Mental disorder and PTSD in Syria during wartime: a nationwide crisis

doi:10.21203/rs.3.rs-19902/v4

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Mental disorder and PTSD in Syria during wartime: a nationwide crisis

https://doi.org/10.21203/rs.3.rs-19902/v4

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published 02 Jan, 2021

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Background: Syria has experienced war since 2011, leaving over 80% under the poverty line and millions being displaced. War and its retaliations have significantly impacted the mental health of Syrians. This study evaluates the post-traumatic stress disorder (PTSD), and the severity of the mental distress caused by war and other factors such as low social support. This study also evaluates other variables and compares the findings with multiple studies of Syria and refugees.

Methods: This is a cross-sectional study that included people who lived in Syria from different governorates. Online surveys were distributed into multiple online groups and included Kessler 10 (K10) questionnaire, the Screen for Posttraumatic Stress Symptoms (SPTSS) tool, the Multidimensional Scale of Perceived Social Support, and demographic and war-related questionnaires.

Results: Our study included 1951 participants, of which, 527 (27.0%) were males and 1538 (78.8%) aged (19-25) years. Among participants, 44% had likely severe mental disorder, 27% had both likely severe mental disorder and full PTSD symptoms, 36.9% had full PTSD symptoms, and only 10.8% had neither positive PTSD symptoms nor mental disorder on the K10 scale. Around 23% had low overall support. Half of the responders were internally displaced, and 27.6% were forced to change places of living three times or more due to war. Around 86.6% of the responders believed that the crisis was the main reason for their mental distress. Those with high SPTSS and K10 scores were found to take more days off from work or school due to negative feelings and having somatic symptoms. Moreover, the number of times changing places of living due to war, educational level, and being distressed by war noise were the most important factors for more sever PTSD and mental distress. No differences in PTSD and mental disorder prevalence were noted in governorates and type of job. A strong correlation (r=0.623) was found between SPTSS and K10 scores.

Conclusion: The conflict in Syria has left the population at a great risk for mental distress which was more severe compared to Syrian refugees elsewhere. Many measures with an emphasis on mental health are needed to aid the people against a long-term avoidable suffering.

Psychiatry

Psychology

Conflict

global health

K10

mental distress

PTSD

public health

refugees

social support

Syria

war

Warfare has acute and chronic effects on the community and is considered one of the most devastating events that can be experienced. The indirect effects of warfare can also be as disastrous can continue for years after the settling of the conflict. The aftermath of war is challenging, emanating from food and resource shortage, displacement, and disease outbreak (1). Since the beginning of the Syrian conflict in 2011, many people have been wounded, 511,000 have died (2), more than 5.6 million have been externally displaced (3), and over 6.2 million have been internally displaced (4). In 2014, it was estimated 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 as only 1.5 hospital beds and 1.22 physicians were available per 1000 people, making mental medical conditions almost impossible to treat (5). The health sector and economic situation are much worse at the time of this study.

The damage to the medical infrastructure and the loss of medical staff have greatly affected the health system in Syria. Mental health has faced even greater challenges during the conflict as it has been neglected for decades and very few psychologists and psychiatrists exist in Syria. The education sector has also been significantly injured after many facilities being demolished by the war. With the destruction of the Syrian social structure, most children had to grow up in a war-burdened environment which scarred their normal development (6). These disturbances and loss of both social and emotional support have led to patterns of severe mental trauma (7). This has left many people paralysed and incapable of facing everyday challenges, mainly due to years if not decades of severe mental distress and the high financial burdens which have been threatening several generations. Furthermore, the post-traumatic effects will have a longer-lasting impact which may continue for several years after the conflict resolves (8-10).

Many Syrians have fled the country and sought asylum in different countries. Although most of them lived in a relatively much safer environment after facing grave dangers to reach their destination, they suffered mentally as they were far from their homeland, their family members, friends, and usual work environment, and might be experiencing bad living conditions such as living in camps. Many of the people who left the conflict zone have also developed mental disorders that might be different from those but from those who have stayed (11). Furthermore, several studies indicate that mental distress is higher in conflict areas. This study evaluates mental disorders, post-traumatic stress disorder (PTSD), and the amount of social support among Syrians who remained in Syria and their relevant factors. This study used self-reported questionnaires in light of lack of funding that medical research in Syria is facing and unavailable resources for proper diagnosis (12-16). This study also assessed for other variables and compared them with other studies for a better evaluation of the mental disorders among Syrians and refugees.

