Longitudinal investigation of the relationships between trauma exposure, post-migration stress, sleep disturbance, and mental health in Syrian refugees

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.

Challenges in substance use treatment as perceived by professionals and Arabic-speaking refugees in Germany

BACKGROUND

Substance use (SU) and substance use disorders (SUDs) have been recently documented among forcibly displaced populations as a coping mechanism to migration and postmigration stressors. Although the literature exploring substance use among refugees has grown recently, little is known about SU among Arabic-speaking refugees and, more specifically, on the challenges and experiences in regards to SU treatment. This study investigates this topic from the perspectives of Arabic-speaking refugees and professionals in Germany.

METHODS

Design and participants To expand our knowledge on this topic, a qualitative approach was employed by conducting in-depth and semi-structured interviews among 26 participants (13 refugees and 13 professionals) in Germany during 2020-2021. Purposive sampling was used to recruit Arabic-speaking refugees in two rehabilitation centers in Berlin. Data and analysis Interviews were conducted with 26 participants of which 13 were refugees and 13 professionals. Refugees were interviewed individually in the rehabilitation centers, they ranged from 21 to 52 years of age, and their average time in Germany was 6.3 years. An open-ended survey was conducted among the professionals via the SoSci-survey platform, and they ranged from 22 to 66 years of age, with an average of 5 to 9 years of work experience. Data were analyzed using thematic analysis.

RESULTS

Three themes resulted from the thematic analysis: (1) The treatment is facilitated by institutional and emotional support; (2) The affected refugees struggle with complex contextual barriers to access SUD treatment; and (3) Individual and community preventive strategies are needed.

CONCLUSIONS

This study provides insight into the support and challenges of accessing effective SU treatment and prevention among Arabic-speaking refugees in Germany. Collaborative efforts by the community, professionals, and policymakers are needed to facilitate access to effective treatment and implement culturally and linguistically sensitive approaches for the treatment and prevention of SU among refugees.

Subjective Sleep Disturbances in Sexual Assault Survivors: Associations With Trauma and Posttraumatic Stress Disorder Symptom Severity

Prior work implicates sleep disturbance in the development and maintenance of posttraumatic stress disorder (PTSD). However, the majority of this literature has focused on combat veteran men, and limited work has examined links between sleep disturbance and PTSD symptoms in sexual assault survivors. This is a notable gap in the literature, as sexual trauma is disproportionately likely to result in PTSD and is more common in women. We sought to examine the relations between subjective sleep disturbance, sexual assault severity, and PTSD symptoms in a sample of sexual assault survivors with PTSD (PTSD+), without PTSD (PTSD-), and healthy controls. The sample (N = 60) completed the Insomnia Severity Index and prospectively monitored their sleep for 1 week using the Consensus Sleep Diary. The sexual assault survivors also completed the Sexual Experiences Survey and PTSD Checklist-5. Results of group comparisons found that the PTSD+ group reported significantly higher insomnia symptoms, longer sleep onset latency, more nocturnal awakenings, and lower sleep quality compared to the healthy control group and higher insomnia symptoms compared to the PTSD- group. Results of regression analyses in the sexual assault survivors found that insomnia symptoms and number of nocturnal awakenings were significantly associated with higher PTSD symptoms, and sexual assault severity was significantly associated with higher insomnia symptoms, longer sleep onset latency, and lower sleep quality. These findings highlight specific features of sleep disturbance that are linked to trauma and PTSD symptom severity among sexual assault survivors.

Relationship between Posttraumatic Stress Disorder and Sleep Disturbances in Syrian Refugees in the United States

Background  Posttraumatic stress disorder (PTSD) is associated with disturbed sleep. However, the impact of sleep disturbances and PTSD symptomology in refugee populations is not well known. This study examined how PTSD-related sleep symptoms and overall sleep quality were impacted by previous and current traumatic and stressful experiences. Methods  Adult Syrian refugees living in Southeast Michigan were assessed via scheduled in-home interviews. Overall sleep quality was measured using the Pittsburgh Sleep Quality Index. PTSD-related sleep disturbances were measured using the Pittsburgh Sleep Quality Index Addendum. The presence of PTSD symptomatology was assessed via self-report using the Posttraumatic Stress Disorder Checklist. The Life Events Checklist for the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition-5 screened for prior traumatic events experienced and the Postmigration Living Difficulties Questionnaire was assessed for postmigration stressors. Correlational analysis was conducted between overall sleep quality, PTSD symptom severity, and previous trauma experienced. A stepwise linear regression analysis was conducted to examine the role of overall sleep quality, PTSD-specific sleep disturbances, current living difficulties, and the number of preimmigration traumatic events directly experienced or witnessed due to the presence of overall PTSD symptomology. Results  A total of 53 adults completed the study. PTSD-disturbed sleep was found to be positively associated with overall poor sleep quality ( r  = 0.42, p  < 0.01), PTSD symptomology ( r  = 0.65, p  < 0.01), and current living difficulties ( r  = 0.37, p  < 0.05). The PTSD-related sleep disturbances (B = 0.66, p  < 0.01) and postmigration living difficulties (B = 0.44, p  < 0.01) were found to be the strongest predictors of PTSD symptoms. Conclusion  Disturbed sleep is strongly associated with current stressful experiences and PTSD symptomology among Syrian refugees.

