Then, We Lost Everything:’ Afghan Refugee Mental Health Challenges Post-2021 Evacuation

Background

The 2021 evacuation of Afghan citizens after the Taliban takeover of the country represents the largest non-combat airlift in US history [1]. The evacuation, Operation Allies Refuge (OAR), and the subsequent US resettlement of Afghan evacuees, Operation Allies Welcome (OAW), marked the end of the US’s 20-year military presence in Afghanistan. Official statements report 85,000 Afghan evacuees were brought to the US [2]. The lead-up to the US evacuation of Afghanistan was chaotic and urgent [3]. In 8 days, the Taliban went from controlling one provincial capital to half of the country’s capitals [4]. On 16 August, over 100,000 people swarmed Hamid Karzai International Airport. On 27 August, suicide bombings at the airport killed 150 Afghans and 13 US troops [5]. After the last US plane departed on 30 August, the Taliban took control of the airport and ceased departures [6].

Theoretical/Conceptual Framework

Research shows that Afghans experience a high burden of traumatic events and mental health disorders while in their home country [7–10]. Like other refugees [11–13], Afghan refugees that resettled prior to 2021 have high rates of mental health disorders [14, 15]. While OAR and OAW provided physical safety, the psychological well-being of evacuees is a pressing concern given their abrupt displacement. This study uses qualitative and quantitative methods to understand the mental health impacts of the evacuation on this population.

Methods

Overview

The research team utilized semi-structured interviews and mental health screeners. Sampling included adult Afghans who were evacuated during OAR/OAW and were resettled in Rhode Island (RI). Researchers worked with a post-resettlement organization to recruit participants via phone and ensure a variety of immigration statuses were represented, including Special Immigrant Visa (SIV) eligible petitioners, SIV-eligible dependents, and non-SIV eligible individuals.1

Qualitative

The interview protocol asked about living and working in Afghanistan prior to the evacuation; the days leading up to the evacuation; the Kabul airport and the evacuation; the international staging bases; the US bases; resettlement in RI; and post-resettlement hopes. The interviews and screeners were conducted in Dari, Pashto, and English by two interviewers. The transcripts were translated by research assistants when necessary.

The transcripts were coded in NVivo using a grounded theory approach by one coder. The coder engaged in iterative rounds of coding until they produced a codebook from which key themes were inductively identified and cross-validated with the quantitative data collected from the mental health screeners.

Quantitative

The research team employed factor analysis (FA), [16] which examines the correlations between individual responses to scored questions by eigenvalue decomposition of the correlation matrix. This provides insights into which questions showed stronger relationships with all other items without examining the entire correlation matrix. Loadings can be interpreted as an average correlation between single questions and all other questions. Multiple factors can be extracted, representing the associations among questions that remain after accounting for the largest correlations between questions. Although you can extract as many factors as there are question items, this would be impractical since each question would represent unique information. Empirical decision rules help, such as selecting the number of factors based on the number of eigenvalues greater than one, examining the scree plot of eigenvalues to identify the point where factors no longer explain much variance in the data, or extracting factors that explain at least 50% of the variance in the data [16].

Given the small sample, the authors made an a priori choice to focus on three factors. Quantitative data were collected using measures of depression (PHQ-9), PTSD (PCL-5), and generalized anxiety (GAD-7). We examined three factors assuming that they would represent each of these three traits. This approach identified common experiences with mental health to provide context to qualitative responses, while mitigating the risk of obtaining results that would not generalize.

We used Bayesian estimation, which is more reliable with small samples [17, 18]. We specified the prior to be the same as a non-Bayesian analysis but multiplied the estimated standard error by two to be conservative. This implied an assumption that 99.9% of the distribution we observed should have only represented the middle 95%.

Mixed-Methods

Qualitative and quantitative findings were explored alongside each other, with the research team examining overlaps of themes and constructs identified in each of the specified analyses. Researchers drafted, reviewed, and refined a narrative of the synthesized findings to enhance the rigor of the mixed-methods study results.

Human Subjects Approval

The project was approved by Brown University’s Institutional Review Board (Protocol #3147). Verbal consent, used to reduce the risk of linking participants' names to the study, was obtained due to security threats to individuals who worked with the US government in Afghanistan. A mental health safety plan was in place for participants.

Results

Thirty-two individuals completed the semi-structured interviews and 23 of the respondents completed the mental health questionnaires (6 women, 26 men, ages 18–65). Educational backgrounds ranged from no formal education to graduate students. All interviewees spoke Dari and or Pashto, some spoke English.

