Mental health in Syrian children with a focus on post-traumatic stress: a cross-sectional study from Syrian schools

Prevalence and risk factors associated with mental disorders among migrants in the MENA region: A systematic review and meta-analysis

BACKGROUND

The MENA region has experienced extraordinary events in recent years, resulting in an influx of refugees and displaced people who are vulnerable to mental disorders. Several previous studies have examined their prevalence, but none have focused on this region. This systematic review provided an estimate of the prevalence of mental illness and associated risk factors in the MENA region, and overcame the methodological limitations of individual studies.

METHODS

Thorough searches of the relevant databases were carried out to locate relevant published articles. Furthermore, cross-sectional studies were conducted to assess mental disorders in refugees, asylum seekers, migrants, or internally displaced people residing in the MENA region. Only studies meeting the aforementioned criteria were considered. For this purpose, RStudio software version 2023.12.0 + 369 with netmeta package was used for measurement and data analysis. JBI used to assess study quality.

RESULTS

The results, including 32 cross-sectional studies with a total of 21659 participants were obtained and discussed. The overall prevalence was 42% (95% CI; 30%, 54%) for depression, 43% (95% CI; 31%, 57%) for anxiety, 22% (95% CI; 11%, 39%) for stress, and 45% (95% CI; 36%, 53%) for PTSD. As a result, it was noted that being female was associated with depression, and being female and unemployed was associated with PTSD, however being married was protective against this later.

CONCLUSION

Compared to the rest of the globe, MENA has a greater rate of mental illness among refugees. Nevertheless, much effort should be devoted on listing causes associated, as well as their management and prevention.

Coping Mechanisms and Posttraumatic Stress Exhibited by Children in Areas of Yemen's Armed Conflict in Southern Saudi Arabia

This study is an attempt to explore war-related trauma, its stressful effects, and the coping strategies of Saudi schoolchildren. The authors hypothesized that children exposed to war-related trauma will show higher levels of PTSD, and that those with higher levels of PTSD symptoms use more maladaptive coping strategies. The study describes the correlation between traumatic events and posttraumatic stress disorder (PTSD) as well as coping strategies. Five hundred twenty-seven intermediate and high school students, 12 to 18 years old, living in the conflict zone in southern Saudi Arabia completed three standardized self-reported scales: the War Zone Traumatic Events Checklist, the Child PTSD Symptom Scale, and the Children's Coping Strategies Checklist. Each participating student was randomly chosen. Analysis was based on two groups: the high-PTSD symptoms group (182 children) and the low-PTSD symptoms group (345 children). The study was conducted between September 2020 and April 2022 while the war was ongoing as part of an ongoing larger study. Children exposed to war-related traumatic events exhibited greater prevalence rates for PTSD. The children reported high levels of PTSD symptoms and applied a variety of coping strategies to manage related stress. Participants rarely reported that psychological or educational interventions had been used to manage the war-related traumatic experiences and PTSD or to improve related coping styles. The results are discussed in the context of mental health services needed for children in the conflict zone. To bridge the gap between health care services and the needs of children with PTSD, and for better understanding and interventions, health professionals are invited to develop a biopsychosocial model that identifies the risks of PTSD related to exposure to war-related traumatic events in school-aged children and, hence, provide a multidisciplinary intervention program that educates, encourages, and supports teachers and parents in following medical recommendations and goals.

Mental health consequences among Sudanese due to the armed conflicts and civil unrest of 2023: a cross-sectional study

AIM

To investigate depression, anxiety, PTSD, and insomnia levels among Sudanese citizens during the 2023 Armed Forces conflict in Sudan.

METHODS

An online survey was distributed. It is composed of five parts, covering the following areas: (a) sociodemographic data; (b) depression assessment; (c) generalized anxiety disorder assessment; (d) post-traumatic stress disorder assessment; and (e) insomnia assessment.Statistical Package for Social Sciences version 27 was used for data analysis; frequency and percentage were used to describe the qualitative variables. The Pearson correlation coefficient and Chi-square test were used for correlation and association analysis; a p-value equal to or less than .05 was considered statistically significant.

RESULTS

The study included 221 participants, whose ages were 35.02 ± 11.83 years. Among the participants, 57.5% were female. The length of stay in the war zone was 39.29 ± 31.71 days. The sound of gunfire, bombs, or explosions was the most frequent war violence personally experienced by participants or their family members, friends, or acquaintances, in 203 (91.8%) and 221 (100%), respectively. Moderate-severe and severe depression were present in 25.3% and 62.0%, respectively. Moderate and severe anxiety were present in 36.2% and 52.9%, respectively. 58.8% had PTSD. Sub-threshold insomnia was present in 57.5%. There was a negative correlation between sex (female) and depression (correlation coefficient = -.183, p-value = .006), which indicates that depression is more likely to be in females. For PTSD, there was a negative correlation between age and PTSD (correlation coefficient = -.150, p-value = 0.026), which indicates that younger age groups were more likely to experience PTSD. Additionally, there was a negative correlation between marital status (married) and PTSD (correlation coefficient = -.175, p-value = .009), which indicates that married participants were more likely to experience PTSD.

CONCLUSIONS

Exposure to war-related trauma can also lead to mental health issues. These findings emphasize the urgent need for proper mental health support and interventions in war-affected areas to address the prevalent mental disorders.

Impact of Syrian Conflict on the Oral Health of Adolescents: A Cross-Sectional Study

BACKGROUND

The Syrian conflict has had a negative impact on the psychological and overall health of adolescents. However, little is known about the oral health of those who are internally displaced.

AIMS

The purpose of this study was to investigate the relationship between mental health state and self-reported oral health and habits in Syrian adolescents.

METHODS

A total of 99 adolescents living in Syria were included in the study. The participants were given four questionnaires: the International Trauma Questionnaire (ITQ), the Depression Anxiety Stress Scale-21 (DASS-21), the Epworth Sleepiness Scale (ESS), and the World Health Organization (WHO) Oral Health Questionnaire for Children (2013). The relationship between self-reported oral and mental health was evaluated.