Improving Sleep Health Among Refugees: A Systematic Review

Purpose of Review

Sleep disorders among refugees are common yet understudied. Interventions are difficult in resource-limited settings where most of these populations live. A systematic review of sleep disorders in refugee populations is warranted to identify prevalence, comorbidities, and the limitations of the current state of sleep health among refugees.

Recent Findings

Sleep disturbances, particularly insomnia and nightmares, occur with a higher prevalence among refugees. Diseases associated with insomnia in this population included fibromyalgia, posttraumatic stress disorder, depression, and anxiety. Risk factors include trauma, migration, lower socioeconomic status, lower educational level, and settlement in areas with a high influx of new residents or proximity to conflict. Only a few partially successful therapies were identified.

Summary

This review identifies the high prevalence of the disturbed sleep in this population and its risk factors. It proposes ways of increasing awareness of it in this vulnerable population as a first step toward remediation.

Emotion dysregulation mediates the association between acute sleep disturbance and later posttraumatic stress symptoms in trauma exposed adults

Background: Sleep disturbance is common within days to weeks following a traumatic event and has been associated with emotion dysregulation, a strong risk factor for PTSD development. This study aims to examine if emotion dysregulation mediates the relationship between early post-trauma sleep disturbance and subsequent PTSD symptom severity.Methods: Adult participants (n = 125) completed questionnaires regarding sleep disturbance (via Pittsburgh Sleep Quality Index Addendum; PSQI-A) and emotion dysregulation (via Difficulties in Emotion Regulation Scale; DERS) within 2 weeks after exposure to traumatic events.Results: PTSD symptom severity was assessed with PTSD Checklist for DSM-5 (PCL-5) at 3-month follow-up. There were strong correlations between PSQI-A, DERS, and PCL-5 (r ranges between .38 and .45). Mediation analysis further revealed significant indirect effects of overall emotion regulation difficulties in the relationship between sleep disturbance at 2 weeks and PTSD symptom severity at 3 months (B = .372, SE = .136, 95% CI: [.128, .655]). Importantly, limited access to emotion regulation strategies emerged as the single, significant indirect effect in this relationship (B = .465, SE = .204, 95% CI [.127, .910]) while modelling DERS subscales as multiple parallel mediators.Conclusions: Early post-trauma sleep disturbance is associated with PTSD symptoms over months, and acute emotion dysregulation explains part of this association. Those with limited emotion regulation strategies are at particular risk of developing PTSD symptoms. Early interventions focusing on the appropriate strategies for emotion regulation may be crucial for trauma-exposed individuals.

Practitioners' Perspectives on Barriers and Benefits of Telemental Health Services: The Unique Impact of COVID-19 on Resettled U.S. Refugees and Asylees

The COVID-19 pandemic and associated sequelae have disproportionately exacerbated refugee mental health due to health disparities, poverty, and unique risk factors. In response to the pandemic, most mental health providers have shifted to virtual platforms. Given the high need for services in this population, it is essential to understand the effectiveness and potential barriers to serving refugees via telehealth. This study is one of the first to examine the extent that socio-cultural and structural barriers impact telemental health services received by resettled refugees during the COVID-19 pandemic. This study also addresses the potential benefits of telemental health service delivery to refugees. We surveyed 85 providers serving refugee and non-refugee clients in the United States. Statistical analyses revealed that more significant socio-cultural and structural barriers, including access to technology, linguistic challenges, and privacy limitations, exist for refugees compared to non-refugee clients. Potential benefits of telemental health for refugees during the pandemic included fewer cancellations, fewer transportation concerns, and better access to childcare. These results highlight the need to address the disparity in telemental health service delivery to refugees to limit inequities for this population.

Development of Culturally Informed Trauma Therapy Approach for Muslim Refugee Families

Refugees from predominantly Muslim countries have been exposed to severe traumatic experiences in their country of origin. Further their stress continues during the resettlement process in the host country. Although the number of Muslim refugees is increasing in the U.S. and Europe, the existing literature is not adequate to derive a conclusion on treatment efficacy for specifically traumatized Muslim refugee families. An inadequate treatment approach for this population may result in negative/ineffective therapy outcomes. Thus, the aim of this study is to develop a culturally responsive treatment model. For this purpose, this study offers an integrated family-based therapy approach, which is influenced by narrative, art, and narrative exposure approaches for refugee families. This integrated family therapy model consists of 12 weekly sessions and includes 4 phases: a) diagnostic interview, b) narration of the life story, c) exposure to the trauma, and d) re-narrate and reprocessing of the traumatic events. Future studies should test the feasibility and effectiveness of the integrated model using the randomized controlled trials, as the acquisition of such treatment models is essential to the development of a culturally sensitive treatment model for Muslim refugees.