1) Sampling

This is a cross-sectional study conducted in Syria from 3/3/2019 to 24/3/2019. Online surveys in Arabic were distributed to participants from several Syrian governorates. Only participants who lived in Syria at the time of the survey and answered the demographic in addition to the K10 questions were enrolled. The questionnaires were posted online twice each day at 10 AM and 10 PM in social media groups with different topics such as educational, cuisine, market, entertainment, cultural, musical etc. Any participant who spoke Arabic, lived in Syria at the time of the study, and answered the required questions was included.

2) Consent and approval for study

The informed consent was taken online for using and publishing the data before carrying on with the survey. Confidentiality was assured and no identity-revealing questions were asked. This method was approved by Damascus University.

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

3) Questionnaires
Socioeconomic status (SES)

There is no suitable validated SES measurement to use in the Syrian population as we cannot ask directly about the monthly salary which is highly inappropriate in Syria and due to the huge differences between the normal wage in Syria and other countries. Therefore, SES was assessed through three criteria; 1) the level of education, 2) the profession of the participant or that of the working family member/partner, 3) and the monthly income adequacy of the individual who was the main source of income in the household. 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 mental distress (17-19). An Arabic version of the K10 + LM questionnaires was used which was validated in Arabic (17, 18). 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 the Multidimensional Scale of Perceived Social Support (MSPSS) was used to measure the social support that the individual receives from their social network, including friends, family, and the significant other (20, 21). 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. The scores and measures were validated in Arabic (21). The questionnaire and its translation are available (22).

PTSD

The Screen for Posttraumatic Stress Symptoms (SPTSS) tool was used; a self-reporting screening method for PTSD that is very concise and suitable as it is easy to understand and does not focus on specific traumatic events. SPTSS 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-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 other three scores represent 1. Scoring 3 or more on avoidance cluster, 2 or more on re-experience, and 1 or more on excessive hyper-arousal is an indication of PTSD for that specific cluster. The scores and measures are validated in Arabic (22, 23). This scale, however, is based on the diagnostic and statistical manual of mental disorders (DSM) IV. 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 identifies cases with less severe trauma exposure (24).

Other Questions

Subjects were asked basic demographic questions such as gender, age, educational level, governorate of current living, and whether they had consanguineous parents. Subjects were also asked a few questions, both directly and indirectly about war, including changing place of living due to war, losing someone close, and being distressed from war noises. Finally, subjects were asked if they had any chronic medical condition.

This study defined third-degree consanguineous parents as having parents who were first cousins, and fourth-degree consanguineous parents as having parents who were second cousins, or second cousins once removed who is either a child of one's second cousin, or one's parent's second cousin.

4) Data Process:

Data were processed using IBM SPSS software version 26 for Windows (SPSS Inc, IL, USA). Chi-square was used with nominal variables such as in (Table 3) while one-way analysis of variance (ANOVA), and independent t-tests were performed to determine statistical significance when having a numeric variable with a nominal one such as in (Table 2 and Table 4). Pearson correlation was also used when having two numeric variables.

Through the same software, odds ratios (ORs) and the 95% confidence intervals for the groups were calculated using the Mantel–Haenszel test. Values of less than 0.05 for the two-tailed P values were considered statistically significant. Bonferroni correction was used to reduce type 1 error when comparing multiple variables in Table 2 and Table 3. It is calculated by P=α\m where α in our study is 0.05 and m is the number of hypotheses.

Overall, 2173 filled in the survey. However, 198 were excluded as they did not answer all the questions, or their replies were invalid. Another 24 participants refused to be enrolled despite their initial consent when initiating the survey. The study included 1951 responders with 527 (27.0%) being males, and 1538 (78.8%) participants being within the age range of (19-25) years.

Among responders, 19.2% (CI 95%: 17.5% - 21%) were 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 a severe mental disorder according to K10 scale. Other characteristics of the subjects are demonstrated in (Table 1).

According to SPTSS questionnaire, 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.

K10 results:

According to Table 2, there were significantly higher K10 scores in participants who changed places of living multiple times due to war, females, participants with low SES, low educational levels, younger age groups, and participants who were distressed from war noise. When regressing the previous significant variables on K10 scores by using forward linear regression, they were all significant (P<0.05). Regression model is demonstrated in (Table 5). Other variables and their correlation with K10 scores are demonstrated in (Table 2).

