BJPsych Open (2020)

6, e68, 1–8. doi: 10.1192/bjo.2020.54

Review

Anxiety, depression and post-traumatic

stress disorder in refugees resettling in
high-income countries: systematic
review and meta-analysis
Jens-R. Henkelmann*, Sanne de Best*, Carla Deckers*, Katarina Jensen*, Mona Shahab, Bernet Elzinga
and Marc Molendijk

Background to populations living in conflict or war settings, both for child/

The number of refugees is at its highest since the Second World adolescent and adult refugees. Estimates were similar over dif-
War and on the rise. Many refugees suffer from anxiety, ferent home and resettlement areas and independent of length
depression and post-traumatic stress disorder (PTSD), but exact of residence.
and up-to-date prevalence estimates are not available.
Conclusions
Aims Our data indicate a challenging and persisting disease burden in
To report the pooled prevalence of anxiety and mood disorders refugees due to anxiety, mood disorders and PTSD. Knowing this
and PTSD in general refugee populations residing in high-income is relevant for the development of public health policies of host
countries and to detect sources of heterogeneity therein. countries. Scalable interventions, tailored for refugees, should
become more readily available.
Method
Systematic review with meta-analyses and meta-regression. Keywords
Refugees; mental health; depression; anxiety; PTSD.
Results
Systematic searches (final search date 3 August 2019) yielded 66 Copyright and usage
eligible publications that reported 150 prevalence estimates © The Author(s), 2020. Published by Cambridge University Press
(total sample N = 14 882). Prevalence rates were 13 and 42% on behalf of the Royal College of Psychiatrists. This is an Open
(95% CI 8–52%) for diagnosed and self-reported anxiety, 30 and Access article, distributed under the terms of the Creative
40% (95% CI 23–48%) for diagnosed and self-reported depres- Commons Attribution licence (http://creativecommons.org/
sion, and 29 and 37% (95% CI 22–45%) for diagnosed and self- licenses/by/4.0/), which permits unrestricted re-use, distribu-
reported PTSD. These estimates are substantially higher relative tion, and reproduction in any medium, provided the original work
to those reported in non-refugee populations over the globe and is properly cited.

Refugees are people forced to flee from their home country for that there is ‘a substantial lack of data concerning the wider
reasons such as war, violence or fear of persecution. According to extent of psychiatric disability among people living in protracted
a recent estimate, the number of forcibly displaced people is displacement situations’.13
around 70 million (of whom 26 million have refugee status). This Meta-analyses have been performed on the topic as well. In
estimate is the highest since the Second World War and it is on adult refugees, for instance, Fazel et al14 report a prevalence of
the rise. This is partly due to the ongoing Syrian civil war, which 4–6% for depression (based on 14 studies) and 8–10% for PTSD
forced millions of people to flee.1,2 (based on 17 studies). Two more recent meta-analyses including
The majority of refugees are repeatedly exposed to stress and mainly adult refugees15,16 report substantially higher prevalence
traumatic events in their home country and during their journey (25–45% for depression, 21–35% for anxiety disorders and 31–
to safer areas.3 During resettlement they often face unemployment, 63% for PTSD). This difference is probably due to the inclusion
loneliness and uncertainty about asylum procedures4 and the of both interview and self-report assessments in the latter studies,
future.5 Limited access to food and/or medical care is common.6 while Fazel et al14 included only studies in which mental health
These factors may all contribute to the relatively high prevalence status was assessed by means of an interview.
of mental disorders in refugees.7–9 To obtain a better perspective on prevalence rates, between-
The mental health status of refugees has been the topic of a large study heterogeneity should be explained as well as understood,17
number of studies, but it has proven to be difficult to estimate the and this can be achieved by means of subgroup and meta-regression
prevalence of mental illness in this population. The systematic analyses.18,19 Yet, to date, few efforts have been made to understand
reviews on this topic10–12 show large variations in reported preva- and explain heterogeneity in prevalence rates of mental illness in
lence rates (e.g. between 5 and 80% for depression and between 3 refugees. Additionally, it is unknown whether the earlier reported
and 88% for post-traumatic stress disorder (PTSD)). This was estimates of prevalence also apply to more recent refugee move-
recently confirmed by Morina et al,13 who performed a systematic ments and whether they differ as a function of country of resettle-
review on psychiatric disability in refugees and internally displaced ment and/or country of origin and length of residence.
persons. Their results show large variations in the prevalence not Well-informed and up-to-date information on prevalence rates
only of mood and anxiety disorders, but also of alcohol dependence of mental health problems in refugees is necessary not only for a
and psychotic symptoms. In fact, the conclusion of this study was more fine-tuned assessment of risks and their needs, so that subse-
quent public health policies can be developed, but also to gain a
more general understanding of the etiology of mental disorders.
* Joint first authors. The present paper reports an updated version of previous meta-

