1. Introduction
By the end of 2015, 65.3 million individuals were forcibly displaced worldwide. About 7% (4.9 million) of all refugees worldwide came from Syria [
1]. Over the last two years, Germany and Europe have been witnessing the largest migration recorded in their recent history. Compared with 2014, the number of asylum applications in Germany increased by 155.3% in 2016. In 2015, 441,899 asylum applications (30.8% women) and 1,091,894 entrances of refugees were documented. Most asylum requests came from Syria (35.9%; 158,657) and 6.9% (29,784) were from Iraq. Over fifteen percent (15.3%) of the applications were recorded in Bavaria [
2]. In 2016, the number of applications even reached 722,370 [
3]. Most of the requests came consistently from Arabic speaking countries (Syria 36.9%; Iraq 6.9%).
Migrants, in general, are a heterogeneous group and the prevalence rates of mental disorders vary widely between studies [
4]. The majority of studies with migrants ascertained higher prevalence rates of mental disorders [
5] as well as higher symptom scores [
6,
7,
8] in comparison to the German population. In a systematic overview of Lindert et al. [
4], the prevalence rates for refugees were higher than those for labor migrants. Prevalence rates of posttraumatic stress disorder (PTSD) vary widely for refugees, between 4% and 86%, for depression between 3% and 81%, and for anxiety between 5% and 90% [
4].
Heterogeneous findings have also been reported about the mental health of refugees who are resettled in Germany. Gäbel et al. [
9] found symptoms of PTSD in 40% of the 40 participants from 13 different countries. In 1999, Traue et al. [
10] examined 99 refugees from Kosovo. Symptoms of PTSD were detected in 42% of the participants, while depression and anxiety were even more frequent, with 80% of the participants manifesting symptoms. In a survey on Russian and ex-Yugoslavian descent refugees [
11], at least one mental disorder was present in only 3.5% of the refugees. This outcome was explained as an under-diagnosis by physicians with lacking psychiatric expertise.
Few studies have investigated the mental health problems of the Arabic speaking refugees in the recent years. In a sample of 310 Syrian refugees in Lebanon, the prevalence of current depression was 43.9% [
12]. In a sample of 352 refugees from Syria, Alpak et al. [
13] reported a frequency of PTSD of 33.5%. They found positive correlations between PTSD, number of traumatic events experienced, and female gender. Kazour et al. [
14] found a lifetime prevalence of 35.4% and a point prevalence of 27.2% for PTSD in Syrian refugees in Lebanon. In a survey among Iraqi refugees resettled in the United States, the prevalence of emotional distress, anxiety, and depression was approximately 50% and the risk for PTSD about 31% [
15]. In a sample of 225 Iraqi refugees resettled in western Sydney with a mean duration of stay in Australia of 59 months, Slewa-Younan et al. [
16] measured PTSD symptoms. Ninety-five percent of participants reported having experienced one or more potentially traumatic event, with a mean of 14.28 events (SD = 8.69). Thirty-one percent of participants met the criteria for clinically significant PTSD symptomatology.
So far, only a few studies have investigated the mental health consequences of refugees from the more recent migration movement in Germany. Richter et al. [
17] ascertained one or more mental disorders in 64% of 283 refugees from different countries (mostly from Iran, Russia, Afghanistan, and Iraq). Most frequently they found PTSD (33%) and depression (22%) symptoms. In a cohort of Syrian refugees, the prevalence of depression, examined with Patient Health Questionnaire (PHQ)-4, was 20%, corresponding to results for the German population with the same questionnaire [
18]. The prevalence of generalized anxiety was moderately higher in the Syrian refugee sample (19.3%). However, they assume an underrepresentation of the prevalence rates because a high number of men (80%) were included in their study. Also, the prevalence rates could have been underestimated due to avoidance reactions by highly distressed refugees who did not participate in this survey. During the significantly increased arrival of refugees in the summer of 2015, Kröger et al. [
19] estimated the extent of posttraumatic stress and depressive symptoms amongst adult asylum seekers from different regions (Balkan States, the Middle East, Northern Africa, rest of Africa) in Braunschweig, Germany. Participants reported high total numbers of traumatic events. The prevalence of PTSD was 20.5% (the Middle East) and 23.6% (total sample); while the emergences of a clinical/subclinical depression were 35.9% (the Middle East) and 25.4% (total sample). Compared to the German population, the prevalence of PTSD was significantly higher amongst asylum seekers.
The different results of the studies illustrate the heterogeneity of the refugee population. In the majority of the studies, a representative sample of refugees could not be recruited. The studies also lack comparability, as they used different psychometric instruments. Information on mental health among refugees is insufficient and therefore further research is required [
20]. Several Arabic-speaking countries have witnessed long-lasting war. In the last two years, the most applications for asylum in Germany were requested from Arabic speaking people [
2,
3]. Refugees who came from countries with intense human rights violations have an increased rate of psychopathological symptoms [
21] and the exposure to violence is associated with higher rates of trauma-related disorders [
22].