When using Pearson correlation, positive correlations (P<0.001) were found between K10 scores and higher numbers of days being unable to work, study, or manage daily activities because of the negative feelings (r=0.110), more frequent visits to a health professional because of the negative feelings (r=0.110), and more frequent physical problems being attributed to the negative feelings (r=0.180). K10 scores were not correlated with the type of work (P=0.357) and are demonstrated in (Figure 2).

MSPSS results:

When comparing the governorate of current living and MSPSS, we did not find a statistically significant difference P=0.662. When using one-way ANOVA, high overall support was associated with fewer times of reporting physical problems being attributed to the negative feelings (P=0.040). However, P-value was higher than 0.05 with other LM questions.

According to table 2, significantly higher MSPSS scores were found in engaged participants, and with higher SES groups (P<0.001). When regressing the previous two variables from Table 2 on MSPSS scores by using forward linear regression, only SES was found significant (P<0.001) with an R²of 2.3%. Regression model is demonstrated in (Table 5).

Comparing SPTSS clusters with each variable is demonstrated in (Table 3). SPTSS total scores were not correlated with the type of work (P=0.357) and are demonstrated in (Figure 2). When comparing the governorate of current living with having PTSD, no statistically significant difference was observed P=0.681. However, disturbance of K10 scores among governorates is demonstrated in (Figure 1). The mean SPTSS score was higher by at least 4.5 points when having one or more chronic medical conditions compared to not having any (P<0.001, F=12.6).

We used forward linear regression on avoidance scores with the statistically significant variables of avoidance, except for the variables with an asterisk in Table 3. This showed the number of times changing places of living, and education were statistically significant (P<0.05). When using the same method on hyper-arousal, distress from war noise, number of times changing places of living, and education were statistically significant (P<0.05). When using the same method on re-experience, distress from war noise, losing someone due to war, educational level were statistically significant (P<0.05). All regression models are demonstrated in (Table 5).

Comparisons between K10, SPTSS, and MSPSS results:

When using independent t-test, the mean score of K10 was 32.9 (±23.9) in participants with avoidance symptoms, 23.9 (±8.4) in participants without avoidance symptoms, and t=-22.69 (P<0.001). The mean score of K10 was 32.1 (±9.2) in participants with hyper-arousal symptoms, 22.6 (±7.9) in participants without hyper-arousal symptoms, and t=-22.76 (P<0.001). The mean score of K10 was 32.3 (±9.2) among participants with re-experience symptoms, and 23.5 (±8.2) in participants without re-experience symptoms, and t=-21.78 (P>0.001).

Using one-way ANOVA, MSPSS scores were significantly associated with worse K10 results and SPTSS clusters which are demonstrated in (Table 4). When using Pearson correlation, higher K10 and SPTSS symptoms scores were significantly associated with lower family, friends, and significant other support. Family support score was significantly (P<0.001) correlated with K10 score (r=-0.195), avoidance score (r=-0.236), arousal score (r=-0.195), and re-experience score (r=-0.192). Friend support score was also significantly (P<0.001) correlated with K10 score (r=-0.171), avoidance score (r=-0.257), arousal score (r=-0.214), and re-experience score (r=-0.192). Finally, significant other support was significantly (P<0.001) correlated with K10 score (r=-0.160), avoidance score (r=-0.233), arousal score (r=-0.177), and re-experience score (r=-0.157).

Other results:

When using one-way ANOVA and independent t-test, more days were declared being unable to work, study, or manage daily life because of the negative feelings among subjects with more SPTSS symptoms (P=0.061), avoidance symptoms (P=0.0190(, hyper-arousal symptoms (P=0.034), and re-experience symptoms (P=0.043). Fewer subjects declared they could work but had to cut down on what they did which was statistically insignificant (P>0.05). Furthermore, more frequent visits to health professionals because of what was felt was associated with total PTSD symptoms (P=0.063), avoidance symptoms (P>0.05), hyper-arousal symptoms (P=0.022), and re-experience symptoms (P=0.022). More subjects also declared that having physical health problems being the main cause of the negative feelings was associated with more SPTSS symptoms (P<0.0001), avoidance symptoms (P=0.003), hyper-arousal symptoms (P<0.0001), and re-experience symptoms (P<0.0001).

