Mental disorder and PTSD in Syria during wartime: a national-wide crisis

doi:10.21203/rs.3.rs-19902/v1

Background: Syria has experienced war over the past seven years, leaving a high percentage of the population below the poverty line. This has significantly impacted Syrians which is reflected in the psychiatric aspect. This study evaluates the severity of the mental disorder caused by war and other factors, and evaluates the post-traumatic stress disorder (PTSD) in addition to support provided to Syrians.

Methods: Online surveys including the Kessler 10 (K10) survey, the Screen for Posttraumatic Stress Symptoms (SPTSS) tool, the Multidimensional Scale of Perceived Social Support (MSPSS) and demographic and war-related questions were used for this study.

Results: Our study included 1951 participants, comprising 527 (27.0%) males and 1538 (78.8%) aged (19-25) years. Of all the participants in the study, 44% had severe mental disorder, 27% had severe mental disorder with full PTSD symptoms, 36.9% had full PTSD symptoms, 79% had at least one PTSD symptom, and 10.8% had neither PTSD symptoms nor mental disorder. Only 23.2% had low overall support. Half of the responders were internally displaced and 27.6% of these participants were forced to move three times or more due to war. Only 13.4% of the responders did not believe that the crisis was the reason for their distress. Those with high SPTSS and K10 scores were found to take more days off of work or school due to negative feelings and have somatic symptoms. Moreover, low levels of education, low socioeconomic status, chronic medical conditions, war variables for example distress caused by war noises, changing place of living due to war were all associated with high distress and the presence of PTSD symptoms in this study. Strong significant correlation (r=0.623) was found between SPTSS and k10 score.

Conclusion: The conflict in Syria has left the country’s population at great risk of psychological and mental distress. Drastic measures are required to save an entire population from permanent psychological suffering.

Psychiatry

K10

mental disorder

PTSD

war

social support

PTSD symptoms

conflict

Syria

refugees

For the purposes of this study, the term disaster refers to an unsettling event which causes disruption to the community and its functions, leading to devastating losses, impacting the community’s ability to survive – particularly when its resources are no longer sufficient. This often occurs when a threat is presented to a vulnerable population experiencing various challenges (1). Because of its acute and chronic effect on the community, warfare is considered one of the most devastating events that a human being can experience. Even when someone survives war, the face the challenges emanating from food and resource shortage, displacement, and disease outbreak (2).

The Syrian conflict has had a devastating effect on the Syrian population. Since its beginning in 2011, many have been wounded, 511,000 have died (3), more than 5.6 million have been externally displaced (4), and 6.2 million have been internally displaced (5). The damage to health infrastructure and loss of health personnel has greatly affected the health system in Syria. The mental and psychological sector, which had previously been neglected in Syria, has faced even greater challenges during the conflict. The education sector has also suffered significant damage after being greatly destroyed by the war. With the destruction of the Syrian social structure, most children have had to grow up in a war-burdened environment which may have negative effects on their psychological development (6). These disturbances and loss of both social and emotional support have led to patterns of severe psychological trauma (7).

Although research has shown that factors including increased poverty and limited social support may affect mental health as much as the impact of trauma itself, the level of mental health among refugees differs from that among those who live in conflict areas. (8). Several studies indicate that the prevalence of psychological problems is higher in conflict-affected areas, but the duration of the post-traumatic effects will have a longer lasting impact and may continue for several years after the end of the conflict (9–11). This demonstrates the importance of understanding the impact of the Syrian conflict on the mental health of its young population. A better understanding will help with the implementation of the proper interventions that can improve the quality of life of Syrians, and ensure they live a healthy life that will allow them to pursue their dreams and be proactive in their communities. The purpose of this study is to assess the prevalence of mental disorder, psychological distress, and post-traumatic stress disorder (PTSD) amongst the Syrian population, and the amount of support that Syrians received with relation to their different demographic and war-related variables.

1) Sampling:

Our study is a cross-sectional study conducted in Syria from 3/3/2019 to 24/3/2019. Online surveys in Arabic were conducted on participants from several Syrian provinces. Only participants who lived within Syrian borders at the time of the survey who answered demographic questions and all K10 questions were enrolled. The questionnaires were posted online twice each day at 10 AM and 10 PM in groups with different topics such as educational, cuisine, sells, entertainment, cultural, musical etc.

2) Consent And Approval For Study:

Informed consent was given before proceeding with the survey, and for using and publishing the data. Confidentiality was assured and no identity-revealing questions were asked.

Our study protocol and ethical aspect were reviewed and approved by Damascus University deanship in Damascus, Syria.

3) Questionnaires:

• Socioeconomic status (SES):

SES was assessed through three criteria; (1) the education level and profession of the participant or the working family members, (2) the monthly family income of the participant if they were living alone, or of the house provider if living in family. SES was then divided into four different categories: lower, upper lower, middle, and upper.

• Screening For Mental Disorder:

Kessler 10 is typically used in screening surveys to measure psychological distress (12–14). An Arabic version of the K10 + LM questionnaires was used (12, 13). It is a self-reported measure that is used to assess anxiety and depression symptoms over the previous four weeks. It contains ten questions with scores ranging from 10 to 50. Subjects who score under 20 are likely to be well, those who score 20–24 could have a mild mental disorder, those who score 25–29 have moderate mental disorder, and finally those who score 30 and above have a severe mental disorder. Each question has five possible responses with scores ranging from 1 to 5.

• Social Support:

An Arabic version of Multidimensional Scale of Perceived Social Support (MSPSS) (15, 16) was used to measure the support that the individual receives from their social network including friends, family, and significant other (15, 16). The measure contained 12 questions with four questions for each source. Support received was then divided into three categories: low support with a mean score of 1 to 2.9, moderate support with a mean score of 3 to 5, and finally high support with a mean score of 5.1 to 7.

