Clinical and screening tools for psychic illness in asylum seekers and refugees: a narrative review

Clinical and screening tools for psychic illness in asylum seekers and refugees: a narrative review

Jacopo Santambrogio1, Elisabetta Leon2, Anna Maria Auxilia3, Martina Capellazzi3, Sergio Terrevazzi1, Francesca Ceccon4, Antonio Amatulli5, Elena Miragliotta2, Chiara Peri5, Raffaele Bracalenti5, Fabrizia Colmegna2, Massimo Clerici2,3

1Presidio “G. Corberi” - RSD “Beato Papa Giovanni XXIII”, Mental Health and Addiction Department, ASST Brianza, Limbiate (Monza), Italy; 2Mental Health and Addiction Department, IRCCS San Gerardo dei Tintori, Monza, Italy; 3Department of Medicine and Surgery, University of Milan Bicocca, Monza, Italy; 4Mental Health and Addiction Department, ASST Brianza, Vimercate (Monza), Italy; 5Istituto Psicoanalitico per le Ricerche Sociali, IPRS, Rome, Italy.

Summary. Background. According to UNHCR, at the end of June 2024 there were 8 million asylum seekers and 43.7 million refugees worldwide, a 16% increase versus year end 2023 for both categories; these rapidly growing numbers are posing significant political, humanitarian, and healthcare challenges. These are persons who have been displaced due to wars, persecution, political and economic instability, climate change, and other disasters. Trauma, an inevitable consequence of forced displacement, is a crucial factor in the development of psychiatric diseases, causing short and long-term synaptic alterations. Post-traumatic stress disorder (PTSD), anxiety, depression, and impulse control disorders are prevalent in this sub-population; providing efficient mental health services is a global challenge that requires developing early mental health screening and treatment programs. Purpose. The main purpose of this study is to examine the available scientific literature regarding the scales used for evaluating psychiatric impairment in asylum seekers and refugees. We are particularly interested in analysing these psychometric scales from a culturally unbiased perspective, in which the psychiatric evaluation is devoid of cultural features that could influence the outcome of the interview. Method. We carried out a search on PubMed for articles published between inception and September 30, 2024 containing references to clinical and screening tools that evaluate mental illness among asylum seekers and refugees. Various scales are used to screen for PTSD (11), anxiety (12) and depression (11) with a significant heterogeneity in the number of items and how the scales are administered, but only one for identifying psychosis. Two tools were used to screen specifically for substance use disorders. In various studies, general scales were used for screening for mental illness. We found that in general there was little information regarding when and how the tools are administered, and if they are used for follow-up interviews. Conclusions. This review highlights the need to create a specific, easy-to-use tool that avoids cultural biases to screen for mental illness, including PTSD, anxiety, psychosis, substance abuse and suicidal tendences, among asylum seekers and refugees.

Key words. Asylum seekers, clinical tools, mental illness, refugees, screening tools.

Strumenti clinici e di screening per i disturbi psichici in richiedenti asilo e rifugiati: una revisione narrativa.

