Posttraumatic stress disorder and comorbid depression among refugees: Assessment of a sample from a German refugee reception center

Abstract

In 2015, a large number of refugees arrived in Germany, mostly driven to emigrate by devastating circumstances in their countries of origin. Arriving refugees are distributed to reception centers within the German federal states, frequently facing marginal conditions in terms of overcrowding or waiting time of several months until their application for asylum is processed. Most of these refugees underwent numerous traumatizing experiences—both in their country of origin and while fleeing from their country of origin. Furthermore, they faced and will likely continue to face various access barriers to mental health care. In this study, we assessed a sample of 85 refugees from a reception center in Germany selected due to their observed psychological strain. Results showed that the majority suffered from posttraumatic stress disorder, mostly with symptoms of intrusion, hyperarousal, avoidance, and dissociation. Most refugees also suffered from comorbid depression. We discuss implications of these findings for reception services and the need for more preventive psychiatric care.

Keywords

application for asylum migration posttraumatic stress disorder (PTSD)refugee reception refugees

Introduction

War, terrorism, political tensions, and oppression have resulted in unprecedented numbers of people searching for safe haven. Currently, Germany is the destination country for the majority of refugees arriving in countries of the European Union. In 2015, 476,649 refugees applied for asylum in Germany (Federal Office for Migration and Refugees, 2016), nearly a 6% annual increase to Germany’s population. Shortly after they arrived, the refugees were distributed to the German federal states—a process that has continued as of this writing in early 2016. Due to the higher-than-expected rate of asylum seekers, the federal states’ refugee reception centers continue to host far more refugees than they are capable of (Ministry for the Interior and Sports of Lower Saxony, 2014). The initial application for asylum is made within these refugee reception centers. During the process, the refugees are interviewed by office workers (non-clinicians) of the Federal Office for Migration and Refugees about their reasons for seeking asylum. Although these interviewers are not clinicians, they must judge whether each asylum seeker suffers from a mental disorder as result of torture, war, and/or other causes of the flight from their country of origin—a judgment that can considerably influence the refugee’s residence permit. There are various studies showing the inability of non-clinicians—even if they are trained in psychological issues—to judge or consider mental illness in the context of asylum decisions (e.g., Gäbel, Ruf, Schauer, Odenwald, & Neuner, 2006; Tay et al., 2013; Wilson-Shaw, Pistrang, & Herlihy, 2012). The lack of clinicians engaged in the process of assessment also means there are inadequate measures in place to implement the European Union Council Directive 2003/9/EC (2003) requiring special protection for traumatized persons in terms of rehabilitative measures. The mechanisms to identify traumatized and thus particularly vulnerable refugees are either nonexistent or insufficient (Laskowski, 2013). This appears to be an ongoing problem, as some years before the 2015 influx of refugees into Germany, researchers Laban, Gernaat, Komproe, and De Jong (2007) found an under-utilization of mental health services compared to the prevalence of psychiatric disorders in asylum seekers.

Posttraumatic stress disorder (PTSD) is described in the International Classification of Diseases 10 (ICD-10; World Health Organization, 1992, p. 147) as a result of “a stressful event or situation (of either brief or long duration) of an exceptionally threatening or catastrophic nature, which is likely to cause pervasive distress in almost anyone.” Refugees run a high risk of experiencing such events: war and torture belong to the established categories of repeated, prolonged, and man-made traumatizing events possessing the highest risk to cause a PTSD (Luchterhand, 1971; Terr, 1991; van Ommeren et al., 2001). Undergoing numerous traumatic experiences not only in the country of origin but also during and after their flight to the host country, the type of trauma experienced by refugees can be described as cumulative and thus their risk of developing a PTSD is highly probable (Schauer et al., 2003). Perera et al. (2013) showed that peri- and post-migration stressors clearly enhance the risk of developing symptoms of and suffering from PTSD. Furthermore, post-migration factors (here, difficult living conditions in the overextended refugee reception centers and possible experiences of discrimination) can negatively influence the refugees’ ability to cope with their traumatic experiences (Birck, 2004; Carswell, Blackburn, & Barker, 2011; Goodkind et al., 2014). Therefore, the findings of high prevalence rates of PTSD (30% to 40%) in refugees are not surprising (e.g., Gäbel et al., 2006; Steel et al., 2009). Other authors have reported high rates of PTSD in refugees, combined with high comorbidity rates of other mental disorders before the latest 2015 influx (Norredam, Garcia-Lopez, Keiding, & Krasnik, 2009; Schubert & Punamäki, 2010; van Ommeren et al., 2001). Prolonged residence in a refugee reception center and being without a residence permit seems to be associated with mental and physical symptoms of depression, anxiety, and somatoform (physically manifested) disorders (Gerritsen et al., 2006; Laban, Gernaat, Komproe, Schreuders, & De Jong, 2004). The stress of waiting for residence permission is often exacerbated by other post-migration living factors such as low language proficiency of the host nation’s language, family issues, discrimination, or other challenging socioeconomic living conditions (Laban, Gernaat, Komproe, van der Tweel, & De Jong, 2005; Ryan, Benson, & Dooley, 2008). These findings highlight the relevance of post-migration stressors in the context of comorbidities.