• PTSD:

The Screen for Posttraumatic Stress Symptoms (SPTSS) tool was used, which is a self-reporting screening method for PTSD that is very concise and suitable as it is easy to understand, respond to, and does not focus on specific traumatic events. SPTSS is only a screening method and is not meant to be a definitive diagnostic tool for PTSD. It measures three PTSD clusters over the previous 4 weeks; avoidance with 7 items, hyper-arousal with 5 items, and re-experience with 5 items. Each question has 5 potential responses, ranging from “Not at all” to “More than once every day”, with scores ranging from 0 to 4. However, when calculating the final score for each cluster, the first two scores represent 0 and the others represent 1. Scoring 3 or more on avoidance cluster, 2 or more on re-experience, and 1 or more on excessive arousal is considered as positive PTSD for that specific cluster. This scale, however, it based on diagnostic and statistical manual of mental disorders (DSM) IV (17, 18). These three clusters are close to what is used in the International Classification of Disease 11 (ICD-11) criteria although using DSM IV criteria usually identify cases with less severe trauma exposure (19).

• Other Questions:

The subjects were asked basic demographic questions such as gender, age, educational level, province of current living and whether they have consanguineous parents. Subjects were asked a few questions, both directly and indirectly about war, including changing place of residence due to war, losing someone close, and being distressed by war noises. Subjects were also asked to declare whether they suffer from any chronic medical condition. This study defined third-degree consanguineous parents as when the parents are first cousins, fourth-degree consanguineous parents when they are second cousins, or second cousins once removed.

4) Data Process:

Data was processed using IBM SPSS software version 26 for Windows (SPSS Inc, IL, USA). Chi-square, one-way analysis of variance (ANOVA), and independent-t tests were performed to determine statistical significance between the groups. Pearson correlation was also calculated. Through the same software, odds ratios (ORs) and the 95% confidence intervals for the groups were calculated using Mantel–Haenszel test. Values of less than 0.05 for the two-tailed P values were considered statistically significant.

Overall, 2173 responded for the survey. However, 198 were excluded as they did not answer all the questions, or their replies were invalid and 24 refused to be enrolled. The study included 1951 responders with 527 (27.0%) being males and 1538 (78.8%) participants were in the age range of (19-25) years. Within responders, 19.2% (CI 95%: 17.5% - 21%) are likely to be well, 19.5% (CI 95%: 17.8% - 21.3%) had a mild mental disorder, 16% (CI 95%: 14.9% - 18.1%) had a moderate mental disorder, and 44.7% (CI 95%: 42.6% - 47.0%) had severe mental disorder according to K10 scale. Other characteristics of the subjects are demonstrated in (Table 1).

TABLE 1

Characteristics of the subjects with characteristics of war, current medical conditions, and K10 Scale

Characteristic

Frequency (n=1951)

Percentage%

Characteristic

Frequency (n=1951)

Percentage%

Age

14 - 18

19 - 25

26 - 45

46 - 65

52

1538

333

28

2.7

78.8

17.1

1.4

Changing area of living due to war

No

Yes within the same city

Yes with changing the city

Yes I had to do both

977

429

488

57

50.1

22.0

25.0

2.9

Gender

Male

Female

527

1424

27.0

73.0

Number pf times changing place of living due to war

No

Once

Twice

Thrice and more

977

224

211

539

50.1

11.5

10.8

27.6

Marital Status

Single

Engaged

Married

Divorced

Widowed

1617

86

217

21

7

83.0

4.4

11.1

1.1

0.4

Place of origin

Damascus, Rif-Dimashq, and Aleppo

Homs and Hama

Al-Jazira region

Southern Syria

Syrian coast

Idlib

Other

1045

354

94

142

200

82

34

53.6

18.1

4.8

7.3

10.3

4.2

1.7

Consanguinity

No

Yes third-degree relatives

Yes fourth-degree relatives

Yes but not close relatives

1416

300

97

138

72.6

15.4

5.0

7.1

A relative being endangered by the war

No

Yes

284

1667

14.6

85.4

Medical Conditions

Negative

Asthma

Hypertension

Diabetes

Asthma, Hypertension

Diabetes, Hypertension

Other

1008

63

23

6

4

121

81.9

5.1

1.9

0.5

0.3

9.8

Characteristic (n=1951)

Frequency (Percentage%)

CI:95%

Kessler psychological distress Scale (K10)

No

Mild

Moderate

Severe

376 (19.3%)

381 (19.5%)

322 (16.5%)

872 (44.7%)

17.5% – 21.0%

17.8% – 21.3%

14.9% – 18.1%

42.6% – 47.0%

Being distressed from the war noises

No

Yes

407

1544

20.9
79.1

SPTSS items

Avoidance

No Avoidance

1040 (53.3%)

910 (46.6%)

51.2% - 55.6%

44.3% - 48.8%

Educational level

Primary School

High School

University or any high institute

Masters or PhD

27

127

1671

126

1.4

6.5

85.6

6.5

Arousal

No Arousal

Re-experience

No Re-experience

Two or more

Full SPTSS symptoms

1257 (64.4%)

693 (35.6%)

1150 (58.9%)

800 (41.0%)

1186 (60.8%)

720 (36.9%)

62.4% - 66.5%

33.4% - 37.5%

56.9% - 61.2%

38.7% - 43.0%

58.7% - 62.7%

35.0% - 39.1%

MSPSS

Family

Low

Medium

high

Friends

Low

Medium

high

402 (20.6%)

575 (29.5%)

971 (49.8%)

738 (37.8%)

666 (34.2%)

546 (28.0%)

