Seven-year data trends in mental health of refugees in transit: a repeated cross-sectional study

Summary

Background

The mental health of refugees in transit—an inherently unstable and high-risk context—remains underresearched in the field of refugee research. This study aimed to address this gap by providing insights into the mental health of refugees in transit, identifying vulnerable subgroups, and documenting mental health trends over a seven-year period.

Methods

Seven annually repeated cross-sectional studies with comparable methodologies were conducted, with data collected from 2017 to 2023. Official population data were used to weight the sample for each year by gender, age, and geographical region, improving alignment with population sociodemographic characteristics. A total of 1375 refugees, 87.2% male (1200/1377), average age 25.66 years (SD = 8.33), originating from the Middle East and Africa and residing in Serbia as a case study of a transit context along the route to Europe, participated in the study. They completed the Refugee Health Screener-15 (RHS-15), which assesses symptoms of depression, anxiety, PTSD, distress, and coping capacity, and a sociodemographic questionnaire.

Findings

Results revealed 90.5% (1246/1377) of participants screened positive for mental health problems. Most participants experienced severe distress and moderate symptoms of depression, anxiety, and PTSD. Interestingly, despite this, most participants perceived themselves as able to cope with challenges, with 50.3% (693/1377) reporting they feel able to cope with most or any challenge. Mental health symptoms showed a complex, non-linear trajectory across years, with peaks in 2017, 2020–2021, and again in 2023. Acute or chronic health problems were positively related with higher levels of symptoms, while international protection status, education, gender, age, having children or partner, employment status, and duration of time in transit were not associated with mental health outcomes.

Interpretation

The findings highlight the substantial mental health burden faced by refugees in transit, pointing to specific vulnerable groups and illustrating how broader socio-political events are mirrored in psychological trends (e.g., mass border closures, the COVID-19 pandemic). The study underscores the need for systemic, timely, and context-sensitive mental health interventions, and calls for attention to the transit phase as a unique and critical point in the refugee journey.

Funding

This study is part of the projects that PIN–Psychosocial Innovation Network implemented with the support of UNHCR Serbia, Open Society Foundation, IOM and Swiss Agency for Development and Cooperation, and Karl Kahane Foundation. Maša Vukčević Marković, Irena Stojadinović Vujičić, and Jana Dimoski receive institutional support from Ministry of Education, Science and Technological Development of the Republic of Serbia (No. 451-03-137/2025-03/200163).

Research in context.

Evidence before this study

We searched PubMed, Web of Science, PsycINFO, Scopus, and Google Scholar for studies on refugees’ mental health. Search terms included combinations of “refugee”, “asylum seeker”, “migrant”, “displacement”, „forced migration“, “mental health”, “psychological difficulties”, “distress“, “RHS”, “Refugee Health Screener”, ”depression”, “anxiety”, “PTSD”, “post-traumatic stress”, “transit”, “Western Balkans” or “Europe.”. We also screened reference lists of relevant journal articles and book chapters. Inclusion criteria were empirical studies or systematic reviews focusing on mental health outcomes among refugee populations in countries of origin, transit countries, and destination countries within Europe; exclusion criteria were studies that (a) exclusively addressed topics unrelated to mental health (e.g., physical health, demographic issues), (b) examined refugee populations of nationalities other than those from the Middle East or Africa (e.g., Ukraine), (c) focused on migrant populations without forced displacement, (d) explored refugees transiting to countries outside Europe (e.g., the USA), or (e) or articles without empirical basis.

The vast majority of identified studies were conducted in high-income Western European countries, typically the final destinations for refugees. Very few studies examined mental health during transit—the period between leaving the country of origin and arriving in the intended destination country—which may last for years and entails distinct mental health risks. Existing evidence from transit settings is scarce, fragmented, and of variable methodological quality, with limited sample sizes and convenience-based recruitment. No systematic review or meta-analysis to date has synthesized findings on refugees’ mental health in transit, and the evidence base is insufficient to estimate the burden of mental health difficulties among refugees in these contexts.

Added value of this study

This study provides the first evidence on mental health outcomes among refugees from the Middle East and Africa in transit to Europe, based on data systematically collected over a seven-year period. Official population data were used to weight the sample for each year by gender, age, and geographical region, improving alignment with known population sociodemographic characteristics. While most existing research has focused on pre-migration and post-migration contexts, this work uniquely captures the underexplored transit phase, offering new insights into how instability and prolonged uncertainty shape mental health. In addition, by examining trends over the course of seven years, the study identifies broader socio-political events that are reflected in mental health difficulties in transit populations—an area where evidence has been scarce. This approach steps beyond interpreting mental health difficulties of refugees solely in terms of their individual experiences, but highlights a complementary perspective of the impact of broader socio-political events. Together, these findings advance the literature by filling a critical gap and strengthening the empirical foundation for contextually informed mental health support in transit settings.

Implications of all the available evidence

The high prevalence of mental health problems among refugees in transit underscores the necessity of ensuring the availability of further psychological assessment and mental health and psychosocial support services along transit routes to address recognized mental health risks and provide continuity of care. It also identifies a particularly vulnerable subgroup of refugees, offering evidence that can guide the prioritization of care in contexts with limited resources. Finally, by linking mental health outcomes with broader socio-political circumstances, the study highlights the critical importance of dedicating adequate resources to mental health protection and care during large-scale crises, which affect not only directly impacted populations but also those indirectly exposed.