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Henkelmann et al

analyses14–16 on prevalence rates of self-reported and diagnosed cross-sectional studies that is recommended by the USA National
anxiety disorders, depressive disorders and PTSD in general adult Institutes of Health.26
and child/adolescent refugee populations, resettled in high-income
countries. Informed by earlier work, we have a particular interest in Data extraction
investigating potential sources of heterogeneity in reported preva-
From the eligible papers, at least two independent researchers extracted
lence rates.
data on sample size, percentage of females, mean age, country of origin,
host country, assessment type, prevalence rates of depressive disorders,
Method anxiety disorders and PTSD, whether language-adapted assessments
were included, and the average time of stay in the host country at
time of assessment. In extracting prevalence data, we ensured that
This systematic review has been performed and is reported accord-
PTSD was not included in reported prevalence rates for ‘any anxiety
ing to the guidelines and checklists set forth by MOOSE20 and
disorder’. Following the literature in this field, we considered the
PRISMA.21 A review protocol was drafted and pre-registered at
depressive disorders as representing a single category. If prevalence
PROSPERO (CRD42018100539).
rates were reported for multiple depressive disorders in a single
sample, we aimed to pool these estimates (preferably with the help of
Search and selection strategy the corresponding author of the article on the sample). If we could
We searched Embase, PubMed, Web of Science and Google Scholar22 not come to a reasonable and single estimate, the article was excluded.
for articles reporting on prevalence rates of depressive disorders,
anxiety disorders and/or PTSD in general refugee samples. The fol- Statistical analysis
lowing search string was used: ((refugee* OR displace* OR stateless*) Analyses were performed in jamovi (version 0.9)27 and Stata
AND ((psych* AND (disor* OR ill* OR health)). Only articles that (version 13) for macOS.28 Summary tables on characteristics of
were written in English, German, French, Spanish, Turkish, Danish eligible papers were created.
or Dutch were considered. Reference lists of reviews and meta-analyses Random-effects meta-analyses were used to pool the data on
were used as additional sources of eligible articles. We also conducted a prevalence rates. Prevalence estimates were reported together with
grey literature search and went through the preprint services PsyArXiv, their respective two-tailed 95% confidence intervals (CIs). We stabi-
SocArXiv and MedArXiv for eligible articles. The final search date was lised the variance by means of double arcsine transformations,
3 August 2019. which is the method of choice when outcome data are prevalence
A first decision on eligibility was based on the title and abstract rates.29 For interpretational purposes, we present data that is
of candidate articles. A next decision was based on the article’s full back-transformed. Heterogeneity among studies was quantified
text. At least two members of the review team made a final decision using the I2-statistic and its statistical significance was assessed
on the eligibility of each article, based on the inclusion and exclusion using the Χ2-statistic.30 If heterogeneity in outcome was present, sub-
criteria provided below. group and meta-regression analyses were performed. Predictors of
heterogeneity were: mean age of the sample, percentage of females
Inclusion and exclusion criteria in the sample, average amount of time in the host country for the
Articles were included if they reported: (a) the prevalence rates of sample (in months), type of assessment (diagnosis versus cut-off
anxiety disorders, depressive disorders or PTSD as assessed accord- score), continent of origin (Africa, Asia, Europe, and a ‘mix’ or
ing to a structured or semi-structured diagnostic interview or a vali- ‘other’ category), host continent (Australia, Europe or North
dated cut-off score on a questionnaire; (b) data on refugee samples America), whether assessments were language adjusted/included
residing in countries that have reached very high human develop- the use of an interpreter (yes versus no) and methodological quality
ment in 2019, defined and compiled by the United Nations (as a continuous score). Publication bias was assessed by means of
Development Programme23,24 and classified here as ‘high-income Kendall’s tau, a rank correlation test for the assessment of funnel
countries’; and (c) original data (i.e. reviews, for example, were plot asymmetry.30 Statistical significance was set at P < 0.05.
excluded). Note that, due to the second inclusion criterion, intern-
ally displaced populations were not investigated here. Results
To include homogeneous diagnostic descriptions, notably for
PTSD, papers had to be published after the publication of DSM-
Study selection
III-R in 1987. If two articles reported on the same data-set, we
included the article that contained the most information. If an We identified 1988 articles after removal of duplicates, of which 117
article reported the presence of mental illness on the basis of both articles were deemed relevant after screening of title and abstract.
a diagnosis and a cut-off score, we included (only) the diagnostic After full text assessment, another 51 articles were excluded. The
data.25 final number of articles that was included was 66 (total sample
Articles were excluded if: (a) the sample reported on was not size N = 14 882, average sample size per study n = 225, range
drawn from the general refugee population (e.g. articles reporting 6–1603). From these articles we could extract 150 prevalence esti-
data gathered in a hospital were excluded) or (b) no relevant mates (K). Figure 1 summarises the search and selection process.
outcome data could be extracted from the article, even after The mean age of the included samples was 33.4 years (s.d. =
contact with (or attempts to contact) the corresponding author of 12.3) and 45.8% were women. Asia (40.9%), Europe (10.6%) and
the article. The final inclusion decision for each article was based Africa (9.1%) were the most frequently reported continents of
on full agreement among the members of the review team. origin. The most frequently reported continents of resettlement
were Europe (39.4%), North America (30.3%) and Australia
(24.3%). Most studies (63.6%) applied self-report measures to esti-
Assessment of methodological quality mate prevalence rates of mental health problems (36.4% used diag-
The methodological quality of eligible studies was independently nostic interviews). The characteristics of the studies are presented in
assessed by two members of the review team (C.D. and M.M.) Table 1. No studies on internally displaced populations in high-
using the quality assessment tool for observational cohort and income countries were detected. Hence, as a result of the second