RESULTS

Adolescents with symptoms of mental disturbances or abnormal sleep conditions were statistically more likely to self-report the health of their teeth and gums as below average, less likely to brush their teeth regularly, and reported more frequent smoking (p<0.05). Moreover, symptoms of mental disturbances and abnormal sleep conditions were statistically more likely in adolescents living in rural areas and whose parents' education did not exceed secondary school (p<0.05).

CONCLUSION

Syrian adolescents reported mental disturbances, which were reflected in their poor oral health and habits. These findings confirm the need for psychiatric and oral health care programs for Syrians who remain in areas of conflict.

Mental Health and Psychosocial Problems among Children and Adolescents in Jordan: A Scoping Review

Introduction: In Jordan, mental health morbidity among children and adolescents is on the rise. Several studies in Jordan have assessed mental health issues and their associated factors among adolescents; however, there remains a lack of a collation of data regarding such issues. Objectives: To review the prevalence rates of mental health problems among children and adolescents in Jordan to understand the evidence base concerning psychiatric morbidity. Methods: The PubMed database, Cochrane Library, Virtual Health Library (VHL) Lilac, and APA PsycArticles were searched for literature published between January 2010 and May 2023. Studies were included if they were conducted on children and adolescents (≤19 years), were observational studies that reported prevalence data regarding psychosocial problems, and were studies conducted in Jordan. Results: The search yielded 211 records, of which 33 studies were assessed for eligibility and 28 met the inclusion criteria. The sample age ranged from 6-19 years. The prevalence rates ranged from 7.1% to 73.8% for depression, 16.3% to 46.8% for anxiety, 13.0-40.6% for ADHD, 11.7-55.2% for overall emotional and behavioral difficulties, 16.2-65.1% for PTSD, and 12-40.4% for eating disorders. Conclusions: The findings highlight the magnitude of mental health problems among children and adolescents and the heterogeneity of the results. Further studies are needed to investigate the prevalence of eating disorders among refugees, as well as sleeping disorders and substance use disorders among all adolescents.

Impact of the Russian Invasion on Mental Health of Adolescents in Ukraine

OBJECTIVE

Very limited evidence is available on the psychological impact of war on adolescents in Ukraine. This study compared war experiences and posttraumatic stress disorder (PTSD), anxiety and depression in adolescents living in war-torn and peaceful regions of Ukraine, more than 2 years after Russia first invaded in 2014.

METHOD

The cross-sectional study included 2,766 students aged 11 to 17 years living in the war-torn Donetsk region and in Kirovograd in central Ukraine. Self-reported PTSD, depression, and anxiety were assessed by Harvard Trauma Questionnaire, Patient Health Questionnaire-9, and Generalized Anxiety Disorder-7. Data were collected from September 2016 to January 2017. Binary and multinomial logistic regression models were used to examine the association between PTSD, anxiety, and depression and regions.

RESULTS

War trauma and daily stress were higher in adolescents in the Donetsk region; 881 (60.2%) adolescents had witnessed armed attacks, 204 (13.9%) were victims of violence, and 409 (27.9%) were forced to leave their homes. They also had significantly increased risks for PTSD (odds ratio [OR] 4.11, 95% CI 2.37-7.13), severe anxiety (OR 3.10, 95% CI 1.83-5.27), and moderately severe/severe depression (OR 2.65, 95% CI 1.79-3.92).

CONCLUSION

Traumatic events and daily stress were strongly associated with psychological distress in adolescents living in a war-torn region in Ukraine. These findings can help in understanding, measuring, and addressing the long-term impact that the current escalating war in Ukraine will have on adolescents' mental health and social functioning.

Post-traumatic stress disorder in youth exposed to the Syrian conflict: A systematic review and meta-analysis of prevalence and determinants

A decade of ongoing armed conflict in Syria has damaged the physical and mental health of millions of adults and children. This study aimed to systematically review the prevalence of post-traumatic stress disorder among youth exposed to the Syrian conflict, and understand its individual and contextual determinants. The screening procedure resulted in 26 studies, with a total of 11,400 Syrian children and adolescents. The prevalence was 36% (95% CI (0.29-0.43), p < 0.001). Loss of family members or acquaintances, witnessing violence, and social withdrawal increased the risk of post-traumatic stress disorder, while social trust and social support were protective factors.

The Relationship Between Spirituality and Post-Traumatic Stress Symptoms in Syrian Adolescents in Jordan

The civil war in Syria began in 2011 and escalated over years resulting in one of the largest humanitarian crises since the Second World War. Injury, loss, poverty, and immigration trapped the Syrian population in a diversity of psychological disorders, including post-traumatic stress disorder (PTSD). Spirituality has, on the other hand, been consistently reported as a resilient factor against developing mental disorders. Hence, spirituality or religiosity have been incorporated in clinical and psychotherapeutic practice for several mental disorders. We explored the association between spirituality and the development of PTSD symptoms among Syrian refugee adolescents in Jordanian schools. A sample of 418 Syrian adolescent students (age range between 12-16 years) from Jordanian schools in the northern part of the country were enrolled in the study after informing on study context and objectives. The study questionnaire included sample demographics, smoking status, PTSD checklist - Civilian Version (PCL-C), two spirituality-targeting questions, and trauma and loss history. `Almost half of participants (N = 196) showed moderate PTSD symptoms while around 30% (N = 124) had a severe level of PTSD symptoms. On the other hand, 3 out of four students perceived themselves as highly spiritual. The study resulted in a positive correlation between belief in God and God's thankfulness. Furthermore, increased spirituality level did not appear to lower the risk of developing PTSD symptoms. Spiritual self-perception of Syrian refugee adolescents showed neither protective nor aggravating effect of on the occurrence of post-traumatic stress symptoms. Additional research and more accurate tools are needed to assess the potential impact of spiritual/religious values towards PTSD symptoms among adolescents.

Post-traumatic stress disorder interventions for children and adolescents affected by war in low- and middle-income countries in the Middle East: systematic review

BACKGROUND

Millions of children and adolescents are exposed to wars, affecting their psychological well-being. This review focuses on psychosocial interventions in low and middle-income countries (LMICs) in the Middle East, where mental health services are limited.