Due to the high risk of mental disorders among refugees, a mental health support project in cooperation between a German refugee reception center and a psychiatric clinic in Germany was established. Since 2012, refugees can access psychological/psychiatric diagnostics in order to overcome barriers to mental health care. In the context of this cooperative project, we had the possibility to collect information about traumatization and mental disorders in refugees. According to the empirical findings so far, we expected that: (1) refugees with psychological strain will suffer from PTSD with a very high probability; and (2) the majority will suffer from comorbid mental disorders.

Methods

Setting and sample

The referral of refugee patients to an established outpatient clinic in Germany was accomplished by the clinic’s cooperative project with a nearby refugee reception center, determined by the patients’ psychological strain. Their psychological strain was not limited to symptoms of a PTSD but defined by mental distress in general. Previously trained social workers of the refugee reception center identified persons who seemed to suffer from mental distress and confirmed their impression by using the PROTECT questionnaire,¹ then referred them to the clinic. These social workers had many years of experience in interacting with refugees showing psychological strain. By using the PROTECT questionnaire, as requested by the EU Council Directive 2003/9/EC (2003), they resorted to 10 standardized questions to avoid misjudgments and to keep the expenditure of time to a limited extent. To identify additional psychiatric conditions, they could also fill out a description field. Patients then followed the commonly used, more detailed assessment procedure in the clinic, which is described in this study. The assessments were conducted by five psychologists who were experienced in transcultural diagnostics (for an overview, see Özkan & Belz, 2015) and treatment was supervised constantly by a transcultural trauma therapist with more than 20 years of experience in psychiatry.

Translators enabled the discussion during the assessment in order to ensure a high quality of communication. The translators were briefed before and debriefed after every session. In these briefings, the translators were informed about mental disorders and their implication for the assessment, the meaning of questionnaire inquiries within the assessment, and were free to ask questions related to the case at hand within the limit of privacy rights of the patient. In addition to an anamnestic interview and clinical appraisal, we used self-assessment questionnaires to objectify the data collection.

A total of 182 refugees were referred to the clinic from September 2012 to September 2015. Of these 182, only 85 patients (46.7%) were able to fill out the questionnaires described below, due to analphabetism (illiteracy) or lack of translations into multiple, rarer languages (e.g., Tigrinya, Kurmanji, Sorani). This meant that 97 patients (53.3%) did not fill out the questionnaires and thus were not included in this study. We did not translate any questionnaires ourselves, but relied on previously translated versions, available from the questionnaires’ authors. Clinical diagnoses according to ICD-10 were given based on the anamnestic interview, clinical appraisal, and questionnaire scores, taking all three sources of information into account.

The clinical diagnosis of (1) PTSD was given if the questionnaire score (ETI PTSD, see below) exceeded cutoff; PTSD diagnosis was given in n = 66 of n = 74 cases, also considering anamnestic information and clinical appraisal under supervision. If the cutoff was not exceeded, but anamnestic information and clinical appraisal still indicated the existence of a PTSD, it was—in agreement with the supervisor—still diagnosed in some cases (n = 3 of n = 11). The clinical diagnosis of (2) depression was given if the cutoff was exceeded (BDI-II, see below); depression was diagnosed in n = 59 of n = 65 cases. Again, even if the questionnaire score cutoff was not exceeded, a depressive episode was diagnosed in n = 16 of n = 20 cases, under supervision.

During the assessment sessions, next to diagnostic information, the following information was systematically gathered: self-harming behavior, suicidality, and types of traumatizing events. To differentiate between types of traumatizing events, the patients’ anamneses were analyzed by the psychologists based on the 2 × 2 scheme of Maercker (1997). Following this scheme, traumatizing events were assigned to four categories: (1) If the traumatizing event was caused by other persons (e.g., sexual assault, violence, rape, war, torture) it was categorized as man-made event. (2) If the traumatizing event was caused by catastrophes (e.g., natural disasters, technical catastrophes, accidents in job or traffic) it was categorized as accidental event. (3) If the traumatizing event was of short duration (e.g., single event, sudden and surprising) it was categorized as single event. (4) If the traumatizing event was of long duration (e.g., repeated events, unforeseeable course) it was categorized as multiple event. Additionally, sexual traumatization was defined as a man-made traumatizing event with sexual content (e.g., rape, penetration with objects, act of indecency). The appraisal of the type of traumatizing events was accomplished under supervision.

The patients were between the ages of 18 and 64 (M = 31.6; SD = 10.6). Of the total sample, 34.1% were female. The countries of origin of the majority of the sample were Syria (30.6%), followed by Afghanistan (29.4%), Russia/Turkey (11.8% each), Iraq (5.9%), and Chechnya/Lebanon (2.4% each). The remaining patients came from Somalia, Pakistan, Eritrea, Palestine, and Nepal (1.2% each). According to their countries of origin, most patients spoke Arabic (30.6%), followed by Dari (27.1%), Turkish (11.8%), Russian/Kurdish (10.6% each), Chechen (3.5%), and Somali, Urdu, Pashtun, Tigrinya, Nepalese (1.2% each).