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 Anxiety, depression and PTSD in refugees resettling in high‐income countries

Records identified through databases Embase, PubMed, Web of Science and

Identification
Google Scholar (n = 1961).
Records identified through reference lists and grey literature (n = 35).
Total identified records = 1996

Records screened after duplicates Records excluded (n = 1871)

Screening

removed (n = 1988)

Records excluded, with reasons (n = 51)

- No cut-off scores (n = 14)
Full-text articles assessed for
Eligibility

- No refugees (n = 23)
eligibility (n = 117)
- No psychopathology (n = 11)
- Suitable, but data not available also
not after contact with authors (n = 3)

66 independent studies (150 prevalence estimates; N = 14,882) included

I 16 independent prevalence estimates on anxiety assessed by diagnosis
II 20 independent prevalence estimates on anxiety assessed with self-report
Included

II 23 independent prevalence estimates on depression assessed by diagnosis

IV 32 independent prevalence estimates on depression assessed with self-report
V 26 independent prevalence estimates on PTSD assessed by diagnosis
VI 33 independent prevalence estimates on PTSD assessed with self-report

Fig. 1 Flowchart on identification, screening and inclusion of eligible publications. PTSD, post-traumatic stress disorder.

inclusion criterion (i.e. inclusion if the refugee sample resided in a adolescent and adult samples, with no statistically significant differ-
high-income country), only studies that assessed mental health in ences between the age groups. Between-study heterogeneity was
refugees (as opposed to internally displaced populations) were high in all analyses. Supplementary Table 4 presents prevalence esti-
included. Supplementary Table 1, available at https://doi.org/10. mates by child/adolescent and adult refugee samples and assessment
1192/bjo.2020.54, provides additional information on the samples method (i.e. self-report versus diagnostic interview).
and applied methodology of the included articles. In supplementary Table 5, prevalence rates of anxiety, depres-
sion and PTSD in child/adolescent and adult refugees are set out
Quality assessment against rates in non-refugee populations living in conflict or war set-
tings. Prevalence rates for all three disorders are substantially higher
Methodological quality scores for the included studies ranged
in refugees relative to those reported in non-refugees over the globe
between −1.5 and 9 (mean 4.3, s.d. = 2.5; supplementary Tables 2
and this is so for both child/adolescent and adult refugees (all P <
and 3). The interrater reliability of the methodological quality
0.05). In adult refugees, prevalence rates of anxiety, depression
assessments was high (κ = 0.79, s.e. = 0.09).97 On average, the meth-
and PTSD are significantly higher than in populations living in con-
odological quality score of the included studies was modest to
flict or war settings. This latter difference was not statistically sig-
good. Most studies were clear in the formulation of study goals,
nificant in child/adolescent refugees.
population and participation rate. However, hardly any study
assessed potential confounding variables or performed follow-up
assessments. Obviously, no studies were masked (‘blinded’) to partici- Moderator analysis
pant status. Prevalence rates of anxiety, depression and PTSD did not differ as a
function of continent of origin or continent of resettlement (supple-
Prevalence of anxiety, depression and PTSD in adult and child/ mentary Tables 6 and 7). Differences in prevalence rates based on
adolescent refugees the years that the input studies were published were not observed
Table 2 provides overall random-effects pooled prevalence esti- (supplementary Table 8). Prevalence rates were also not associated
mates for anxiety, depression and PTSD in refugees by assessment with the average duration of residence, mean age and gender distri-
method (i.e. self-report versus diagnostic interview) and by age bution of the sample, nor with the methodological quality of the
status (i.e. child/adolescent versus adult). For forest plots on these study (supplementary Table 9). Supplementary Table 10 provides
estimates we refer to supplementary Figs 1–6. Prevalence estimates information on the associations among the moderators. In about
were on average higher when they were derived from self-report 10% of the included articles it was not clear whether language-
rather than interview. This difference was statistically significant adapted assessments were performed or whether an interpreter
for anxiety disorders, where a 29% difference in prevalence rates was present during the assessment. The prevalence rates reported
was observed. The differences in prevalence estimates as a function in these studies did not differ significantly from those reported in
of assessment method for depression (10%) and PTSD (8%) were articles in which it was clear whether language adaptation was
not significant. Prevalence estimates were high in both child/ applied or an interpreter was present.

