Post-Traumatic Stress Disorder Symptoms and Associated Risk Factors: A cross-sectional study among Syrian refugees

Antoine Aoun, Janine Joundi & Najwa El Gerges

INTRODUCTION

Several studies found that refugees develop post-traumatic stress disorder (PTSD) after having endured war trauma¹, or certain circumstances related to migration like moving to a new country, being unemployed and poor housing². PTSD is described as distress and disability due to a traumatic event that occurred in the past³. In 2013, the American Psychiatric Association revised the PTSD diagnostic criteria in the fifth edition of its Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and PTSD was included in a new category, Trauma- and Stressor-Related Disorders⁴. All of the conditions included in this category required exposure to a traumatic or stressful event as a diagnostic criterion⁴. The person with PTSD often avoids trauma-related thoughts and emotions, and discussion of the traumatic event⁴. PTSD patients are invariably anxious about re-experiencing the same trauma. The trauma is usually re-lived by the person through disturbing, repeated recollections, flashbacks, and nightmares⁴. Symptoms of PTSD generally begin within the first 3 months after the provocative traumatic event, but may not begin until several years later⁴. A large number of children (10-40%), 16 or younger, who have experienced a traumatic event in their life, tend to develop PTSD later on⁵. Moreover, many families with children growing in war zones and then moving to safer places, experience trauma, stress and reduced functioning⁶. These families have different resilience rates in their survival mechanisms, coping strategies and adaptation levels⁷.

The latest war in Syria has led to the migration of large parts of the Syrian population to neighboring countries such as Lebanon, Jordan and Turkey⁸.The United Nations High Commissioner for Refugees (UNHCR) estimates that approximately 1.5 million refugees are located in Lebanon⁹. These refugees have been exposed to several types of traumatic events that may increase the incidence of mental health problems¹⁰.

We hypothesize that the proportion of positive PTSD screens would be high among Syrian refugees with the presence of some specific related risk factors. Thus, the objective of our study was to examine PTSD symptoms and to determine the associated risk factors in a sample of Syrian refugees living in North Lebanon.

METHODS

1. Study design and population

This was a cross-sectional study that aimed to assess the proportion of Syrian refugees in North Lebanon who were at high risk of developing PTSD, and to examine the association of PTSD high risk with other factors. The survey was carried out during February and March 2016. A convenient sample of Syrian refugees of both gender, aged between 14 and 45 years, living in North Lebanon, was selected out of a population of 262,151¹¹.

The estimated minimum sample size, calculated using Raosoft sample size calculator, with a margin of error of 5% and a confidence interval of 95%, was 384 refugees. A total number of 450 Syrian refugees, residing in individual tented settlements (ITSs), collective shelters (CS) or Primary Health Care Centers (PHCs) located in North Lebanon, was selected according to inclusion and exclusion set criteria.

The inclusion criteria were: Syrian refugees, aged (14-45 years), physically and mentally independent. Hence, all subjects that were younger than 14 or older than 45, speechless, deaf, physically and mentally dependent, or have undergone recent moderate or severe surgery (less than one week earlier), were excluded from the study.

2. Ethical considerations

The study protocol received approval from the Notre Dame University (NDU) Institutional Review Board (IRB). The approval comprised details about the procedure of the study and the rights of the participants. Informed consent was obtained from each participant. The questionnaires were answered anonymously, ensuring confidentiality of collected data.

3. The Interview questionnaire

The interview questionnaire was divided into six sections consisting of a total of 46 questions. The questions were dichotomous, close-ended and open-ended. A cover page described the purpose of the study, ensuring the anonymity and confidentiality, and soliciting the consent of participants. The questionnaire collected data on the demographic and socio-economic characteristics of the participants. Information about health status and stressful life events (SLE) were also obtained. The PC-PTSD (Primary Care Post-Traumatic Stress Disorder) tool was used to screen PTSD.

For the purposes of the study, subjects were classified as having/not having positive PC-PTSD. The results were used to calculate the proportion of Syrian refugees who are at high risk of developing PTSD.