Riassunto. Introduzione. Secondo l’Agenzia dell’ONU per i Rifugiati (UNHCR), alla fine di giugno 2024 si contavano 8 milioni di richiedenti asilo e 43,7 milioni di rifugiati nel mondo, con un aumento del 16% rispetto alla fine del 2023 per entrambe le categorie. Si tratta di persone costrette a fuggire a causa di guerre, persecuzioni, instabilità politica ed economica, cambiamenti climatici e altre catastrofi. Il trauma – conseguenza inevitabile dello spostamento forzato – è un fattore cruciale nello sviluppo di disturbi psichiatrici, poiché provoca alterazioni sinaptiche sia a breve che a lungo termine. Disturbi da stress post-traumatico (PTSD), ansia, depressione e disturbi del controllo degli impulsi sono particolarmente diffusi in questa popolazione. Fornire servizi di salute mentale efficaci rappresenta una sfida globale, che richiede lo sviluppo di programmi precoci di screening e trattamento. Scopo. L’obiettivo principale di questo studio è esaminare la letteratura scientifica esistente sulle scale psicometriche utilizzate per valutare il disagio psichiatrico nei richiedenti asilo e nei rifugiati. In particolare, ci interessa analizzare questi strumenti da una prospettiva culturalmente neutra, in modo che la valutazione psichiatrica non sia influenzata da caratteristiche culturali che potrebbero alterare l’esito del colloquio. Metodo. È stata effettuata una ricerca su PubMed per articoli pubblicati dal concepimento del database fino al 30 settembre 2024, che facessero riferimento a strumenti clinici e di screening utilizzati per valutare le malattie mentali tra richiedenti asilo e rifugiati. Sono state individuate diverse scale per lo screening del PTSD (11), dell’ansia (12) e della depressione (11), con una notevole eterogeneità nel numero di item e nelle modalità di somministrazione – ma solo uno strumento per l’identificazione della psicosi. Due strumenti sono stati utilizzati specificamente per identificare disturbi da uso di sostanze. In quattro studi sono state impiegate scale generali per lo screening della sofferenza psichica. In generale, abbiamo riscontrato una scarsità di informazioni su quando e come tali strumenti vengano somministrati e se siano utilizzati anche nei follow-up. Conclusioni. Questa revisione narrativa evidenzia la necessità di sviluppare uno strumento specifico e di facile utilizzo, privo di bias culturali, per lo screening dei disturbi mentali – compresi PTSD, ansia, psicosi, uso di sostanze e tendenze suicide – tra richiedenti asilo e rifugiati.

Parole chiave. Disturbi psichici, richiedenti asilo, rifugiati, strumenti clinici, strumenti di screening.

Background

In today’s era of globalization and demographic change, migration is a significant and ongoing topic1. The growing number of persons displaced by wars, persecution, political and economic instability, climate change and other disasters poses significant challenges in politics, humanitarian efforts, and healthcare2. Trauma plays a crucial role in the development of psychiatric disorders, leading to short and long-term synaptic alterations3. Forced migration can cause a specific type of psychological trauma by exposing individuals to stressful events such as torture, poverty, difficulties adapting to a new environment, and separation from family and friends4. Poor social support and low resilience at both individual and community level can exacerbate potential mental health problems in refugees and asylum seekers5,6, with research suggesting that this sub-population is more likely to experience post-traumatic stress disorders (PTSD), anxiety, depression, and impulse control disorders than the general population. This is not only due to the stress of the displacement itself but also exposure to pre-migration trauma such as violence, torture, and violent deaths of family and friends, which is a strong predictor of depression and PTSD development particularly in minors7-9. Furthermore, post-traumatic stress reactions can persist and even increase over time, many years after resettlement10. This vulnerability is not only linked to pre-migration trauma but also to post-migration difficulties such as separation from family, difficulties with language, housing and asylum procedures, detention, and unemployment11,12.

It is important to use a scale that is culturally unbiased when assessing mental health in migrant populations, as people have different expectations, attitudes, languages, perceptions, based on their culture13,14. Persons from cultures other than that in which the scale was created may not be familiar with certain items and terms used, so to obtain accurate and reliable data it is crucial to use psychometric instruments or scales with which the people being assessed feel at ease15. It is also important to use a scale that can be understood by people of all levels of intelligence and education16,17.

In this narrative review, we have focused on asylum seekers and refugees as the population of interest, due to the particularly harrowing nature of their experiences that are likely to result in mental illness. Asylum seekers are particularly susceptible to anxiety as they have left their home country to escape war and/or persecution due to their race, religion, political beliefs, or nationality and have applied for international protection from United Nations High Commissioner for Refugees (UNCHR), but their request is still pending18. When their application for asylum is successful, they obtain refugee status19.

Methods

We interrogated the PubMed database with the search term “PTSD OR psychosis OR depression OR anxiety OR ADHD OR autism OR intellectual disability OR bipolar disorder OR personality disorder AND refugee OR asylum seekers” from inception up to September 30, 2024. In the first selection phase, the authors interrogated the database independently, taking as inclusion criteria the association between psychiatric disorders and specific scales and interviews used for evaluation and the language in which they were written (English); they then discussed the selected articles, sharing questions and doubts to eliminate articles that did not fully comply with the inclusion criteria. At the end of this process, 1445 articles were identified.

Results

Perusing the 1445 articles extracted from the database, we identified a total of 37 clinical tools for mental health, the main characteristics of which are summarized in table 1.