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.

Around 60% of Syrian students in Syria have PTSD and/or problematic anger (32). 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 (33). In Turkey, it was found that the prevalence of PTSD was 33.5% among Syrian refugees using DSM-IV-TR criteria (34). 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 (35). 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 (36, 37). Around 10-40% of trauma survivors will develop PTSD (38) which is associated with a decreased quality of life (39). 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 (33). 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 (40). 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 (34). 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 (41).

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 (42).

Social support:

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 (43). 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 (44). 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 (45-47). 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 (48). Another study found a high prevalence of laryngopharyngeal reflux which is also related to war variables (49). 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 (50).

Moreover, war has affected university students (51), and prevented research from being properly conducted due to a shortage of resources (52). 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.

Limitations:

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, 53). 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.

The Syrian conflict has caused severe mental distress in the Syrian society. Efforts and interventions to improve the psychological wellbeing of the Syrian population are needed to ensure the people are prepared for the reconstruction of their country when the situation improves. The results of this study reflect the underlying disaster that made people severely mentally impaired. The social support relatively had a weak effect, meaning that resources should be re-allocated to other aspects of care. Syrian people have serious concerns about financial and psychiatric aspects of their lives and require various measures to ameliorate their situation. These results also emphasises on the importance of security either economically or in terms of personal safety which are more important in the long term than support from family, friends, and the significant other as higher mental distress is seen in those who remained in Syria compared to refugees in camps.

This study suggests that internally displaced people, and even those who were not displaced in the conflict, experienced more severe mental disorder than the Syrian refugees in most countries. The number of times changing places of living due to war and being distressed from war noise have contributed the most to the high K10 and SPTSS scores. More than 60% of the population suffered from PTSD and severe mental disorders. Having a high educational background was associated with less severe mental disorders and PTSD. Moreover, a higher number of times changing places of living due to war, a lower educational level, and being distressed from war noise were associated the most with sever PTSD and mental distress. No significant differences in mental disorders, or PTSD were noted among participants from different governorates or with different job types. Many other variables have contributed to these findings altogether which indicate the need for addressing multiple issues. Females and young participants suffered more on the psychiatric aspect.

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 the age of 18 years, another online informed consent was taken from the guardian 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:

N/A

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:

All authors have read and approved the manuscript.

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.

Acknowledgements:

We sincerely appreciate the valuable contributions made by Dr Ayham Ghareeb and Dr Yousef Mahmoud and acknowledge their kind collaboration in making this research possible, and facilitating its conduction, and distribution of the survey

We also appreciate the valuable contributions made by S. Hakeem for medical media for their aid in largely distributing the surveys among people.

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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

1538

333

2.7

78.8

17.1

1.4

Changing area of living due to war

Yes within the same city

Yes with changing the city

Yes I had to do both

977

429

488

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

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

217

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

142

200

53.6

18.1

4.8

7.3

10.3

4.2

1.7

Consanguinity

Yes third-degree relatives

Yes fourth-degree relatives

Yes but not close relatives

1416

300

138

72.6

15.4

5.0

7.1

A relative being endangered by the war

Yes

284

1667

14.6

85.4

Medical Conditions

Negative

Asthma

Hypertension

Diabetes

Asthma, Hypertension

Diabetes, Hypertension

Other

1008

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)