PC-PTSD questionnaire: The PC-PTSD was initially developed in a Veteran Affairs primary care setting and is currently used to screen for PTSD, based on the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-4) diagnostic criteria¹². The screen consisted of 4 questions related to a traumatic life event: In the past month you (1) Have had nightmares about it or thought about it when you did not want to?; (2) Tried hard not to think about it or went out of your way to avoid situations that reminded you of it?; (3) Were constantly on guard, watchful, or easily startled?; (4) Felt numb or detached from others, activities, or your surroundings? The answers to these questions were dichotomous (Yes/No) and the total screen was considered "positive" when a patient answered "yes" to three out of four questions. PC-PTSD showed a high sensitivity (86%) and moderate specificity (57%) when using a cutoff score of 2¹³.

In order to validate the Arabic version of the PC-PTSD questionnaire, it was translated into Arabic and translated back into English. The original version of the Arabic questionnaire was pilot-tested on 10 Syrian refugees to ensure the validity of the answers, and to guarantee its reliability.

Anthropometric measurements: The main anthropometric measurements were weight and height. Participants were dressed in light clothes and barefooted, and standing height was measured to the nearest 0.1 cm using a stadiometer. Body weight was measured to the nearest 100g using an electronic scale. Body Mass Index (BMI) is a measure of weight adjusted to height (kg/m²), calculated by dividing weight (in kilograms) by the square of height (in metres). For the purposes of the study, BMI was recoded into four categories: underweight, normal, overweight and obese.

4. Data entry and statistical analysis

The Statistical Package for Social Science (SPSS) for Windows (version 22) was used for data entry and analysis.

First, bivariate analyses of categorical variables were performed using the Fisher exact tests, Chi-squared tests and Student’s t-test. The dependent variable was the high risk of PTSD, using the PC-PTSD tool. Thus, the PC-PTSD score was considered the dependent variable: a dichotomous variable of PC-PTSD (-) and PC-PTSD (+), and all variables that might be a risk factor or might lead to PTSD were set as the independent variables. Two main independent variables were: age and gender. Other variables included: marital status, place of residence, number of people and families living in the same household (crowding index), income, education status, profession, work status, lifestyle habits, medical or psychological problems, medication taken and SLE. Frequencies and percentages were calculated for qualitative variables, and mean and standard deviations for quantitative variables (BMI, crowding index). A p-value of 0.05 or less was considered to be statistically significant.

RESULTS

Table 1: Socio-demographic characteristics of the 450 Syrian refugees

Table 2: Health characteristics and migration factors of the 450 Syrian refugees

Table 3: Socio-demographic characteristics associated with positive screen for PTSD among the 450 Syrian refugees (bivariate analyses)

*Significant with p-value < 0.05

Table 4: Health characteristics and migration factors associated with positive screen for PTSD among the 450 Syrian refugees (bivariate analyses)

* Significant with p-value < 0.05

All the socio-demographic, health and migration characteristics of our sample of Syrian refugees were described in Tables 1 and 2. Out of the 450 participants, 47.3% had positive PC-PTSD. In order to study the association between the socio-demographic characteristics among the Syrian refugeesand PTSD screening, abivariate association was explored as shown in Table 3. The results indicate a significant difference between gender groups, as almost half of the women (49.9%) had a positive screen for PTSD compared to 33.3% of the men (p=0.011). Mean age was significantly higher in refugees with positive PC-PTSD (28.9 ± 7.6 years) versus those with negative PC-PTSD (26.9 ± 8.5 years) (p=0.009). PTSD screening was shown to be significantly associated with marital status. In fact, positive PC-PTSD was mostly perceived in divorced participants (80%) compared to 69.2% of widowed, 50.5% of married, and 16.7% of single subjects (p=0.000). Yet, crowding index, current place of residence, educational level, employment status, and income were not significantly associated with positive PC-PTSD (p>0.05).

The association of health characteristics and migration factors among the Syrian refugees with PTSD screening was displayed in Table 4. A significant association was observed between the presence of medical condition and positive screen for PTSD, as 61.9% of subjects suffering from a medical condition had a positive PC-PTSD, compared to 42.4% of participants without medical conditions (p=0.000). However, BMI and tobacco consumption were not significantly associated with PTSD screening (p>0.05). PTSD screening was significantly associated with the presence of psychological disorders. Thus, 90.9% of refugees who sought professional help for psychological disorders had positive PC-PTSD, versus 46.2% of those who did not (p=0.003). Positive PC-PTSD was significantly associated with the increase in the number of SLE. In fact, none of the participants without any stressful event had a positive PC-PTSD, compared to 36.5% of participants with 1-2 SLE, 58.7% of participants with 3-4 SLE and 75% of participants with 5-6 SLE (p=0.000). On the other hand, no significant association was observed between PC-PTSD and migration status (p>0.05).