Taken together, the qualitative and quantitative results reveal the individual, interpersonal, and structural facets of mental health effects the evacuation and resettlement had on Afghan evacuees.

Qualitative Results

The qualitative data revealed interpersonal- and structural-level themes of anguish over to mass family separation, traumatic memories of life and service in Afghanistan, and isolation and lack of control in a new country.

Anguish over family separation

Many codes pertain to stories of familial separation. One participant described their fears about bringing their family to the airport. This is because the Taliban had surrounded the airport, and the interviewee was afraid that the Taliban would take retaliatory measures against them and their family for supporting the US mission. In the words of the interviewee: “I couldn't leave by myself to go safely from Afghanistan. How should I bring my family?”.

Another interviewee recounted how she and her daughter had been separated from the rest of their family on the tarmac. People aboard one of the C-17 s reportedly pulled her daughter onto the plane, and she had to decide whether to join her now US-bound daughter or stay at the airport and locate her other family members.

Another interviewee described how a bombing separated him from his sister. He recounted the incident: “She [my sister] was with us but her child was left behind the airport gates, so she went to get her child and come back. But there was an explosion right outside of the airport at that exact time and she was not able to come back.”

Multiple interviewees who had been active duty described receiving notifications that they were to be evacuated too late to bring their eligible family members along. Some were unaware that they were going to be evacuated until hours before. One participant guarded the airport for days, not realizing he was to be evacuated at the end of his duty. He did not have enough time to retrieve his family.

Participants described anxieties about family members left behind. Multiple participants report that Taliban members come to their old house demanding that their family turn over the individual’s whereabouts. As one participant described: “I am just hoping for my family to be okay in Afghanistan. The Taliban got my child and were beating my child,” while another participant told the research team: “the Taliban came in our house and took our property… aren’t giving us our salaries. The people working with the US government- they are finding that out and wanting to take their properties. They have beat my father back home… So that’s not good and I am feeling very upset about that.”

Traumatic memories of life and service in Afghanistan

Participants recalled combat-related events. One individual interviewed described being present for a suicide bombing attack on a hotel. Afghans involved in the US war effort were at risk for retaliatory attacks. One member of the ANA described how Taliban members were targeting their house: “They [Taliban] put two times a bomb behind my doors. They wanted to blast me and kill me, but Allah saved me.”

Civilian participants also recounted experiences related to living in a conflict zone. One individual described their general fear: “In Afghanistan, it’s not a good place for living. If you want to do something… someone is coming to stop you and maybe someone is coming to shoot you.” Others described witnessing terrorist attacks as they were on their way to a university class as well as shock over the Taliban resurgence: “I myself never think that Taliban came in Afghanistan again. It was almost two hours far from Kabul- on that time even, I didn't think that the Taliban came over and tomorrow will be inside Kabul. Never thought that.”

Isolation and lack of control in a new country

Participants described feelings of stress and depression stemming from a deep sense of loss after fleeing Afghanistan: “Physically, we are both good. But mentally, like my brother- I think he's facing some sort of depression. He's not telling me. I don't know, but I think he has some issues.”

Others described how loneliness affected their daily lives. These descriptions were often paired with an explanation about how they were never alone in Afghanistan due to living in joint family households. One interviewee described missing this sense of community: “We don’t have any connections with neighbors… We don’t have any connections right now. We are alone right now.”

Another interviewee describes the anguish of having to rebuild their life: “Now we don’t have anything. We’re starting in zero… It’s not good also for me and my uncle, and most[ly] it’s not good for my uncle because he made a good life for him. He’s made a home… and he buy a car, and he has a good family and good life in Afghanistan. And he loses anything.”

Participants described feeling out of control. Multiple interviewees told researchers that they were forced to choose between two bad options: stay behind in Afghanistan or start over in another country. One interviewee stated: “A person that lives 20 years 25 years in a country and prepares everything for themselves: home, car, right? Everything. And suddenly, you leave everything… It is so difficult. Right? But it is also difficult to live there, to go ahead with that situation. Nothing is, you know, possible. Work is not possible. Education is not possible… Everything is difficult.”

This feeling of loss coupled with powerlessness is repeated across interviews: “The journey, as I told you, was difficult because you are losing everything: the jobs, the country, the family, and the relatives that you have. It’s difficult. It’s not easy if you go somewhere to be a refugee. But we have to tolerate. We have to be patient with this kind of [event] that’s happened. We don’t have another option to do it.”

Economic anxieties added to feelings of powerlessness. In Afghanistan, men are generally the sole earner for an expanded household. Many interviewees described stress around the need to support family in the US and Afghanistan, while contending with costs of living, transferring credentials, and language barriers.

