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Table 2 Characteristics of studies assessing long-term mental health of war refugees

From: Long-term mental health of war-refugees: a systematic literature review

Author(s) Refugee population (host) Displacement duration, yrs. Sample selection (response rate %) Measures Measures reliability and validity Prevalence Statistically significant risk factors
Beiser & Hou (2001) 608 Southeast Asian (Vietnamese Chinese, Vietnamese and Laotians) (Canada) >10 of residence random and non-random (95 %; follow-up = 45 %) Self-report developed for the study Developed for the study. No data reported. Depression = 2.3 % DEPRESSION
Univariate: depressive symptoms experienced early in the process of resettlement
(decreased over 10-year period)
-Depression Multivariate: depressive levels experienced early in the process of resettlement; unemployment or unstable employment (for men); poor English language proficiency (for women and those who did not become engaged in the labour market during the earliest years of resettlement)
Bhui et al. (2003) 180 Somali (UK) 8 of residence random (49 %) SCQ and HSCL Reported as previously validated in other refugee groups (data not reported). Anxiety and Depression = 23 % ANXIETY AND DEPRESSION
Univariate: separated or widowed, being retired or unemployed, taking medication, not having declared asylum on entry, not having a conflict with immigration on arrival, less time in the UK (<7 yrs), shortage of food, without shelter, being lost, kidnapped, brainwashed
Multivariate (controlling for age, gender, conflict with immigration, detention on entry, declaration of seeking asylum on entry, current asylum status, income, current employment status, employment status when in Somalia, accommodation type, cigarette smoking, alcohol use, drug use and number of residence years): number of traumatic events, shortage of food and being lost, having no combat experience
Birman & Tran (2008) 212 Vietnamese (USA) 11.5 of residence Non-random (−) HSCL–25 Reported as previously validated in this refugee group (data not reported). Depression = 20.8 % DEPRESSION
-Depression Anxiety = 20.3 % Univariate: lower satisfaction with social support (by like-ethnic friends and one’s spouse), alienation, lower life satisfaction
-Anxiety
In this sample, Cronbach’s alpha: Anxiety = 0.93
Multivariate: lower satisfaction with social support (by like-ethnic friends and one’s spouse)
Depression = 0.94.
ANXIETY
Univariate: females, poor English language, exhibiting more Vietnamese behaviour
Multivariate: females, pre-migration trauma, exhibiting more Vietnamese behaviour
Blair (2000) 124 Cambodian (USA) 8.1 of residence random (83 %) NIMH DIS NIMH DIS: Reported as previously validated in other non-refugee cultures (data not reported). Depression = 51 % DEPRESSION
-Depression GAD =14 % Univariate: Pre-migration – higher number of war traumas, loss of immediate family member (a parent, a sibling or a child), higher number of problems while trying to escape, being separated from family while in refugee camp; resettlement – higher number of resettlement stressors, financial stress (lower rates of working outside the home, lower income, receiving welfare)
-Anxiety Social phobia = 27 %
-Social phobia Panic disorder = 7 %
-Panic dis. PTSD = 45 %
Comorbidity: PTSD and Depression = 71 %
DICA-R
-PTSD DICA-R: Reported as previously validated in other non-refugee cultures (data not reported). PTSD and Social Phobia = 32 %
PTSD
Univariate: Pre-migration – higher number of war traumas, loss of immediate family member (a sibling), being separated from family while in a refugee camp, higher number of problems while trying to escape, higher number of incidents of abuse; resettlement – higher number of resettlement stressors
Bogic et al. (2012) 854 refugees from former Yugoslavia (Germany, Italy, and the UK) 9.3 of residence random and non–random MINI Reported as previously validated in other non-refugee cultures (data not reported). Depression = 34.3 % DEPRESSION
-Depression PTSD = 33.1 % Univariate: female, older age, lower education, higher number of war and post-war traumatic events, shorter time since war trauma, more migration stressors, unemployment, not feeling accepted by host country, poor host language fluency, temporary residence status, residing in Germany or the UK compared to Italy
-PTSD GAD = 8.7 %
-GAD
-Social phobia Social phobia = 6.4 %
-Panic disorder Panic disorder = 10.0 %
-Agoraphobia
Agoraphobia = 18.6 %
-OCD
OCD = 4.8 %
Comorbidity:
PTSD and Depression =65.1 %
GAD and PTSD = 43.2 %
Social Phobia and PTSD = 15.9 %