All patients were asked for permission to report their anonymized data and were informed as to the purpose of this assessment in written form. All patients signed said declaration of agreement, which was approved by the ethics council of the clinic.

Measures

Essen Trauma Inventory (ETI)

To assess the severity of traumatization² and related symptoms, the Essen Trauma Inventory (ETI, for an overview see Tagay & Senf, 2014) was used. Patients answered the extended version (self-assessment) in their native language. The ETI focuses on four symptom clusters of PTSD and acute stress reaction, using an overall score of 23 scale items: (1) intrusion, (2) avoidance, (3) hyperarousal, and (4) dissociation. Each item is formulated as a question and can be answered using 4-point scales (0 = not at all to 3 = very often) such as “Did the event cause upsetting thoughts or images that came to your mind although you didn’t want them to?” Tagay and Senf (2014) found good internal consistencies, measured by Cronbach’s alpha, for all four scales (α between .82 and .87). Furthermore, two overall scores were created. Within the ETI total score, the points of all four scales were added and thus covered the symptoms of acute stress reaction (Tagay & Senf, 2014, referring to the DSM-IV). For the ETI PTSD score, the points of the three scales intrusion, avoidance, and hyperarousal were added.

Symptom Checklist (SCL-90-R)

To assess general psychopathological symptoms, the patients answered the revised version of the Symptom Checklist (SCL-90-R, Derogatis, 1983; Franke, 2002). The SCL-90-R contains 90 items (self-assessment). Each item is formulated as a question describing “problems and complaints” during the last 7 days. Patients answered the questions using 5-point scales (0 = not at all to 4 = extremely) such as “How much were you bothered by headaches?,” completing nine scales: (1) somatization, (2) obsessive-compulsive, (3) interpersonal sensitivity, (4) depression, (5) anxiety, (6) hostility, (7) phobic anxiety, (8) paranoid ideation, and (9) psychoticism. Franke (2002) found good internal consistencies for the scales (α between .74 and .88 for a clinical sample). In addition, the Global Severity Index (GSI) was computed by summing the scores of the nine dimensions and seven additional items (e.g., “How much were you bothered by feelings of guilt?”), then dividing by the total number of responses.

Beck Depression Inventory Revision (BDI-II)

To assess severity of depressive symptoms, the Beck Depression Inventory Revision (BDI-II; Beck, Steer, & Brown, 2009) was applied.³ It contains 21 questions (self-assessment) with options to answer uniquely, each describing a criterion of a depressive episode (e.g., “trembling”). Here, we report the overall sum score of the BDI-II, which was calculated by adding the scores of each item (ranging from 0 to 63 points). Kühner, Bürger, Keller, and Hautzinger (2007) found good internal consistencies for the different samples (α between .89 and .93).

Data analysis

SPSS 23 was used to analyze data. For our numeric variables, we created means (M) and standard deviations (SD). Different statistical analyses were performed for our dataset. For within-sample analyses, we created Pearson correlations, t-tests with Cohen’s effect sizes (d), chi-squared tests, and two general linear models (GLM) for repeated measures, each accounting for one level of dependency in our dataset: scale values for the ETI and the SCL were added as within-individual factors. For multiple comparisons, alphas were corrected using the Bonferroni method (significance was set at p < .05). All tests of significance were two-tailed.

Results

PTSD and comorbidity

The majority of our sample (N = 85) suffered from mental disorders (n = 81, 95.29%). Of these patients, n = 71 received a second, n = 9 received a third, and n = 4 received a fourth diagnosis. In n = 75 (88.2%) cases, a mild, moderate, or severe depressive episode was diagnosed (ICD-10: F32.0 to F32.3). As the second most frequently occurring mental disorder, we diagnosed a PTSD in n = 69 (81.2%) cases. Arranged most-to-less in frequency, diagnoses included harmful use of alcohol (ICD-10: F10.1; n = 5, 5.9%), adjustment disorder (ICD-10: F43.2; n = 4, 4.7%), mixed dissociative conversion disorder (ICD-10: F44.7; n = 2, 2.4%), and acute stress reaction (ICD-10: F43.0; n = 2, 2.4%)—amongst other diagnoses, each given in single cases.⁴

As described, we found high rates of PTSD in our refugee sample. Some patients reported acute self-harming behavior (n = 22, 25.9%), n = 46 (54.1%) reported acute or latent suicidal thoughts. In sum, n = 82 patients—96.5% of our total sample—reported to have experienced traumatizing events. Of these n = 82 patients, (1) all reported the traumatizing events to be man-made, (2) none reported accidental events, (3) the majority reported multiple traumatizing events (n = 75, 91.5%) vs. single traumatizing events (n = 7, 8.5%). In the case of a given PTSD, the time criterion was met (symptoms were reported to have endured more than a month).