Quantitative Results

The quantitative results reveal the individual-level themes of turmoil, difficulty relaxing, and difficulty concentrating. Table 1 provides FA results. Factor 1 appeared to represent a sense of general life turmoil. Loadings were generally positive, suggesting feelings of depression, PTSD, and anxiety showed the strongest correlations regardless of trait measured. This is consistent with research suggesting depression, PTSD, and anxiety are all highly correlated.

Table 1.

Quantitative results

Loading, [95% CI]
Item	Factor 1	Factor 2	Factor 3	Wording
PHQ
1	0.14 [-0.39, 0.69]	0.29 [-0.26, 0.84]	−0.65 [−1.21, −0.14]	1. Little interest or pleasure in doing things
2	0.52 [0.04, 0.98]	0.11 [−0.52, 0.69]	0.31 [−0.25, 0.86]	2. Feeling down, depressed, or hopeless
3	0.76 [0.28, 1.20]	−0.18 [−0.75, 0.36]	−0.34 [−0.91, 0.23]	3. Trouble falling or staying asleep, or sleeping too much
4	0.88 [0.50, 1.24]	0.03 [−0.47, 0.52]	0.07 [−0.46, 0.54]	4. Feeling tired or having little energy
5	0.37 [−0.11, 0.83]	0.66 [0.15, 1.12]	0.12 [−0.36, 0.63]	5. Poor appetite or overeating
6	0.84 [0.42, 1.26]	0.24 [−0.29, 0.77]	0.37 [−0.13, 0.91]	6. Feeling bad about yourself — or that you are a failure or have let yourself or your family down
7	0.19 [−0.33, 0.72]	0.50 [−0.02, 1.08]	0.62 [0.08, 1.12]	7. Trouble concentrating on things, such as reading the newspaper or watching television
8	0.62 [0.17, 1.07]	0.20 [−0.36, 0.73]	0.66 [0.17, 1,12]	8. Moving or speaking so slowly that other people could have noticed? Or the opposite — being so fidgety or restless that you have been moving around a lot more than usual
9	0.84 [0.41, 1.25]	0.28 [−0.19, 0.90]	0.40 [−0.17, 0.94]	9. Thoughts that you would be better off dead or of hurting yourself in some way
PCL
1	0.71 [0.27, 1.19]	0.20 [−0.33, 0.75]	0.26 [−0.37, 0.87]	1. Repeated, disturbing, and unwanted memories of the stressful experience?
2	0.38 [−0.08, 0.87]	0.62 [0.07, 1.17]	−0.35 [−0.86, 0.21]	2. Repeated, disturbing dreams of the stressful experience?
3	0.62 [0.18, 1.07]	0.19 [−0.34, 0.64]	−0.14 [−0.75, 0.40]	3. Suddenly feeling or acting as if the stressful experience were actually happening again (as if you were actually back there reliving it)?
4	0.54 [0.10, 0.99]	−0.27 [−0.89, 0.27]	0.21 [−0.32, 0.74]	4. Feeling very upset when something reminded you of the stressful experience?
5	0.58 [0.11, 1.08]	0.53 [0.03, 1.10]	0.45 [−0.08, 0.93]	5. Having strong physical reactions when something reminded you of the stressful experience (for example, heart pounding, trouble breathing, sweating)?
6	0.80 [0.33, 1.27]	−0.18 [−0.83, 0.38]	−0.09 [−0.65, 0.49]	6. Avoiding memories, thoughts, or feelings related to the stressful experience?
7	0.57 [0.09, 1.07]	0.10 [−0.42, 0.59]	−0.05 [−0.59, 0.50]	7. Avoiding external reminders of the stressful experience (for example, people, places, conversations, activities, objects, or situations)?
8	0.41 [−0.05, 0.86]	0.51 [−0.05, 1.11]	0.26 [−0.31, 0.79]	8. Trouble remembering important parts of the stressful experience?
9	0.45 [−0.04, 0.97]	0.47 [−0.07, 0.95]	0.11 [−0.37, 0.65]	9. Having strong negative beliefs about yourself, other people, or the world (for example, having thoughts such as: I am bad, there is something seriously wrong with me, no one can be trusted, the world is completely dangerous)?
10	−0.11 [−0.74, 0.44]	−0.18 [−0.74, 0.51]	0.54 [−0.01, 1.06]	10. Blaming yourself or someone else for the stressful experience or what happened after it?
11	0.91 [0.55, 1.30]	0.25 [−0.43, 0.88]	−0.02 [−0.64, 0.54]	11. Having strong negative feelings such as fear, horror, anger, guilt, or shame?
12	−0.4 [−0.60, 0.47]	0.25 [−0.23, 0.75]	−0.67 [−1.21, −0.14]	12. Loss of interest in activities that you used to enjoy?
13	0.60 [0.13, 1.09]	0.63 [0.15, 1.12]	−0.07 [−0.66, 0.57]	13. Feeling distant or cut off from other people?
14	−0.10 [−0.61, 0.42]	0.84 [0.46, 1.26]	−0.14 [−0.69, 0.44]	14. Trouble experiencing positive feelings (for example, being unable to feel happiness or have loving feelings for people close to you)?
15	0.44 [−0.12, 1.09]	−0.50 [−0.92, −0.00]	−0.55 [−1.11, 0.02]	15. Irritable behavior, angry outbursts, or acting aggressively?
16	0.04 [−0.39, 0.52]	−0.24 [−0.75, 0.32]	−0.01 [−0.55, 0.57]	16. Taking too many risks or doing things that could cause you harm?
17	0.77 [0.38, 1.17]	−0.13 [−0.74, 0.48]	−0.34 [−0.80, 0.19]	17. Being “superalert” or watchful or on guard?
18	0.75 [0.31, 1.20]	0.08 [−0.50, 0.61]	0.25 [−0.29, 0.88]	18. Feeling jumpy or easily startled?
19	0.00 [−0.48, 0.51]	0.18 [−0.42, 0.74]	−0.19 [−0.80, 0.38]	19. Having difficulty concentrating?
20	0.72 [0.26, 1.16]	0.03 [−0.58, 0.57]	−0.18 [−0.74, 0.33]	20. Trouble falling or staying asleep?
GAD
1	0.32 [−0.16, 0.83]	0.54 [−0.04, 1.07]	0.58 [0.09, 1.08]	1. Feeling nervous, anxious, or on edge
2	0.70 [0.22, 1.14]	0.13 [−0.46, 0.67]	0.11 [−0.38, 0.63]	2. Not being able to stop or control worrying
3	−0.04 [−0.60, 0.48]	0.83 [0.34, 1.26]	0.09 [−0.42, 0.69]	3. Worrying too much about different things
4	0.21 [−0.31, 0.69]	0.79 [0.35, 1.26]	0.30 [−0.31, 0.96]	4. Trouble relaxing
5	0.19 [−0.33, 0.66]	0.78 [0.32, 1.21]	−0.17 [−0.66, 0.30]	5. Being so restless that it's hard to sit still
6	0.22 [−0.25, 0.78]	−0.17 [−0.71, 0.32]	0.52 [−0.07, 0.99]	6. Becoming easily annoyed or irritable
7	0.55 [0.07, 1.01]	0.32 [−0.23, 0.87]	−0.15 [−0.72, 0.41]	7. Feeling afraid as if something awful might happen