AIMS

Our primary aim was to evaluate the effectiveness of trial-assessed psychosocial interventions in reducing post-traumatic stress disorder (PTSD) symptoms in children and adolescents aged ≤18 years who were exposed to war in LMICs in the Middle East. Changes in other psychological conditions and symptoms were evaluated where reported.

METHOD

PubMed, Cochrane Library and Ovid were searched without year restriction, in December 2021. Previous review reference lists were also checked. Only studies published in English were included. Each study was evaluated for risk of bias and results are presented as a narrative synthesis.

RESULTS

Three group-based interventions were identified and evaluated across six studies: 'Teaching Recovery Techniques', 'Writing for Recovery' and 'Advancing Adolescents'. Two studies took place in post-war settings, and four in a context of ongoing conflict. Positive experiences and improved social skills were indicated following most interventions, but Teaching Recovery Techniques was the only programme associated with a statistically significant reduction in PTSD score. Differences in follow-up interval limited comparability of outcomes.

CONCLUSIONS

This review highlights a paucity of evidence for effective treatment options for children and adolescents affected by war from LMICs in the Middle East. Promising indications of reductions in PTSD symptoms, specifically from Teaching Recovery Techniques, require further rigorous evaluation and long-term follow-up.

Knowledge, stigma, and beliefs toward mental illnesses among schoolteachers in Damascus

BACKGROUND

Teachers have an important role in promoting the mental wellbeing of their students, hence their knowledge and attitudes toward mental health disorders should be assessed. A very few studies regarding this topic were conducted in Syria, but due to the recent events which have had occurred the country, it is essential to deal with students who suffer from mental illnesses professionally especially that such disorders may be stigmatized by the society.

AIMS

This paper aims to investigate knowledge, beliefs, and attitudes toward mental disorders in a sample of Syrian schoolteachers.

METHOD

A cross-sectional study using self-administered questionnaire was conducted in Damascus and Refdimashq, involving 400 teachers from 16 schools.

RESULTS

The results showed that the prevalence of stigmatizing positions toward psychiatric illnesses was low among teachers. The contributors did not state a correlation between spiritual beliefs and psychological disorders. It was also found that teachers were neutral in their knowledge about mental illnesses and psychiatric treatment or interventions along with their mental health resources. However, 42.5% of the participants use the internet for such purposes.

CONCLUSION

In general, teachers of Damascus and its Refdimashq had a reasonable degree of awareness about mental disorders and treatments. Furthermore, neither stigma nor the relation between religious thoughts and mental disorders had been ascertained.

Post-traumatic stress disorder (PTSD), anger and mental health of school students in Syria after nine years of conflict: a large-scale school-based study

BACKGROUND

The Syrian crisis has entered its ninth year with many being affected by the war. This is the largest-scale study that aims to evaluate the psychological profile of secondary school students in Syria.

METHODS

This is a cross-sectional study in schools in Damascus, Syria. The surveys assessed working habits, smoking, war exposure, grades, socioeconomic status (SES), social support, health-related quality of life (HRQL), post-traumatic stress disorder (PTSD), problematic anger, and other parameters.

RESULTS

This study included 1369 students of which 53% suffered from PTSD and 62% from problematic anger. Around 46% declared a fair or worse general health and 61% had moderate or severe mental health. Only 9.3% did not report exposure to any war-related variable. War exposure had an impact on PTSD, anger, and HRQL, but not on students' grades. Smoking, having consanguineous parents, and working did not have a clear association with grades or anger. Social support weakly reduced PTSD and anger scores. Interestingly, working was associatedwith lowerPTSD scores but was associated with a worse physical component of HRQL.

CONCLUSION

This is the largest study on school students in Syria that reports the psychological ramifications of war. Although the direct effects of war could not be precisely described, the high burden of PTSD and anger distress was a strong reflection of the chronic mental distress.

The posttraumatic stress interview for children (KID-PIN): development and validation of a semi-structured interview of PTSD symptoms among displaced children in the Middle East

BACKGROUND

In populations affected by mass disaster such as armed conflict and displacement, children are at risk of developing mental ill-health, in particular post-traumatic stress disorder (PTSD). Valid and reliable screening instruments are needed to assess the severity of PTSD symptoms among children and to identify individuals in need of treatment.

METHOD

In the context of an ongoing war in the Middle East, we developed the KID-PIN as a semi-structured interview for PTSD symptoms that can be administered by trained paraprofessionals. To achieve a culturally and contextually appropriate instrument, the development was based on open-ended interviews with affected children and involved both local and international experts. Using the KID-PIN and instruments for constructs associated with PTSD, 332 Iraqi and Syrian displaced children were interviewed. A subset of the sample (n = 86) participated in validation interviews based on experts applying the Clinician-Administered PTSD Scale for DSM-5-Child/Adolescent Version (CAPS-CA-5).

RESULTS

The KID-PIN demonstrated excellent internal consistency (Cronbach's alpha = 0.94) with good convergent validity. Confirmatory factor analyses of the KID-PIN showed an acceptable fit with the DSM-5 and other common models; the best fit was reached with the Hybrid model. Receiver operating characteristic analyses indicated that the cut-off score of 28 or higher on the KID-PIN is the optimum cut-off for a probable PTSD diagnosis.

CONCLUSION

The utility of the newly developed KID-PIN as a screening instrument for PTSD in children is supported by the measure's high internal consistency and good convergent and structural validity, as well as its diagnostic accuracy.

Conflict-related health research in Syria, 2011-2019: a scoping review for The Lancet - AUB Commission on Syria

BACKGROUND

The volume of health-related publications on Syria has increased considerably over the course of the conflict compared with the pre-war period. This increase is largely attributed to commentaries, news reports and editorials rather than research publications. This paper seeks to characterise the conflict-related population and humanitarian health and health systems research focused inside Syria and published over the course of the Syrian conflict.