To ascertain the comorbidity of PTSD and other mental disorders, we examined how many patients were given the diagnosis PTSD and at least one additional diagnosis (n = 67, 78.82%). Almost all patients who suffered from PTSD also had a depressive episode (PTSD with depressive episode: n = 65; PTSD without depressive episode: n = 4). A total of n = 10 patients suffered from a depressive episode without PTSD. Only n = 6 patients suffered from neither a depressive episode nor PTSD. Thus, there was a high probability that patients suffering from PTSD were also suffering from a depressive episode (χ²(1, N = 85) = 12.56, p < .001). Furthermore, the BDI-II score and the ETI PTSD score were strongly correlated (r(63) = .398, p < .01; see Table 1 for all correlations, means, and standard deviations). In sum, as expected, high rates of PTSD were found within our sample, as well as a high comorbidity between PTSD and a depressive episode (in all but four cases).

Table 1.

Correlations, means, and standard deviations.

Measure	1	2	3	4	5	6	7	M ± SD
1. Gender	–							1.66 ± 0.48
2. Age	−.067	–						31.58 ± 10.57
3. Suicidality	−.264*	−.031	–					0.54 ± 0.50
4. Sex. trauma	−.447**	.062	.047	–				0.20 ± 0.40
5. ETI Total	.009	.099	.126	.128	–			44.58 ± 10.64
6. ETI PTSD	.008	.040	.096	.111	.959**	–		35.78 ± 7.71
7. BDI II	−.025	.155	.280*	.003	.372**	.398**	–	32.34 ± 11.13
8. SCL GSI	−.075	.179	.198	.301**	.695**	.686**	.616**	2.14 ± 0.84

Note. Gender is defined as 1 = female, 2 = male. Suicidality is defined as 0 = no suicidality, 1 = suicidal thoughts are acute or latent. Patients were asked about sexual traumatization in their biography (0 = no, 1 = yes) in terms of violation and/or sexual abuse. Questionnaires: Essen Trauma Inventory total score (ETI Total; 0 to 69) and PTSD score (ETI PTSD; 0 to 51); Beck Depression Inventory (BDI II; 0 to 63); Symptom Check List global symptom score (SCL GSI (0 to 4). N = 85; df = 83 for all variables except for BDI-II (n = 65; df = 63).

*p < .05. **p < .01.

Gender differences

We compared male and female patients for all variables described in Table 1. We also checked for differences in diagnoses of PTSD and depression. The p-values were corrected using the Bonferroni method for nine comparisons. Results showed no significant differences between male and female for the following: age, suicidality, ETI total, ETI PTSD, BDI II, and SCL GSI. There was also no difference between female and male patients concerning given diagnoses of PTSD or depression. There was a significant difference between male and female patients on sexual traumatization (χ²(1, N = 85) = 16.96, p < .001). More sexual traumatization was found in female patients (13/29, 44.8%) compared to male patients (4/56, 7.1%).

Severity of PTSD symptoms

Overall, the mean ETI total score exceeded the cutoff of 40 points for clinically relevant symptoms (M = 44.58, SD = 10.64). According to the classification by Tagay and Senf (2014), only a minority of the patients showed unremarkable symptoms (n = 3, 3.5%), followed by marginal symptoms (n = 18, 21.2%), followed by the majority who showed clinically relevant symptoms (n = 64, 75.3%). The mean ETI PTSD score also exceeded the cutoff of 27 points for clinically relevant symptoms (M = 35.78, SD = 7.71). Again, only a minority of patients showed unremarkable symptoms (n = 2, 2.4%), followed by marginal symptoms (n = 9, 10.6%), followed by the clinically relevant majority (n = 74, 87.1%). The n = 69 patients with diagnosed PTSD reached a mean ETI total score of M = 46.77 (SD = 8.95) and a mean ETI PTSD score of M = 37.25 (SD = 6.25), both exceeding the cutoffs.

The values of the four scales within the ETI varied within the scores for patients suffering from PTSD. To test for significant differences on the scale level, we standardized the sum-scales by the number of items per scale. A GLM revealed a significant variation (GLM: F(3, 204) = 99.27, p < .001, partial η²= 0.59). In sum, the patients with PTSD reported mostly symptoms of (1) intrusion, followed by (2) hyperarousal, (3) avoidance, and (4) dissociation (see Figure 1 for details).

Figure 1.

Mean values with 95%-CIs of the ETI’s (Essen Trauma Inventory) sum-scales in refugees with PTSD (n = 69); range from 0 to 3: intrusion (INTR; M = 2.39, SD = 0.48); avoidance (AVOI; M = 2.04; SD = 0.44); hyperarousal (HYP; M = 2.21; SD = 0.49); and dissociation (DISS; M = 1.58; SD = 0.62). Bonferroni corrected pairwise comparisons showed significant differences between all scales (p ranged from p = .034 to p < .001 in all six comparisons).

Domains of complaints

The mean SCL-90-R GSI score for our total sample (N = 85) was M = 2.14, SD = 0.84. We created T-values according to the standard tables defined for the associated age range (Franke, 2002). Overall, n = 80 (94.1%) of the patients showed clinically relevant symptoms (T ≥ 60). The patients with PTSD (n = 69) scored M = 2.24, SD = 0.77, all exceeding the critical T-value of 60. We also found intrapersonal variation between the nine scales of the SCL-90-R in patients with PTSD (GLM: F(8, 544) = 25.35, p < .001, partial η²= 0.27; see Figure 2 for details).