Prevalence of common mental disorders in adult Syrian refugees resettled in high income Western countries: a systematic review and meta-analysis

BACKGROUND

The immense social upheaval and ongoing humanitarian crisis created by the 2011 war in Syria has forced millions of civilians to flee their homeland, many of whom seek refugee status in Western nations. Whilst it is known that the prevalence of mental illness is higher within refugee populations, this systematic review and meta-analysis aims to pool the prevalence rates of common mental disorders (namely posttraumatic stress disorder, depression and generalized anxiety disorder) in adult Syrian refugees resettled in high income Western countries.

METHODS

Seven electronic databases (Medline, PsychInfo, CINAHL, PTSDpubs, SCOPUS, PubMed and Embase) were searched up to the 31st of December 2020. Using pre-determined inclusion and exclusion criteria, relevant articles were screened by title and abstract, and later by full text. A meta-analysis was used to estimate the prevalence rates for each mental illness.

RESULTS

Eleven studies met the eligibility criteria for the systematic review. Nine of these studies had a low-moderate risk of bias and were included in the meta-analysis. Of the 4873 refugees included in the meta-analysis, the total pooled prevalence rate of having any of the three mental disorders was 33% (CI 95%, 27-40%), 40% for anxiety (CI 95%, 31-50%), 31% for depression (CI 95%, 20-44%) and 31% for PTSD (CI 95%, 22-41%). A meta-regression revealed that the total pooled prevalence rate for having any of the three mental disorders was not influenced by age, host country, duration in host country, educational or marital status.

CONCLUSIONS

Despite significant study heterogeneity, the prevalence rates of common mental disorders in adult Syrian refugees resettled in high-income Western countries are significantly higher than reported rates in the general population.

Engaging Refugees With a Culturally Adapted Digital Intervention to Improve Sleep: A Randomized Controlled Pilot Trial

Refugees are exposed to multiple stressors affecting their mental health. Given various barriers to mental healthcare in the arrival countries, innovative healthcare solutions are needed. One such solution could be to offer low-threshold treatments, for example by culturally adapting treatments, providing them in a scalable format, and addressing transdiagnostic symptoms. This pilot trial examined the feasibility, acceptance, and preliminary effectiveness of a culturally adapted digital sleep intervention for refugees. Sixty-six refugees participated, with 68.2% of them seeking psychological help for the first time. Only three participants did not show clinically significant insomnia severity, 93.9% reported past traumatic experiences. Participants were randomly assigned to the intervention group (IG) or the waitlist control group (CG). Insomnia severity, measured by the Insomnia Severity Index, and secondary outcomes (sleep quality, fear of sleep, fatigue, depression, wellbeing, mental health literacy) were assessed at baseline, 1 and 3 months after randomization. The self-help intervention included four modules on sleep hygiene, rumination, and information on mental health conditions associated with sleep disturbances. 66.7% of the IG completed all modules. Satisfaction with the intervention and its perceived cultural appropriateness were high. Linear multilevel analyses revealed a small, non-significant intervention effect on insomnia severity of Hedge's g = 0.28 at 3-months follow-up, comparing the IG to the CG [F _{2, 60} = 0.88, p = 0.421]. This non-confirmatory pilot trial suggests that low-threshold, viable access to mental healthcare can be offered to multiple burdened refugees by culturally adapting an intervention, providing it in a scalable format, and addressing a transdiagnostic symptom.

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.

Sleep, circadian system and traumatic stress

The human circadian system creates and maintains cellular and systemic rhythmicity essential for the temporal organization of physiological processes promoting homeostasis and environmental adaptation. Sleep disruption and loss of circadian rhythmicity fundamentally affects master homeostasic regulating systems at the crossroads of peripheral and central susceptibility pathways, similar to acute or chronic stress and, thus, may play a central role in the development of stress-related disorders. Direct and indirect human and animal PTSD research accordingly suggests circadian-system-linked sleep, neuroendocrine, immune, metabolic and autonomic dysregulation, linking circadian misalignment to PTSD pathophysiology. Additionally, there is evidence that sleep and circadian disruption may represent a vital pre-existing risk factor in the prediction of PTSD development, while sleep-related symptoms are among the most prominent in trauma-associated disorders. These facts may represent a need for a shift towards a more chronobiological understanding of traumatic sequel and could support better prevention, evaluation and treatment of sleep and circadian disruption as first steps in PTSD management. In this special issue, we highlight and review recent advances from human sleep and chronobiological research that enhances our understanding of the development and maintenance of trauma-related disorders.