METHODS

As part of a broader scoping review covering English, Arabic and French literature on health and Syria published from 01 January 2011 to 31 December 2019 and indexed in seven citation databases (PubMed, Medline (OVID), CINAHL Complete, Global Health, EMBASE, Web of Science, Scopus), we analyzed conflict-related research papers focused on health issues inside Syria and on Syrians or residents of Syria. We classified research articles based on the major thematic areas studied. We abstracted bibliometric information, study characteristics, research focus, funding statements and key limitations and challenges of conducting research as described by the study authors. To gain additional insights, we examined, separately, non-research publications reporting field and operational activities as well as personal reflections and narrative accounts of first-hand experiences inside Syria.

RESULTS

Of 2073 papers identified in the scoping review, 710 (34%) exclusively focus on health issues of Syrians or residents inside Syria, of which 350 (49%) are conflict-related, including 89 (25%) research papers. Annual volume of research increased over time, from one publication in 2013 to 26 publications in 2018 and 29 in 2019. Damascus was the most frequently studied governorate (n = 33), followed by Aleppo (n = 25). Papers used a wide range of research methodologies, predominantly quantitative (n = 68). The country of institutional affiliation(s) of first and last authors are predominantly Syria (n = 30, 21 respectively), the United States (n = 25, 19 respectively) or the United Kingdom (n = 12, 10 respectively). The majority of authors had academic institutional affiliations. The most frequently examined themes were health status, the health system and humanitarian assistance, response or needs (n = 38, 34, 26 respectively). Authors described a range of contextual, methodological and administrative challenges in conducting research on health inside Syria. Thirty-one publications presented field and operational activities and eight publications were reflections or first-hand personal accounts of experiences inside Syria.

CONCLUSIONS

Despite a growing volume of research publications examining population and humanitarian health and health systems issues inside conflict-ravaged Syria, there are considerable geographic and thematic gaps, including limited research on several key pillars of the health system such as governance, financing and medical products; issues such as injury epidemiology and non-communicable disease burden; the situation in the north-east and south of Syria; and besieged areas and populations. Recognising the myriad of complexities of researching active conflict settings, it is essential that research in/on Syria continues, in order to build the evidence base, understand critical health issues, identify knowledge gaps and inform the research agenda to address the needs of the people of Syria following a decade of conflict.

Disability among Syrian refugees living in Sultanbeyli, Istanbul: Results from a population-based survey

OBJECTIVES

To estimate the prevalence of disability among Syrian refugees living in Sultanbeyli district, Istanbul and compare people with and without disabilities in terms of demographic and socio-economic characteristics.

METHODS

Using the municipality refugee database as the sampling frame, 80 clusters of 50 people (aged 2+ years) were selected using probability proportionate to size sampling of clusters and random selection of households within clusters. Disability assessment included: i) self-reported difficulties in functioning (using the Washington Group Short Set-Enhanced tool and Child Functioning Modules), ii) Rapid Assessment of Musculoskeletal Impairment and iii) screening for symptoms of common mental disorders for children aged 8-17.

RESULTS

The overall prevalence of disability was 24.7% (95% CI 22.1-27.4), when including people self-reporting a lot of difficulty/cannot do in at least functional domain (15%, 95% CI 13.1-17.2), moderate/severe MSI (8.7%, 95% CI 7.6-9.9), and/or symptomatic anxiety, depression and PTSD among children 8-17 (21.0%, 95% CI 18.2-23.9). Men with disabilities were significantly less likely to be in paid work compared to their peers without disabilities (aOR 0.3 95% CI 0.2-0.5). Overall 60% of households included at least one person with a disability. Households with at least one person with a disability had a significantly higher dependency ratio, lower proportion of working-age adults in paid work, and were more likely to be female headed and in receipt of social protection schemes (p<0.05).

CONCLUSION

Disability is common among Syrian refugees in Sultanbeyli. People with disabilities in this setting experience greater vulnerability to poverty and exclusion from work, highlighting an urgent need for inclusive services, programmes and policies that are developed and implemented in partnership with people with disabilities.

Children's Reactions to War, Armed Conflict and Displacement: Resilience in a Social Climate of Support

PURPOSE OF REVIEW

The aim of this review was to unravel recent evidence for children's reactions to war and armed conflict focusing on resilience factors mitigating adverse psychological and psychiatric consequences.

RECENT FINDINGS

Three categories of mitigating resilience factors emerged from the literature - personal, family, and community factors. In addition, a unifying model of moderating resilience factors emerged, proposing a higher-tier environmental dimension conceptualized here as social climate of support. Wars and armed conflict affect children both by direct exposure to threats, and by disruption of the social fabric supporting development. The notion of producing a climate of social support can direct policy toward service provision and resilience-based programs that both build individual capacities and encompass development of the resources of families, schools, community, and societal structures supportive of children's adjustment and wellbeing. Future research should shift toward systems thinking within a socio-ecological nesting of individual, familial, community, and societal systems.

Public health consequences after ten years of the Syrian crisis: a literature review

Ten years of the Syrian war had a devastating effect on Syrian lives, including millions of refugees and displaced people, enormous destruction in the infrastructure, and the worst economic crisis Syria has ever faced. The health sector was hit hard by this war, up to 50% of the health facilities have been destroyed and up to 70% of the healthcare providers fled the country seeking safety, which increased the workload and mental pressure for the remaining medical staff. Five databases were searched and 438 articles were included according to the inclusion criteria, the articles were divided into categories according to the topic of the article.

Through this review, the current health status of the Syrian population living inside Syria, whether under governmental or opposition control, was reviewed, and also, the health status of the Syrian refugees was examined according to each host country. Public health indicators were used to summarize and categorize the information. This research reviewed mental health, children and maternal health, oral health, non-communicable diseases, infectious diseases, occupational health, and the effect of the COVID − 19 pandemic on the Syrian healthcare system. The results of the review are irritating, as still after ten years of war and millions of refugees there is an enormous need for healthcare services, and international organization has failed to respond to those needs. The review ended with the current and future challenges facing the healthcare system, and suggestions about rebuilding the healthcare system.