The present study aims to determine the frequency of PTSD, depression, and generalized anxiety amongst asylum seekers in collective accommodation centers for refugees in the municipal area of Erlangen. Furthermore, the prevalence of traumatic events (TEs) will be reported. A further objective of the study was to test the comprehensibility and cultural appropriateness of the Arabic translations of the questionnaires in this sample.
4. Discussion
This study examined the prevalence of TEs, and the manifestation of PTSD, and depressive and anxiety symptoms in Arabic speaking asylum seekers who were placed in collective accommodation centers in Erlangen, Germany. The main result of the present study was the identification of high rates of mental distress in Arabic speaking refugees. Also, asylum seekers without mental distress had fewer TEs and a longer duration of stay in Germany in comparison to asylum seekers with distress in at least one diagnostic category. Men and woman seemed to be equal in TEs and prevalence of PTSD, and depressive and anxiety symptoms.
It is well known that the prevalence rates for refugees are higher than for labor migrants, but they vary widely between international studies [
4]. In comparison to other studies about refugees from Syria [
12,
13,
14] and Iraq [
15,
16], we found consistent results. Compared to studies from Germany [
17,
18,
19], we found similar or higher levels of mental distress.
The manifestation of depression and anxiety symptoms were also high in our sample. In general, the prevalence rates in the literature for depression in refugees vary between 3% and 47%, and for anxiety between 5% and 90% [
4]. In studies in Germany, the prevalence rates for depression vary between 20% and 80% [
10,
17,
18,
19], and for anxiety between 19.3% and 80% [
10,
18]. In our sample, 57.1% of the asylum seekers endorsed symptoms of at least moderate depression and 39.3% for at least moderate anxiety. Therefore, our findings are consistent with previous research in Germany.
In a systematic overview, Lindert et al. [
4] found varying prevalence rates for PTSD in refugees between 4% and 86%. In other studies in Germany, the prevalence rates varied from 20.5% to 42% [
9,
10,
17,
19]. In our sample, 35.7% of the asylum seekers endorsed symptoms of PTSD. In comparison to the recent published study by Kröger et al. [
19], we found higher rates of PTSD. In this study, the prevalence rate for PTSD were 20.5% in people from the Middle East. The prevalence rates of PTSD could have been underestimated due to avoidance reactions with PTSD and the limited recruitment. However, the samples are not fully comparable. The survey of Kröger et al. [
19] included about 16% of the registered asylum-seekers in Lower Saxony, Germany in 2015. They recruited a sample of 280 refugees of different descent; however, only 39 persons originated from the Middle East, with 12.8% women. Moreover, the current housing conditions and the duration of stay of the participants in this study are unclear. Our study is focused on Arabic speaking asylum seekers in collective accommodation centers. We achieved a high response rate of over 80% in the three largest centers in Erlangen (Bavaria), with a high percentage of women (35.7%). However, our results are comparable to those of Richter et al. [
17]. In their study, many refugees from Iraq (therefore Arabic speaking persons) were included and they also used ETI to measure PTSD; 32.2% of the participants met the criteria for PTSD.
In the overall picture, in comparison with the general German population, there is a significantly higher rate of mental disorders in refugees. In our sample, 64.3% (
n = 36) of the asylum seekers had distress in at least one diagnostic category compared to 27.7% in the German general population [
33]. In our sample, 80.4% reported at least one TE and 35.7% showed symptoms of PTSD; in contrast, in the German general population, only 23.8% reported at least one TE and 2.9% met the criteria for PTSD [
34]. For a moderate depression (PHQ-9 ≥ 10), the rates in adults in Germany are 8.1% (10.2% women; 6.1% men) [
35]; in our sample, 57.1% (65% women; 59.4% men) presented moderate depression and 23.2% presented severe depression (PHQ-9 ≥ 20). A moderate anxiety was reported by 39.3% of our sample in contrast to 5.9% of the general German population [
36].
The prevalence rates in our study are higher than in the Arabic samples. The review by Tanios et al. [
37] showed different rates of anxiety disorders in Arab populations, with 28.2% in Jordan, 16% in Saudi Arabia, 16.7% in Lebanon, and 10% in the United Arab Emirates. In Lebanon, Karam et al. [
38] found a 3.4% lifetime prevalence rate of PTSD, 16.7% prevalence rate of anxiety, and 12.6% prevalence rate of mood disorders. The lifetime prevalence of any disorder was 25.8%. In the postconflict area of the Gaza Strip, de Jong et al. [
39] reported a lifetime prevalence for PTSD of 17.8%.
We did not find significant differences between female and male individuals in the number of experienced TEs and the degree of PTSD as well as depression symptoms and anxiety. Furthermore, no gender differences between asylum seekers without mental distress and those with distress in at least one diagnostic category were found. Kessler et al. [
40] reported that women are more than twice as likely to present lifetime PTSD than men. Contrariwise, Hauffa et al. [
34] did not find a significant difference between men and woman in PTSD prevalence in the German population. However, in the German population, women are found to be more anxious than man [
36] and depression is diagnosed in women almost twice as frequently as in men [
35]. In a review for anxiety disorders in Arabic speaking countries, most studies showed higher prevalence rates in woman than in men [
37]. Some recent studies with refugee populations from Arabic speaking countries found a positive correlation between mental disorders and female gender [
12,
15], while others did not report gender differences [
13,
18]. In contrast, de Jong et al. [
39] found in the Gaza Strip sample that men had more PTSD symptoms than women. In our sample, 64.3% had distress in at least one diagnostic category, approximately half of the sample (46.4%) had two or more diagnostic categories. These results are comparable to those from Richter et al. [
17]. In their study, 63.6% of the asylum seekers who settled in collective accommodation centers had at least one psychiatric diagnosis. However, a larger sample of Arabic speaking refugees is needed to confirm our results.