Many of these tools are available in several languages and can be either self-administered or administered by trained professionals. Those most frequently used are the Harvard Trauma Questionnaire (HTQ), the Hopkins Symptom Checklist-25 (HSCL-25), and the Mini International Neuropsychiatric Interview (MINI)20. The conditions most frequently screened for are overall mental health, post-traumatic stress disorder (PTSD), depression, and anxiety.

Scales for PTSD, depression, anxiety disorders

Twenty-three different scales were found for assessing Post-Traumatic Stress Disorder (PTSD), Major Depressive Disorder (MDD), anxiety disorders and identifying the presence of traumatic experiences21-40. While most of these tools are not specific to refugees, the Harvard Trauma Questionnaire is a widely used cross-cultural screening tool that is employed to assess PTSD, MDD, and can even verify the presence of a history of torture41. Additionally, some of these scales also investigate other psychiatric conditions such as suicide risk, psychosis, sleep disturbances, and anxiety42.

Scales for psychosis

The Prodromal Questionnaire - Brief (PQ-B)43, a shorter version of the 92-item Prodromal Questionnaire, is a self-report scale used to screen for prodromal symptoms of psychosis. It is comprised of six items and is specifically used as a screening measure for psychosis risk syndromes. It was employed as part of a study protocol for Syrian refugees to assess their mental health44. The purpose of the study we extracted from the data base was to evaluate the effectiveness of group problem management plus (gPM+), which is a low-intensity psychological intervention for adults who experience psychological distress.

Scales for substance use disorders

Our search found two specific tools used to screen for substance use disorders among refugees and asylum seekers: the Alcohol User Identification Test (AUDIT) and the Alcohol, Smoking and Substance Involvement Test-linked Brief Intervention (ASSIST-linkedBI). The AUDIT was initially developed by the World Health Organization (WHO) for use in primary health care as a screening instrument45. It comes with a well-validated threshold score of 8 for hazardous or harmful consumption, while a score of 20 or more is suggested as indicating possible alcohol dependence. The AUDIT has been found to be suitable for identifying hazardous or harmful consumption, even among patients with different cultural backgrounds46.

• AUDIT was used in a comprehensive study on the health and wellbeing of Bhutanese refugees in Nepal, with face-to-face interviews being conducted with 8000 participants47. The primary objective of the study was to evaluate the prevalence of hazardous and harmful alcohol consumption among this population with a specific focus on identifying elevated risk predictors. It was designed to provide valuable insights into the most effective interventions to address this complex issue and to promote the overall health and safety of refugees in the region.

• ASSIST-linked BI: Widmann et al. used this scale to assess psychopathology in 330 male Somali khat users in Kenya and to test the efficacy of Screening and Brief Interventions (SBI)48. Khat leaves (Catha edulis) with their mild stimulant effects are traditionally chewed in social contexts in many African and Arab countries including Somalia49. The ASSIST interview was divided into two parts. The first consisted of eight questions that evaluated the current and lifetime use of khat, and a risk score was derived from the respondent’s answers. The second part of the interview involved providing feedback on the individual’s risk score, along with information on the health and social risks associated with their consumption pattern. The individual’s concerns were also discussed, and their change-thoughts strengthened. Additionally, advice was given on how to reduce risks, and a self-help booklet was provided to support the individual. The patient’s responsibility and confidence were emphasized throughout the intervention process.

Scales for Suicidal Tendencies

Only one scale was found for the identification of suicidal tendencies in refugees and asylum seekers: the Depressive Symptom Index-Suicidality Subscale (DSI-SS). This 4-item self-report scale is a subscale of the Hopelessness Depression Symptom Questionnaire which was originally developed as a brief screening tool for suicide risk in general health settings50,51.

Discussion

The purpose of this review is to examine the state of scientific literature regarding tools for the evaluation and screening of mental illness among asylum seekers and refugees.

Various scales were used to screen for PTSD and depression. These tools vary significantly in their characteristics, such as number of items and means of administration. Some, such as the Clinician-Administered PTSD Scale (CAPS-5), must be administered by a clinician; others, such as the Harvard Trauma Questionnaire (HTQ), are self-reporting. Not all of these scales are used for follow-up after a first assessment (table 1).