DISCUSSION AND CONCLUSION

PTSD represents the most frequently occurring mental disorder occurring among refugees¹⁴. PTSD prevalence rates ranging between 15% and 80% have been reported in refugees. A study of Cambodian refugees living in the Thailand-Cambodia border camp indicated that 15% had PTSD¹⁵. A cohort study aimed to show the prevalence of PTSD among Iranian, Afghani and Somalian refugees that have moved to the Netherlands at a 7-year interval [(T1=2003) - (T2=2010)]. Results displayed a high prevalence at both T1 (16.3%) and T2 (15.2%). The reason for this high unchanged prevalence may be due to the late onset of the PTSD symptoms, and the low use of mental health care centers¹⁶. De Jong and colleagues reported that 50% of the refugees in Rwandan and Burundese camps had serious mental health problems, mainly PTSD¹⁷. While Teodorescu and colleagues aimed to illustrate the prevalence of PTSD among refugees in Norway; results showed that 80% of the refugees had PTSD¹⁸. In our study, the high proportion of positive screen for PTSD among Syrian refugees was estimated at 47.3%. In 2006, a mental health assessment demonstrated that Lebanese citizens exposed to war were more likely to develop psychiatric problems such as PTSD¹⁹. Subsequently, a cross-sectional study was done in South Lebanon on 681 citizens in 2007 (1-year after the 2006 war in Lebanon). The aim of the study was to examine the prevalence of PTSD 12 months after 2006 war cessation. Results showed that the prevalence of PTSD was 17.8%¹⁹. A recent cross sectional study, aimed to show the prevalence of PTSD and explore its relationship with various variables. The study included 352 Syrian refugees settled in camps in Turkey. An experienced psychiatrist evaluated the participants, and results demonstrated that 33.5% of study participants had PTSD, mainly female refugees, people who experienced 2 or more SLE, or those who had a family history of psychiatric disorder²⁰.

PTSD has been associated with a wide range of traumatic events: emotional or physical abuse²¹, sexual abuse²², parental break-up²³, death of a loved one²⁴, domestic violence²⁵, kidnapping²⁶, military services²⁷, war trauma²⁸, natural disasters²⁹ and medical conditions including cancer³⁰, heart attack³¹, stroke³², intensive-care unit hospitalization³³, and miscarriage³⁴.

Our findings should be interpreted taking into account several limitations. The first limitation is the use of screening tools, instead of the more accurate diagnosis of the clinician, in order to detect PTSD. Given that a standardized screening tool for PTSD was used, our rates are likely an overestimate of the true prevalence rates. Secondly, this study was conducted with a limited sample of Syrian refugees and therefore should not be generalized to all refugees of other eras or from other countries. The third limitation is represented by the lack of information on the presence of other Axis I psychiatric comorbidities such as anxiety or mood disorder that could facilitate the development of PTSD or influence its manifestations^35-36.

Refugees are an important group to examine, given the high prevalence of mental health disorders. Although refugees are evaluated for health problems, currently there are no standardized screening and clinical practice guidelines for assessing PTSD in all refugees. Therefore, we may be missing opportunities to detect and treat these harmful and potentially fatal conditions. Our findings suggest the need to consider a standardized screening tool for PTSD in this population. In addition, a far greater percentage of patients may have “PTSD symptoms,” that are abnormal but do not meet full criteria of the DSM5 for PTSD diagnosis, but still cause functional impairment and may later develop into a diagnosable PTSD. Given the overall high prevalence, one possible model for evaluation would be a stepped screening approach: Positive screens for PTSD could trigger a standardized clinical diagnosis for PTSD with more comprehensive assessment and early intervention. Considering the high cost of treating individuals with PTSD, screening and intervention strategies should be addressed. Greater awareness among providers and increased targeted assessment and treatment efforts may increase early detection of a wide range of PTSD, preventing more serious future health problems and functional impairment among refugees.

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