As expected, high prevalence rates of mental disorders were found and significant correlations between all three questionnaires were observed, which confirmed a high comorbidity. The asylum seekers in our study are accommodated in collective housings for refugees, which is an additional stress factor (e.g., because of divided rooms and lack of privacy). They also suffer from the burden of having no clear residence permission. It is well known that stress can have a crucial impact on mental health [
41,
42]. Higher rates of PTSD are associated with a temporary residence permit [
43]. Demiralay and Haasen [
42] classify residence permission status and economic conditions (e.g., living conditions) as stress factors for the acculturation process. Nickerson et al. [
44] found in their study with refugees from Iraq that post-migration living difficulties are a predictor for PTSD and depression. In our study, a longer duration of stay in Germany was related to a decrease of symptom scores in ETI as well as PHQ-9 and GAD-7. Moreover, asylum seekers with distress in at least one diagnostic category reported a shorter duration of stay in Germany. A possible explanation is that the mental health of some asylum seekers has improved with longer duration of stay in Germany. Morina et al. [
45] estimate remission in an average of 44% of individuals with PTSD in a mean observation period of 40 months. However, the remission rates varied between 8% and 89%, whereupon the highest mean of remission rate (60%) was reported in participants with PTSD following the exposure to a natural disaster. According to this, we expect that the symptom levels will decrease within the next months. Laban et al. [
46] suggest that residence permission is beneficial for mental health mainly because of the improvement of living difficulties. Putatively, refugees with an expectancy of getting the residence permit soon reported an improvement of their emotional well-being. Resilience factors may help to restrict the emergence of severe psychopathology. Mental health has been considered to be one of the most important factors of successful adaption and resettlement of refugees [
47]. Higher acculturation scores are indirectly related to lower scores for depressed mood and promote mental health indirectly by reducing social alienation and, subsequently, lowering family and personal stress [
48]. A positive emigration is favored by flexible coping strategies, social support, and optimism [
41]. Van Lente et al. [
49] showed that positive mental health is predicted by lower levels of loneliness and higher levels of social support in refugees.
In terms of cultural validity, we asked participants to report problematic formulations in the translations to us. The instruments were well accepted by the participants. Difficulties in understanding or interpreting were very rare. We expect that a good linguistical comprehensibility and good conceptual equivalences relate to the acceptability of the concepts of all three measurements. However, there is a need for several culturally adapted and validated questionnaires for Arabic-speaking refugee populations. Research on selected refugees settled in the West may not allow for results to be generalized to the majority of the world’s refugees [
39]. Even the native Arabic speaking population has a large variety of cultures, political systems, ethnicities, and religious beliefs [
50]. Cultural beliefs affect interpretation of mental symptoms [
51]. Cultural validity of health instruments is crucial for improving our understanding and assessment of health. [
52]. Vindbjerg et al. [
53] assessed the factorial structure of PTSD in an Arabic speaking population of refugees with the Harvard Trauma Questionnaire [
54]. The results of their study indicate that the construct of PTSD is valid among this population.
Concerning demographic properties, our sample is comparable to the basic population of asylum seekers in Germany. In 2016, most asylum applications were made by men (65.7%) and 34.3% by woman, and most requests came from Syria (36.9%) and Iraq (6.9%). The majority of applications (47.2%) were made from asylum seekers between 18 and 35 years old [
3]. In our sample, 35.7% were women and the mean age of the total sample was 27.2 years (range: 18–45). Moreover, in our study, we included 83.6% of Arabic speaking asylum seekers who were settled among the three biggest collective accommodation centers in Erlangen and fulfilled the inclusion criteria for our study.
Despite the high response rate, our sample is small and our results should be interpreted in the context of certain limitations that should be addressed in future research. First of all, our study recruitment was focused on Arabic speaking asylum seekers who are placed in collective accommodation centers. Therefore, this sample may not accurately reflect the mental health of the Arabic speaking refugee population in other accommodation forms in Germany. A representative sample of the refugee population is crucial for obtaining correct prevalence rates. However, due to the importance of this kind of data, more detailed studies are needed which will include larger samples. These studies should also compare their results to data obtained from Arabic countries. An additional shortcoming of the present investigation is in regard to the lack of information on psychiatric comorbidity other than PTSD, depression, and anxiety. Also, the question of whether depression and anxiety is the consequence of TEs cannot be answered by our data due to the cross-sectional design of our study. Furthermore, the measurements are not validated for refugee populations and the ETI is based on DSM-IV. Updated research based on DSM-V conceptualization of PTSD is necessary.