GAD and depression = 50.7 % Multivariate: older age, lower education, higher number of war-related traumatic events, shorter time since war trauma, more migration stressors, unemployment, not feeling accepted by host country, temporary residence status, residing in Germany or the UK compared to Italy
PTSD
Univariate: older age, lower education, higher number of war and post-war traumatic events, longer time since war trauma, more migration stressors, unemployment, not feeling accepted by host country, poor host language fluency, temporary residence status, residing in Germany or the UK compared to Italy
Multivariate: older age, lower education, higher number of war and post-war traumatic events, not having a combat experience, more migration stressors, temporary residence status, residing in Germany vs. Italy or the UK
ANXIETY (any anxiety disorder)
Univariate: female, older age, lower education, higher number of war and post-war traumatic events, not having a combat experience, more migration stressors, unemployment, not feeling accepted by host country, poor host language fluency, temporary residence status, residing in Germany or the UK compared to Italy
Multivariate: lower education, higher number of war and post-war traumatic events, not having a combat experience, more migration stressors, not feeling accepted by host country, temporary residence status
Buseh et al. (2000) 50 Liberian males (USA) 8.6 of residence non–random (−) CES–D Reported as previously validated in other non-refugee cultures (Cronbach’s alpha =0.85). Depressive Mood =60 % DEPRESSION
-Depression Univariate: more acculturative stress; CES–D subscales depressed affect, somatic/retarded activity, and interpersonal affect were positively correlated with all items on acculturative stress; CES–D subscale positive affect less perceived hate, less perceived cultural shock and lower overall acculturative stress
In this study, Cronbach’s alpha = 0.91.
Carlson & Rosser–Hogan (1994) 50 Cambodian (USA) 9.9 since leaving home country (5.4 of residence) random (100 %) HSCL–25 HSCL-25: Reported as previously validated in this refugee culture (test-retest reliability = 0.89; specificity = 0.73 and sensitivity = 0.88). Depression = 80 % DEPRESSION, ANXIETY, PTSD, Univariate: higher number of traumatic events
-Depression PTSD = 86 %
-Anxiety Anxiety = 88 %
PCL–C –amended
-PTSD
PCL-C: Validated in other cultures (not reported in the study).
In this study, test-retest reliability = 0.85.
Caspi et al. (1998) 161 Cambodian (USA) 7 of residence random (78 %) HSCL–25 HSCL-25 and HTQ validated in this culture (not reported in the study). Not reported DEPRESSION, ANXIETY AND PTSD
-Depression
Multivariate: no relationship observed with child loss
-Anxiety
HTQ
-PTSD
Chung & Kagawa–Singer (1993) 2180 Southeast Asian (Cambodian, Laotian, and Vietnamese) (USA) 5.9 of residence random (−) HOS Reported as previously validated in other non-refugee cultures (data not reported). In this study, Cronbach’s alpha for depression = 0.85 and for anxiety = 0.89. Not reported DEPRESSION
-Depression Univariate: Cambodians (followed by Lao and Vietnamese)
-Anxiety
Multivariate (controlling for ethnicity and number of years in the USA): higher number of pre-migration traumatic events and female gender; for the >5 yrs in the USA: female gender, higher number of traumatic events, longer time in refugee camp, longer time in the USA, unemployment, low family income, poor English, being Vietnamese (compared to Cambodians)
ANXIETY
Univariate: Cambodians (followed by Lao and Vietnamese)
Multivariate: Regardless of ethnicity and years in the USA – higher number of traumatic events, female gender, older age, receipt of public assistance, lower family income, poor English, being Lao; for refugees >5 yrs in the USA: female gender, older age, longer in the USA, higher number of traumatic events, longer time in refugee camp, unemployment, receiving public assistance, low family income, low English proficiency, Lao, Cambodian
Craig et al. (2008) 126 Bosnian (USA) 9 of residence random (25.2 %) MHI MHI and PSDS reported as previously validated in other non-refugee cultures (MHI: Cronbach’s Alpha >0.80, test-retest reliability > 0.58; Depression = 31.7 % DEPRESSION
-Depression PTSD = 66.6 % Univariate: females, older age, lower education
-Anxiety Anxiety = 40.5 %
PSDS
-PTSD PTSD
Univariate: older age, lower education
ANXIETY
Univariate: older age, lower education
PSDS Cronbach’s alpha = 0.94–0.98, test-retest reliability 0.69–0.72).
In this study, MHI Cronbach’s alpha for anxiety = 0.95 and for depression = 0.96;
PSDS Cronbach’s alpha =0.97.