Introduction

By the end of 2024, over 123.2 million people were forcibly displaced, including more than 40 million refugees or asylum seekers.¹ Among them, a notable proportion originates from Middle Eastern or African countries,c^,1 and Europe remains one of the continents hosting the highest number of refugees.²

The forced migration is usually divided into pre-migration, migration, and post-migration period, each one bringing different stressful and traumatic experiences.³ The majority of studies of refugees from Middle East and Africa transiting to Europe were focused on the pre-migration and post-migration period, while the migration period, also known as transit, remained underresearched.

Refugees in a transit context

Transit describes the period refugees, asylum seekers, and migrantsd spend in countries they pass through to reach their intended destination.⁴ Although the term suggests a temporary phase, evidence shows that transit of refugees from Middle East or Africa to Europe can last from several days to up to several years, and vary depending on circumstances.⁵ During this time, refugees face additional life-threatening experiences, including dangerous journeys such as river and sea crossings,⁵ exposure to smugglers and human traffickers, harsh living conditions, and limited access to health, social services, and the labor market.^4,5

The transit also poses challenges for meeting refugees’ mental health needs. Recent findings showed that support for refugees in transit remains short-term and largely dependent on donor funding.⁶ Furthermore, the lack of consensus among practitioners regarding approaches to care in transit settings was documented.⁷ These findings highlight a significant risk of unmet mental health needs.

Refugees’ mental health

The mental health of refugees has been widely explored, primarily from a pathogenic perspective. Most studies showed higher prevalence of mental health difficulties among refugees compared to the general population.^3,8, 9, 10 This also applies for studies focused on refugees in Europe, which showed their mental health is harmed (e.g.11, 12, 13).

However, despite evidence that context significantly affects findings–such as higher prevalences of depression among resettled Syrian refugees in low-compared to middle-income countries,¹⁴ and numerous risks associated with transit⁵–most studies have been conducted in high-income and destination countries (e.g.11, 12, 13). There are few studies conducted specifically in the European transit context, which have broadly stated the presence of mental health problems among refugees,15, 16, 17 and demonstrated effects of traumatic events prior and during transit to mental health problems.^15,16,18, 19, 20 Studies also explored positive psychological aspects of psychological functioning such as hope,²¹ and posttraumatic growth²² However, what remains as a critical gap is a more comprehensive assessment of mental health of refugees in transit, including a trend analysis of mental health problems.

Present study

This study aims to address this gap by providing insights into the mental health of refugees originating from the Middle East and Africa and transiting to Europe. It focuses on the Western Balkan route,e the second most used migratory pathway to Europe for those moving from the Middle East, Eastern Mediterranean, and South Asia.²³

More specifically, this study focuses on Serbia as a case study of a transit context. In Serbia, authorities prioritize controlled migration over integration, and most funds are directed toward providing basic services rather than promoting long-term inclusion. Although national policies formally guarantee access to accommodation, education, healthcare, social assistance, and employment, these rights are largely limited in practice.^6,24

Furthermore, this study aims to present data on mental health trends among this population over a seven-year period. The period from 2017 to 2023 was marked by major global crises that posed significant challenges, especially for vulnerable populations. One of the most profound disruptions was the COVID-19 pandemic, which had particularly severe consequences for marginalized groups. Refugees, often residing in overcrowded and resource-limited settings, faced restricted access to hygiene supplies, healthcare, and social services.²⁵ The pandemic introduced additional difficulties, such as limitations on movement within countries, on cross-border travel, and, in some cases, lockdowns within collective accommodation.²⁶ In addition to the pandemic, this period was also defined by major shifts in border policies. Until 2016, the Balkan Route was open, allowing free passage toward Western Europe. However, beginning in March 2016, border closures were implemented, resulting in thousands of refugees becoming stranded in transit.²⁷ Their movement became increasingly difficult, leading to prolonged stays in inadequate conditions and increased uncertainty. Furthermore, strong anti-migrant movements began to rise and strengthen across Europe, and data from Serbia indicated extremely negative public attitudes towards refugees,²⁸ constituting a risk factor for discrimination, social exclusion, and consequently, poorer mental health outcomes.²⁰ Finally, this period also witnessed war, civic unrest, natural disasters, and humanitarian crises in countries of origin from which many refugees come, contributing to the large numbers of people seeking safety, but also increased stress among those who left their countries of origin but whose families and friends are still there. Taken together, the events that unfolded over the seven-year period represent significant stressors and sources of trauma. Investigating whether these global and regional developments are mirrored in mental health trends is essential for understanding the broader psychosocial impact of compounded adversity during displacement. By doing so, the study would highlight the importance of the sociopolitical context and fill an important gap in the existing refugee mental health research, which has predominantly interpreted mental health outcomes at the individual level and in relation to personally experienced stressful or traumatic events.

Therefore, the main aim of this study is to assess the mental health of refugees in transit. Moreover, it seeks to provide insights into mental health trends over a seven-year period and to link these trends with the wider sociopolitical context. The study also aims to identify particularly vulnerable subgroups of refugees in transit.

Methods

Study design

A series of repeated cross-sectional studies was conducted annually from 2017 to 2023.

Participants

A convenience sample was collected each year, comprising a total of 1375 refugees originating from the Middle East and Africa and residing in Serbia. The inclusion criteria were: at least 14 years old; and fluent in one or more of the following languages: Farsi, Arabic, French, or English. Participants were either accommodated in asylum and reception centers, social protection accommodation facilities in case of unaccompanied children, or privately accommodated. The majority of participants (87.2%) were male, with a mean age of 25.66 years (SD = 8.33), spanning from 14 to 65 years. Approximately 9.8% of the sample consisted of minors (ages 14–17). Almost half of the participants across years were the refugees from Afghanistan (47.0%), followed by Iran (15.7%) and Syria (11.0%). The initial composition of the sample highly corresponded to the refugee population transiting through Serbia, in regards to gender and country of origin.²⁴ However, to further enhance alignment with known population sociodemographic characteristics, data were weighted based on the official reports.