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Henkelmann et al

Table 1 Characteristics of included studies and samples

Study n Mean age, yearsa Female, % Country of origin Host country Analysisb
31
Westermeyer (1988) 97 37 46 Laos USA I, III
Hinton et al (1993)32 201 33 52 Vietnam USA I, III, V
Carlson & Rosser-Hogan (1994)33 50 42 52 Cambodia USA II, IV, VI
Cheung (1994)34 223 40 53 Cambodia New Zealand V
Pernice & Brook (1994)35 129 N.K. N.K. ‘Indochina’ New Zealand II. IV
Weine et al (1995)36 20 35 50 Bosnia and Herzegovina USA IV, VI
Malekzai et al (1996)37 30 42 50 Afghanistan USA V
D’Avanzo & Barab (1998)38 175 29 100 Cambodia Mix II, IV
Almqvist & Broberg (1999)39 39 8 26 Iran Sweden VI
Favaro et al (1999)40 40 31 48 Mix Italy III, V
Mollica et al (1999)41 534 50 59 Bosnia and Herzegovina Croatia II, VI
Sack et al (1999)42 30 22 33 Cambodia USA I, V
Tousignant et al (1999)43 203 16 52 Mix Canada I, III
Papageorgiou et al (2000)44 95 10 57 Bosnia and Herzegovina Greece II, IV, VI
Blair (2000)45 124 37 61 Cambodia USA I, V
Gernaat et al (2002)46 51 38 47 Afghanistan The Netherlands I, III, V
Lie (2002)47 240 41 51 Mix Norway VI
Rothe et al (2002)48 87 15 43 Cuba USA VI
Slodnjak et al (2002)49 265 15 53 Bosnia and Herzegovina Slovenia II, VI
Keller et al (2003)50 70 28 20 Mix USA II, IV, VI
Turner et al (2003)51 120 38 53 Kosovo UK IV
Fox et al (2004)52 237 11 54 Mix USA IV
Jaranson et al (2004)53 1134 35 47 Mix USA VI
Lie (2004)54 175 43 47 Bosnia and Herzegovina Norway II, IV, VI
Laban et al (2005)55 294 35 35 Iraq The Netherlands I, III, V
Marshall et al (2005)56 490 52 65 Cambodia USA I, V
Steel et al (2005)57 1161 39 35 Vietnam Australia I, III, V
Bhui et al (2006)58 143 35 50 Somalia UK I, III, V
Roth & Ekblad (2006)59 91 42 40 Kosovo Sweden II
Schweitzer et al (2006)60 63 34 33 Sudan Australia II, VI
Ahmad et al (2008)61 290 30 57 Mix Sweden VI
Hodes et al (2008)62 109 17 39 Mix UK VI
Coffey et al (2010)63 17 42 94 Mix Australia II, VI
Nickerson et al (2010)64 315 38 52 Iraq Australia II, VI
Silove et al (2010)65 126 47 61 Bosnia and Herzegovina Australia I, III, V
Beiser et al (2011)66 1603 43 46 Sri Lanka Canada V
Groark et al (2011)67 6 17 33 Mix UK I, III, V