Figure 2.

Mean values with 95% CI of the SCL-90-R (SCL = symptom checklist) scales in refugees with PTSD (n = 69), range from 0 to 4: somatization (SOMA; M = 1.96, SD = 0.93); obsessive-compulsive (OBS; M = 2.51, SD = 0.79); interpersonal sensitivity (INT; M = 2.29, SD = 0.91); depression (DEPR; M = 2.39, SD = 0.68); anxiety (ANX; M = 2.53, SD = 0.99); hostility (HOST; M = 1.61, SD = 0.92); phobic anxiety (PHOB; M = 2.09, SD = 1.10); paranoid ideation (PARA; M = 2.35, SD = 0.97); and psychoticism (PSYC; M = 1.85, SD = 0.95). The majority of Bonferroni corrected pairwise comparisons between the scales was significant (p < .05 in 26 of 36 comparisons).

Discussion

We found that most refugees in our sample of 85 who showed psychological strain within a German refugee reception center and were referred to a specialized clinic met the criteria for PTSD (81.2%) as well as for depression (88.2%). In line with Ford, Grasso, Elhai, and Courtois (2015), who argued that PTSD among refugees often occurs in a more severe way, the patients with PTSD in this sample showed a higher ETI PTSD score (M = 37.25) than a sample from Tagay and Senf (2014) consisting of ambulant patients with PTSD who were not refugees (M = 32.35). From June to September 2015, the refugee reception center hosting our sample became massively overcrowded (Stief, 2015), leading to substandard sheltering: for instance, refugees slept in tents, on the floor, and/or in the corridors. We assume that these and other post-migration stressors reduced the ability of the refugees to cope with their traumatic experiences, leading to higher and more severe amounts of diagnosed PTSD (Birck, 2004; Carswell et al., 2011).

We also found that refugees in our sample who suffered from PTSD also suffered from a comorbid depressive episode in the majority of cases (94.2%). In this context, we found a high correlation between the BDI-II score and the ETI PTSD score. We also found other comorbid mental disorders (e.g., alcohol abuse), but only concerning small numbers or single cases. Schubert and Punamäki (2010) also reported high comorbidity between PTSD and depression for refugees and asylum seekers within a center for torture survivors in Finland. Like the sample we presented in this study, these torture survivors came from a vast variety of countries (e.g., Iraq, Lebanon, Kosovo), suggesting that comorbidity between PTSD and depressive episodes seems to be nonrelated to culture or country of origin. We thus conclude that if refugees suffer from PTSD, there is a high probability that they also suffer from comorbid depressive episodes. In the long run, as refugees stay in the host country, comorbid mental disorders as a consequence of an untreated PTSD or other post-migration stressors can lead to other psychotic, affective, and/or neurotic disorders (Norredam et al., 2009).

For the ETI, we found the following hierarchy of symptoms within our sample: patients with PTSD most frequently reported intrusions/flashbacks, followed by hyperarousal, avoidance, and dissociation. Interestingly, the same hierarchical structure of symptoms was found in the PTSD sample of Tagay and Senf (2014). Our clinical experience suggests higher intrusions/flashbacks associated with strong hyperarousal in acute and/or severe PTSD, while dissociation and avoidance seem to dominate in chronic cases. In this regard, our results suggest that more patients with PTSD were traumatized in the recent past.

In sum, 182 patients have been referred to the clinic involved in our study in the past 3 years. Over these same 3 years, 22,294 refugees have arrived at the refugee reception center involved in our study. Given a prevalence of PTSD in 30% to 40% of refugees (Gäbel et al., 2006; Steel et al., 2009), a high number of unreported cases of PTSD can be assumed. Restricted access (Keller & Baune, 2005; Westermeyer, Vang, & Neider, 1983) or access barriers to mental health care (e.g., perceived availability of translators, concerns over social stigma; Johnson-Agbakwu, Allen, Nizigiyimana, Ramirez, & Hollifield, 2014) can aggravate the non-treatment of refugees with PTSD. Additionally, psychiatric symptoms are often not recognized in patients who have physical (somatoform) complaints (McFarlane, Atchison, Rafalowicz, & Papay, 1994; Polusny et al., 2008). An unknown number of unregistered cases of patients suffering from mental distress may not have reported symptoms for various reasons including feelings of shame/guilt (associated with sexual traumatization), avoidance, lack of knowledge of mental health care, or different concepts of (mental) health problems or illness behavior.