Measures

Refugee Health Screener 15 (RHS-15)

The instrument has been designed and validated for mental health screening of refugees. It consists of 15 items: the first 13 assess common symptoms of depression (5), anxiety (4), and PTSD (4); one item measures perceived overall coping capacity, and the final item is a current distress thermometer. Symptomatology items are presented alongside a five-point Likert-type scale (0 = not at all, 1 = a little bit, 2 = moderately, 3 = quite a bit, and 4 = extremely). For the assessment of overall coping capacities, the respondent is asked to indicate if they feel that they are 0 = able to handle anything that comes their way, 1 = able to handle most things that come their way, 2 = able to handle some things but not able to cope with other things, 3 = unable to cope with most things, and 4 = unable to cope with anything. Finally, on the distress thermometer, respondents are asked to indicate the level of distress during the past week on an 11-point scale (from 0 = no distress “Things are good” to 10 = extreme distress “I feel as bad as I ever have”). Those who score 12 or higher on the first 14 items and/or five or more on distress thermometers should be considered as screen positive. RHS-15 showed overall good psychometric properties in a previous study, with the Cronbach alpha for the scale being 0.95.²⁹

The demographic characteristics questionnaire included information about: age, gender, country of origin, international protection applications, level of education, marital/partner status, whether they have children, health status, and time of leaving the country of origin.

Procedure

Data were collected annually from 2017 to 2023, from April to July each year. Data collection was part of regular mental health screening research conducted by organization PINf in Serbia. Research data were collected using the paper-and-pencil method during field visits to accommodation centers Serbia, including 13 asylum or reception centers,g out of 18 that operated throughout the study period,³⁰ located in 12 cities across all geographical regions of the country,h or at the PIN's premises or partner organization's premises in Belgrade for adults participants who were privately accommodated,i or children who were accommodated at social protection facilities in the Belgrade area.j Four language versions of the RHS were administered, in English, French, Arabic, and Farsi. Data were collected by psychologists specialized in refugee mental health, supported by trained cultural mediators. Mediators were familiarized with the questionnaire in advance and assisted participants by explaining the study and addressing any questions. Participants were recruited through convenience sampling in accommodation centers by the research team, in cooperation with accommodation center staff. The sample was collected to maximize the number and heterogeneity of respondents. Potential participants were informed about the study and invited to attend group or individual information sessions where they could learn more about the research. Prior to participation, all participants were informed about the purpose and procedures of the study and invited to join. Those who met the inclusion criteria and agreed to participate provided written informed consent, or had their legal guardian provide consent on their behalf. The time needed to fill in the questionnaires was around 20 min. After the data collection process, participants were debriefed and were offered free psychological support available at the accommodation facilities where they were living, provided by local non-governmental organizations.

Ethics approval

The Institutional Review Board of the Department of Psychology of the Faculty of Philosophy, University of Belgrade provided ethical approval for the study (protocol numbers #2023-014, #2022-019, #2021-029, #2020-42, #2021-99, #2019-015). All participants included in the study had previously provided written informed consent.

Data analysis

Data were weighted to reflect the demographic composition of the refugee population transiting through Serbia for each year of the study period. Population data used for weighting were obtained from official annual reports of the Commissariat for Refugees and Migration of the Republic of Serbia through personal communication. Weights were calculated for each year based on gender (male/female), age category (child/adult), and geographical region (Middle East/Africa). For 2017, the proportion of children was estimated using projections derived from subsequent years, due to a lack of available data from the authorities. Cases with missing information on any of the three variables were weighted using available data. Weighting was performed in IBM SPSS Statistics 26. Detailed population parameters obtained from the Commissariat are provided in the Supplementary Material (see Table S8).

Participants with missing data on the RHS-15 were excluded from all analyses, while those with missing socio-demographic information were retained. Since no reference standards or state-level data exist on the duration of transit, we applied empirical criteria to limit extreme values and improve the interpretability of the findings with respect to the transit phase. Outliers on the months in transit variable were identified through boxplot inspection and excluded from the sample. We used two scores as originally proposed by the authors²⁹: the RHS total score (items 1–14) and the single-item distress score (item 15), along with a one-item measure of coping capacities (item 14). Single-item measures were included for descriptive purposes only. We calculated three subscale scores corresponding to symptoms of depression (items 1, 2, 4, 6, and 9), anxiety (items 3, 5, 7, and 8), and PTSD (items 10–13) due to their clinical relevance, face validity in capturing distinct symptom dimensions, and empirical support for the three-factor model.³¹

Descriptive statistics and intercorrelations were calculated for all study measures. Polynomial contrast analysis within one-way ANOVA was used to examine changes in symptom levels across seven time points. Trends up to the fifth order were tested to capture potential nonlinear patterns. Finally, to identify subgroups at greater risk of depression, anxiety, and PTSD symptoms, a linear mixed model with random intercepts for participants was applied to account for individual differences across repeated measurements. Symptom intensity was entered as the dependent variable, while symptom type (depression, anxiety, or PTSD) was modeled as a within-subject factor, and demographic variables as fixed between-subject predictors, including gender (male/female), international protection application (yes/no), having a partner (yes/no), having children (yes/no), being employed (yes/no), having health conditions (yes/no), age (in years), education (in degree stages), and months in transit (in months). Descriptive and trend analyses were performed on weighted data, whereas analyses examining associations between variables were conducted on unweighted data. All analyses were performed using IBM SPSS Statistics, version 22, with the linear mixed model estimated in JASP. The reporting of this study follows the STROBE guidelines.³²

Role of the funding source

The funding source was not involved in the study design, data collection, data analysis, interpretation of the data, or the writing of the manuscript.