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

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

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

104

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

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

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%

TABLE 2: Demonstrate rrelationship between variables and K10 and mspss scores.
Characteristic	K10 score				MSPSS Score
Characteristic	Mean	SD	P value	F	Mean	SD	P value	F
Gender Female Male	29.3 27.0	9.8 9.7	<0.001	21.8	51.3 50.5	18.2 18.4	NS	0.9
Consanguinity No Yes third-degree relatives Yes fourth-degree relatives Yes but not close relatives	28.8 28.7 26.1 29.7	9.9 9.5 9.4 9.9	0.038^NS	2.8	51.0 50.5 55.4 50.6	18.4 18.6 16.9 16.4	NS	1.9
Marital status Single Engaged Married Widowed Divorced	28.7 28.0 28.7 28.9 29.8	9.8 10.1 10.1 9.6 11.6	NS	0.2	50.7 58.5 52.1 51.6 45.8	18.2 15.7 19.0 16.5 17.9	0.002	4.4
Educational level Primary School High School University or any high institute Masters or PhD	39.7 30.5 28.4 29.1	9.3 8.9 9.8 9.7	<0.001	13	39.5 50.2 51.3 51.6	19.9 18.4 18.1 18.9	0.011^NS	3.7
SES Lower Upper Lower Middle Upper	32.0 30.4 28.3 27.4	11.1 9.8 9.7 10.0	<0.001	8.5	38.2 48.0 51.4 55.0	17.8 18.1 18.3 17.1	<0.001	15.9
Working No Yes	28.9 28.4	9.8 9.8	NS	1.0	51.1 51.3	18.0 18.5	NS	0.1
Age groups 14 - 18 19 - 25 26 - 45 46 - 65	31.7 28.6 29.3 20.8	9.6 9.8 10.1 6.7	<0.001	8.1	50.5 51.2 50.7 48.5	17.0 18.1 18.7 22.2	NS	0.3
Losing someone close due to war No Yes	28.0 29.1	9.7 9.9	0.013^NS	6.2	51.7 50.7	18.1 18.3	NS	1.3
A relative being endangered by the war No Yes	28.1 28.8	9.6 9.9	NS	1.4	50.2 51.2	18.4 18.2	NS	0.7
Distressed from war noises Negative Positive	27.1 29.1	9.9 9.8	<0.001	13.5	50.2 51.3	18.5 18.2	NS	1.3
Changing place of living due to war No Within the same city Changing the city Doing both	28.0 29.6 29.5 28.4	9.6 9.8 10.2 9.4	0.005^NS	4.2	52.2 50.9 49.3 48.8	18.3 18.1 18.3 16.1	0.027^NS	3.1
Number of times changing places of living due to war No Once Twice Thrice and more	28.0 27.5 29.3 30.4	9.6 10.3 9.6 9.9	<0.001	8.8	52.2 51.8 50.6 49.0	18.3 17.3 17.8 18.5	0.011^NS	3.7
The reason declared of stress in the last period:* Educational Economical Social War-related Medical Other	27.6 29.5 30.4 30.2 32.9	9.3 10.2 10.2 9.7 8.4	<0.001	7.3	54.2 52.8 49.7 49.9 54.1 38.5	17.4 17.3 18.0 19.8 19.8 20.8	0.001	4.4
Do you consider that the crisis was the main cause of your distress lately?* No Kind of Yes totally	26.2 28.5 31.3	9.5 9.9 9.8	<0.001	28.3	53.2 51.2 50.0	18.8 18.1 18.0	0.054^NS	2.9
One-way ANOVA test was used in this table * These were not included in the regression as they do not generate extra results and they overlap with most variables. When using Bonferroni correction, P= (0.05\14) ≈ 0.004 or less to be statistically significant.