This study has important limitations. First, we had to exclude 97 patients because of analphabetism or lack of translations of the questionnaires into their native tongue, making a self-assessment impossible. Clearly, translations of the questionnaires are needed to assess patients who only speak Tigrinya, Kurmanji, or Sorani in order to avoid their exclusion from diagnosis and treatment. Furthermore, a validation of the PROTECT questionnaire, which has already been used in multiple refugee reception centers, would improve the screening process significantly. Second, due to the recency of migration from war-torn countries as well as post-migration stressors, some patients at the refugee reception centers were still experiencing acute stress. Peritraumatic stress responses can be triggered by reminders of events during the flight that are still salient, or by ongoing stressors in the refugee reception center. Peritraumatic stress is associated with a high frequency of dissociative symptoms (Bovin & Marx, 2011; Schauer & Elbert, 2010), which was found in our sample (ETI score for dissociation M = 1.58), compared to ambulatory patients with PTSD (Tagay & Senf, 2014; M = 1.21). At the time of assessment, the traumatic events in the home country leading to the diagnosis of PTSD met the time criterion and thus were objectively over. Due to possible peritraumatic stressors and/or events, however, it was not always possible to distinguish between PTSD and additional acute stress reactions. Longitudinal assessments are needed to make this distinction. Fischer and Riedesser (1998) proposed the term “psycho-traumatic” instead of “post-traumatic” stress disorder, because of the difficulty distinguishing between peritraumatic and posttraumatic stress. Third, we did not distinguish other salient subgroups based on nationality, socioeconomic status before migration, number of pre- or peri-migration traumatic events, social support, residence factors, or individual personality traits. Considering these as possible risk factors for developing a PTSD could allow for more precise conclusions, but this would require a larger sample.

Conclusion and recommendations

Refugees, by definition, often undergo traumatic experiences in their country of origin and/or during their flight from their country of origin. This study indicates that refugees with psychological strain in a German refugee reception center suffered from PTSD and comorbid depression with high probability. Symptoms of intrusions/flashbacks were identified as being the strongest in these refugees, followed by ongoing, severe symptoms of hyperarousal, avoidance, and dissociation.

Due to the massive increase in numbers of refugees in Germany, there has been great pressure on social support personnel (e.g., office workers, social workers, caregivers) in the refugee reception centers. This led to fewer patients being sent for assessment during the 2015 peak of the wave of refugees, possibly because staff within the centers had significantly less time to appraise refugees’ psychological state. Thus, more trained personnel and more cooperation with clinicians are needed to improve assessment. Mental disorders can only be treated successfully if they are noticed and if patients are referred correctly. Non-treatment of PTSD can lead to chronic symptoms. Clearly, there is an urgent need to improve access to preventive psychiatric and psychosocial care for refugees within German reception centers. Moreover, due to the severity of symptoms, it is crucial to provide ongoing supervision and training for the personnel working in refugee reception centers or similar facilities to avoid secondary traumatization.

Footnotes

Acknowledgments

We thank Margarita Neff-Heinrich for her native speaker English proofreading.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was funded by the Asklepios Clinical Center Goöttingen.

Notes

Biographies

Maria Belz, Dipl.-Psych., is employed as a psychologist within the outpatient center of the Asklepios Clinicum Göttingen, Germany, where she studies transcultural psychotherapy. Her published works focus on mental health services for migrants, mental health of traumatized refugees, and speech reduced interventions.

Michael Belz, Dipl.-Psych., Dr. rer. nat., is employed as a psychologist within the psychiatric and psychotherapeutic department of the University Medical Center Göttingen, Germany. He studies group processes, interpersonal communication, and psychotherapeutic interventions in the field of geropsychiatry. His published works focus on movement patterns in small groups, competition over resources, and social validation of information within group discussions.

Ibrahim Özkan, Dipl.-Psych., Dr. disc. pol., a clinical psychologist and certified psychotherapist, works in the outpatient center of the Asklepios Clinicum Göttingen, Germany, where he is the supervisor of the clinical expert team for culture, migration, and mental illness. He also works as therapist, medical psychologist, and educator at the center for key competences at the art department of the Georg-Augusta-University of Göttingen. His core interests are migration, migration and mental health, psychotrauma, refugees, intercultural work in mental healthcare, practice management, and psycho-oncology. He is a co-founder and board member of the DTPPP (Dachverband der transkulturellen Psychiatrie, Psychotherapie und Psychosomatik im deutschsprachigen Raum), the Association of Transcultural Psychiatry Psychotherapy and Psychosomatics of German-speaking Countries, board member at the European society of integration in medical healthcare, and consultant and scientific consultant on several European projects.

Iris Graef-Calliess, MD, PhD, is a specialist in psychiatry and psychotherapy and medical director of the Center for Transcultural Psychiatry & Psychotherapy at Wahrendorff Clinic, Hannover, Germany. She is an assistant professor at Medical School of Hannover, Germany, and heads the research group on social and transcultural psychiatry. Her published work focuses on transcultural psychiatry and psychotherapy, mental health of immigrants, acculturation & identity, global mental health, innovative mental health care, social psychiatry, and young professionals.

References

Beck

A. T.

Steer

R. A.

Brown

G. K.

(2009) Beck-Depression-Inventory (BDI-II), Frankfurt, Germany: Pearson Assessment.

Birck

(2004) Symptoms associated with war and torture refugee survivors, with and without psychotherapy. Zeitschrift für Klinische Psychologie und Psychotherapie 33(2): 101–109. doi: 10.1026/0084-5345.33.2.101.

Bovin

M. J.

Marx

B. P.

(2011) The importance of the peritraumatic experience in defining traumatic stress. Psychological Bulletin 137(1): 47–67. doi: 10.1037/a0021353.