D'Avanzo & Barab (1998) 175 Cambodian females (USA and France) ≥5 of residence non–random (−) HSCL–25 Reported as previously validated in other non-refugee cultures (test-retest reliability for depression = 0.82, anxiety = 0.84, sensitivity = 0.93 and specificity = 0.76 for either). Depression = 73.7 % (France = 85.3 %; USA = 65 %) DEPRESSION
-Depression Univariate: refugee women in France were more likely to be symptomatic of depression
-Anxiety
Anxiety = 81.3 % (France = 85 %; USA = 79 %)
In this study, Cronbach’s alpha for depression = 0.86 and anxiety = 0.86.
Delic-Ovcina (2010) 637 Bosnian males (USA) 6–16 (97.7 % ≥ 8 years) of residence non–random (−) IES Reported as previously validated in this refugee culture (data not reported). PTSD = 76.5 % PTSD
-PTSD Univariate: older age, married, lower education, perceived poor general health, recentness of dental visit, higher frequency of smoking, lack of physical activity, no health care coverage and insufficient funds for health care services
In this study, Cronbach’s alpha = 0.96.
Gerritsen et al. (2006) 178 Afghan, Iranian and Somali (Netherlands) 8.8 of residence random (59 %) HSCL–25 Reported as previously validated in other refugee cultures (data not reported). Depression = 29.3 % (sample includes 232 recently arrived refugees (M = 5.6 yrs.)
-Depression
-Anxiety
HTQ PTSD = 10.6 % PTSD AND DEPRESSION/ANXIETY
-PTSD
Anxiety = 27.7 % Multivariate: asylum seeker (but not for PTSD) being from Iran or Afghanistan; female, higher number of traumatic events, higher post-migration stress, less social support
Hinton et al. (1998) 3401 Vietnamese males (USA) 8–11 of residence random (85–96 %) HSCL–D Reported as previously validated in this refugee culture (sensitivity = 0.86 and specificity = 0.96). Depression = 8.8 % DEPRESSION
-Depression (San Francisco = 9.8 % Univariate: older age and veteran (in particular for those at the San Francisco and Santa Clara sites), less educated, poorer English proficiency, more recently arrived, poorer, unemployed or disabled, re-education camp survivors
Santa Clara = 8.2 %
Houston = 8.6 %)
Multivariate: unemployed or disabled, veterans, poorer English proficiency, income below poverty line, living in Houston
Hollifield et al. (2006) 252 Kurdish and Vietnamese (USA) Kurds = 7.0 and Vietnamese 7.8 of residence non–random (−) HSCL–25 HSCL-25: Reported as previously validated in other refugee cultures (data not reported).PSS-SR: Reported as previously validated in other non-refugee cultures (Cronbach’s alpha = 0.91, test-retest reliability = 0.74). In this study, Cronbach’s alpha =0.95. Depression = 38.9 % DEPRESSION, PTSD, ANXIETY
-Depression PTSD = 31.3 %
-Anxiety Anxiety = 25.0 % Univariate: higher number of war-related traumatic events
PSS-SR
-PTSD
Multivariate: higher number of war-related traumatic events
Hunt & Gakenyi (2005) 69 Bosnian (UK) 5–8 since war trauma non–random (69 %) IES–R Validated in this culture (not reported in this study). In this study, Cronbach’s alpha =0.83 PTSD = 77 % Not reported
-PTSD (IES–R > 45)
Jaranson et al. (2004) 1134 Ethiopian (Oromo and Somali) (USA) 7.5 since leaving home country (3.4 of residence) non–random (97 %) PCL–C Reported as previously validated in other non-refugee cultures (data not reported).In this study, Cronbach’s alpha =0.93. PTSD = 13 % PTSD
-PTSD Univariate: being exposed to torture
Multivariate: male, being Oromo, change in religious practices since migration, higher number of traumatic events, exposure to torture
Kolassa et al. (2010) 444 Rwandans (refugee camp in Uganda) ~13 since war trauma random (−) PDS Reported as previously validated in this refugee culture (test-retest reliability = 0.93). In this study, test-retest reliability = 0.87, PTSD = 49.5 % PTSD
-PTSD Multivariate: higher number of traumatic events
sensitivity = 0.87 and specificity = 0.86.