18.8% – 22.4%

27.6% - 31.5%

47.6% - 52.2%

35.5% - 40.2%

31.7% - 36.3%

26.2% - 30.2%

Type of work

At a company

Clerk or at a restaurant

Education

Freelancer

Journalism

Law

Health care

Unemployed

103

21

104

78

4

10

234

1100

6.2

1.3

6.3

4.7

0.2

0.6

14.2

66.5

SES Level

Lower

Upper Lower

Middle

Upper

30

483

1044

394

1.5

24.8

53.5

20.2

Significant other

Low

Medium

high

511 (26.2%)

613 (31.4%)

826 (42.4%)

24.3% - 28.3%

29.4% - 33.5%

40.1% - 44.7%

Losing someone due to the war

No

Yes

697

1254

35.7

64.3

Total MSPP

Low

Medium

high

452 (23.2%)

830 (42.5%)

669 (34.3%)

21.3% - 25.1%

40.3% - 44.6%

32.2% - 36.5%

K10 Results:

When comparing all groups of mental disorder, females had more severe mental disorders compared with males P < 0.0001, mainly when comparing mild and moderate mental disorder P = 0.01 (OR, 1.560; 95% CI 1.112–2.188). Lower educational levels were seen in subjects with more severe mental disorders P = 0.004, mostly when comparing no with mild mental disorder P = 0.042. Having a chronic medical condition was also associated with more severe mental disorder P < 0.0001. Furthermore, lower SES was associated with more severe mental disorder P = 0.0001.

More severe mental disorder was also seen in subjects older than 25 years old compared to those younger than 25 years old with a P = 0.049. When comparing all age groups with all K10 results, older age group had more severe mental disorder with a P = 0.0004. Declaring being distressed from war noises was associated with more severe mental disorder P = 0.0004. Losing someone due to war and having a relative being endangered by the war were statistically insignificantly associated with more severe mental disorder (P > 0.05). Although changing place of living due to war was not statistically significantly correlated with more severe mental disorder, number of times of such changes were statistically significantly associated with more severe mental disorder (P < 0.0001); as more severe mental disorders were observed when changing place of living several times due to war. Furthermore, more subjects revealed that the war was the reason for their distress among more severe distressed groups P < 0.0001.

There was no statistical significance when comparing different K10 results with provinces of currently living P = 0.219. However, 57.3% of responders from Idlib had severe mental disorder, 49.3% in Damascus, and 51.4% in Deir ez-Zor. In addition, Aleppo, Daraa, Hama, Homs, Latakia, Raqqa, As-Suwayda, Al-Hasakah, and Rif Dimashq had prevalence for severe mental disorder ranging 45.5–40.5%. Quneitra and Tartus had 38.9% and 33.3% severe mental disorder respectively. Only 9.8% had score not suggestive for PTSD in Idlib while AL-Hasakah was 11.1% while other provinces ranged from 16.9% in Damascus to 29.4% in Raqqa (Fig. 1).

When using one-way ANOVA, subjects with more severe mental disorder declared more days of being unable to work, study or manage their day because of these feelings (P = 0.030). Less subjects declared that they can work but had to cut down on their activities but it was statistically insignificant (P > 0.05). Furthermore, The more severe mental disorder that the subject had, the more times they had to visit a health professional because of what they felt (P = 0.004), declaring that having physical health problems was the main cause of these feelings(P < 0.0001). Scatter plots of these results are demonstrated in (Fig. 2).

When using Pearson correlation, correlations were found with P < 0.001 as higher K10 scores were found with higher numbers of days being totally unable to work, study, or manage their day because of these feelings (r = 0.110), more number of times having to visit a health professional because of these feelings (r = 0.110), and more frequent physical problems being attributed to these feelings (r = 0.180). Consanguinity, type of work, marital status, and declaring if the exams were the reason for the recent distress were not found to be correlated with mental disorder levels P > 0.05. Comparisons between subjects with low, moderate and severe mental disorder and each variable are demonstrated in (Table 2).