Carswell

Blackburn

Barker

(2011) The relationship between trauma, post-migration problems and the psychological well-being of refugees and asylum seekers. International Journal of Social Psychiatry 57(2): 107–119. doi: 10.1177/0020764009105699.

Council Directive 2003/9/EC of 27 January 2003 laying down minimum standards for the reception of asylum seekers (2003). Official Journal of the European Union, L31, 18–25. Retrieved from: http://eur-lex.europa.eu/LexUriServ/LexUriServ.do?uri=OJ:L:2003:031:0018:0025:EN:PDF.

Derogatis, L. R. (1983). SCL-90: Administration, scoring and procedures manual-I for the revised version and other instruments of the psychopathology rating scale series. Baltimore, MD: Johns Hopkins University School of Medicine, Clinical Psychometrics Research Unit.

Federal Office for Migration and Refugees. (2016). Current figures on asylum seekers. Retrieved from: https://www.bamf.de/SharedDocs/Anlagen/DE/Downloads/Infothek/Statistik/Asyl/statistik-anlage-teil-4-aktuelle-zahlen-zu-asyl.pdf?__blob=publicationFile.

Fischer

Riedesser

(1998) Textbook of psychotraumatology, Stuttgart, Germany: Ernst Reinhardt Verlag.

Ford

J. D.

Grasso

D. A.

Elhai

J. D.

Courtois

C. A.

(2015) Posttraumatic stress disorder: Scientific and professional dimensions, 2nd ed. San Diego, CA: Elsevier.

10.

Franke

G. H.

(2002) SCL-90-R – the Symptom Checklist by L. R. Derogatis, Göttingen, Germany: Beltz Test.

11.

Gäbel

Ruf

Schauer

Odenwald

Neuner

(2006) Prevalence of posttraumatic stress disorder (PTSD) and possibilities of determination in the asylum procedure practice. Zeitschrift für Klinische Psychologie und Psychotherapie 35(1): 12–20. doi: 10.1026/1616-3443.35.1.12.

12.

Gerritsen

A. A. M.

Bramsen

Devillé

Willigen

L. H. M.

Hovens

J. E.

Ploeg

H. M.

(2006) Physical and mental health of Afghan, Iranian and Somali asylum seekers and refugees living in the Netherlands. Social Psychiatry and Psychiatric Epidemiology 41(1): 18–26. doi: 10.1007/s00127-005-0003-5.

13.

Goodkind

J. R.

Hess

J. M.

Isakson

LaNoue

Githinji

Roche

Parker

D. P.

(2014) Reducing refugee mental health disparities: A community-based intervention to address postmigration stressors with African adults. Psychological Services 11(3): 333–346. doi: 10.1037/a0035081.

14.

Johnson-Agbakwu

C. E.

Allen

Nizigiyimana

J. F.

Ramirez

Hollifield

(2014) Mental health screening among newly arrived refugees seeking routine obstetric and gynecologic care. Psychological Services 11(4): 470–476. doi: 10.1037/a0036400.

15.

Keller

Baune

B. T.

(2005) Impact of social factors on health status and help seeking behavior among migrants and Germans. Journal of Public Health 13(1): 22–29. doi: 10.1007/s10389-004-0082-x.

16.

Kühner

Bürger

Keller

Hautzinger

(2007) Reliability and validity of the revised Beck Depression Inventory (BDI-II). Der Nervenarzt 78(6): 651–656. doi: 10.1007/s00115-006-2098-7.

17.

Laban

C. J.

Gernaat

H. B. P. E.

Komproe

I. H.

De Jong

J. T. V. M.

(2007) Prevalence and predictors of health service use among Iraqi asylum seekers in the Netherlands. Social Psychiatry and Psychiatric Epidemiology 42(10): 837–844. doi: 10.1007/s00127-007-0240-x.

18.

Laban

C. J.

Gernaat

H. B. P. E.

Komproe

I. H.

Schreuders

B. A.

De Jong

J. T. V. M.

(2004) Impact of a long asylum procedure on the prevalence of psychiatric disorders in Iraqi asylum seekers in The Netherlands. The Journal of Nervous and Mental Disease 192(12): 843–851. doi: 10.1097/01.nmd.0000146739.26187.15.

19.

Laban

C. J.

Gernaat

H. B. P. E.

Komproe

I. H.

van der Tweel

De Jong

J. T. V. M.

(2005) Postmigration living problems and common psychiatric disorders in Iraqi asylum seekers in the Netherlands. The Journal of Nervous and Mental Disease 193(12): 825–832. doi: 10.1097/01.nmd.0000188977.44657.1d.

20.

Laskowski

S. R.

(2013) Asylum. In: Ehlers

Fehling

Pünder

(eds) Special administrative law: Volume 3, Heidelberg, Germany: C. F. Müller, pp. 707–753.

21.

Luchterhand

E. G.

(1971) Sociological approaches to massive stress in natural and man-made disasters. In: Niederland

W. G.

Krystal

(eds) Psychiatric traumatization: Aftereffects in individuals and communities, Boston, MA: Little, Brown & Company, pp. 29–51.

22.

