Distress, depression, and mental disorder:
Our study showed that 80.7% of the studied sample scored above 20 in the K10 test, and around 60% of the population reported symptoms consistent with moderate to severe mental disorder. Changing places of living multiple times due to war, being females, having a low SES, low educational levels, younger age groups, and being distressed from war noise were associated with higher K10 scores. High K10 scores were also correlated with more frequent visits to the doctor, more days off work, and more physical problems. Over 80% of the participants were younger than 25 years of age. We did not find significant differences when comparing mental disorders among governorates and different types of jobs.
Among a typical population, 13% scored 20 or above in the K10 questionnaire. In primary care, around 25% of patients in primary care scored 20 or over in high-income countries (17, 18). These numbers are much higher in low-income countries; in Iraq, around 60% of Syrian refugees had probable depression (25). Another study found that 56% of the Syrian refugees at Alzatary Camp in Jordan suffered from mental distress, and 46% believed they needed mental support (26). At least 49.7% of the refugees in Germany were screened positive for a mental disorder, with 21.7% having depression and 10.3% having major depression (27). Whilst depression was the most common mental disorder among Syrian refugees in Sweden with the prevalence being 40.2% (28), a study on Syrian school students found that the depression rate was 32% in 2018 (29).
Several factors increase the risk of developing mental distress. It is known that the most important period for the development of the mental balance is during the adolescence. Unfortunately according to some studies, around 20% of young people in the world suffer from mental problems (30). Many studies revealed that mental disorders prevalence is often two times higher among females than males (28, 31). Male Syrian refugees also reported facing more traumatic events (25).
PTSD and traumatic exposure:
In this study, 36.9% of the participants had full PTSD symptoms, 60.8% had two or more positive PTSD symptoms, and only 21% did not have any PTSD symptom. Our study showed that 49.9% had to change places of living due to war, with 27.6% having to change their place of living three times or more. Moreover, 64.3% lost someone due to war, and 85.4% had a relative or a close friend who was endangered by the war. The number of times changing places of living due to war, educational level, and distress from war noise contributed the most to the high PTSD scores overall. We did not find significant differences in PTSD prevalence among governorates and different types of jobs.
One study in 2019 found that 61.4% of Syrian refugees met the DSM-5 symptom criteria for probable PTSD with a significant difference between males and females (25). However, another study on Syrian refugees in Lebanon found that 27.2% had a PTSD point prevalence and 35.4% had a lifetime prevalence (32). In Turkey, it was found that the prevalence of PTSD was 33.5% among Syrian refugees using DSM-IV-TR criteria (33). Moreover, 34.9% of refugees in Germany had PTSD (27) while it reached 29.9% in Sweden (28), and 35.1% in students in Syria (29).
Approximately 70% of people experience at least one traumatic incident in their life (34). This might cause persistent avoidance and re-experiencing of the event in addition to other symptoms that reveal an emotional stimulation or a stress response (35, 36). Around 10-40% of trauma survivors will develop PTSD (37) which is associated with a decreased quality of life (38). Prevalence rates of PTSD are widely varied across studies due to differences in measures and periods in which the studies were conducted. Moreover, 59.1% responded positively when screening for trauma exposure in Syria while refugees from Aleppo had higher PTSD prevalence than from Homs (32). Another study conducted in Syria on school students showed that 50.2% of participants were internally displaced (29). Another study on Syrian refugees in Iraq showed that 98.5% of refugees had encountered at least one traumatic event, and 86.3% of them encountered at least three (25).
Other variables also took part such as age, gender, illness history, level of social support, and cultural background (39). Besides, a study on Syrian refugees in Turkey found that experiencing two or more traumatic events significantly increased the risk of PTSD, and the ratio of females having PTSD was four times more than males (33). Numerous studies about gender differences showed that males are less likely to develop PTSD after traumatic events, and therefore the prevalence of PTSD among women will be higher. In contrast, a study in Lebanon showed no significant differences in PTSD and depression rates between male and female university students who faced war-related trauma (40).
Age is considered a significant risk factor for developing PTSD; a meta-analysis of 29 studies on trauma-exposed adults revealed that exposure to a traumatic event at a younger age was an important risk factor for PTSD (41).