Table 2

Comparisons between Subjects with Low, Moderate and Severe Mental Disorder and Each Variable.
Characteristic	No Mental Disorder	Mild Mental Disorder	P value	Moderate Mental Disorder	P value	Severe Mental Disorder	P value	P value*
Gender Male Female	129 246	121 260	NS	74 248	0.010	203 670	NS	< 0.0001
Consanguinity No Yes third-degree relatives Yes fourth-degree relatives Yes but not close relatives	273 52 26 24	275 59 22 25	NS	231 54 17 20	NS	637 135 32 69	NS	NS
Marital status Single Engaged Married Divorced Widowed	310 18 41 4 1	312 15 47 6 1	NS	267 17 35 0 3	NS	728 36 94 11 2	NS	NS
Educational level Primary School High School University or any high institute Masters or PhD	0 13 344 18	2 23 326 30	0.042^a	3 23 273 23	NS	22 68 728 55	NS	0.004^a
Type of work At a company Clerk or at a restaurant Education Freelancer Journalism Law Health care Unemployed	20 3 18 11 0 3 55 204	16 2 21 17 2 2 52 210	NS	12 5 18 12 1 1 37 191	NS	55 11 47 38 1 4 90 493	NS	NS
Chronic Medical Conditions Negative Asthma Hypertension Diabetes Asthma, Hypertension Diabetes, Hypertension Other	206 8 1 0 0 1 10	198 10 7 1 0 1 14	NS^b	173 9 5 2 0 1 12	NS	431 36 10 3 6 1 85	0.014^b	< 0.0001^b
SES Lower Upper Lower Middle Upper	3 63 206 103	6 94 205 76	0.011	5 76 187 54	NS	16 250 446 161	NS	0.0001
Age groups 14–18 19–25 26–45 46–65	7 305 53 10	7 285 78 11	NS^c	7 255 55 5	NS	31 693 147 2	0.038	0.0004^c
Losing someone close due to war No Yes	156 219	135 246	0.081	112 210	NS	294 579	NS	0.061
A relative being endangered by the war No Yes	56 319	59 322	NS	50 272	NS	119 754	NS	NS
Distressed from war noises Negative Positive	109 266	82 299	0.017	54 268	NS	162 711	NS	0.0004
Changing place of living due to war No Yes within the same city Yes with changing the city Yes I had to do both	205 76 84 10	198 68 103 12	NS	164 81 69 8	0.074	410 204 232 27	NS	NS
Number of times changing place of living due to war No Once Twice Thrice and more	205 53 34 83	198 55 43 85	NS	164 36 43 79	NS	410 80 91 292	0.023	0.0003
The reason declared of stress in the last period: Educational Economical Social War-related Medical Other	87 23 84 6 2 1	86 22 82 9 6 0	NS	66 18 76 10 5 2	NS	150 64 262 25 20 10	NS	0.015
Do you consider that the crisis was the main cause of your distress lately? No Kind of Yes totally	81 131 70	47 131 70	0.0003	40 104 110	NS	94 294 330	NS	< 0.0001
NS: Not significant. ^* P value is calculated when using chi square on all K10 results (no, low moderate, and high) and other variables. ^a P = 0.051 between subjects of no or low mental disorder when compared with primary school and high school with subjects of higher education and P = 0.0004 when comparing between these subjects of all K10 results. ^b P = 0.070 when calculated between having a chronic medical condition or not among subjects of no or mild distress, P = 0.003among subjects of moderate or severe distress, and it was P < 0.0001 when compared between all K10 results. ^c P = 0.024 when comparing ages below 25 years and above 25 years among subjects of no or mild distress, and P = 0.049 when compared between al K10 results.

SPTSS results:

According to SPTSS questionnaire (Table 1), 53.3% (CI 95%: 51.2% − 55.6%) met the criteria for having symptoms of avoidance, 64.4 (CI 95%: 62.4% − 66.5%) for hyper-arousal, 58.9% (CI 95%: 56.9% − 61.2%) for re-experience, and 36.9% (CI 95%: 35.0% − 39.1%) for full PTSD symptoms. Province of currently living of subjects along with their K10 scale result and full SPTSS with gender are demonstrated in (Fig. 1). Comparing SPTSS clusters with each variable is demonstrated in (Table 3). SPTSS clusters were found more among female but with no statistical significance (P > 0.05). However, being at a higher education status was correlated with less positive avoidance and arousal clusters (P < 0.0001) and re-experience cluster P = 0.004. Having a chronic medical condition was correlated with having symptoms of avoidance (P = 0.057), arousal (P = 0.001), and re-experience (P = 0.007) clusters. Furthermore, being at a low SES was correlated with more SPTSS symptoms for avoidance (P = 0.028), arousal (P = 0.003) and re-experience (P = 0.055).

Moreover, more positive PTSD symptoms were found in older age groups, when losing someone due to war, and with increased number of changing place due to war (P < 0.05). Being distress from war noises was correlated with positive arousal symptoms (P = 0.0001), and re-experience symptoms (P = 0.001), but not with avoidance symptoms (P > 0.05). More subjects who replied as the war being the cause for most of distress had positive SPTSS clusters than who did not P < 0.0001. However, consanguinity, marital status, working, type of work, and having a relative being endangered from war were not correlated with any of the 3 clusters of SPTSS (P > 0.05).

When comparing province of current living with having PTSD, it was no statistical significant P = 0.681. Overall, 15.9% in from Idlib, 16.1% in Tartus, and 11.1% from Al-Hasakah had no PTSD symptoms while other provinces ranged from 19.7% in Damascus to 23.5% in Raqqa. However, 29.8 from As-Suwayda had no PTSD symptoms and only 25.5% had full PTSD symptoms. Furthermore, responders who had full PTSD symptoms in other provinces ranged from 32.5% in Daraa and 47.1% in Raqqa.

When using one-way ANOVA and independent t-test, more days were declared as being unable to work, study or manage their day because of these feelings among subjects with more positive SPTSS clusters (P = 0.061), positive avoidance cluster (P = 0.0190, positive arousal cluster (P = 0.034), and re-experience cluster (P = 0.043). However, less subjects declared they can work but had to cut down on what they did but it was statistically insignificant (P > 0.05). Furthermore, the more positive SPTSS symptoms that the subject had, the more times they had to visit a health professional because of what they felt (P = 0.063), positive avoidance cluster (P > 0.05), positive arousal cluster (P = 0.022), and positive re-experience cluster (P = 0.022). More subjects also declared that having physical health problems being the main cause of these feelings more often when having more positive SPTSS symptoms (P < 0.0001), positive avoidance cluster (P = 0.003), positive arousal cluster (P < 0.0001), and positive re-experience cluster (P < 0.0001). Scatter plots for these results are demonstrated in (Fig. 2).

When using Pearson correlation, higher numbers of days being totally unable to work, study, or manage because of these feelings was correlated with higher total SPTSS score (r = 0.057), and re-experience score (r = 0.056) and both had P < 0.05. More number of times having to visit a health professional because of these feelings was also correlated with higher scores of re-experience (r = 0.096), arousal (r = 0.068), SPTSS score (r = 0.076) at P < 0.01. Furthermore, more frequent physical problems being attributed to these feelings was correlated with higher scores of SPTSS (r = 0.137), re-experience (r = 0.164), arousal (r = 0.125), and avoidance (r = 0.074) at P = 0.01 or less.