Muhtz et al (2011)68 502 71 56 Eastern Germany Germany V
Bogic et al (2012)69 854 42 51 Yugoslavia Mix I, III, V
Heeren et al (2012)70 86 30 65 Mix Switzerland I, III, V
Rasmussen et al (2012)71 660 47 48 Mix USA I, III, V
Warfa et al (2012)72 189 34 48 Somalia Mix I, III, V
Bronstein et al (2013)73 222 16 0 Afghanistan UK II, IV
Cleveland & Rousseau (2013)74 188 33 40 Mix Canada II, IV, VI
Hollifield et al (2013)75 251 33 50 Mix USA II, IV, VI
Rees et al (2013)76 44 39 16 Papua-New-Guinea Australia VI
Tay et al (2013)77 52 39 35 Mix Australia III, V
Heeren et al (2014)78 99 34 49 Mix Switzerland II, IV, IV
Lamkaddem et al (2014)79 172 39 51 Mix The Netherlands VI
Mölsä et al (2014)80 128 59 60 Somalia Finland II
Slewa-Younan et al (2014)81 225 38 56 Iraq Australia VI
Vervliet et al (2014)82 77 16 13 Mix Belgium II, IV, VI
Völkl-Kernstock et al (2014)83 41 17 15 Mix Austria VI
Hocking & Sundram (2015)84 131 35 16 Mix Australia II, VI
Jensen et al (2015)85 93 14 19 Somalia Mix Norway II, IV, VI
McGregor et al (2015)86 10 18 80 Mix Australia VI
Vonnahme et al (2015)87 386 34 47 Bhutan USA II, IV, VI
Morina et al (2016)88 51 43 45 Mix Switzerland II, IV, VI
Park et al (2017)89 131 19 65 North-Korea South-Korea II
Georgiadou et al (2018)90 200 33 31 Syria Germany II, VI, V
Javanbakht et al (2018)91 167 47 50 Syria USA II, IV, VI
Richter et al (2018)92 56 32 44 Mix Germany I, V
Schweitzer et al (2018)93 104 32 100 Mix Australia II, IV, VI
Kartal et al (2019)94 138 40 45 Bosnia Australia, Austria II, IV, VI
Leiler et al (2019)95 367 30 27 Mix Sweden II, IV, VI
Poudel-Tandukar et al (2019)96 225 39 50 Bhutan USA II, IV
a. Where the mean age of the sample was not available we report the median age of the sample.
b. This column indicates in which meta-analysis the study is included: I, depression diagnosis; II, depression self-report; III, anxiety diagnosis; IV, anxiety self-report; V, post-traumatic stress
disorder (PTSD) diagnosis, VI, PTSD self-report.

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 Anxiety, depression and PTSD in refugees resettling in high‐income countries

Table 2 Prevalence of anxiety, depression and post-traumatic stress disorder by assessment method