The Hopkins Symptoms Checklist-25 (HSCL-25) and the Beck Depression Inventory were the most used for depression and anxiety disorders, but this category too was characterized by heterogeneity of number of items, methods of administration and possibility of using the tools as follow-up.

The only scale for psychosis found in our study was the Prodromal Questionnaire - Brief (PQ-B).

Various studies used general scales of screening for mental illness such as the Mini International Neuropsychiatric Interview (MINI), the Composite International Diagnostic Interview (CIDI) Patient Health Questionnaire (PHQ-15) or the Structured Clinical Interview for DSM (SCID).

We found two specific tools used to screen for substance use disorders among asylum seekers and refugees: the Alcohol User Identification Test (AUDIT) and the Alcohol, Smoking and Substance Involvement Test-linked Brief Intervention (ASSIST-linked BI).

There were very few references to exactly when and where the scales were administered. Those we found indicated that most were administered in the post-resettlement period, but in many cases there is no indication as to how long after the person’s arrival in the host country they meet with a health operator for mental health screening. It would be useful if, in the future, studies regarding the use of scales with asylum seekers and refugees include information regarding when they are administered and if they are used as follow-up.

Furthermore, only a few screening tools have been validated for the asylum seeker and refugee sub-population. Among the validation studies Magwood et al. identified in their systematic study of 2022, there were only four screening tools that were seen to be commonly used69. These were the Harvard Trauma Questionnaire (HTQ) for post-traumatic stress disorder and traumatic events (validated in six studies), the Refugee Health Screener (RHS) in both the 13- and 15-item versions for depression, anxiety, and posttraumatic stress disorder (validated in five studies), the Hopkins Symptom Checklist (HSCL-25) for depression and anxiety (validated in six studies) and the Mini International Neuropsychiatric Interview (MINI) (adapted and validated in two studies).

In addition to the scales presented in table 1, we found a number of references to screening tools that however did not completely meet our inclusion criteria. Though not completely pertinent to the review, we consider them to be of interest as they could be adapted for use with asylum seekers and refugees. They are listed below.

• The Clinical Global Impression Severity Scale and the Global Assessment of Functioning can be used to score the severity of the illness and its impact on patients’ functioning. In addition, the Prolonged Grief-13 scale that can be used to investigate the presence of a particular syndrome52-55.

• There are also screening tools that can be used to detect potential psychiatric disorders or distress in primary healthcare settings. These include the General Health Questionnaire-28, the Perceived Stress Scale, and the Kessler Psychological Distress Scale. The Self-Reporting Questionnaire-20 is an interesting tool that can evaluate not only psychological distress but also suicidality56-59.

• Scales such as the Psychological Outcome Profiles can be used to monitor the progress of therapy and the outcome of the treatment.

• The Post-traumatic Growth Inventory can assess positive outcomes of patients who have suffered traumatic experiences60,61.

• The Acholi Psychosocial Assessment Instrument is a useful tool consisting of 60 items in six subscales specifically created to assess depression-like, anxiety-like, and behavioural problems in Ugandan adolescents traumatised by war62.

• Finally, there are various scales focused on the quality of life, such as the EQ-5D-5L, Quality of Life Inventory, WHO Disability Assessment Schedule 2.0, WHO Quality of Life-BREF, WHO-5 Well-being Index, Medical Outcome Study, and Health of the Nation Outcome Scales. As our review dealt with mental illness, these scales were out of scope but are used to measure the effectiveness of treatment for asylum seekers and refugees, as they can measure physical and mental well-being, social relationships, and support63-69.

Conclusions

Mental illness among asylum seekers and refugees is a major problem; this sub-population is vulnerable to PTSD and depression, but also other to psychiatric illnesses as anxiety, psychosis, and substance use disorders causing disability70. Suicidal intention and suicide attempts are reported as being significantly prevalent among this sub-population. There is growing and consistent evidence that treatments for PTSD and other psychiatric illnesses such as individual psychotherapy, group therapy, pharmacological treatments and psychosocial interventions are effective among these patients and should be initiated as soon as possible after their arrival in the host country. As the initial period of resettlement for asylum seekers and refugees is difficult and a considerable cause of distress, it is crucial to perform a mental illness screening procedure to plan the correct interventions. The screening process must take into account pre-migration vulnerability as well as stress and illness resulting from the migration itself. Various factors, such as transcultural issues, can contribute to psychiatric illnesses remaining undiagnosed in this sub-population70. It must also be considered that the first approach to asylum seekers and refugees differs from country to country: in many cases, the first-care professionals who encounter them are not mental health workers and are not familiar with the tools usually used in a clinical or research setting. Finally, when analysing these scales it is important to consider the time necessary for administration which in some cases can be quite long, and the fact that they are complex both for the clinician and for the individual who has been through a traumatic journey, is likely to have difficulty in understanding the language and in general is in a very stressful situation.