Marshall et al. (2005) 490 Cambodian (USA) 20–22 of residence random (87 %) CIDI Reported as previously validated in other non-refugee cultures (data not reported). Depression = 51 % DEPRESSION
-Depression PTSD = 62 % Univariate: poor English language, retired or disabled, unemployed, below federal poverty level, older age, higher number of pre–and post-migration traumatic events
-PTSD Comorbidity of PTSD and depression = 71 %
Comorbidity of depression and PTSD = 86 %
Multivariate: (adjusted for age, gender, year of immigration, and pre- and post-migration trauma exposure): older age, higher number of pre- and post–migration traumatic events
PTSD
Univariate: older age, males, poor English language, retired or disabled, unemployed, below federal poverty level, higher number of pre–and post–migration traumatic events
Multivariate (adjusted for age, gender, year of immigration, and pre- and post-migration trauma exposure): older age, higher number of pre and post–migration traumatic events
Matheson et al. (2008) 90 Somali (Canada) ≥9 (90 % sample) of residence non–random (−) IES-R IES-R: Reported as previously validated in other non-refugee cultures (data not reported). Depression 22.5 % DEPRESSION
-PTSD PTSD = 22.2 % Univariate: higher number of traumatic events, assault from a stranger or familiar other, coping strategies involving engagement with emotions and avoidant coping efforts
BDI
-Depression
In this study, Cronbach’s alpha =0.96.
BDI: Validated in other cultures (not reported in the study). Multivariate: the relation between trauma experiences and depression was fully 9confounded by endorsement of emotion-focused coping strategies in relation to acculturation stressors
In this study, Cronbach’s alpha = 0.90.
PTSD
Univariate: higher number of traumatic events, collective trauma, threat to other, assault from a stranger or familiar other, coping strategies involving engagement with emotions and avoidant coping efforts
Multivariate: higher number of traumatic events
Mollica et al. (1998) 993 Cambodian (refugee camp on Thailand–Cambodia border) ≥5 of residence random (98 %) HSCL–25 HTQ and HSCL-25: Reported as validated in this culture (data not reported). Depression 55 % DEPRESSION, PTSD, PTSD SUB–SCALES (except avoidance, which had no dose–effect relationship), ANXIETY
-Depression PTSD = 14.7 %
-Anxiety
HTQ
-PTSD
Multivariate (covariates: gender, age, marital status, education, trauma exposure, and one of the symptom scale or sub-scales): dose–response relationship between cumulative trauma and symptoms – recent trauma had a more potent effect except for emotional numbing (roughly equally 'potent')
Nicholson (1997) 447 Southeast Asian (Vietnamese, Cambodians, Laotians and Hmong) (USA) 9.2 of residence non–random (−) HTQ HTQ: Reported as validated in this culture (data not reported). Depression = 40 % PTSD, ANXIETY, DEPRESSION
-PTSD PTSD = 14 %,
HSCL–25 Anxiety = 35 % Multivariate: degree of current stress was the strongest predictor, self–perceived poor health status, greater number of experienced traumatic events (in particular for PTSD), while greater number of witnessed events and rural background (confounded through current stress), and female gender (confounded through lower income) had indirect effects on all mental health. In addition, low income and being unmarried predicted depression; greater number of witnessed events predicted PTSD; and female gender predicted anxiety
-Depression
-Anxiety In this study, Cronbach’s alpha =0.95.
HSCL-25: Reported as validated in this culture (data not reported).
In this study, Cronbach’s alpha for depression = 0.89 and anxiety = 0.89.
Onyut et al. (2009) 1422 Somalis and Rwandans (refugee camp in Uganda) ≥9 (80 % sample) of residence random (<90 %) PDS PDS: Reported as previously validated in other non-refugee cultures (data not reported). PTSD = 37.8 % DEPRESSION
-PTSD Univariate: male gender (only for Rwandese), being Somali, higher number of traumatic events, functioning deficits, physical health deficits
HSCL-25
-Depression
-Anxiety
In this study, sensitivity = 0.86 and specificity = 0.88
PTSD
Univariate: male gender (only for Rwandese), being Somali, higher number of traumatic events, functioning deficits, physical health deficits
HSCL-25: Validated in other refugee cultures (not reported in the study).
In this study, for depression subscale sensitivity = 0.67 and ANXIETY
Univariate: female gender (only for Somali), being Somali, higher number of traumatic events, functioning deficits, physical health deficits
specificity = 0.73.
Sabin et al. (2003) 170 Guatemalan (refugee camp in Mexico) 20 of residence random (93 %) HSCL–25 HSCL-25 and HTQ: Reported as previously validated in other refugee cultures (data not reported). Depression = 38.8 % DEPRESSION
-Depression
PTSD = 11.8 % Univariate: female, widowed, witnessing disappearance of others, torture, mutilation, higher number of traumatic events
-Anxiety Anxiety = 54.4 %
HTQ
-PTSD
In this study, HTQ Cronbach’s alpha =0.87; HSCL-25 Cronbach’s alpha =0.95.