ka na Prevalence (95% CI) I2 Kendall’s taub

Anxiety 36 6728 0.30 (0.22–0.37) 99.1*** 0.37*
Diagnosis 16 3634 0.13 (0.08–0.17)c 95.4***
Self-report 20 3094 0.42 (0.31–0.52)c 98.2***
Children/adolescents 5 493 0.32 (0.28–0.37) 98.6***
Adults 28 5911 0.28 (0.19–0.38) 98.2***
Depression 55 10 466 0.36 (0.30–0.42) 98.6*** 0.13
Diagnosis 23 5230 0.30 (0.23–0.38) 98.0***
Self-report 32 5236 0.40 (0.31–0.48) 98.3***
Children/adolescents 7 995 0.28 (0.19–0.37) 90.4***
Adults 40 8750 0.36 (0.30–0.43) 98.6***
PTSD 59 13 288 0.34 (0.29–0.40) 99.1*** 0.14
Diagnosis 26 7578 0.29 (0.22–0.37) 99.1***
Self-report 33 5710 0.37 (0.30–0.45) 98.0***
Children/adolescents 7 662 0.52 (0.35–0.68) 94.5***
Adults 42 11 948 0.29 (0.23–0.36) 99.2***
a. Numbers for k (prevalence estimates per analysis) and n (number of subjects per analysis) do not add up to the total in pooled estimates reported separately for mixed child/adolescent
and adult refugees. This is due to the inclusion of some samples that assessed mental health in mixed child/adolescent and adult refugee groups in our study and these could not be
categorised in a single age category.
b. Kendall’s tau: rank correlation test for funnel-plot asymmetry. A significant correlation is an indication of the presence of publication bias.
c. Difference in proportions: Z = −1.96, P < 0.05.
*P < 0.05; **P < 0.01; ***P < 0.001.

pre-migration stressors, policy makers and clinicians may have

Discussion
the power to change them. Clinically, it is highly relevant to eluci-
date in more detail which pre-, peri- and post-migration factors spe-
This systematic review with meta-analyses shows that up to 1 in 3
cifically contribute to the depression, anxiety and PTSD symptoms.
refugees has diagnosable current depression and/or PTSD.
Follow-up studies have directly compared refugees from one country
Diagnosable anxiety disorders are estimated to be present in 1–2
or region with individuals who stayed in that area, considering indi-
out of 10 refugees. The prevalence of these disorders assessed by
vidual and environmental risk and resilience factors, such as types of
cut-off scores on self-report instruments is even higher. Together
traumatic and stressful life event, personality characteristics, socio-
these findings, evidentially, suggest a significant and chronic
economic status and resources. Such knowledge may help in the
burden in refugees due to poor mental health, impeding their func-
development of prevention strategies and scalable treatment
tioning and possibilities to adapt.1,98
options that specifically could help those refugees in need of care.103
When method of assessment is considered, the results reported
In the current study we had only limited information on such
here are largely in line with the results reported in earlier meta-ana-
pre- and post-migration factors. We tried to cluster reasons for
lyses.14–16 This could suggest that prevalence rates of anxiety,
fleeing, for example war or violence versus natural disasters. This
depression and PTSD in refugee populations do not change over
attempt was unsuccessful because of heterogeneity and a lack of
time. Strengthening this suggestion is that we did not find evidence
clear information in articles. The only variable linking to post-
that prevalence rates depended on the year that the input studies
migration factors that was consistently reported over studies was
were published.
length of residence. Remarkably, length of residence was found to
be unrelated to prevalence rates. This seems to indicate that time
in itself does not have much of a healing effect. However, this
Risk factors for mental disorders in refugee populations
finding should be viewed with caution. First, the potential associ-
The pooled prevalence rates we report resemble those for other trau- ation between length of residence and prevalence of mental disor-
matised populations (e.g. childhood sexual or emotional abuse), ders was assessed by means of meta-regression and this may have
with particularly strong associations with PTSD and depression, been underpowered owing to the small number of observations
and moderate associations with anxiety.99–101 Prevalence rates of and the use of study averages.104 Second, length of residence prob-
anxiety, depression and PTSD among adult refugees are high rela- ably interacts with other post-migration factors (e.g. whether per-
tive not only to non-refugee populations, but also to populations manent residence is received) in the outcomes of our meta-analyses.
living in conflict or war settings. This seems to suggest that it is The current research reports high prevalence of anxiety, depres-
not only the exposure to conflict and war itself that makes a sion and PTSD for both male and female adult and child/adolescent
refugee vulnerable to, for instance, PTSD, but that the flight and/ refugees. We did not observed moderating effects of mean age and
or additional post-migration factors may aggravate the trauma- gender distribution of a sample on prevalence rates, despite previous
related symptoms. For anxiety disorders and PTSD, we found meta-analytic findings and reviews showing indications for differ-
similar trends for child/adolescent refugees, although these were ences in prevalence rates as a function of age.9,10 For instance, the
not statistically significant. As only five papers were included on meta-analysis by Fazel et al14 showed higher prevalence of PTSD
childhood/adolescent anxiety and seven on childhood/adolescent for adolescents and young adults compared with adults. These dif-
depression and PTSD, the lack of significance could well be due ferences are also evident in our study, as PTSD prevalence rates are
to insufficient statistical power. reported to be 0.27 in adults and 0.52 in children/adolescents, yet
Besides pre-migration factors such as exposure to war, torture with overlapping confidence intervals.
or persecution, post-migration factors, including life-threatening
journeys, long-lasting asylum procedures, family separation,
unemployment and discrimination, have consistently been shown Assessment by self-report versus diagnostic interview
to affect prevalence of mental disorders.6,94,102 Awareness of the Self-report screening instruments are popular in the assessment of
role of post-migration stressors needs to increase since, unlike refugees because they are widely available in many languages, are