In conclusion, this review highlights the need to create a transcultural and specific tool to screen for mental illness among asylum seekers and refugees; a simple and short tool that covers PTSD, anxiety, depression, psychosis, suicidal tendencies avoiding potential cultural biases that may cause misunderstandings to be used in the encounter with first responders, whether they be mental health operators or other care professionals.

A promising screening tool is the STAR-MH (Screening Tool for Asylum-seeker and Refugee Mental Health) that was developed for early detection of MDD and PTSD in migrants/asylum seekers. It is a brief screening device designed also for use by mental health and other health operators without specific training71. It has been seen to achieve positive results in the field and the Italian validated version will be available shortly.

Conflict of interests: the authors have no conflict of interests to declare.

Authors’ contributions: all the authors contributed to the conception and design of the review. JS: conceptualization, methodology, first draft writing, first draft revision, second revision, coordinating the manuscript; EL: conceptualization, methodology; AMA, MartC, EM, EC: data collecting; ST, FranC, AA: second revision; CP, RB: second revision, supervision; FabC: conceptualization, methodology, revision, supervision; MassC: conceptualization, methodology, first draft revision, second revision and over all supervision.

Acknowledgements: we would like to pay tribute to our friend and colleague, Dr Matteo Sibilla, who passed away in August 2021. He was a dedicated clinician and a passionate researcher. A special thanks to Frances Anderson for her kind help with the English revision.

Bibliography

1. Kroening ALH, Dawson-Hahn E. Health considerations for immigrant and refugee children. Adv Pediatr 2019; 66: 87-110.

2. Priebe S, Giacco D, El-Nagib R. Public health aspects of mental health among migrants and refugees: a review of the evidence on mental health care for refugees, asylum seekers and irregular migrants in the WHO European Region [Internet]. Copenhagen: WHO Regional Office for Europe, 2016.

3. Bennett MR, Lagopoulos J. Stress and trauma: BDNF control of dendritic-spine formation and regression. Prog Neurobiol 2014; 112: 80-99.

4. Gambaro E, Mastrangelo M, Sarchiapone M, et al. Resilience, trauma, and hopelessness: protective or triggering factor for the development of psychopathology among migrants? BMC Psychiatry 2020; 20: 358.

5. Siriwardhana C, Stewart R. Forced migration and mental health: prolonged internal displacement, return migration and resilience. Int Health 2013; 5: 19-23.

6. Sisto A, Vicinanza F, Campanozzi LL, Ricci G, Tartaglini D, Tambone V. Towards a transversal definition of psychological resilience: a literature review. Medicina 2019; 55: 745.

7. Bronstein I, Montgomery P. Psychological distress in refugee children: a systematic review. Clin Child Fam Psychol Rev 2011; 14: 44-56.

8. Lincoln AK, Lazarevic V, White MT, Ellis BH. The impact of acculturation style and acculturative hassles on the mental health of somali adolescent refugees. J Immigr Minor Heal 2016; 18: 771-8.

9. Reavell J, Fazil Q. The epidemiology of PTSD and depression in refugee minors who have resettled in developed countries. J Ment Health 2017; 26: 74-83.

10. Mollica RF, Sarajlic N, Chernoff M, Lavelle J, Vukovic IS, Massagli MP. Longitudinal study of psychiatric symptoms, disability, mortality, and emigration among Bosnian refugees. JAMA 2001; 286: 546-54.

11. Bogic M, Njoku A, Priebe S. Long-term mental health of war-refugees: a systematic literature review. BMC Int Health Hum Rights 2015; 15: 29.

12. Santambrogio J, Cimminiello N, Wisidagamage Don P, et al. Influence of post-migration living difficulties on mental health among refugees and asylum seekers: a scoping-review on clinical tools. Int J Soc Psychiatry 2024; 70: 1191-201.

