigrants. There is strong evidence which supports the effect of trauma-focused group therapy in improving PTSD, depression, and anxiety of Iranian immigrants and asylum seekers. Even 2-day per week sessions have represented promising effects (23). However, it was reported that the symptoms would return 5 years after the intervention, which emphasizes the need for long-term follow-ups (24).

Psychodrama
Psychodrama therapy, originally developed by Moreno, is a form of group therapy that combines role-playing, dramatization, and action techniques to explore and resolve interpersonal conflicts and emotional problems (5). Psychodrama can be particularly useful for individuals who have experienced trauma, as it allows them to externalize their emotions and experiences in a safe and supportive environment. By taking on different roles in the drama, clients can gain insight into their own emotions and relationships, as well as those of others. Additionally, psychodrama can help clients develop a sense of empowerment, by allowing them to actively engage with their experiences and work towards resolving them.
Studies have reported that psychodrama therapy can be effective in reducing symptoms of PTSD and depression among refugees and immigrants (5). One study conducted with Afghan refugees found that psychodrama therapy led to significant reductions in symptoms of PTSD and depression, as well as improvements in social functioning (25). Psychodrama therapy has shown promising results in improving social avoidance and discomfort among immigrant female students, while its effectiveness in treating social phobia needs further investigation. The therapy has also been found to enhance social skills in immigrant labor children and reduce their aggression using psychoanalytic techniques (26,27). 
While psychodrama therapy has demonstrated promise in treating trauma-related symptoms among refugees and immigrants, further research is required to fully understand its effectiveness and the specific mechanisms underlying its therapeutic benefits. Nonetheless, psychodrama therapy offers a unique and engaging approach to trauma treatment, particularly for individuals who may have difficulty expressing their emotions through traditional talk therapy approaches.

Limitations
Despite the growing recognition of the importance of culturally adapted mental health interventions, there remains a notable lack of research on highly culturally-modified therapeutic approaches, particularly those tailored for Iranian and Persian-speaking immigrant populations. Existing studies often focus on employing therapists who share the same race, nationality, or linguistic background as their clients, assuming that this commonality alone can bridge cultural gaps. While such measures may enhance initial rapport and communication, they fall short of addressing the deeper cultural, social, and religious nuances that shape individuals’ mental health experiences and coping mechanisms. True cultural adaptation requires a comprehensive understanding of the client’s unique worldview, values, and lived experiences, which extends far beyond shared ethnicity or language.
Furthermore, many current interventions fail to incorporate the specific stressors, traditions, and expectations that define the immigrant experience. For example, Iranian immigrants often face acculturation stress, discrimination, and grief linked to separation from their homeland, yet these factors are rarely integrated into standard therapeutic models. To achieve meaningful and lasting outcomes, mental health interventions must go beyond surface-level modifications and instead weave cultural competence into every aspect of therapy, from the framing of psychological issues to the techniques used for resolution. Without such robust cultural integration, interventions risk being less effective, leading to poor adherence and suboptimal outcomes for immigrant populations (28,29).

Conclusion
Addressing the mental health needs of Iranian and Persian-speaking immigrants requires interventions deeply attuned to their cultural, social, and psychological contexts. While therapies such as CBT, trauma-focused group therapy, and psychodrama have shown potential, their effectiveness depends on careful cultural adaptation that goes beyond merely sharing the language or nationality of the therapist. Barriers such as fear of gossip, concerns about privacy, skepticism toward therapy, and preferences for online meetings emphasize the need for flexible, culturally tailored approaches. Additionally, integrating considerations like gender roles and religious or social support can significantly enhance therapy adherence and outcomes.
Despite these advances, there is a notable lack of studies on highly culturally-modified interventions that fully incorporate the unique values, practices, and challenges of Iranian immigrants. While some adaptations exist, many interventions remain insufficiently tailored, resulting in lower adherence and limited effectiveness. Further research is needed to develop and evaluate interventions that holistically address cultural differences, stigma, and acculturation stress while providing long-term support for those navigating the uncertainties of migration and resettlement.

Conflict of Interest
Authors declare no conflict of interest.