MSPSS Results:

Females had more family support than males (P = 0.018). Subjects with lower educational level had more support from friends than those with higher educational levels such as university and above P = 0.009. Responders with higher SES-level had more overall support than people with low SES (P < 0.0001). Responders in older age groups had less family support than younger age groups (younger than 25) P = 0.002. Responders who had to move from place to place due to war had less overall support than those who did not (P = 0.047) and less family support when compared with number of times they had to move (P = 0.013). Responders who did not have a chronic medical condition had more overall support than the ones who did (P = 0.005). Responders who declared being single or married had lower overall support than those who declared being engaged (P = 0.004). However, being single had the lowest support from the significant other compared to being married, which also had much lower support compared to being engaged (P < 0.0001).

Overall support according to total MSPSS score was not statistically significantly correlated with gender, consanguinity, educational level, age, all other war questions, and having a job or its type (P > 0.05). From the responders, 79% had at least one or more PTSD symptom. Only 10.8% did not have PTSD symptom and had a score less than 20 on K10. However, 27% had severe mental disorder according to K10 with full PTSD symptoms and 10.8% had severe mental disorder and two PTSD symptoms. Finally, within low overall MSPSS score, only 30.8% had both severe mental disorder and three PTSD symptoms and 12.6% had severe mental disorder and two PTSD symptoms.

When comparing province of currently living and MSPSS, we found no statistical significance P = 0.662. From Quneitra, 44.4% of responders had low social support while other provinces ranged from 26% in Daraa to 11.1% in Al-Hasakah. High support ranged from 51.1% in As-Suwayda to 29.6% in Deir ez-Zor.

When using one-way ANOVA, high overall support was correlated with less times of reporting physical problems being attributed to these feelings (P = 0.040). However, P value was 0.05 with other LM questions.

Comparisons Between K10, SPTSS, And MSPSS Results:

Higher levels of mental disorders were correlated with each of the SPTSS clusters (avoidance, arousal, and re-experience), with having two SPTSS clusters, and with having full SPTSS clusters P < 0.0001. Comparisons between having different severities of mental disorder and SPTSS clusters with odd ratios are demonstrated in (Table 4). Subjects with high support from family, friends, or significant other had lower levels of mental disorders P < 0.0001. Furthermore, the higher the support regardless from family friends or significant other, the less the possibility of having positive SPTSS symptoms is P < 0.0001. This is demonstrated in more details in (Table 5).


Table 3 Comparing Each SPTSS Cluster with Other Variables
	Avoidance			Arousal			Re-experience
	Negative (n = 910)	Positive (n = 1040)	P value	Negative (n = 693)	Positive (n = 1257)	P value	Negative (n = 800)	Positive (n = 1150)	P value	P value^#
Gender Male Female	247 663	280 760	NS	208 485	319 938	0.073	239 561	288 862	0.051	NS
Consanguinity No Yes third-degree relatives Yes fourth-degree relatives Yes but not close relatives	656 134 53 67	759 166 44 71	NS	496 103 42 52	919 197 55 86	NS	591 111 47 51	824 189 50 87	NS	NS
Marital status Single Engaged Married Divorced Widowed	750 47 97 10 5	866 39 120 11 2	NS	574 31 78 6 3	1042 55 139 15 4	NS	661 31 94 9 4	955 55 123 12 3	NS	NS
Educational level Primary School High School University or any high institute Masters or PhD	2 45 807 56	23 81 864 70	< 0.0001	2 30 624 37	25 96 1047 89	< 0.0001	5 44 700 51	22 82 971 75	0.004	0.001
Medical Conditions Negative Asthma Hypertension Diabetes Asthma, Hypertension Diabetes, hypertension Other	492 30 6 1 1 2 39	515 33 17 5 5 2 82	0.057^a	372 20 3 1 1 3 18	635 43 20 5 5 1 103	0.001^a	444 19 3 1 1 2 33	563 44 20 5 5 2 88	0.007^a	< 0.0001^a
SES Lower Upper Lower Middle Upper	14 199 490 207	16 283 554 187	0.028	8 136 393 156	22 346 651 238	0.003	9 176 435 180	21 306 609 214	0.055	0.005
Working No Yes	497 267	600 287	NS	385 188	712 366	NS	433 238	664 316	NS	NS
Type of work At a company Clerk or at a restaurant Education Freelancer Journalism Law Medical Unemployed	40 9 53 27 2 7 129 497	63 12 51 51 2 3 105 600	NS	30 5 36 21 1 6 89 385	73 16 68 57 3 4 145 712	NS	45 10 38 31 1 7 106 433	58 11 66 47 3 3 128 664	NS	0.098
Age groups 14–18 19–25 26–45 46–65	24 720 147 19	27 818 186 9	< 0.0001	15 563 102 13	36 975 231 15	< 0.0001	14 639 128 19	37 899 205 9	< 0.0001	0.066
Losing someone close due to war No Yes	351 559	346 694	< 0.039	270 423	427 830	0.067	339 461	358 792	< 0.0001	0.001
A relative being endangered by the war No Yes	138 772	146 894	NS	113 580	171 1086	NS	132 668	152 998	NS	NS
Distressed from war noises Negative Positive	195 715	211 829	NS	185 508	211 1036	< 0.0001	196 604	210 940	0.001	0.003
Changing place of living due to war No Yes within the same city Yes with changing city Yes I had to do both	495 195 195 25	482 233 293 32	0.004	361 138 172 22	616 290 316 35	NS	413 173 191 23	564 255 297 34	NS	0.010
Number pf times changing place of living due to war Never Once Twice Thrice and more	495 123 87 205	482 101 124 333	< 0.0001	361 103 63 166	616 121 148 372	0.001	413 107 91 189	564 117 120 349	0.016	< 0.0001
The reason declared of stress in the last period: Educational Economical Social War-related Medical Other	197 58 212 20 8 4	191 69 292 30 25 9	0.014	155 39 143 8 5 3	233 88 361 42 28 10	0.0001	173 54 164 17 11 1	215 73 340 33 22 12	0.001	0.001
Do you consider that the crisis was the main cause of your distress lately? No Kind of Yes totally	155 326 210	107 336 210	< 0.0001	133 150 319	129 426 466	< 0.0001	127 294 186	135 368 430	< 0.0001	< 0.0001
^# This p value is calculated between having no, one, two or three positive clusters ^a P < 0.0001 when comparing having chronic condition or not for the four groups.