Although only 23.2% of our sample had a low total support, the high prevalence of PTSD, and mental disorders suggest other factors being involved besides low support levels as (r<0.3). SES was the most contributing factor to social support.
The literature indicates that social support was a preventive factor for the development of PTSD for men and women. Furthermore, the incidence of post-traumatic stress increased in those with a low social support. For many who have experienced trauma in their lives, social support was a preventive factor for the development of PTSD (42). This confirms our finding of the negative association between MSPSS scores, and SPTSS and K10 scores (P<0.0001).
However, after a long period of exposure to trauma, the impact of social support as a protective factor may be mitigated (43). A study at Alzatary Camp in Jordan found that 66.7% of refugees staying at the camp reported a great need for mental support (26).
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 experienced at Alzatary Camp in Jordan (26). Similarly, 31.8% of refugees in Sweden, and 29.5% of Syrian students had anxiety (28, 29). Other studies in Syria found that dental and genitival health were associated with PTSD and mental disorders (44-46). Another study found that around 50% of the population had allergic rhinitis which could be from the direct or indirect effects of war or the unique environment (47). Smoking is also common among the Syrian population, mainly social shisha smoking which could be to get away from the daily stress. Shisha smoking is mainly common among university students who consist most of our study (48).
Moreover, war has affected university students (49), and prevented research from being properly conducted due to a shortage of resources (50). Many studies lacked proper funding which ultimately generated limited data. There are many crucial investigations not conducted in most studies in Syria, and delayed treatment can occur due to the financial hurdles which can dramatically affect patients’ care (12-16). This reflects some of the negative outcomes that Syrians have endured, especially in those who were mostly affected by the war.
The stigma of mental health in Syria is very common, and only a few practicing psychiatrists and psychotherapists exist. As social support was only weakly but significantly correlated with lower K10 and SPTSS scores (r<0.3 with P<0.001), other measurements are required to boost mental health in the society. National-wide programs are needed to increase awareness, and humanitarian assistance is required to benefit from international experts in mental health. Financial assistance is also needed as the deteriorating financial situation is a strong contributing factor to the suffering.
Most online surveys in Syria tend to include the young population and females more than males as the young population tends to be members in online groups more often. In contrast, older generations exist mainly in family’s and close friends’ groups, and they are disinterested in filling in surveys that are not directly sent from a person they know, or they simply do not know how to fill them in. This pattern is seen in multiple online studies from Syria. This might have affected the results as the young might react differently compared to the elder. Self-reported symptoms also tend to overestimate the true prevalence of mental symptoms. Besides, the nature of the method – self-reported questionnaires – solicits responses which may vary depending on the participant’s feelings at the time.
Although K10 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 that remain above 24 are indicative to the needs for a referral to a specialist (17, 18). 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 periods that allowed for mental healing or stability.
Furthermore, mental illness rates can be associated with factors that have not been addressed in our study. For example, studies among war-affected displaced populations showed that the number of traumatic events was associated with increased mental illness rates as previously discussed; we could not, however, determine the exact event(s) that the population had faced. Moreover, geographical characteristics appear to influence the psychological wellbeing of displaced populations. Most studies showed that severe mental disorders were more common in cities compared to rural areas (25, 51). However, one study on Syrian refugees found this difference was only with PTSD, not with depression symptoms (25). Our study could not determine the exact place of living, whether it was urban or rural. We could only determine the governorate of origin since responders might have been displaced several times which made it difficult to determine this factor.
This study did not consider the mental background of participants, which could have aggravated the symptoms of PTSD or biased the questionnaire. This study was online which made it difficult to determine the population at risk. Moreover, responders who had an internet connection and were willing to do the questionnaires are probably in a better mental condition than those who are truly severely affected, and do not have internet connection or the will to do the survey. Finally, most of the responders were university students with potentially higher SES than the normal population. For all the previous reasons, this study might have underestimated the true prevalence of distress amongst the general population.
SES could not be accurately determined since asking about the salary is inappropriate in the Syrian culture. There is a huge difference in living costs in Syria, where people can live of a lower income compared to other countries in the region. SPTSS is based on DSM-IV, not V. However, it can resemble ICD-11.