Through this review, the major consequences of the Syrian war on the health of the Syrian population have been reviewed and highlighted. Considerable challenges will face the future of health in Syria which require the collaboration of the health authorities to respond to the growing needs of the Syrian population. This article draws an overview about how the Syrian war affected health sector for Syrian population inside and outside Syria after ten years of war which makes it an important reference for future researchers to get the main highlight of the health sector during the Syrian crisis.

Refugee Mental Health, Global Health Policy, and the Syrian Crisis

The most recent global refugee figures are staggering, with over 82.4 million people forcibly displaced and 26.4 million registered refugees. The ongoing conflict in Syria is a major contributor. After a decade of violence and destabilization, over 13.4 million Syrians have been displaced, including 6.7 million internally displaced persons and 6.7 million refugees registered in other countries. Beyond the immediate political and economic challenges, an essential component of any response to this humanitarian crisis must be health-related, including policies and interventions specific to mental health. This policy and practice review addresses refugee mental health in the context of the Syrian crisis, providing an update and overview of the current situation while exploring new initiatives in mental health research and global health policy that can help strengthen and expand services. Relevant global health policy frameworks are first briefly introduced, followed by a short summary of recent research on refugee mental health. We then provide an update on the current status of research, service provision, and health policy in the leading destinations for Syrians who have been forcibly displaced. This starts within Syria and then turns to Turkey, Lebanon, Jordan, and Germany. Finally, several general recommendations are discussed, including the pressing need for more data at each phase of migration, the expansion of integrated mental health services, and the explicit inclusion and prioritization of refugee mental health in national and global health policy.

Health-related quality of life in refugee youth and the mediating role of mental distress and post-migration stressors

PURPOSE

The aim of this study is to explore how potentially traumatic events (PTEs) from war and flight influence health-related quality of life (HRQoL) in young refugees after recent resettlement. In a model based on earlier theory, we tested if post-migration stressors and mental distress mediated the effect of PTEs on HRQoL, individually and in serial. We also explored how different types of post-migration stressors influenced different dimensions of HRQoL.

METHODS

This study used a cross-sectional design where 160 Syrian youth recently resettled in Norway completed questionnaires at school between May and December 2018. Correlations between types of post-migration stressors and dimensions of HRQoL were explored and a serial multiple mediator model was tested. Models were adjusted for age and gender, using two types of mental distress; post-traumatic stress disorder (PTSD) and general mental distress.

RESULTS

Higher levels of PTEs reduced experienced HRQoL, but this direct effect was mediated by post-migration stressors alone and in serial with mental distress. Despite high levels of mental distress, this did not affect HRQoL independently, only in serial mediation with increased post-migration stressors. Economic concerns and discrimination were types of post-migration stressors affecting several dimensions of HRQoL.

CONCLUSION

Quality of life in refugee is affected by past events from war, stressors in current resettlement and elevated mental distress through complex interrelations. The study reiterates the importance of considering structural and everyday post-migration stressors in policy and intervention to improve the health and wellbeing of refugee youth.

Through Her Eyes: The Impact of War on Syrian Refugee Families

BACKGROUND

The Syrian war conflict ended with devastating impact on Syrian refugee women and their children. A few studies have been done that explored the impact of the civil war and displacement of Syrian families from a cultural perspective. The purpose of this study was to highlight the experiences of the Syrian war-refugee families who have sought shelter in a host country.

METHOD

A descriptive phenomenological study was conducted using a semistructured interview approach among 16 Syrian refugee women who were approached from two Jordanian health care centers.

RESULTS

The main themes discussed how the war ended with financial and social stress, family violence, and hazardous effects on women and children health.

CONCLUSION

This article introduced how culture and religion influence how family unit and members responded to war stressors. This study provided transcultural nursing knowledge, allowing nurses to be grounded in individualized culturally specific care.

Rapid mental health screening in conflict zones: a translation and cross-cultural adaptation into Arabic of the shortened Revised Child Anxiety and Depression Scale (RCADS-25)

Background

During conflict, children and adolescents are at increased risk of mental health problems and in particular, anxiety and depression. However, mental health screening in conflict settings is problematic and carries risk making the need for fast, easy-to-administer, screening instruments paramount. The shortened version of the Revised Child Anxiety and Depression Scale (RCADS-25) is one method of rapidly assessing anxiety and depressive symptoms in youths. This self-report questionnaire demonstrates good internal consistency and diagnostic capacity in clinical and non-clinical populations. Nevertheless, few studies have tested the psychometric properties of translated versions of the RCADS-25 limiting its applicability worldwide.

Objectives

To expand the reach and utility of the RCADS-25, the present study sought to develop an Arabic version of the instrument (RCADS25-Arabic) and to explore its reliability and underlying factor structure. In light of changes to DSM classification, the effects of removing indicator variables for obsessive-compulsive disorder on the psychometrics of the RCADS25-Arabic were also explored.

Method

The scale was back translated into Modern Standard Arabic and administered to 250 Arabic speaking schoolchildren between 8 and 15 years of age in Syria. Mean and standard deviation were used to characterise the sample and summarize scores. The reliability and factor structure of the RCADS25-Arabic was explored using confirmatory factor analysis.

Results

Females were 127 and mean age was 12.11 ± SD 2.35. Males scored lower on anxiety (M 15.05 SD ± 8.0, t(248) = − 3.15, p = .003, d = 0.39) and internalizing factors (M 26.1 SD ± 13.1, t(248) = − 2.36, p = .0160, d = 0.31) with no statistical gender difference recorded for depression (t(248) = − 1.27, p = .202). Fit statistics were good for two- and one-factor solutions (χ²/df = 1.65, RMSEA 0.051, CFI .91, TLI .90 and χ²/df = 1.64 and RMSEA 0.051, CFI .91 and TLI .89 respectively). DIFFTEST showed no significant difference between models (χ²_diff (1) = 0.03, p < 0.86) indicating a one-factor (internalizing) solution was preferable. No improvement in scale integrity was found after deleting obsessive-compulsive disorder items.

Conclusion

The RCADS25-Arabic is useful for rapid screening of depression and anxiety but is better used to identify a one-factor internalizing construct. Obsessive-compulsive disorder items should be retained in the RCADS-25.