Results

Socio-demographic characteristics of the sample collated across years are presented in Table 1, while year-by-year data are shown in Supplemental Material.

Table 1.

Socio-demographic characteristics of the total sample, weighted (2017–2023).

Variables	%
Gender
Male	87.2
Female	7.8
Missing	5.0
Home country
Afghanistan	47.0
Iran	15.7
Syria	11.0
Pakistan	6.1
Burundi	4.0
Morrocco	1.9
Iraq	2.1
Other	5.7
Missing	6.5
Applied for international protection in Serbia
Yes	16.9
No	39.7
Missing	43.4
Educational status
None	9.8
Elementary school graduate	10.1
Secondary school graduate	30.4
University graduate	6.9
Doctoral studies completed	1.1
Missing	41.8
Marital status
Not married	55.9
Married	29.2
Divorced	3.0
Widowed	0.5
Missing	11.4
Having children
Yes	15.6
No	37.5
Missing	46.9
Current employment status
Employed	3.8
Not employed	54.8
Missing	41.4
Suffering from acute or chronic health condition
Yes	17.3
No	54.4
Missing	28.3

Variables	Min	Max	M	SD
Age	14	65	25.66	8.328
Missing (n = 89)
Number of months spent in transit	0	84	23.44	19.915
Missing (n = 749)

Note. % value represents the valid percentages; Min, minimum value, Max, maximum value; M, mean; SD, standard deviation.

The average duration of transit was 23.44 months (SD = 19.915), though the median transit time was 16 months, reflecting the large variation in time spent in transit, ranging from less than one month to 84 months.

Descriptive statistics for the scales used in the study are presented in Table 2.

Table 2.

Descriptive statistics for the scales used in the study, weighted.

	M (sum)a	SD (sum)	Min	Max	zSk	zKu	α
RHS total	28.12	13.19	0	56	−1.364	−5.856	0.88
Depression	10.01	5.30	0	20	−1.015	−6.780	0.73
Anxiety	8.72	4.41	0	16	−1.667	−6.811	0.73
PTSD	7.84	4.71	0	16	−0.227	−7.841	0.76
Cope	1.54	1.24	0	4	5.818	−6.015	/
Distress	6.00	3.15	0	10	−5.273	−6.992	/

Note. RHS, Refugee Health Screener; PTSD, posttraumatic stress disorder symptoms; M(sum), mean of sum scores; SD, standard deviation of sum scores; Min, minimum; Max, maximum; zSk, standardized skewness; zKu, standardized kurtosis; α, measure of internal consistency (Cronbach alpha coefficients); N/A, not applicable.

^aRepresents a mean of sum scores, and thus does not directly reflect the differences in subscales' intensities due to unequal numbers of items per subscale.

While standardized skewness values for the RHS total score and its subscales indicated no substantial deviations from normality, kurtosis values revealed significant deviations, implying platykurtic distributions across scales. Both the cope and distress items exhibited significant deviations from normality in terms of both standardized skewness and kurtosis. While kurtosis indicated platykurtic distributions for both items, the cope item scores were positively skewed, reflecting concentration toward lower values, whereas distress item scores were negatively skewed, indicating concentration toward higher values. Acceptable reliability coefficients were obtained for all scales used in the study.

A total of 90.5% of participants screened positive on the RHS total or distress cut-off scores,³³ indicating the need for further psychological assessment and support. A total of 87.3% of participants met the RHS total cut-off score, while a majority (71.3%) also screened positive for distress. Participants reported moderate levels of depression, anxiety, and PTSD symptoms. Notably, despite this, most participants perceived themselves as able to cope with challenges, indicated by the relatively low mean value. More specifically, 25.8% of participants reported feeling able to cope with anything; 24.5% felt able to cope with most things; 28.2% indicated coping with some things; 12.8% reported being unable to cope with most things, while 8.8% reported feeling unable to cope with anything.

Correlations between RHS subscales are presented in Table 3.

Table 3.

Intercorrelations of measures used in the study, unweighted.

	RHS total	Depression	Anxiety	PTSD	Cope
RHS total	1
Depression	0.899∗∗∗	1
Anxiety	0.899∗∗∗	0.753∗∗∗	1
PTSD	0.854∗∗∗	0.626∗∗∗	0.669∗∗∗	1
Cope	0.297∗∗∗	0.185∗∗∗	0.188∗∗∗	0.183∗∗∗	1
Distress	0.533∗∗∗	0.461∗∗∗	0.504∗∗∗	0.463∗∗∗	0.125∗∗∗

Note. RHS, Refugee Health Screener; PTSD, posttraumatic stress disorder symptoms.

∗p < 0.05; ∗∗p < 0.01; ∗∗∗p < 0.001.

RHS total score and all subscales showed moderate to high intercorrelations, with a very high correlation between RHS total score and depression and anxiety subscales, suggesting substantial overlap. While this raises concerns about discriminant validity, the subscales are presented separately due to their clinical relevance and face validity in capturing distinct symptom domains.³¹

Seven-year data trends

Table 4 presents descriptive statistics for all measures in the study across seven years.

Table 4.

Descriptive statistics of measures used in the study across 7 years (2017–2023), weighted.