13. Ellis C, Hadden L, Jones MW. Language and transient emotional states affect implicit cultural bias. Q J Exp Psychol 2019; 72: 1242-9.

14. Arnault DS. Defining and theorizing about culture: the evolution of the cultural determinants of help-seeking, revised. Nurs Res 2018; 67: 161-8.

15. Sindik J. Data analysis strategies for reducing the influence of the bias in cross-cultural research. Coll Antropol 2012; 36: 31-7.

16. Bonin-Guillaume S, Clément JP, Chassain AP, Léger JM. [Psychometric evaluation of depression in the elderly subject: which instruments? What are the future perspectives?]. Encephale 1995; 21: 25-34.

17. Jorm AF, Scott R, Henderson AS, Kay DW. Educational level differences on the Mini-Mental State: the role of test bias. Psychol Med 1988; 18: 727-31.

18. Schmand B, Lindeboom J, Hooijer C, Jonker C. Relation between education and dementia: the role of test bias revisited. J Neurol Neurosurg Psychiatry 1995; 59: 170-4.

19. Zeitlin H. Asylum seekers. Med Leg J 2020; 88: 177-8.

20. Magwood O, Kassam A, Mavedatnia D, et al. Mental health screening approaches for resettling refugees and asylum seekers: a scoping review. Int J Environ Res Public Health 2022; 19: 3549.

21. Acarturk C, Cetinkaya M, Senay I, Gulen B, Aker T, Hinton D. Prevalence and predictors of posttraumatic stress and depression symptoms among syrian refugees in a refugee camp. J Nerv Ment Dis 2018; 206: 40-5.

22. Raghavan SS, Rosenfeld B, Rasmussen A. Measurement invariance of the brief symptom inventory in survivors of torture and trauma. J Interpers Violence 2017; 32: 1708-29.

23. Norris FH, Hamblen JL. Standardized self-report measures of civilian trauma and PTSD. In: Wilson JP, Keane TM (eds). Assessing psychological trauma and PTSD. New York: The Guilford Press, 2004.

24. Röhr S, Jung FU, Renner A, et al. Recruitment and baseline characteristics of participants in the “Sanadak” Trial: a self-help app for Syrian refugees with post-traumatic stress. Int J Environ Res Public Health 2020; 17: 7578.

25. Sonne C, Mortensen EL, Silove D, Palic S, Carlsson J. Predictors of treatment outcomes for trauma-affected refugees - results from two randomised trials. J Affect Disord 2021; 282: 194-202.

26. Foa EB, McLean CP, Zang Y, et al. Psychometric properties of the Posttraumatic Stress Disorder Symptom Scale Interview for DSM-5 (PSSI-5). Psychol Assess 2016; 28: 1159-65.

27. Blevins CA, Weathers FW, Davis MT, Witte TK, Domino JL. The Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5): development and initial psychometric evaluation. J Trauma Stress 2015; 28: 489-98.

28. Hollifield M, Verbillis-Kolp S, Farmer B, et al. The Refugee Health Screener-15 (RHS-15): development and validation of an instrument for anxiety, depression, and PTSD in refugees. Gen Hosp Psychiatry 2013; 35: 202-9.

29. Foa EB, Cashman L, Jaycox L, Perry K. The validation of a self-report measure of posttraumatic stress disorder: The Posttraumatic Diagnostic Scale. Psychol Assess 1997; 9: 445-51.

30. Tay AK, Rees S, Chen J, Kareth M, Mohsin M, Silove D. The Refugee-Mental Health Assessment Package (R-MHAP); rationale, development and first-stage testing amongst West Papuan refugees. Int J Ment Health Syst 2015; 9: 29.

31. Vaage AB, Thomsen PH, Rousseau C, Wentzel-Larsen T, Ta TV, Hauff E. Paternal predictors of the mental health of children of Vietnamese refugees. Child Adolesc Psychiatry Ment Health 2011; 5: 2.

32. Lee B, Youm Y. Social network effects on post-traumatic stress disorder (PTSD) in female North Korean immigrants. J Prev Med Public Health 2011; 44: 191-200.

33. Nam B, Kim JY, DeVylder JE, Song A. Family functioning, resilience, and depression among North Korean refugees. Psychiatry Res 2016; 245: 451-7.