Table 4

Comparisons between Subjects with Low, Moderate and Severe Mental Disorder and SPTSS clusters.
Characteristic	No Mental Disorder	Mild Mental Disorder	P value	OR (CI: 95%)	Moderate Mental Disorder	P value	OR (CI: 95%)	Severe Mental Disorder	P value	OR (CI: 95%)	P value*
SPTSS No Avoidance	307 68	228 153	< 0.0001	3.030 (2.171–4.227)	157 165	0.003	1.566 (1.161–2.113)	218 654	< 0.0001	2.855 (2.186–3.728)	< 0.0001
No Arousal	275 100	167 214	< 0.0001	3.524 (2.596–4.783)	115 207	0.029	1.405 (1.036–1.905)	136 736	< 0.0001	3.007 (2.245–4.027)	< 0.0001
No Re-experience	280 95	199 182	< 0.0001	2.696 (1.982–3.666)	140 182	0.021	1.421 (1.055–1.915)	181 691	< 0.0001	2.937 (2.232–3.864)	< 0.0001
No or only one item Having two items or more	303 72	200 181	< 0.0001	3.802 (2.747–5.291)	127 195	< 0.0001	1.698 (1.256–2.294)	135 738	< 0.0001	3.559 (2.667–4.762)	< 0.0001
Not having full SPTSS Having full SPTSS	348 27	306 75	< 0.0001	3.155 (1.984–5.025)	231 91	0.008	1.608 (1.132–2.283)	346 527	< 0.0001	3.861 (2.924–5.102)	< 0.0001
OR: Odds ratio. CI: Confidence interval. ^* P value is calculated when using chi square on all K10 results (no, low moderate, and high) and other variables.

Table 5

Comparing Each Support in MSPSS with K10 and SPTSS clusters
	Family Support				Friends support				Significant Other Support
	Low (n = 402)	Moderate (n = 575)	High (n = 971)	P value	Low (n = 738)	Moderate (n = 666)	High (n = 546)	P value	Low (n = 511)	Moderate (n = 613)	High (n = 826)	P value
K 10 No Low Medium High	49 82 76 195	76 99 96 304	248 200 149 374	0.0003* NS* NS*	101 147 130 360	119 121 121 305	154 113 71 208	0.0006* 0.0573* NS*	67 97 90 257	105 118 107 283	202 166 125 333	0.0078* NS* NS*
SPTSS No Avoidance	144 258	222 353	543 427	< 0.0001	266 472	318 348	326 219	< 0.0001	164 346	287 326	459 367	< 0.0001
No Arousal	112 290	169 406	410 560	< 0.0001	208 530	244 422	240 305	< 0.0001	140 370	214 399	338 488	< 0.0001
No Re-experience	121 281	209 366	469 501	< 0.0001	235 503	306 360	259 286	< 0.0001	154 356	264 349	382 444	< 0.0001
No or only one item Having two items or more	115 287	179 396	470 501	< 0.0001	208 530	282 384	275 271	< 0.0001	136 375	244 369	385 441	< 0.0001
Not having full SPTSS Having full SPTSS	206 196	323 252	700 271	< 0.0001	394 344	434 232	402 144	< 0.0001	258 253	384 229	588 238	< 0.0001
NS: not significant. * P < 0.0001 when comparing family support, friend support, or significant other support with all K10 results (no, low moderate, and high).


TABLE 6 Correlations between each cluster of MSPSS and SPTSS.
	Family Support	Friends support	Significant Other Support	Total MSPSS Score
Avoidance	-0.219	-0.225	-0.216	-0.267
Arousal	-0.183	-0.202	-0.175	-0.226
Re-experience	-0.204	-0.192	-0.166	-0.226
Total SPTSS score	-0.233	-0.237	-0.215	-0.277
K10 total score	-0.195	-0.171	-0.160	-0.212
	Avoidance	Arousal	Re-experience	Total SPTSS score
K10 total score	0.537	0.557	0.535	0.621
All correlations were significant at P < 0.001.

When using one-way ANOVA, SPTSS and MSPSS scores were significantly correlated with K10 scale as the higher the mental disorder level, the lower the MSPSS score and the higher the SPTSS score P < 0.0001 (Fig. 3).

When using Pearson correlation, a weak but statistically significant negative correlation was found with SPTSS score and MSPSS score (r=-0.277) (Fig. 4). SPTSS cluster scores correlations with MSPSS and K10 scores are demonstrated in (Table 6). Although K10 score had weak correlation with MSPSS score r=-0.212. A strong correlation was found between K10 score and SPTSS score (r = 0.621) (Fig. 4).