Depression and Anxiety and Their Associated Factors Among Jordanian Adolescents and Syrian Adolescent Refugees

The purpose of the current study was to determine the prevalence of depression and anxiety and their associated factors among Jordanian adolescents (n = 1,878) and Syrian adolescent refugees (n = 1,773) aged 12 to 17 years. The Center for Epidemiologic Studies-Depression Scale for Children (CES-DC), Patient Health Questionnaire-9-Modified, and Generalized Anxiety Disorder-7 questionnaire were used in this study. Approximately 27.2% of Jordanian adolescents and 28.3% of Syrian adolescent refugees had depression as assessed by the CES-DC. Among males, 17.6% of Jordanian adolescents and 19% of Syrian adolescent refugees had anxiety. Among females, 28.1% of Jordanian adolescents and 27.3% of Syrian adolescent refugees had anxiety. Overall, Jordanian adolescents and Syrian adolescent refugees had high prevalence of depression and anxiety. Establishing community-based mental health care in Jordan is crucial. [Journal of Psychosocial Nursing and Mental Health Services, 59(6), 23-30.].

Post-traumatic stress disorder and its association with stroke and stroke risk factors: A literature review

Stroke is a major cause of mortality and disability globally that has multiple risk factors. A risk factor that has recently gained more attention is post-traumatic stress disorder (PTSD). Literature searches were carried out for updated PTSD information and for the relationship between PTSD and stroke. The review was divided into two sections, one exploring PTSD as an independent risk factor for stroke, with a second concentrating on PTSD's influence on stroke risk factors. The study presents accumulating evidence that shows traumatic stress predicts stroke and is also linked to many major stroke risk factors. The review contributes knowledge to stroke aetiology and acts as a reference for understanding the relationship between PTSD and stroke. The information presented indicates that screening and identification of traumatic experience would be beneficial for directing stroke patients to appropriate psychological and lifestyle interventions. In doing so, the burden of stroke may be reduced worldwide.

Mental disorder and PTSD in Syria during wartime: a nationwide crisis

BACKGROUND

Syria has experienced war since 2011, leaving over 80% under the poverty line and millions displaced. War and its retaliations have significantly impacted the mental health of Syrians. This study evaluates the post-traumatic stress disorder (PTSD), and the severity of the mental distress caused by war and other factors such as low social support. This study also evaluates other variables and compares the findings with those of multiple studies on Syria and refugees.

METHODS

This is a cross-sectional study that included people who lived in Syria in different governorates. Online surveys were distributed into multiple online groups and included the Kessler 10 (K10) scale which screens for anxiety and depression, the Screen for Posttraumatic Stress Symptoms (SPTSS) tool, the Multidimensional Scale of Perceived Social Support, and questionnaires on demographic and war-related factors.

RESULTS

Our study included 1951 participants, of which, 527 (27.0%) were males and 1538 (78.8%) between the age of 19 and 25. Among participants, 44% had likely severe mental disorder, 27% had both likely severe mental disorder and full PTSD symptoms, 36.9% had full PTSD symptoms, and only 10.8% had neither positive PTSD symptoms nor mental disorder on the K10 scale. Around 23% had low overall support. Half of the responders were internally displaced, and 27.6% were forced to change places of living three times or more due to war. Around 86.6% of the responders believed that the war was the main reason for their mental distress. Those with high SPTSS and K10 scores were found to take more days off from work or school due to negative feelings and having somatic symptoms. Moreover, the number of times changing places of living due to war, educational level, and being distressed by war noise were the most prominent factors for more severe PTSD and mental distress. No differences in PTSD and mental disorder prevalence were noted in participants living in different governorates or among different types of jobs. A strong significant correlation (r = 0.623) was found between SPTSS and K10 scores.

CONCLUSION

The conflict in Syria has left the population at great risk for mental distress which was higher compared to Syrian refugees elsewhere. Many measures with an emphasis on mental health are needed to help the people against a long-term avoidable suffering.

Implementation of mental health services in conflict and post-conflict zones: Lessons from Syria

OBJECTIVE

We describe the challenges confronted and lessons learned in implementing mental healthcare during the Syrian war to inform effective services for conflict-affected Syrian populations.

MATERIALS AND METHODS

We searched the academic and gray literature. We draw on the experiences of Syrian-American mental health professionals with nine years of experience providing clinical and programmatic mental healthcare in combat settings, siege, internally displaced person camps, and refugee camps.

RESULTS

Collaboration with nonprofessional personnel was essential due to the shortage of formally trained mental healthcare professionals in Syria. The use of psychological and diagnostic terms increased stigma, whereas asking about the patient's identified problem, "suffering," or "challenges" supported engagement. War-related trauma and horizontal violence commonly affect Syrian children, adolescents, and adults. Resilience and engagement were enhanced by sensitivity to patients' dignity, religious acceptance, and faith.

CONCLUSIONS

The Syrian war remains an ongoing public health and humanitarian crisis in which mental healthcare must adapt rapidly to specific needs and resources of the patient and community. Psychiatrists can increase the acceptability and efficacy of their care by being sensitive to Syrian patients' experiences of horizontal violence, loss of dignity, stigma, worldviews in which religion and faith may be important sources of resilience, and culturally acceptable modes of communication.

War-related trauma and post-traumatic stress disorder prevalence among Syrian university students

BACKGROUND

Posttraumatic stress disorder (PTSD) is one of the most prevalent mental disorders in war-affected regions. Syria has endured 9 years of war and yet little is known about the impact of the conflict on the well-being of Syrians who remain. In this study, we investigated trauma and estimated PTSD prevalence among university students in Deir-ez-Zor, a Syrian governorate that was under the siege by ISIS for over 3 years.

METHODS

A descriptive cross-sectional study design was used on a sample of Al-Furat university students in Deir-ez-Zor. We collected data on socio-demographics, trauma exposure, and stress levels. PTSD Checklist for DSM-5 was used to provide prevalence rate estimates, and determine the symptom severity among Syrian university students. Binary logistic regression was used to identify factors associated with the development of PTSD symptoms.