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Henkelmann et al

easy to administer and incur low costs. Earlier meta-analyses in this

Jens-R. Henkelmann, Faculty of Social and Behavioural Sciences, Clinical Psychology
field excluding studies that used self-report screening instruments14 Department, Leiden University, The Netherlands; Sanne de Best, Faculty of Social and
featured only a quarter of the data compared with studies15 that Behavioural Sciences, Clinical Psychology Department, Leiden University;
Carla Deckers, Faculty of Social and Behavioural Sciences, Clinical Psychology
included publications based on both assessment types. The main Department, Leiden University; Katarina Jensen, Faculty of Social and Behavioural
difference between these instruments is that self-report measures Sciences, Clinical Psychology Department, Leiden University; Mona Shahab, Faculty of
at best yield caseness of a mental disorder, whereas interviews Social and Behavioural Sciences, Clinical Psychology Department, Leiden University; and
Clinical Epidemiological Department, Leiden University Medical Center; Bernet Elzinga,
yield a formal diagnosis. The latter is stricter, since the core symp- Faculty of Social and Behavioural Sciences, Clinical Psychology Department, Leiden
toms of a disease and significant interference with everyday life need University; Marc Molendijk , Faculty of Social and Behavioural Sciences, Clinical
Psychology Department, Leiden University; and Leiden Institute of Brain and Cognition,
to be present for formal diagnosis, whereas this is not necessary for Leiden University Medical Center, The Netherlands
caseness. This may explain the higher prevalence rates when assess-
Correspondence: Marc Molendijk. Email: [email protected]
ments were based on self-report. We found the difference in preva-
First received 14 Apr 2020, final revision 2 Jun 2020, accepted 03 Jun 2020
lence rate as a function of assessment method to be statistically
significant only for anxiety disorders. Perhaps this could be due to
the large overlap between anxiety and PTSD and their diagnostic
clustering in previous diagnostic systems (e.g. DSM-IV-TR). This
might have resulted in the development of self-report screening Supplementary material
instruments for anxiety that potentially capture a mix of anxiety Supplementary material is available online at https://doi.org/10.1192/bjo.2020.54.
and stress-related constructs, whereas (subtle) distinctions
between the two could be made in a clinical interview. Data availability
It is important to investigate whether the course of illness and The data that support the findings of this study are available from the corresponding author on
adjustment to the new home situation is different for refugees with reasonable request.
diagnosed disorders compared with those who score above a cut-
off score on a self-report questionnaire. Likewise, it would be interest- Author contributions
ing to investigate whether these groups differ from each other with
M.M. had full access to the data and takes responsibility for the integrity of the data and the
regard to peri- and pre-migration characteristics and events. accuracy of the results presented in this review. Concept and design: all authors. Data acqui-
sition, quality grading and analysis: J.-R.H., S.d.B., K.J., C.D., M.M. Drafting of the manuscript:
J.R.-H., S.d.B., K.J., J.-R.H., M.M. Critical revision of the manuscript for important intellectual con-
Limitations and strengths tent: all authors.

There are several limitations to this study, besides the above-men-

tioned power and measurement problems. The general refugee Funding
population is an extremely heterogeneous population, difficult to This project was funded through continued support by Leiden University.
assess for research purposes, and therefore many studies have to
rely on small samples and non-random sampling methods.7,58 Declaration of interest
A large body of research in this field includes only samples assessed
None.
in high-income countries. As our selection method excluded other ICMJE forms are in the supplementary material, available online at https://doi.org/10.1192/
data, generalisation of our results to refugees in lower-income coun- bjo.2020.54.
tries is limited. Furthermore, this study does not focus on the
burden of displacement within a country. However, since lower-
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