34. Augsburger M, Elbert T. When do traumatic experiences alter risk-taking behavior? A machine learning analysis of reports from refugees. PLoS One 2017; 12: e0177617.

35. Stenmark H, Catani C, Neuner F, Elbert T, Holen A. Treating PTSD in refugees and asylum seekers within the general health care system. A randomized controlled multicenter study. Behav Res Ther 2013; 51: 641-7.

36. Mujeeb A. Mental health of internally displaced persons in Jalozai camp, Pakistan. Int J Soc Psychiatry 2015; 61: 653-9.

37. Borho A, Viazminsky A, Morawa E, Schmitt GM, Georgiadou E, Erim Y. The prevalence and risk factors for mental distress among Syrian refugees in Germany: a register-based follow-up study. BMC Psychiatry. 2020 Jul;20(1):362.

38. Wind TR, van der Aa N, Knipscheer J, de la Rie S. The assessment of psychopathology among traumatized refugees: measurement invariance of the Harvard Trauma Questionnaire and the Hopkins Symptom Checklist-25 across five linguistic groups. Eur J Psychotraumatol 2017; 8 (sup2): 1321357.

39. Hamrah MS, Hoang H, Mond J, Pahlavanzade B, Charkazi A, Auckland S. The prevalence and correlates of symptoms of post-traumatic stress disorder (PTSD) among resettled Afghan refugees in a regional area of Australia. J Ment Health 2021; 30: 674-80.

40. Sele P, Hoffart A, Bækkelund H, Øktedalen T. Psychometric properties of the International Trauma Questionnaire (ITQ) examined in a Norwegian trauma-exposed clinical sample. Eur J Psychotraumatol 2020; 11: 1796187.

41. Paykel ES. The interview for recent life events. Psychol Med 1997; 27: 301-10.

42. Maria M, Dimitra T, Mary G, Stella K, Athanasios N, Sarafis P. Depression, resilience and Post Traumatic Stress Disorder (PTSD) in asylum-seeker war refugees. Mater Sociomed 2021; 33: 26-9.

43. Loewy RL, Pearson R, Vinogradov S, Bearden CE, Cannon TD. Psychosis risk screening with the Prodromal Questionnaire-brief version (PQ-B). Schizophr Res 2011; 129: 42-6.

44. Akhtar A, Giardinelli L, Bawaneh A, et al. Group problem management plus (gPM+) in the treatment of common mental disorders in Syrian refugees in a Jordanian camp: study protocol for a randomized controlled trial. BMC Public Health 2020; 20: 390.

45. Adewuya AO. Validation of the alcohol use disorders identification test (audit) as a screening tool for alcohol-related problems among Nigerian university students. Alcohol Alcohol 2005; 40: 575-7.

46. Medina-Mora E, Carreño S, De la Fuente JR. Experience with the alcohol use disorders identification test (AUDIT) in Mexico. Recent Dev Alcohol 1998; 14: 383-96.

47. Luitel NP, Jordans M, Murphy A, Roberts B, McCambridge J. Prevalence and patterns of hazardous and harmful alcohol consumption assessed using the AUDIT among Bhutanese refugees in Nepal. Alcohol Alcohol 2013; 48: 349-55.

48. Widmann M, Apondi B, Musau A, et al. Comorbid psychopathology and everyday functioning in a brief intervention study to reduce khat use among Somalis living in Kenya: description of baseline multimorbidity, its effects of intervention and its moderation effects on substance use. Soc Psychiatry Psychiatr Epidemiol 2017; 52: 1425-34.

49. Krikorian AD. Kat and its use: an historical perspective. J Ethnopharmacol 1984; 12: 115-78.

50. Suh S, Ryu H, Chu C, Hom M, Rogers ML, Joiner T. Validation of the Korean Depressive Symptom Inventory-Suicidality Subscale. Psychiatry Investig 2017; 14: 577-84.

51. Amiri S. Prevalence of suicide in immigrants/refugees: a systematic review and meta-analysis. Arch Suicide Res 2020; 26: 370-405.

52. Heslehurst N, Brown H, Pemu A, Coleman H, Rankin J. Perinatal health outcomes and care among asylum seekers and refugees: a systematic review of systematic reviews. BMC Med 2018; 16: 89.