RESULTS

A total of 833 students were recruited into the study, 86.4% of the participants were exposed to at least one traumatic event. The estimated PTSD prevalence was 28.2%, and the highest PTSD rates were found among students who were forced into sexual act (46.3%). A significant association was found between PTSD and internal displacement (p = .032), academic year (p = .002), and social economic status (p = .000). Binary logistic regression indicated that PTSD symptoms were predicted by smoking and third-year university students.

CONCLUSIONS

The results presented in this research revealed a high prevalence of trauma exposure and PTSD symptoms among a sample of university students in Deir-ez-Zor. These findings call for immediate actions to help the affected population in restoring their mental health, so they can be prepared to face the challenges and demands of the post-conflict period.

Early-Life Multiple Sevoflurane Exposures Alleviate Long-term Anxiety-Like Behaviors in Mice via the proBDNF/ERK Pathway

Early-life multiple anesthetics exposure causes neurotoxicity and hence cognitive dysfunction on developing brain. However, the effects of early-life multiple sevoflurane exposures on emotional changes, especially upon stress, are far beyond understood. In young male C57BL6/J mice, the present study showed that 3% sevoflurane inhalation for 2 h in three consecutive days did not influence anxiety-like behaviors as measured by open field test, light dark transition, and elevated plus maze test. In addition, foot shocks stress induced both the short- and long-term anxiety-like behaviors. However, triple sevoflurane exposures ameliorated the long-term anxiety-like behaviors induced by the foot shocks. In parallel, foot shocks stress upregulated the expression of phosphorylated extracellular signal-regulated kinase (p-ERK) and brain-derived neurotrophic factor precursor (proBDNF) in the anterior cingulate cortex (ACC), which were significantly inhibited by triple sevoflurane exposures. Immunofluorescence further indicated that the increased p-ERK was mainly expressed in the proBDNF-positive staining cells. Intra-ACC injection of recombinant proBDNF protein upregulated the p-ERK expression and blocked the anxiolytic effect of sevoflurane exposure on long-term anxiety-like behaviors. Therefore, our study demonstrated that multiple sevoflurane exposures alleviate long-term anxiety-like behaviors upon acute stress in young mice by inhibiting proBDNF-ERK signaling in the ACC.

Prevalence of common mental disorders among Syrian refugee children and adolescents in Sultanbeyli district, Istanbul: results of a population-based survey

AIMS

Research demonstrates elevated levels of common mental disorders among Syrian refugees, but the majority of studies have, to date, focused on adult populations. This study aims to estimate the prevalence of depression, anxiety and post-traumatic stress disorder (PTSD) among Syrian children and adolescents living in Sultanbeyli district of Istanbul, Turkey.

METHODS

A population-based survey among Syrian children and adolescents aged 8-17 years living in Sultanbeyli district was conducted in 2019, as part of an all-age survey of disability. 80 clusters of 50 participants (all-ages) were selected from the local municipality's refugee registration database using probability proportionate to size sampling. Children aged 8-17 years were assessed for symptoms of common mental disorders using the Child Revised Impact of Event Scale (CRIES-8) and abbreviated versions of the Center for Epidemiologic Studies Depression Scale for Children (CES-DC) and the Screen for Child Anxiety Related Disorders (SCARED).

RESULTS

Of the 852 participants, 23.7% (95% CI 19.9-27.2) screened positive for symptomatic depression, PTSD and anxiety. The prevalence estimates for depression, PTSD and anxiety were 12.5% (95% CI 9.8-15.6), 11.5% (95% CI 9.1-14.4) and 9.2% (95% CI 6.8-12.1), respectively. Depression and PTSD were significantly more common in older adolescents, whilst anxiety and PTSD were significantly more common in girls. Depression was more common in children from poorer households and those who had received no education. Children coming from larger households were less likely to show symptoms of PTSD.

CONCLUSIONS

Syrian refugee children and adolescents are vulnerable to common mental disorders, and culturally appropriate prevention and intervention support are needed for this population.

Trajectories of psychological symptoms and resilience in conflict-affected children in low- and middle-income countries

Longitudinal studies on children's and adolescents' psychological reactions to conflict-related traumatic events in low- and middle-income countries are scarce. The present study aimed to analyze children's and adolescents' responses to conflict-related potentially traumatic events (PTEs) and the impact of the number of different types of PTEs on psychological symptoms and resilience over time. We investigated the presence of psychological symptoms and resilience, defined as low levels of symptoms and high levels of hope, in a sample of 597 conflict-affected children and adolescents allocated to a waiting list condition in four randomized trials conducted in Burundi, Indonesia, Nepal and Sri Lanka. A decrease in functional impairment (p < 0.001), symptoms of PTSD (p < 0.001), anxiety (p < 0.001), depression (p = 0.052), and an increase in social support (p < 0.001), was observed over a six-month follow-up. More than one third of children and adolescents (34.6%) exposed to conflict-related traumatic events improved at follow-up. Levels of hope did not significantly change. Improvement in psychological symptoms and resilience were significantly associated with the number of different types of PTEs experienced before study entry. This study showed that children and adolescents have the capacity to react to multiple traumatic events, and that the number of different types of traumatic events has an impact on resilience mechanisms. This will help differentiate the choice and focus of psychosocial interventions according to the amount of traumatic events experienced by children and adolescents, and will inform the development and testing of new psychosocial interventions.

Conflict-driven social change: the case of Syrian children and youth

For Syrian children, the civil war which emerged as a consequence of the Arab Spring has driven massive social change both at the structural level of legal, socioeconomic, educational and health systems, and at the intimate heart of everyday family life. This paper reviews recent research to understand the nature and impact of conflict-driven social change on children's lives. Research from the region and Western resettlement contexts indicates that Syrian refugee children have experienced high levels of exposure to conflict-related traumatic events and elevated rates of mental health difficulties, with evidence to suggest that adolescent girls in the region exhibit poorer well-being than boys. The research captures the social destruction experienced by children and families, and the adaptations forced by survival and protection needs to pre-conflict age, gender and family role norms.