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

27.1%

72.9%

280
760

26.9%

73.1%

208
485

30.0%

70.0%

319
938

25.4%

74.6%

0.073^NS

239
561

29.9%

70.1%

288
862

25.0%

75.0%

0.051^NS

Consanguinity

Third-degree relatives

Fourth-degree relatives
Distant relatives

656

134

72.1%

14.7%

5.8%

7.4%

759

166

73.0%

16.0%

4.2%

6.8%

496

103

42
52

71.6%

14.9%

6.1%

7.5%

919

197

55
86

73.1%

15.7%

4.4%

6.8%

591

111

47
51

73.9%

13.9%

5.9%

6.4%

824

189

50
87

71.7%

16.4%

4.3%

7.6%

Marital status

Single

Engaged

Married

Divorced
Widowed

750

10
5

82.5%

5.2%

10.7%

1.1%

0.6%

866

120

11
2

83.4%

3.8%

11.6%

1.1%

0.2%

574

78
6
3

82.9%

4.5%

11.3%

0.9%

0.4%

1042

139
15
4

83.0%

4.4%

11.1%

1.2%

0.3%

661

94
9
4

82.7%

3.9%

11.8%

1.1%

0.5%

955

123
12
3

83.2%

4.8%

10.7%

1.0%

0.3%

Educational level

Primary School

High School

University or any high institute
Masters or PhD

807
56

0.2%

4.9%

88.7%

6.2%

864
70

2.3%

7.8%

83.2%

6.7%

<0.0001

624
37

0.3%

4.3%

90.0%

5.3%

1047
89

1.9%

7.6%

83.4%

7.1%

<0.0001

700
51

0.6%

5.5%

87.5%

6.4%

971
75

1.8%

7.1%

84.5%

6.5%

0.004

0.001

SES

Lower

Upper Lower

Middle

Upper

199

490

207

1.5%

21.9%

53.8%

22.7%

283

554

187

1.5%

27.2%

53.3%

18.0%

0.028 ^NS

136

393

156

1.2%

19.6%

56.7%

22.5%

346

651

238

1.8%

27.5%

51.8%

18.9%

0.003

176

435

180

1.1%

22.0%

54.4%

22.5%

306

609

214

1.8%

26.6%

53.0%

18.6%

0.055^NS

0.005^NS

Working

No
Yes

497
267

65.0%

35.0%

600
287

67.6%

32.4%

385
188

67.2%

32.8%

712
366

66.0%

34.0%

433
238

64.5%

35.5%

664
316

67.8%

32.2%

Age groups

14 - 18

19 - 25

26 - 45

46 - 65

720

147
19

2.6%

79.1%

16.2%

2.1%

818

186
9

2.6%

78.7%

17.9%

0.9%

<0.0001

563
102
13

2.2%

81.2%

14.7%

1.9%

975
231
15

2.9%

77.6%

18.4%

1.2%

<0.0001

639
128
19

1.8%

79.9%

16.0%

2.4%

899
205
9

3.2%

78.2%

17.8%

0.8%

<0.0001

0.066^NS

Losing someone close due to war

No
Yes

351
559

38.6%

61.4%

346
694

33.3%

66.7%

0.039^NS

270
423

39.0%

61.0%

427
830

34.0%

66.0%

0.067^NS

339
461

42.4%

57.6%

358
792

31.1%

68.9%

<0.0001

0.001

A relative being endangered by the war

Yes

138
772

15.2%

84.8%

146
894

14.0%

86.0%

113
580

16.3%

83.7%

171
1086

13.6%

86.4%

132
668

16.5%

83.5%

152
998

13.2%

86.8%

Distressed from war noises

Negative
Positive

195
715

21.4%

78.6%

211
829

20.3%

79.7%

185
508

26.7%

73.3%

211
1036

17.6%

82.4%

<0.0001

196
604

24.5%

75.5%

210
940

18.3%

81.7%

0.001

0.003

Changing place of living due to war

Within the same city

With changing city

Both

495
195
195
25

54.4%

21.4%

2.7%

482
233
293
32

46.3%

22.4%

28.2%

3.1%

0.004

361
138
172
22

52.1%

19.9%

24.8%

3.2%

616
290
316
35

49.0%

23.1%

25.1%

2.8%

413
173
191
23

51.6%

21.6%

23.9%

2.9%

564
255
297
34

49.0%

22.2%

25.8%

3.0%

0.010^NS

Number of times changing places of living due to war

Never

Once

Twice

Thrice and more

495

123

87
205

37.8%

22.7%

13.5%

25.9%

482

101

124
333

31.5%

16.7%

15.9%

35.9%

<0.0001

361

103
63
166

38.0%

23.8%

11.7%

26.6%

616

121
148
372

32.5%

17.2%

16.5%

33.8%

0.001

413

107
91
189

36.4%

22.4%

14.8%

26.5%

564

117
120
349

33.1%

17.6%

14.8%

34.5%

0.016^NS

<0.0001

The main reason declared of stress in the last period:*

Educational
Economical
Social
War-related

Medical

Other

197
58
212
20
8
4

39.5%

11.6%

42.5%

4.0%

1.6%

0.8%

191
69
292
30
25
9

31.0%

11.2%

47.4%

4.9%

4.1%

1.5%

0.014^NS

155
39
143
8
5
3

43.9%

11.0%

40.5%

2.3%

1.4%

0.8%

233
88
361
42
28
10

30.6%

11.5%

47.4%

5.5%

3.7%

1.3%

0.0001

173
54
164
17
11
1

41.2%

12.9%

39.0%

4.0%

2.6%

0.2%

215
73
340
33
22
12

30.9%

10.5%

48.9%

4.7%

3.2%

1.7%

0.001

Do you consider that the crisis was the main cause of your distress lately?*

Kind of

Yes totally

155
326
210

22.4%

47.2%

30.4%

107
336
210

12.6%

39.6%

47.8%

<0.0001

133
150
319

25.6%

45.5%

28.9%

129
426
466

12.6%

41.7%

45.6%

<0.0001

127
294
186

20.9%

48.4%

30.6%

135
368
430

14.5%

39.4%

46.1%

<0.0001

Where NS: not significant.