Maercker

(1997) Therapie der Posttraumatischen Belastungsstörung, Berlin, Germany: Springer.

23.

McFarlane

A. C.

Atchison

Rafalowicz

Papay

(1994) Physical symptoms in post-traumatic stress disorder. Journal of Psychosomatic Research 38(7): 715–726. doi: 10.1016/0022-3999(94)90024-8.

24.

Ministry for the Interior and Sports of Lower Saxony. (2014). Interior Minister Pistorius and Mayor Griesert introduce new reception means for refugees in Osnabrück. Retrieved from http://www.mi.niedersachsen.de/portal/?navigation_id=14797&article_id=129559&_psmand=33.

25.

Norredam

Garcia-Lopez

Keiding

Krasnik

(2009) Risk of mental disorders in refugees and native Danes: A register-based retrospective cohort study. Social Psychiatry and Psychiatric Epidemiology 44(12): 1023–1029. doi: 10.1007/s00127-009-0024-6.

26.

Özkan

Belz

(2015) Clinical diagnosis of traumatised immigrants. In: Schouler-Ocak

(ed.) Trauma and migration: Cultural factors in the diagnosis and treatment of traumatised immigrants, Cham, Switzerland: Springer, pp. 83–93.

27.

Perera

Gavian

Frazier

Johnson

Spring

Westermeyer

Jaranson

(2013) A longitudinal study of demographic factors associated with stressors and symptoms in African refugees. American Journal of Orthopsychiatry 83(4): 472–482. doi: 10.1111/ajop.12047.

28.

Polusny

M. A.

Ries

B. J.

Schultz

J. R.

Calhoun

Clemensen

Johnsen

I. R.

(2008) PTSD symptom clusters associated with physical health and health care utilization in rural primary care patients exposed to natural disaster. Journal of Traumatic Stress 21(1): 75–82. doi: 10.1002/jts.20281.

29.

Ryan

D. A.

Benson

C. A.

Dooley

B. A.

(2008) Psychological distress and the asylum process: A longitudinal study of forced migrants in Ireland. Journal of Nervous and Mental Disease 196(1): 37–45. doi: 10.1097/NMD.0b013e31815fa51c.

30.

Schauer

Neuner

Karunakara

Klaschik

Robert

Elbert

(2003) PTSD and the “building block” effect of psychological trauma among West Nile Africans. European Society for Traumatic Stress Studies Bulletin 10(2): 5–6.

31.

Schauer

Elbert

(2010) Dissociation following traumatic stress. Journal of Psychology 218(2): 109–127. doi: 10.1027/0044-3409/a000018.

32.

Schubert

C. C.

Punamäki

R.-L.

(2010) Mental health among torture survivors: Cultural background, refugee status and gender. Nordic Journal of Psychiatry 65: 175–182. doi: 10.3109/08039488.2010.514943.

33.

Steel

Chey

Silove

Marnane

Bryant

R. A.

van Ommeren

(2009) Association of torture and other potentially traumatic events with mental health outcomes among populations exposed to mass conflict and displacement: A systematic review and meta-analysis. The Journal of the American Medical Association 302(5): 537–549. doi: 10.1001/jama.2009.1132.

34.

Stief, G. (2015, November 8). The Friedlanders [residents of Friedland, a city in Lower Saxony, Germany] know what integration is. Hannoversche Allgemeine. Retrieved from http://www.haz.de/Nachrichten/Politik/Niedersachsen/Niedersachsens–historisches–Durchgangslager–bei–Goettingen–ist–ueberfuellt.

35.

Tagay

Senf

(2014) Essen Trauma Inventory (ETI), Göttingen, Germany: Hogrefe.

36.

Tay

Frommer

Hunter

Silove

Pearson

San Roque

Steel

(2013) A mixed-method study of expert psychological evidence submitted for a cohort of asylum seekers undergoing refugee status determination in Australia. Social Science & Medicine 98: 106–115. doi: 10.1016/j.socscimed.2013.08.029.

37.

Terr

L. C.

(1991) Childhood traumas: An outline and overview. American Journal of Psychiatry 148(1): 10–20.

38.

van Ommeren

De Jong

J. T. V. M.

Sharma

Komproe

Thapa

S. B.

Cardeña

(2001) Psychiatric disorders among tortured Bhutanese refugees in Nepal. Archives of General Psychiatry 58(5): 475–482. doi: 10.1001/archpsyc.58.5.475.

39.

Westermeyer

Vang

T. F.

Neider

(1983) Refugees who do and do not seek psychiatric care: An analysis of premigratory and postmigratory characteristics. The Journal of Nervous and Mental Disease 171(2): 86–91.

40.

Wilson-Shaw

Pistrang

Herlihy

(2012) Non–clinicians’ judgments about asylum seekers’ mental health: How do legal representatives of asylum seekers decide when to request medico-legal reports? European Journal of Psychotraumatology 3: 10.3402/ejpt.v3i0.18406. http://doi.org/10.3402/ejpt.v3i0.18406.

41.

World Health Organization (1992) The ICD-10 classification of mental and behavioural disorders: Clinical descriptions and diagnostic guidelines, Geneva, Switzerland: Author.