Distress, Depression And Mental Disorder:

Among the adult population in general, 13% scored 20 or above in the K10 questionnaire. In primary care, around 25% of patients scored 20 or over. Moreover, 59.4% of Syrian refugees in Iraq had probable depression (20). Another study found that 56% of the Syrian refugees at Alzatary Camp in Jordan suffered from psychological distress and 46% believed they needed psychological support (21). At least 49.7% of the refugees in Germany screened positively for a mental disorder with 21.7% having depression and 10.3% having major depression (22), while depression was the most common with 40.2% prevalence in Sweden (23). A study on Syrian school students found that depression rate was 32% (24). Our study showed higher scores on average in the overall Syrian population, with 80.7% of the study participants scoring above 20. Our study shows that 49.9% had to change place of residence; 22% of displacement occurred within the same city while 25% were displaced to another city; and 2.9% of responders were displaced both within the same city and outside of their city with 27.6% having to change their place of living three times or more. Of all the participants, 64.3% had lost someone due to war and 85.4% had a relative who was endangered by the war. These numbers are similar to one study conducted in Syria on school students which showed 50.2% of them were internally displaced (24).

There are several factors that increase the risk of developing mental and psychological distress. It is known that the most important period for the development of one’s mental and psychological balance is adolescence. Unfortunately, according to studies, approximately 20% of young people around the world suffer from psychological problems (25). Our study shows that the generation older than 25 years of age is at increased risk of more severe mental disorder (p = 0.049), compared to the younger generation studied, which is different from many studies. One theory to explain this difference is that the young subjects of our study lived 7 years of their adolescent life during the war before reaching 25 years of age, compared to the older studied group, which lived previously in a relatively peaceful life. The older population was exposed to more severe stress of losing the lives that they built for themselves, and carried the burden of looking after their families, making it harder for them to cope with such severe stress compared to the younger population, that started its adulthood years by acknowledging the reality of the war.

Many studies revealed that mental disorders prevalence is often twice as high among females compared to males (23, 26). Male Syrian refugees reported facing more traumatic events (20). In this study females had more severe mental disorders compared with males P < 0.0001, mainly when comparing mild and moderate mental disorder (P = 0.01). Other factors also contribute to increased mental disorder including low SES (P = 0.001), chronic disease (P < 0.0001) and lower educational levels (P = 0.004).

PTSD:

Approximately 70% of people experience at least one traumatic incident in their life (27). This includes but is not limited to, persistent avoidance and re-experiencing of the event in addition to other symptoms that reveal an emotional stimulation or stress response (28, 29). PTSD affects between 10–40% of trauma survivors (30), and is associated with decreased quality of life after the traumatic event (31). If PTSD is associated with social disorders with long and persistent forms of severe and horrific psychological experiences, then the disorder is called complex PTSD. This disorder causes a significant and prolonged harm to resources, and requires high psychosocial and emotional support (7). Prevalence rates of PTSD are widely varied across studies due to differences in measures and the periods in which the studies were conducted, in addition to other variables including age, gender, illness history, level of social support and cultural background (32).

Numerous studies have shown that men are less likely to develop PTSD after traumatic events, and therefore the prevalence of PTSD among women is higher. This study shows that SPTSS clusters were found more among females but with no statistical significance (P > 0.05). Similarly, a study in Lebanon (a country neighbouring Syria) showed no significant variance in PTSD and depression rates between male and female university students who faced war- related trauma (33). Another study on Syrian refugees in Iraq showed 98.5% of refugees encountered at least one traumatic event and 86.3% of them encountered at least three (20). In addition, a study on Syrian refugees in Turkey found that experiencing two or more traumatic events predisposed them to PTSD and the odds of females having PTSD was four times more than males (34). Moreover, 59.1% responded positively when screening for trauma exposure and it was found that refugees from Aleppo had more PTSD than from Homs (35).

Age is considered a significant possible risk factor for developing PTSD. A meta-analysis of 29 studies on trauma-exposed adults showed that exposure to a traumatic event at a younger age is an important risk factor for PTSD (36). One study found that 61.4% of Syrian refugees met the DSM-5 symptom criteria for probable PTSD with significant difference between males and females (20). However, another study on Syrian refugees in Lebanon found that 27.2% had a PTSD point prevalence and 35.4% a lifetime prevalence (35) while a study conducted in Turkey found the prevalence of PTSD to be 33.5% among refugees in Turkey using DSM-IV-TR criteria (34). Moreover, 34.9% of refugees in Germany had PTSD (22), while it reached 29.9% in Sweden (23), and 35.1% for PTSD in Syrian students (24).

PTSD With Social Support:

In this study, 36.9% of participants had full PTSD symptoms and 60.8% had two or more and only 21% did not have any PTSD symptoms. Furthermore, more positive PTSD symptoms were found in older age groups (P = 0.05), possibly because of the same reasons mentioned above. The literature indicates that for many men and women social support was a preventive factor for the development of PTSD, as the proportion of people with post-traumatic stress increased in those with a low level of social support. For many men or women who have experienced trauma in their lives, many studies have found that social support was a preventive factor for the development of post-traumatic stress disorder, as the proportion of people with post-traumatic stress increased in those with low levels of social support (37). This study also proves that the higher the support, regardless from family, friends or significant other, the less likely they were to have positive SPTSS symptoms (P < 0.0001). However, within a long period after exposure to trauma, the impact of social support as a protective factor may be mitigated (38). A study at Alzatary Camp in Jordan also found that 66.7% of refugees staying at camp reported a great need for psychological support (21). Although only 23.2% of our sample had low overall support, the high prevalence of PTSD and mental disorder suggest other factors were involved in addition to low support levels. We hypothesise that support may be insufficient in the face of chronic exposure to multiple stress factors which would have a negative impact, mitigating the benefit. This suggests that drastic measures need to be carried out.

Outcomes Of The Psychological Burden:

Being fearful, easily angered, nervous, having difficulty sleeping or staying asleep, absence of hope for the future, and spells of terror or panic were some of the characteristics that the Syrian refugees suffered from at Alzatary Camp in Jordan (21). Similarly, 31.8% of refugees in Sweden and 29.5% of Syrian students had anxiety (23, 24). Other studies In Syria found that dental and genitival health deteriorated more in patients with PTSD and psychological disorders (39–41). Moreover, war affected university students (42), and prevented research from being properly conducted due factors including a shortage of resources (43). This reflects some of the negative outcomes that Syrians have endured, especially those affected by the war.