Post-traumatic stress disorder among Syrian adolescent refugees in Jordan

OBJECTIVE

Studies among Syrian refugees in Turkey, Lebanon and Germany showed high prevalence rates of post-traumatic stress disorder (PTSD). However, data on PTSD among Syrian adolescent refugees in Jordan are scarce. Therefore, this study aimed to assess the prevalence and severity of PTSD, and its associated factors among Syrian schoolchildren refugees resettled in Jordan.

METHODS

This cross-sectional study was conducted among Syrian schoolchildren refugees aged 12-18 years. A stratified cluster random sample was used to select male and female schoolchildren in four cities with the highest density of Syrian refugees. The Child Post-Traumatic Stress Disorder Symptom Scale (CPSS) was used to measure PTSD severity.

RESULTS

The prevalence of moderate to severe PTSD among Syrian schoolchildren refugees in Jordan was 31%. This prevalence was higher in female adolescents compared with males (P = 0.001), and in children who had one or both parents died compared with those whose parents were living together (P = 0.006). The prevalence was lower in those living in Sahab city compared with Mafraq city (P = 0.006).

CONCLUSION

PTSD is a common condition among Syrian adolescent refugees, especially among females, and those who lost one or both parents. Screening for PTSD and other mental health illnesses is highly recommended. Gender-specific psychosocial support and educational programs should be implemented.

Trauma reactivation under propranolol among traumatized Syrian refugee children: preliminary evidence regarding efficacy

Background: There is a dearth of therapeutic solutions for traumatized young patients. Trauma reactivation conducted under the influence of the reconsolidation blocker propranolol (Reconsolidation Therapy) is a simple, cost-effective treatment option that has some promising initial results in adults suffering from posttraumatic stress disorder (PTSD). Objective: To explore the usefulness of this novel treatment in children. The primary outcome was the reduction of PTSD symptoms at the end of treatment, while secondary outcomes included reduction in anxiety and in depressive symptoms. Method: An open-label clinical trial was conducted in a refugee camp in Syria, investigating the safety and efficacy of this therapeutic strategy in 117 children suffering from enduring PTSD symptoms. Participants received propranolol 90 minutes before briefly recalling (i.e. reactivating) a single personal traumatic memory, for 5 consecutive days. Self-reported anxiety, depressive, and PTSD symptoms were assessed at baseline, as well as 4 and 13 weeks after treatment. Results: A significant, clinically meaningful symptom reduction was observed at all post-treatment measurement times vs. baseline. More specifically, between baseline and the 13-week follow-up we observed a 64% PTSD symptoms reduction (d = 2.71). In a similar vein, we obtained a 39% symptoms reduction for depressive symptoms (d = 1.01). The general anxiety symptoms improved, but eventually returned to prior level, probably because of the deteriorating living conditions in the camp. Conclusions: This therapy appeared as a potentially safe and useful treatment strategy for children suffering from PTSD symptoms, warranting replication studies using stronger study designs. The social acceptability and ease of implementation of the treatment should also be noted.

Mental health problems from direct vs indirect exposure to violent events among children born and growing up in a conflict zone of southern Thailand

PURPOSE

This study aims to examine and compare the effects of direct and indirect exposure to armed conflicts on the mental health of primary school students in the three southernmost provinces of Thailand.

METHODS

A school-based survey was conducted. Detailed exposure of traumatic events both directly and indirectly were measured by a self-completed questionnaire. Behavioral-emotional problems were measured by the Strength and Difficulty Questionnaire and screening for post-traumatic stress disorder (PTSD) was done using the Children's Revised Impact of Events Scale (CRIES). Multivariate analysis adjusted for gender and other covariates was used to determine the effect of direct and indirect exposure of armed conflict on mental health problems.

RESULTS

Out of 941 students included in the study, almost half had direct exposure to an armed conflict event. Overall, 42.1% of students had at least one behavioral-emotional problem (47.6% and 38.5% in the direct- and indirect-exposed groups, respectively) and 30.5% was found to have PTSD (37.3% and 25.9% in the direct- and indirect-exposed groups, respectively). Students who had direct exposure to an armed conflict event had a two times higher odds of mental health problems than their peers. Other modifiable factors of mental health problems were receiving news from two sources including other adults and media, and exposure to other non-conflict-related traumatic life events.

CONCLUSIONS

Children living in armed conflict areas of southern Thailand, although without any direct exposure to traumatic events, also suffered from mental health problems. Research on appropriate interventions for these children should be further conducted.

Depressive symptoms among women in Raqqa Governorate, Syria: associations with intimate partner violence, food insecurity, and perceived needs

BACKGROUND

Raqqa Governorate, Syria has recently been affected by overlapping conflicts related to the Syrian Civil war and occupation by ISIS, resulting in widespread displacement and disruption of economic livelihoods. However, little information is currently known about mental health needs and risk factors among women. Therefore, this study sought to examine potential risk factors for depressive symptoms among married women living in northern Syria.

METHODS

Data were collected between March and April 2018 as part of an evaluation of an International Rescue Committee cash transfer program targeted toward vulnerable households. Using cross-sectional data from 214 married women participating in the program, linear regression models were generated to explore the associations between depressive symptoms [nine-item Patient Health Questionnaire (PHQ-9)] and its potential risk factors, including food insecurity, perceived deprivation of basic needs [the Humanitarian Emergency Settings Perceived Needs Scale (HESPER) scale], and past-3-month intimate partner violence (IPV).

RESULTS

The average depressive symptom score was 10.5 (s.d.: 4.9; range: 2-27). In the final adjusted model, any form of recent IPV (β = 2.25; 95% CI 0.92-3.57; p = 0.001), severe food insecurity (β = 1.62; 95% CI 0.27-2.96; p = 0.02) and perceived needs (β = 0.38; 95% CI 0.18-0.57; p = 0.0002) were associated with an increase in depressive symptoms.

CONCLUSION

Study findings point to the need to address the mental health needs of women in conflict-affected areas of Syria. Programming to address risk factors for depression, including IPV and other factors associated with daily stressors such as food insecurity and deprivation of basic needs, may be effective in reducing depression in this population.