Multivariate: female, widowed, witnessing disappearance of others, higher number of traumatic events
PTSD
Univariate: older age, being close to death, witnessed assassination or massacre, disappearance of others, larger household size, lived in 3 or more camps, not having experienced lack of food
Multivariate: disappearance of others, being close to death, larger household size, and not having experienced lack of food
ANXIETY
Univariate: older age, higher number of traumatic events, sexual abuse or rape, witnessing massacre, witnessing disappearance of others, torture
Multivariate: witnessing a massacre, higher number of traumatic events
Schweitzer et al. (2006) 63 Sudanese (Australia) 9 since leaving home country (2 of residence) non–random (−) HSCL-37 HSCL-25 and HTQ: Reported as previously validated in other refugee cultures (data not reported). Depression =16 % DEPRESSION
-Depression PTSD = 13 % Univariate: female, higher number of traumas experienced by family, longer time in transit, family separation, less of ethnic community support
-Anxiety
HTQ
-PTSD
In this study, HTQ Cronbach’s alpha =0.87; HSCL-25 Cronbach’s alpha for depression = 0.89 and for anxiety = 0.82
Multivariate: female, higher number of trauma experienced by family, longer time in transit, longer residence, family separation, unemployment
PTSD
Univariate: female, higher number of trauma experienced by the individual, higher number of trauma experienced by family, less of ethnic community support, more post-migration living difficulties
Multivariate: female, higher number of trauma experienced by the individual, higher number of trauma experienced by family, less of ethnic community support
ANXIETY
Univariate: female, higher number of trauma experienced by the individual, number of trauma experienced by family, less of ethnic
community support, more post-migration living difficulties
Multivariate: female, higher number of trauma experienced by family, longer residence, less of ethnic community support, unemployment, more post-migration living difficulties
Steel et al. (2002) 1161 Vietnamese (Australia) 11.4 of residence random (82 %) CIDI, PVPS PVPS: Developed in this culture (data not reported) Depression =3 % ANXIETY DISORDERS
PTSD = 4 % Univariate: females
-Depression GAD = 0.7 %
Social Phobia = 0.3 %
-PTSD
-GAD Panic disorder = 0.6 %
-Social phobia
OCD = 0.5 %
-Panic PVPS: similar results
disorder
-OCD
Stige & Sveaass (2010) 142 Sri Lankan Tamils & Aceh from Indonesia (Norway) 6.7 of residence combination of random (10 %) and non-random PTSS Validated in other non-refugee cultures (not reported in the study). PTSD = 75.4 % Not reported
-PTSD
In this study, Cronbach’s alpha = 0.98
von Lersner et al. (2008) 100 refugees from former Yugoslavia (85 %), Turkey (8 %) and Iraq (5 %) (Germany) 10.8 of residence non–random (−) MINI MINI: Reported as previously validated in other non-refugee cultures (data not reported). Depression = 42.0 % Not reported
-Depression
PTSD = 44.2 %
-Anxiety GAD = 2 %
-Social phobia Social phobia = 9.6 %
PDS: Validated in other refugee cultures (not reported in the study). Panic disorder = 8 %
-Panic disorder
Agoraphobia = 9 %
-Agoraphobia OCD = 0 %
PDS
-PTSD
Westermeyer (1988) 97 Hmong from Laos (USA) 7–9 since leaving home country (6–8 of residence) random (95 %; 96 % at the follow–up assessment) NIMH DIS Validated in other non-refugee cultures (not reported in the study). Axis 1 disorder = 44 % Not reported
-Depression
Depression = 6.2 %
-GAD GAD = 1 %
-OCD OCD = 0.4 %
  1. Scales: BDI Beck Depression Inventory, CESD Center for Epidemiologic Studies Depression Scale, CIDI Composite International Diagnostic Interview, DICA Diagnostic Interview for Children and Adolescents, DICAR Diagnostic Interview for Children and Adolescents–Revised, HOS Health Opinion Survey, HSCL–D Hopkins Symptom Checklist–Depression Scale, HSCL–25 Hopkins Symptoms Checklist–25, HTQ Harvard Trauma Questionnaire, IES–R Impact of Event Scale–Revised, MHI Mental Health Inventory, MINI The Mini International Neuropsychiatric Interview, PVPS Phan Vietnamese Psychiatric Scale