Measure	Year	N	Mean	SD	Std. Error	Min	Max	α
RHS tot	2017	246	2.234	0.928	0.059	0.00	4.00	0.87
	2018	282	1.966	0.883	0.053	0.00	4.00	0.86
	2019	160	1.819	0.987	0.078	0.00	3.93	0.90
	2020	177	1.980	0.955	0.072	0.00	3.86	0.90
	2021	146	2.293	1.063	0.088	0.00	4.00	0.91
	2022	159	1.915	0.941	0.075	0.00	4.00	0.88
	2023	207	1.841	0.806	0.056	0.00	3.57	0.85
	Total	1377	2.008	0.942	0.025	0.00	4.00	0.88
DEPR	2017	246	2.332	1.101	0.007	0.00	4.00	0.75
	2018	282	1.938	1.036	0.062	0.00	4.00	0.70
	2019	160	1.846	1.087	0.096	0.00	4.00	0.76
	2020	177	1.882	1.061	0.080	0.00	4.00	0.76
	2021	146	2.307	1.067	0.088	0.00	4.00	0.74
	2022	159	1.802	0.955	0.076	0.00	4.00	0.61
	2023	207	1.863	0.978	0.068	0.00	3.80	0.72
	Total	1377	2.002	1.060	0.029	0.00	4.00	0.73
ANX	2017	246	2.426	1.094	0.070	0.00	4.00	0.71
	2018	282	2.156	1.045	0.062	0.00	4.00	0.68
	2019	160	2.026	1.149	0.091	0.00	4.00	0.77
	2020	177	2.250	1.127	0.085	0.00	4.00	0.79
	2021	146	2.456	1.204	0.100	0.00	4.00	0.80
	2022	159	2.081	1.101	0.087	0.00	4.00	0.74
	2023	207	1.857	0.940	0.065	0.00	4.00	0.61
	Total	1377	2.180	1.102	0.030	0.00	4.00	0.73
PTSD	2017	246	2.136	1.165	0.074	0.00	4.00	0.71
	2018	282	1.929	1.103	0.066	0.00	4.00	0.69
	2019	160	1.637	1.221	0.096	0.00	4.00	0.83
	2020	177	1.912	1.191	0.090	0.00	4.00	0.78
	2021	146	2.230	1.324	0.110	0.00	4.00	0.82
	2022	159	1.956	1.211	0.096	0.00	4.00	0.78
	2023	207	1.902	1.034	0.072	0.00	4.00	0.74
	Total	1377	1.961	1.176	0.032	0.00	4.00	0.76
Cope	2017	246	1.360	1.380	0.088	0.00	4.00	/
	2018	282	1.500	1.142	0.068	0.00	4.00	/
	2019	160	1.580	1.230	0.097	0.00	4.00	/
	2020	177	1.660	1.126	0.085	0.00	4.00	/
	2021	146	1.820	1.374	0.114	0.00	4.00	/
	2022	159	1.640	1.303	0.103	0.00	4.00	/
	2023	207	1.420	1.129	0.079	0.00	4.00	/
	Total	1377	1.540	1.244	0.034	0.00	4.00	/
Distress	2017	246	6.840	3.050	0.195	0.0	10.0	/
	2018	282	6.050	3.156	0.188	0.0	10.0	/
	2019	160	5.040	2.859	0.226	0.0	10.0	/
	2020	177	5.950	3.035	0.228	0.0	10.0	/
	2021	146	6.520	3.482	0.288	0.0	10.0	/
	2022	159	5.930	3.323	0.263	0.0	10.0	/
	2023	207	5.400	2.869	0.200	0.0	10.0	/
	Total	1377	6.00	3.147	0.085	0.0	10.0	/

Note. RHS tot, RHS total score; DEPR, Depression; ANX, Anxiety; PTSD, Posttraumatic Stress Disorder symptoms.

To analyze trends in mental health symptomatology across a seven-year period, a one-way ANOVA with polynomial contrasts was conducted. RHS total score, depression, anxiety, and PTSD were used as dependent variables, and the year in which data were collected as a grouping variable.

Results revealed a statistically significant fifth-order trend for all measures analyzed. Specifically, the fifth-order contrast was significant for the RHS total score, F (1, 1369) = 10.656, p = 0.001, depression, F (1, 1369) = 9.499, p = 0.002, anxiety, F (1, 1369) = 5.949, p = 0.015, and PTSD subscale, F (1, 1369) = 10.177, p = 0.001. Detailed trends in mental health symptomatology across seven years are presented in Fig. 1.

Fig. 1.

Trends in mental health symptomatology across seven years (2017–2023).Note.The theoreticalrange of scores onthey-axis is 0–4. Higher scores indicate higher symptom severity.

These results indicate a complex, non-linear pattern of change over time and suggest that symptom levels fluctuated over time in a pattern that cannot be captured by simple linear or quadratic trends. Fluctuations in symptom severity were observed over the seven-year period, with notable peaks in 2017, followed by a decline, and subsequent increases in 2020 and 2021. Symptoms decreased again in 2022, with a slight uptick observed in 2023.

Finally, to identify subgroups at greater risk of depression, anxiety, and PTSD symptoms, a linear mixed model with random intercepts for participants was applied. Symptom intensity was entered as the dependent variable, while symptom type was modeled as a within-subject factor, and demographic variables as fixed between-subject predictors.

Results indicated a significant effect of symptom type on symptom intensity (F (2, 716) = 20.396, p < 0.001), with fixed-effect estimates showing that anxiety symptoms were significantly higher than both depression (t (716) = −3.172, p = 0.002) and PTSD (t (716) = −3.215, p = 0.001). Estimated marginal means further showed that anxiety symptoms were slightly higher than depression and PTSD (EM mean ± SE: anxiety = 2.378 ± 0.129, depression = 2.127 ± 0.129, PTSD = 2.126 ± 0.129), with virtually identical mean levels for depression and PTSD. In addition, only health conditions significantly predicted symptom intensity (F (1, 349) = 17.118, p < 0.001), whereas gender, age, education, international protection status, partner status, children, employment, and months in transit were not significant predictors. Full model details are provided in the Supplementary Material.