Presented are the values of the loadings on each factor, and the corresponding 95% CI. Values that are bolded demonstrate that the loading is meaningfully different from zero, because the 95% CI excluded a value of zero.

There were positive loadings on Factor 2 for comments about worry and difficulty relaxing (e.g., “worrying too much about different things”, loading = 0.83, 95% CI [0.34, 1.26]). There was a negative loading for “irritable behavior, angry outbursts, or acting aggressively” (loading = -0.50, 95% CI [-0.92, -0.01]). This may represent a general sense of difficulty relaxing, but not necessarily anger or irritation.

There was a positive loading for “trouble concentrating on things, such as reading the newspaper or watching television” (loading = 0.62, 95% CI [0.08, 1.12]) on Factor 3, paired with negative loadings for “little interest or pleasure in doing things” (loading = −0.65, 95% CI [−1.21, −0.14]) and “loss of interest in activities that you used to enjoy” (loading = −0.67, 95% CI [−1.21, −0.14]). We theorize that this speaks to separation. Participants may still have an interest in reading the paper, it may be difficult to participate in these activities given the worry for family back home. While it was not precise enough to exclude a value of zero, the loading for “blaming yourself or someone else for the stressful experience or what happened after it” was large (loading = 0.54, 95% CI [-0.01, 1.06]). This may represent anguish and guilt with feeling disconnected from family.

Synthesis

Factor 1 in the quantitative analysis showed similarity with the qualitative theme of ‘isolation and lack of control in a new country.’ The qualitative comments reveal the intertwined nature of isolation and turmoil. Specific to Factor 2, powerlessness was also identifiable in difficulty relaxing but not irritability. Angry outbursts are characterized as an externalized facet of psychopathology. The isolation described in the interviews identifies mental health struggles that include feelings of internalized powerlessness.

