Prevalence and predictors of common mental disorders among Syrian refugees in Istanbul, Turkey: a cross-sectional study

Abstract

Purpose

The war in Syria has created the greatest refugee crisis in the twenty-first century. Turkey hosts the highest number of registered Syrian refugees, who are at increased risk of common mental disorders because of their exposure to war, violence and post-displacement stressors. The aim of this paper is to examine the prevalence and predictors of anxiety, depression, and post-traumatic stress disorder (PTSD) symptoms among Syrian refugees living in Turkey.

Methods

A cross-sectional survey of adult Syrian refugees was conducted between February and May 2018 in Istanbul (Sultanbeyli district). Participants (N = 1678) were randomly selected through the registration system of the district municipality. The Hopkins Symptoms Checklist (HSCL-25) was used to measure anxiety and depression and the Posttraumatic Stress Disorder (PTSD) Checklist (PCL-5) assessed posttraumatic stress. Descriptive and multivariate regression analyses were used.

Results

The prevalence of symptoms of anxiety, depression and PTSD were 36.1%, 34.7% and 19.6%, respectively. Comorbidity was high. Regression analyses identified several socio-demographic, health and post-displacement variables that predicted common mental disorders including: being female, facing economic difficulties, previous trauma experience, and unmet need for social support, safety, law and justice. A lifetime history of mental health treatment and problems accessing adequate healthcare were associated with depression and anxiety but not with PTSD.

Conclusions

Mental disorder symptoms are highly prevalent among Syrian refugees in Turkey. The association with post-displacement factors points to the importance of comprehensive health and social services that can address these social, economic and cultural stressors.

Appendix

Appendix A

The sample size was determined to meet the broader aims of the overall study (rather than this specific paper). This included desire to analyze a sample sub-group of those seeking mental health care (reported elsewhere). To determine adequate sample size for the overall study, the following calculation was made:

$$n \, = \frac{{2{\text{ x }}s^{2} {\text{x }}c}}{{d^{2} }}$$

n number of people in one group, s standard deviation, c 7.85 (for 80% power and 5% significance level), d size of the difference to be detected (0.8 SD).

Precise estimates of levels of mental disorders and associated factors could not be determined due to the limited reliable data on mental health among Syrian refugees in Turkey. Therefore, to ensure adequate power to detect conceptually important differences within a multivariate analysis, the following parameters and calculations were used: power = 80%; significance level = 5%; conceptually important difference in outcome scores = 0.8 standard deviation (by convention a ‘large’ difference) (Cohen 1988); size of ‘rarest’ sub-group of respondents we would attempt to include in our analysis = 5%; expected proportion of unusable questionnaires = 10%.

Using these parameters, a sample size of 314 was required to detect a difference when only 5% of the population falls into a particular sub-group of interest. Within this group, we assumed approximately 25% will have used health services (based on findings of studies with other conflict-affected populations). Therefore, the minimum sample size required is 1444, including a 15% incompletion rate. For the sampling process, we assumed around a 50% response rate and so selected 2,865 names of Syrian refugees from the Sultanbeyli municipal registry and 1,678 (59%) participated. As a result, we were slightly above the minimum sample size required.

References:

Cohen, J. 1988. Statistical power analysis for the behavioral sciences, New Jersey, Lawrence Erlbaum.

Appendix B

Variable	PCL-5 score (PTSD) (n = 1345)			HSCL-25 (depression) (n = 1355)			HSCL-25 (anxiety) (n = 1355)
	B	SE	β	B	SE	β	B	SE	β
Female	3.46	0.67	0.13***	0.27	0.03	0.20***	0.33	0.03	0.25***
Age (years)	− 0.22	0.02	0.02	− 0.00	0.00	− 0.06**	− 0.00	0.00	− 0.02
Education (years)	0.07	0.89	0.02	− 0.00	0.00	− 0.00	− 0.01	0.00	− 0.05*
Number of years displaced	− 0.27	0.28	− 0.03	0.01	0.01	0.28	0.02	0.01	0.03
Number of years living in Sultanbeyli	− 0.35	0.33	0.03	− 0.03	0.02	− 0.06	− 0.03	0.02	− 0.06
Household economic situation (ref = Bad)
Average	− 3.90	0.67	− 0.14***	− 0.26	0.33	− 0.19***	− 0.20	0.03	− 0.15***
Good or very good	− 7.85	1.66	− 0.12***	− 0.53	0.08	− 0.16***	− 0.41	0.08	− 0.12***
Long-term illness or disability	3.10	0.72	0.11***	0.15	0.04	0.11***	0.19	0.04	0.13***
Lifetime history of mental health treatment	4.02	1.04	0.92***	0.20	0.05	0.09***	0.28	0.05	0.12***
Unable to access adequate healthcare	2.12	0.75	0.07**	0.12	0.04	0.08**	0.12	0.04	0.08**
You or your family not safe and protected	4.97	1.16	0.11***	0.21	0.06	0.09***	0.21	0.06	0.09***
Problems in your community with law & justice	5.03	0.88	0.15***	0.12	0.04	0.07**	0.12	0.04	0.07**
Not enough emotional support from others	3.47	0.73	0.12***	0.19	0.04	0.13***	0.21	0.04	0.14***
Experienced a potentially traumatic event	6.47	0.68	0.24***	0.23	0.03	0.17***	0.22	0.03	0.16***

1. *p < 0.05
2. **p < 0.01
3. ***p < 0.001