Discussion

This study aimed to provide insights into the mental health of refugees originating from the Middle East and Africa and residing in Serbia as a case study of a transit context along the route to Europe, using weighted data to increase alignment with population sociodemographic characteristics, i.e. gender, age category, and geographical region of origin. Furthermore, it aimed to present data on mental health trends among this population over a seven-year period and identify subgroups at risk.

Results showed that the vast majority of participants are at risk of developing mental health disorders and need further psychological assessment and support. A majority experience severe distress and moderate levels of depression, anxiety, and PTSD symptoms, with anxiety being the most prominent. Several studies conducted in Western Europe assessed the prevalence of mental disorders.^5,6 Although not directly comparable since the RHS is designed to assess symptom severity rather than diagnose mental disorders, these studies reach a corresponding conclusion that psychological distress among refugees is high.8, 9, 10 However, some findings from transit diverge from trends reported in post-settlement settings. For instance, our study showed anxiety symptoms are the most pronounced, while studies in destination countries mostly focused on high prevalences of depression and PTSD,¹⁴ and reported lower levels of anxiety compared to depression and PTSD,^8,9 even though inconsistency in findings is notable.¹⁰ One plausible interpretation is that the unpredictability and uncertainty intrinsic to the transit phase—marked by insecurity, unstable legal status, and constant movement—may disproportionately trigger anticipatory anxiety, excessive worry, and hypervigilance.

It is important to note that despite pronounced psychological problems, refugees in our study perceived themselves as capable of coping with challenges, although approximately one in five reported being unable to cope with most or any difficulties. Studies conducted in similar transit contexts have already documented the coexistence of psychological difficulties and strengths.²² During transit, individuals often focus on immediate survival tasks, which may temporarily enhance their perceived coping capacity despite considerable distress. Furthermore, their current geographic position—having already traversed a significant portion of the route and approaching Western Europe—may further support their coping efforts. The transient nature of this phase may thus prompt short-term psychological mobilization, as individuals frame their experience as temporary and draw on heightened resilience to endure it.

The results revealed a complex, non-linear trajectory of mental health symptomatology among refugees in transit over a seven-year period, with peaks observed in 2017, 2020 and 2021, and 2023.

The pronounced peak in 2017 coincides with major geopolitical changes, most notably the closure of the Balkan Route in March 2016.²⁷ This policy shift transformed the nature of transit from a swift passage toward destination countries to a prolonged period of waiting in transit countries, often in inadequate conditions.^26,27 It pushed refugees toward more dangerous transit routes, as reflected in the higher proportion of individuals who experienced pushbacks in 2017 compared to 2014 and 2015,³⁴ and additional stressful or traumatic events during these incidents, which have been shown to exert an incremental negative effect on mental health outcomes.⁵ These new circumstances likely intensified feelings of uncertainty, frustration, and helplessness. Moreover, delays in family reunification likely compounded psychological distress, particularly among those whose family and friends stayed in active conflict zones.

The subsequent decrease in symptom severity—most noticeable from 2018 onward—may reflect several concurrent processes. Some degree of situational adaptation may have occurred, with individuals adjusting expectations over time. The informal support networks, services, and peer-to-peer information exchange may have offered partial relief, and alternative smuggling routes became increasingly known, enabling some individuals to restore a sense of agency.

The deterioration of mental health symptoms among refugees in transit observed in 2020 and 2021 can likely be associated with the impact of the COVID-19 pandemic, which posed unique and severe challenges for this population. Refugees in transit experienced restricted access to hygiene resources, heightened exposure to health risks due to overcrowded living conditions, and further reduced access to healthcare and social services. This is well reflected in the data, indicating that three-quarters of refugees lacked anyone to turn to for support during difficult times throughout the pandemic.³⁵ In addition, pandemic-related mitigation measures significantly curtailed movement both within and across national borders, in which refugees spent a longer period in transit during the 2020 and 2021 pandemic years, compared to other years. In some transit countries, such as Serbia, complete lockdowns were imposed, leading to violations of human rights. These restrictions disrupted daily routines, social interactions, and access to essential support systems. Moreover, about two-thirds of refugees reported lacking information about the reasons for the lockdown measures introduced during the pandemic,³⁵ which likely constituted an additional burden, contributing to uncertainty, fear, and a diminished sense of control. An additional reason for the increase in mental health problems may lie in the rise of negative public attitudes towards refugees, as indicated by a study conducted during this period.²⁸ Such attitudes reflect a predominantly anti-migrant atmosphere, which contributes to discrimination and social exclusion—factors representing additional risks for poor mental health outcomes.²⁰

A slight resurgence of mental health symptoms was observed in 2023. This followed a decrease from 2021 to 2023 during a period of post-pandemic stabilization. While no single event can be identified as the contributing factor, this pattern coincides with multiple global crises that could have been associated with elevated psychological distress among refugees. Namely, in August 2021, the Taliban regained control of Afghanistan, the most represented country of origin among refugees in Serbia. This led to a sharp deterioration in civil rights, which deepened humanitarian needs. In 2022, mass protests erupted across Iran, the second most represented country of origin, due to widespread outrage over state repression involving arbitrary detentions and torture. The Syrian conflict remains one of the world's most persistent humanitarian crises, and as of 2023, 15.3 million people in Syria required humanitarian assistance. Finally, other recent conflicts in the Middle East and Africa, as well as natural disasters such as earthquakes in Turkey, which impacted refugee populations³⁶—may still be a risk factor for their mental health.