The theme of anguish over family separation seems to have direct correspondence to Factor 3. Aware of family back home, participants felt an inability to engage with or appreciate daily activities. Participants did not report a loss of interest in activities that they had previously enjoyed, underscoring the temporal context of their resettlement. Participants may not have renounced joy, but rather the sudden change of circumstance makes it difficult to experience joy until all family members are safe.

The qualitative theme of trauma from life and service in Afghanistan may induce feelings of depression and anxiety—as seen in all three factors in the quantitative output (Table 1). The traumas experienced in Afghanistan were not isolated events, but rather prolonged realities culminating in the trauma of evacuation. This may have implications for comorbid symptoms of depression, PTSD, and anxiety unique to this population.

Discussion

The mixed methods results contextualize the individual, interpersonal and structural facets of Afghan refugee mental health. The quantitative measures administered point to personal level factors and the qualitative results give more context to the mental health of these refugees, including mention of family interactions and societal differences between home country and relocation to the US.

On the individual level, trauma is within the context of community, narrating how this unfolds across time in conflict-related traumas, evacuation, and resettlement impacts. Aspects of loss, depression, and distress for individuals are tied to experiences of family/community separation. This helps to contextualize what is seen quantitatively as to the intersecting lived experiences of aspects of depression, anxiety and PTSD symptoms. The first factor identified in the FA is thus easily anticipated from extensive previous research on the comorbidity of depression, PTSD, and anxiety.

On the interpersonal level, the interview data suggests a relationship between individual feelings of stress, depression and trauma with familial separation and feelings of isolation. From a policy point of view, the SIV eligibility criteria for dependents (immediate family members) was a major limitation of the 2021 airlift. This stipulation is based on a Euro-American understanding of ‘immediate family,’ which does not translate to Afghan society where families are intergenerational. While this is an immigration policy question, the resultant feelings of isolation may be lessened through responsible outreach brokered by refugee community members and their wider new communities.

On a structural level, the interview data connects individual feelings of stress, depression and trauma with wider economic and cultural shifts. Men in particular expressed stress over not being able to provide for their families in the US and at home in Afghanistan, since a single breadwinner household is difficult to maintain in the US. Almost all interviewees expressed sadness over their inability to return to their homeland, as well as their need to accept that they are now refugees.

Clinical implications may be drawn from these findings for emergency medicine professionals. Knowledge of the overlap of depression, anxiety and PTSD symptoms while suggesting the best practice of combined assessments, may also point to necessary additional assessments even in cases of sub-threshold diagnostic results, including referrals to mental health professionals. Additionally, social work interventions may also be provided to refugees as personal level factors may be impacted by family situations and larger social contexts that may limit individual mental health interventions if unaddressed.

Limitations

Future studies should expand this sample size beyond RI. Males are overrepresented in the current sample given that males were more likely to be SIV-eligible due to their work for the US. A more gender-representative sample would add nuance to our findings; other studies have found that depression around family safety especially affects Afghan women due in part to their role as caretakers [19].

Contribution to the Literature

To the authors’ knowledge, this study represents the first in depth-analysis of the mental health needs of the most recent wave of Afghan refugees. We advance a novel mixed-methods approach to studying refugee mental health. FA of the three administered mental health measures gives insight into symptomology and experiences of the respective mental health challenges. Statistical analyses of these self-report measures report the degree of noted symptomatology instead of measurement of the underlying constructs. Our approach examines measurement of dimensions of psychopathology in this sample, further contextualizing these refugees' experience and its impact on mental health.

Conclusion

This study elucidates several themes including experiences of turmoil, anguish, and trauma amongst the Afghan refugee population evacuated in 2021. These experiences cut across three different levels—individual, interpersonal, and structural—and therefore have different levers for intervention including clinical, community, and policy. The findings underscore the need for targeted interventions addressing the multifaceted challenges faced by Afghan evacuees, informing future research and mental health support initiatives for this vulnerable population.

Author Contributions

Conceptualization [Alexandria Nylen, Giovanna Deluca, Adam Levine, Omar Bah]; Qualitative Methodology [Alexandria Nylen]; Quantitative Methodology [Jodi Sutherland, Joshua Ray Tanzer]; Data collection [Alexandria Nylen]; Writing [Alexandria Nylen, Giovanna Deluca, Bazif Bala, Jodi Sutherland, Joshua Ray Tanzer, Omar Bah, Adam Levine]; Funding [Adam Levine and Alexandria Nylen].

Funding

Noah Ruttenberg and Perri Peltz, Gift, Adam C Levine.