Estimates in 2014 found that 82.5% of Syrians lived below the poverty line. Syria’s deteriorating economy presents a challenge in terms of resource allocation to the health sector. Only 1.5 hospital beds and 1.22 physicians are available per 1000 people, making psychological health almost impossible to treat (44). This study demonstrated how the scores of K10 and SPTSS have increased, indicating serious deterioration of mental health in Syria.

The Syrian conflict has contributed to a great deal of mental and psychological distress in Syrian society. Efforts and interventions to improve the psychological and mental wellbeing of the Syrian population are necessary to ensure the Syrian generations are in good shape to care for themselves and their loved ones, and to engage in the reconstruction of their country when the situation improves.

The results of this study reflect the underlying disaster that made people severely psychologically impaired and indicate that social support only had a weak correlation, meaning that resources should be re-allocated to other aspects of care. Syrian people have concerns far beyond just social support and require various methods of treatment. This study suggests that internally displaced people, and even those who were not displaced in the conflict, experienced more severe mental disorder than the refugees in many countries. This emphasises the importance of security either economically or in terms of safety which are more important than support from family, friends and the significant other.

Although K 10 is a good screening method to detect recent anxiety and depressive symptoms, it is not an appropriate alternative for medical consultation. However, after clinical diagnosis, K10 can be used for assessment as scores which remain above 24 are indicative of the need to refer the patient to a specialist (12, 13). Symptoms associated with PTSD can also be seen in the normal phase of dealing with stress, which the Syrian population has been experiencing since 2011, with no time for mental healing or stability. In addition, the nature of the method – a questionnaire – solicits responses which may vary depending on the participant’s feelings at the time.
Furthermore, mental illness rates can be correlated with factors that have not been addressed in our study. For example, studies among war-affected displaced populations show that the quantity of traumatic events was found to be correlated with the increase of mental illnesses rates (45); we could not determine the exact event(s) that the population studied had faced. Moreover, geographical characteristics appear to have an influence on psychological wellbeing in displaced populations. Most studies showed that severe psychological disease prevalence was higher in cities compared to rural areas (20, 46), however one study on Syrian refugees only found this difference in PTSD, not in depression symptoms (20). Our study could not determine the exact place of living, whether it was city or rural, as we could only determine the province of origin since responders might have been displaced several times which made it difficult to determine this factor.
This study did not look at history of mental illness amongst participants, which also could have aggravated the symptoms of PTSD or mislead the questionnaire.
This study was online which made it difficult to determine the population at risk. Responders who had an internet connection and were willing to do the questionnaire might be in better mental condition than those who are severely affected, and most of our responders were university students with potentially higher SES, therefore the prevalence of distress may be even higher amongst the wider population. This study did not include internally-displaced populations without internet access.
SES could not be accurately determined as questions regarding salary are inappropriate in Syrian culture. There is a huge difference in living costs geographically in Syria, which means that people can live a better life on a lower income compared to other countries in the region. PTSD questionnaire is according to DSM-IV not V. However, it can resemble ICD-11.
Some answers may have contained missing data. However, this data was excluded if it was in the K-10 questionnaire as it is the core of the study.
The tool used is to assess PTSD symptoms in the previous 4 weeks, a factor that can underestimate the prevalence of mental distress throughout the Syrian conflict. As is widely understood in the literature, PTSD and depression rates in single studies vary between 4.4 to 86% for PTSD and 2.3 to 80% for depression (47). These variations in reported prevalence may have several justifications for example the period between the exposure to trauma and the evaluation process, or trauma severity and quantity that participants have witnessed (48).

ANOVA	Analysis of variance
CI	Confidence Interval
DSM	Diagnostic and statistical manual of mental disorders
ICD	International Classification of Disease
K10	Kessler
MSPSS	Multidimensional Scale of Perceived Social Support
OR	Odds ratios
PTSD	post-traumatic stress disorder
SES	Socioeconomic status
SPSS	Statistical Package for the Social Sciences
SPTSS	Screen for Posttraumatic Stress Symptoms

Ethics approval and consent to participate:

Online informed consent was taken before proceeding with the survey for participating in the research, and for using and publishing the data. We assured to maintain confidentiality and asked no questions that might reveal the person’s identity. No subjects were under age of 14. For subjects under age of 18 years, an online informed consent was taken that the guardian agreed that the subjects can participate in the survey as this method was agreed in the study protocol.

Our study protocol and ethical aspects were reviewed and approved by Damascus University deanship, Damascus, Syria.

Consent for publication:

Online consent for using and publishing the data were taken before participating in the research.

Availability of data and materials:

The data can be made available upon reasonable request.

Competing interests:

We have no conflict of interest to declare.

Funding:

We received no funding in any form.

Authors' contributions:

AK: Conceptualization; Data curation; Formal analysis; Investigation; Methodology; Project administration; Supervision; Resources; Validation; original draft; Writing - review & editing.
RAZ: original draft; Investigation.
OHA: original draft.
LM: Writing - review & editing.
AA: Formal analysis. Software.
BAA: Data curation, Methodology.

All authors have read and approved the manuscript.

Acknowledgements:

We would like to thank Dr Yousef Mahmoud MD, and Dr Ayham Ghareeb MD for their aid in making this research possible and facilitating its conduction, and distribution of the survey. We would also like to thank S. Hakeem for medical media for their aid in largely distributing the surveys among people.

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Mental disorder and PTSD in Syria during wartime: a national-wide crisis

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Abstract

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Abbreviations

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