Overall, the findings suggest that socio-political developments may be closely reflected in the mental health of refugees in transit—relation already documented in general population studies,³⁷ underscoring the need to address mental health not only at the individual level but through broader systemic and societal approaches. The results carry important practical implications–large-scale crises, even when not explicitly recognized as mental health emergencies, can have substantial psychological consequences.

Similarly to research conducted in destination countries,³⁸ our results confirm that individuals with acute or chronic health problems are at significantly elevated risk of mental health problems. Poor health in unstable conditions where medical care is often unavailable adds further insecurity and may be a significant cause of mental health distress, likely exacerbating perceptions of threat and hopelessness.¹⁸ This finding reinforces the need for integrated health and psychosocial services, which are often limited in transit settings.³

Information on participants' legal status was not associated with mental health problems. One explanation for this could be the ambiguous meaning of asylum application status in this context. Applying for asylum does not necessarily reflect an individual's long-term intention. This is particularly relevant in the Serbian context, where expressing an intention to seek international protection is an administrative requirement for accessing accommodation centers and services. As such, this distinction may be more instrumental than substantive. Consequently, those seeking international protection and those who are not may not differ substantially in their psychological needs. Future studies should assess migration intentions and their mental health implications more systematically.

None of the socioeconomic variables were found to be related to mental health problems. This did come as a surprise, particularly regarding age and gender, for which robust evidence indicates that females and younger individuals are at higher risk for mental health problems.^37,39,40 Different aspects of this context may create risks and difficulties so profound that usual differences between socio-demographic groups become less relevant, as all subgroups are exposed to specific and often severe challenges. For instance, females may be more exposed to sexual violence, whereas males are often the ones taking riskier routes first and experiencing pushbacks. Younger individuals may face developmental vulnerabilities but may also experience fewer physical difficulties or be better technologically equipped, which enables easier access to information within the dynamic and constantly changing transit environment. Furthermore, there is typically more support available for children and women, while support for elderly people and men has been recognized as a significant gap.⁶ Finally, family structure may represent both a protective and a risk factor.⁴¹ On one hand, it can provide a sense of belonging and stability within unstable circumstances, on the other hand, it may bring additional stress related to ensuring the safety of family members in a dangerous environment. Employment status was also not associated with psychological outcomes. This may reflect the instability of labor and temporality of stay in transit contexts, where employment is often informal and may not offer the same protective functions as it does in stable settings. Finally, one possible explanation for the absence of significant effects for these predictors may be an unbalanced distribution within these variables, which likely reduced the statistical power to detect potential differences.

Interestingly, the total time in transit was not associated with mental health outcomes. This may suggest that the quality and intensity of specific experiences play a more critical role than duration alone.²⁰

Several limitations of this study should be acknowledged. First, due to non-probability sampling and lack of representativity, the generalizability of the findings remains limited. Nonetheless, the data were weighted to increase alignment with population sociodemographic characteristics, including gender and age, and geographical region. However, while the existing weights allow for some population-level inferences, they cannot resolve selection bias, sampling frame limitations, or lack of alignment to unknown parameters in the population. Second, although some validation studies of RHS have been conducted (e.g.^29,33,42), these were based on limited samples, contexts, and language versions. Therefore, the validity of RHS-15 translations used in this study and in this context remains to be further examined. However, this instrument is deliberately selected to minimize participant burden and ensure feasibility across multiple years and locations with limited resources for research implementation. In addition, the used instrument showed robust psychometric properties and was specifically developed for use with refugee populations. An additional limitation related to mental health assessment is the exclusive reliance on the RHS, which is a screening tool and does not allow conclusions about clinical diagnoses or a detailed assessment of symptom severity. Future studies should include structured clinical interviews or additional diagnostic instruments to provide a more comprehensive understanding of the prevalence and nature of mental health outcomes. Third, data on response rates, as well as reasons for non-participation, were not consistently recorded due to ethical concerns and logistical challenges. Since the study was conducted with an underprivileged and vulnerable population, ensuring that participation is genuinely voluntary was set as a priority. Requiring individuals to formally refuse participation or to provide reasons for non-participation might have introduced perceived pressure, and seemed ethically inappropriate and harmful, especially given the power asymmetries present in settings where refugees live. This limits our ability to assess the potential bias associated with non-participation, such as response bias. Fourth, while we attempted to interpret trends in mental health data across the seven-year period by contextualizing them with socio-political events, we did not systematically collect data on participants' subjective experiences or perceptions of contextual changes. Future research should include such measures to better understand the mechanisms underlying observed trends. Fifth, we did not collect data on individual traumatic or stressful experiences. We chose not to include these measures primarily to avoid potential risks of stress and retraumatization for participants. Moreover, the association between traumatic stress and mental health outcomes has already been robustly established, including in this context.^5,19,20 Sixth, although we collected information on participants' legal status, these data should be interpreted with caution. Applying for asylum does not necessarily reflect the individual's long-term intentions, as indicated by studies conducted in Serbia documenting how many times refugees have tried to cross the border.¹⁷ Future studies should assess the relationship between migration intentions and mental health implications more systematically. Seventh, our study focuses on refugees transiting along the Western Balkan route using Serbia as a case study of a transit context,^17,43 and due to contextual differences, the generalizability of findings beyond this specific route is limited. Furthermore, our research focuses on refugees in transit, and even though the duration of transit varied among participants consistently with previous research,³⁴ we acknowledge these differences in both the length and nature of the transit experience indicate heterogeneity of the sample, which may limit generalizability of the findings. Eight, although our study aimed to include refugees and asylum seekers, at the time of data collection, it was not possible to determine whether participants would ultimately be granted international protection. While we acknowledge that these distinctions may influence individuals' transit experiences, due to the absence of objective criteria for determining eligibility for legal protection in Serbia, all participants in our study were treated equally, based on the shared criterion that they were registered within Serbia's official asylum system. Finally, underreporting of symptoms may have occurred due to stigma or fear of judgment. On the contrary, some individuals may exaggerate symptoms to positively influence asylum procedures. However, many participants had not applied for asylum, and all of them were informed that responses would have no impact on their legal status or access to services.