Chi-square test was used in this table.

^#This p value is calculated between having no, one, two or three positive clusters

* These were not included in the regression as they do not generate extra results and they overlap with most variables.

When using Bonferroni correction, P= (0.05\14) ≈ 0.004 or less to be statistically significant.

TABLE 4: Comparing Each Support in MSPSS with K10 and SPTSS clusters

Family Support

Friends support

Significant Other Support

Mean

P value

Mean

P value

Mean

P value

K 10

Low

Medium

High

21.0

19.0

18.3

17.7

6.6

6.8

7.2

<0.001

17.2

15.1

14.3

14.0

7.0

7.3

<0.001

19.6

17.9

17.3

16.6

7.3

7.6

7.7

7.9

<0.001

SPTSS

Avoidance

20.2

17.4

6.6

7.2

<0.001

16.5

13.4

7.1

7.2

<0.001

19.2

16.1

7.3

7.9

<0.001

Arousal

20.0

18.0

6.6

7.2

<0.001

16.3

14.1

7.1

7.3

<0.001

18.9

16.8

7.4

7.9

<0.001

Re-experience

20.1

17.8

6.5

7.3

<0.001

16.3

13.9

6.9

7.5

<0.001

18.8

16.7

7.3

8.0

<0.001

None
One
Two
Three

20.6

20.1

18.7

16.9

6.4

6.6

7.0

7.4

<0.001

17.1

16.4

14.5

13.1

6.9

6.8

7.3

<0.001

19.4

19.1

17.6

15.7

7.0

7.5

7.7

7.9

<0.001

NS: not significant.

One-war ANOVA test was used in this table.

Table 5: demonstrating forward linear regression on K10 scores, MSPSS, Avoidance, Hyper-arousal, and re-experience score with their relevant statistically significant variables.
	Model	R	R²	Adjusted R²	Std. Error of the Estimate	Change Statistics					Unstandardized Coefficients β	Standardized Coefficients β	Sig.
	Model	R	R²	Adjusted R²	Std. Error of the Estimate	R² Change	F Change	df1	df2	Sig. F Change	Unstandardized Coefficients β	Standardized Coefficients β	Sig.
K10 score	Number of time changing place of living	.125^a	.016	.015	9.757	.016	30.728	1	1948	.000	.838	.106	.000
	Gender	.160^b	.026	.025	9.709	.010	20.440	1	1947	.000	-2.098	-.095	.000
	SES	.191^c	.037	.035	9.657	.011	21.896	1	1946	.000	-1.481	-.107	.000
	Educational level	.207^d	.043	.041	9.629	.006	12.350	1	1945	.000	-1.539	-.067	.004
	Age group	.212^e	.045	.043	9.620	.002	4.803	1	1944	.029	-1.100	-.053	.022
	Being distressed from war noise	.218^f	.047	.044	9.610	.002	4.861	1	1943	.028	1.224	.051	.028
MSPSS score	SES	.151^a	.023	.022	18.010	.023	45.328	1	1945	.000	3.865	.151	.000
Avoidance score	Number of time changing place of living	.106^a	.011	.011	1.854	.011	22.114	1	1947	.000	.150	.100	.000
Avoidance score	Educational level	.119^b	.014	.013	1.852	.003	5.702	1	1946	.017	-.236	-.054	.017
Hyper-arousal score	Being distressed from war noise	.126^a	.016	.015	1.455	.016	31.549	1	1947	.000	.419	.116	.000
	SES	.159^b	.025	.024	1.449	.009	18.503	1	1946	.000	-.184	-.089	.000
	Number of time changing place of living	.180^c	.032	.031	1.444	.007	14.430	1	1945	.000	.093	.079	.000
	Educational level	.188^d	.035	.033	1.442	.003	5.789	1	1944	.016	-.185	-.054	.016
re-experience score	Being distressed from war noise	.114^a	.013	.012	1.610	.013	25.648	1	1947	.000	.440	.110	.000
	Losing someone due to war	.153^b	.024	.023	1.601	.011	21.020	1	1946	.000	.349	.103	.000
	Educational level	.173^c	.030	.029	1.596	.007	13.063	1	1945	.000	-.306	-.081	.000

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