53. Boynton L, Bentley J, Strachan E, Barbato A, Raskind M. Preliminary findings concerning the use of prazosin for the treatment of posttraumatic nightmares in a refugee population. J Psychiatr Pract 2009; 15: 454-9.

54. Bruhn M, Rees S, Mohsin M, Silove D, Carlsson J. The range and impact of postmigration stressors during treatment of trauma-affected refugees. J Nerv Ment Dis 2018; 206: 61-8.

55. Prigerson HG, Boelen PA, Xu J, Smith K V, Maciejewski PK. Validation of the new DSM-5-TR criteria for prolonged grief disorder and the PG-13-Revised (PG-13-R) scale. World Psychiatry 2021; 20: 96-106.

56. Cheung Chung M, AlQarni N, AlMazrouei M, et al. The impact of trauma exposure characteristics on post-traumatic stress disorder and psychiatric co-morbidity among Syrian refugees. Psychiatry Res 2018; 259: 310-5.

57. Clukay CJ, Dajani R, Hadfield K, Quinlan J, Panter-Brick C, Mulligan CJ. Association of MAOA genetic variants and resilience with psychosocial stress: a longitudinal study of Syrian refugees. PLoS One 2019;14: e0219385.

58. Kessler RC, Andrews G, Colpe LJ, et al. Short screening scales to monitor population prevalences and trends in non-specific psychological distress. Psychol Med 2002; 32: 959-76.

59. van Heemstra HE, Scholte WF, Nickerson A, Boelen PA. Can circumstances be softened? Self-efficacy, post-migratory stressors, and mental health among refugees. Int J Environ Res Public Health 2021; 18: 1440.

60. Knefel M, Kantor V, Nicholson AA, et al. A brief transdiagnostic psychological intervention for Afghan asylum seekers and refugees in Austria: a randomized controlled trial. Trials 2020; 21: 57.

61. Wen K, McGrath M, Acarturk C, et al. Post-traumatic growth and its predictors among Syrian refugees in Istanbul: a mental health population survey. J Migr Heal 2020; 1-2: 100010.

62. Betancourt TS, Bass J, Borisova I, et al. Assessing local instrument reliability and validity: a field-based example from northern Uganda. Soc Psychiatry Psychiatr Epidemiol 2009; 44: 685-92.

63. Grochtdreis T, Röhr S, Jung FU, et al. Health Care Services utilization and health-related quality of life of Syrian Refugees with post-traumatic stress symptoms in Germany (the Sanadak Trial). Int J Environ Res Public Health 2021; 18: 3408.

64. Palic S, Kappel ML, Makransky G. Rasch validation and cross-validation of the health of nation outcome scales for monitoring of psychiatric disability in traumatized refugees in Western psychiatric care. Assessment 2016; 23: 734-43.

65. van den Heuevel WJ. Health status of refugees from former Yugoslavia: descriptive study of the refugees in the Netherlands. Croat Med J 1998; 39: 356-60.

66. Doumit R, Kazandjian C, Militello LK. COPE for Adolescent Syrian Refugees in Lebanon: a brief cognitive-behavioral skill-building intervention to improve quality of life and promote positive mental health. Clin Nurs Res 2020; 29: 226-34.

67. Tay AK, Rees S, Miah MAA, et al. Functional impairment as a proxy measure indicating high rates of trauma exposure, post-migration living difficulties, common mental disorders, and poor health amongst Rohingya refugees in Malaysia. Transl Psychiatry 2019; 9: 213.

68. Carlsson JM, Mortensen EL, Kastrup M. Predictors of mental health and quality of life in male tortured refugees. Nord J Psychiatry 2006; 60: 51-7.

69. Alexander N, Mathilde S, Øivind S. Post-migration stressors and subjective well-being in adult syrian refugees resettled in Sweden: a gender perspective. Front Public Health 2021; 9: 717353.

70. Santambrogio J, Ciscato V, Lorusso O, et al. The challenge of diagnosing cultural syndromes: a narrative review. Int J Soc Psychiatry 2024; 70: 1016-27.

71. Hocking DC, Mancuso SG, Sundram S. Development and validation of a mental health screening tool for asylum-seekers and refugees: the STAR-MH. BMC Psychiatry 2018; 18: 69.