This study offers rare insights into the mental health of refugees from the Middle East and Africa in transit to Europe. The high prevalence of those who screened positive for mental health problems underscores the need for the availability of psychological assessment and adequate support along transit routes. Furthermore, the study identifies subgroups who are at elevated risk and may require more targeted and intensive support. This information is especially valuable for countries with limited resources where efficient prioritization of services is sometimes required. Finally, our study addresses a gap in refugee mental health research, which has largely focused on individual-level mental health outcomes linked to personal trauma. By highlighting the broader sociopolitical context, our findings provide a complementary perspective on factors associated with mental health. The findings emphasize that mental health should not be addressed solely at the individual level. Broader systemic and societal interventions are also necessary, given that socio-political developments are closely reflected in mental health outcomes. The study highlights the critical importance of dedicating resources to mental health protection and care during large-scale crises, which affect not only directly impacted populations but also those indirectly exposed.

Conclusion

The findings highlight the substantial mental health burden faced by refugees from the Middle East and Africa in transit to Europe, and identify a specific vulnerable subgroup. The results demonstrate how broader socio-political events are reflected in mental health trends, emphasizing that mental health cannot be addressed in isolation from wider contextual factors. This study draws attention to the transit phase as a critical stage in the refugee journey, and advocates for systemic, timely, and context-sensitive mental health interventions.

Contributors

Conceptualization–Maša Vukčević Marković;, Jana Dimoski; data curation–Maša Vukčević Marković;, Jana Dimoski, Draga Šapić formal analysis–Maša Vukčević Marković;, Jana Dimoski funding acquisition–Maša Vukčević Marković;, Draga Šapić;, lsidora Živić, lrena Stanković;, Aleksandra Bobić;, lrena Stojadinović Vujičić investigation–Maša Vukčević Marković;, Draga Šapić;, lsidora Živić, lrena Stanković;, Aleksandra Bobić;, lrena Stojadinović Vujičić;, Jana Dimoski; methodology–Maša Vukčević Marković;, Jana Dimoski; project administration–Maša Vukčević Marković;, Draga Šapić;, lsidora Živić, lrena Stanković;, Aleksandra Bobić;, lrena Stojadinović Vujičić;, Jana Dimoski; Writing–original draft–Maša Vukčević Marković;, Draga Šapić;, lsidora Živić, lrena Stanković;, Aleksandra Bobić;, lrena Stojadinović Vujičić;, Jana Dimoski; Writing–review & editing–Maša Vukčević Marković;, Jana Dimoski.

Data sharing statement

All of the individual participant data collected during the trial will be available after de-identification. The statistical analysis plan and informed consent form will be available. The data will be available to any researcher who wishes to access the data for any purpose. The data that support the findings of this study are openly available indefinitely in OSF at https://doi.org/10.17605/OSF.IO/48J2M.

Declaration of interests

UNHCR Serbia, the Open Society Foundation, IOM, the Swiss Agency for Development and Cooperation, and the Karl Kahane Foundation provided funding for the study.

MVM was engaged under grants funded by Save the Children North West Balkans and Balkans Migration and Displacement Hub, the Karl Kahane Foundation, UNICEF Serbia, Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ). The Ministry of Education, Science and Technological Development of the Republic of Serbia provided funding for part of the MVM salary. MVM is the founder of the Consortium on Mental Health of Refugees in Transit (CoReMH) and served as coordinator of its working groups. MVM is co-coordinator of the Working Group for the Protection and Improvement of the Mental Health of Refugees in Serbia, together with representatives of WHO Serbia and the Commissariat for Refugees and Migration of the Republic of Serbia.

DŠ was engaged under grants funded by Save the Children North West Balkans and Balkans Migration and Displacement Hub, the Karl Kahane Foundation, UNICEF Serbia, Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ). DŠ is the founder of the Consortium on Mental Health of Refugees in Transit (CoReMH) and served as coordinator of its working groups.

IŽ was engaged under grants funded by the Karl Kahane Foundation, UNICEF Serbia.

IS was engaged under grants funded by IOM, the Swiss Agency for Development and Cooperation, the Karl Kahane Foundation, UNICEF Serbia.

AB was engaged under grants funded by Karl Kahane Foundation, UNICEF Serbia.

ISV was engaged under grants funded by Save the Children North West Balkans and Balkans Migration and Displacement Hub, the Karl Kahane Foundation, UNICEF Serbia. The Ministry of Education, Science and Technological Development of the Republic of Serbia provided funding for part of the ISV salary. ISV was co-coordinator of the Working Group for the Protection and Improvement of the Mental Health of Refugees in Serbia, together with representatives of WHO Serbia and the Commissariat for Refugees and Migration of the Republic of Serbia.

JD was engaged under grants funded by the Karl Kahane Foundation, UNICEF Serbia, Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ). The Ministry of Education, Science and Technological Development of the Republic of Serbia provided funding for part of the JD salary.

The funding sources were not involved in the study design, data collection, data analysis, interpretation of the data, or the writing of the manuscript. The authors declare no other competing interests.