The prevalence of mental illness in refugees and asylum seekers: A systematic review and meta-analysis

Rebecca Blackmore; Jacqueline A Boyle; Mina Fazel; Sanjeeva Ranasinha; Kylie M Gray; Grace Fitzgerald; Marie Misso; Melanie Gibson-Helm

doi:10.1371/journal.pmed.1003337

. 2020 Sep 21;17(9):e1003337. doi: 10.1371/journal.pmed.1003337

The prevalence of mental illness in refugees and asylum seekers: A systematic review and meta-analysis

Rebecca Blackmore ¹, Jacqueline A Boyle ¹, Mina Fazel ², Sanjeeva Ranasinha ¹, Kylie M Gray ^3,⁴, Grace Fitzgerald ¹, Marie Misso ¹, Melanie Gibson-Helm ^1,^*

Editor: Paul Spiegel⁵

PMCID: PMC7505461 PMID: 32956381

Abstract

Background

Globally, the number of refugees and asylum seekers has reached record highs. Past research in refugee mental health has reported wide variation in mental illness prevalence data, partially attributable to methodological limitations. This systematic review aims to summarise the current body of evidence for the prevalence of mental illness in global refugee populations and overcome methodological limitations of individual studies.

Methods and findings

A comprehensive search of electronic databases was undertaken from 1 January 2003 to 4 February 2020 (MEDLINE, MEDLINE In-Process, EBM Reviews, Embase, PsycINFO, CINAHL, PILOTS, Web of Science). Quantitative studies were included if diagnosis of mental illness involved a clinical interview and use of a validated assessment measure and reported at least 50 participants. Study quality was assessed using a descriptive approach based on a template according to study design (modified Newcastle-Ottawa Scale). Random-effects models, based on inverse variance weights, were conducted. Subgroup analyses were performed for sex, sample size, displacement duration, visa status, country of origin, current residence, type of interview (interpreter-assisted or native language), and diagnostic measure. The systematic review was registered with PROSPERO (CRD) 42016046349. The search yielded a result of 21,842 records. Twenty-six studies, which included one randomised controlled trial and 25 observational studies, provided results for 5,143 adult refugees and asylum seekers. Studies were undertaken across 15 countries: Australia (652 refugees), Austria (150), China (65), Germany (1,104), Italy (297), Lebanon (646), Nepal (574), Norway (64), South Korea (200), Sweden (86), Switzerland (164), Turkey (238), Uganda (77), United Kingdom (420), and the United States of America (406). The prevalence of posttraumatic stress disorder (PTSD) was 31.46% (95% CI 24.43–38.5), the prevalence of depression was 31.5% (95% CI 22.64–40.38), the prevalence of anxiety disorders was 11% (95% CI 6.75–15.43), and the prevalence of psychosis was 1.51% (95% CI 0.63–2.40). A limitation of the study is that substantial heterogeneity was present in the prevalence estimates of PTSD, depression, and anxiety, and limited covariates were reported in the included studies.

Conclusions

This comprehensive review generates current prevalence estimates for not only PTSD but also depression, anxiety, and psychosis. Refugees and asylum seekers have high and persistent rates of PTSD and depression, and the results of this review highlight the need for ongoing, long-term mental health care beyond the initial period of resettlement.

In a systematic review and meta analysis, Rebecca Blackmore and colleagues investigate the prevalence of mental illness among adult refugees and asylum seekers in studies undertaken across 15 countries.

Author summary

Why was this study done?

Globally, the numbers of refugees and asylum seekers have reached record highs.
This systematic review aims to estimate how common mental illnesses are in current adult refugee and asylum-seeker populations.

What did the researchers do and find?

We performed a comprehensive literature search looking for studies that diagnosed mental illness in refugee and asylum-seeker populations.
For studies to be included, the diagnosis must have resulted from a clinical interview using a validated diagnostic assessment measure.
We found adult refugee and asylum seekers have high and persistent rates of posttraumatic stress disorder (PTSD) and depression. The prevalence of anxiety disorders and psychosis are more comparable to findings from general populations.

What do these findings mean?

The increased prevalence of PTSD and depression appears to persist for many years after displacement.
These results highlight the importance of early and ongoing mental health care, extending beyond the period of initial resettlement, to promote the health of refugees and asylum seekers.

Introduction

Globally, the numbers of refugees and asylum seekers have reached record highs [1]. Ongoing conflicts around the world raise challenging social, political, and humanitarian issues [2]. For host-country health systems, the refugee crisis can have major implications for service planning and provision. Refugees and asylum seekers may have been exposed to traumatic events such as conflict, loss or separation from family, a life-threatening journey to safety, long waiting periods, and complexities with acculturation [3,4]. A sizable proportion are therefore at risk of developing psychological symptoms and major mental illness that can persist for many years after resettlement [5].

Estimates of the prevalence of mental illness in refugees vary greatly, even at the level of systematic reviews. Fazel and colleagues (2005) [6] conducted a systematic review and meta-analysis of refugees resettled in high-income countries, covering the period 1986–2004, and reported a prevalence of 9% for posttraumatic stress disorder (PTSD), 5% for major depressive disorder, and 4% for generalised anxiety disorder, based on studies reporting at least 200 participants. A subsequent systematic review into the association between torture or other traumatic events and PTSD and depression, covering studies between 1987 and 2009 and comprising 81,866 refugees and conflict-affected populations, reported an unadjusted weighted prevalence of 30% for PTSD and 30% for depression [7]. A recent systematic review of 8,176 Syrian refugees resettled in 10 countries reported a prevalence of 43% for PTSD, 40% for depression, and 26% for anxiety [8]. As the literature has focused on either specific cultural groups or specific host nations or has combined internally displaced populations with refugees and asylum seekers, there is a lack of estimates on the prevalence of mental illness in more representative refugee and asylum-seeker populations [9–12]. There is also a lack of research investigating the full breadth of mental illness, as the literature has mainly focused on PTSD and depression, hence the need for a comprehensive, worldwide, systematic review to investigate mental illness in the current refugee populations.

Some of the variation across individual studies may be attributable to methodological differences. For example, self-report measures tend to overestimate symptomatology, yet the literature relies heavily on these data rather than comprehensive psychiatric assessments using validated diagnostic tools [7,13]. There is also no uniform refugee experience: country of origin or resettlement, duration of displacement, or experience of displacement, amongst other important factors.

Given the changing nature of forced displacement and record numbers of refugees and asylum seekers, it is timely to reexamine this topic based on the many studies published since the two previously mentioned major reviews. Current prevalence information could be a powerful tool for advocacy and also assist host countries and humanitarian agencies to strengthen health services to provide the essential components of timely diagnosis and treatment for mental illnesses, in line with the priorities and objectives of the World Health Organization (WHO) Draft Global Action Plan ‘Promoting the health of refugees and migrants’ (2019–2023) [14]. Providing appropriate, early, and ongoing mental health care to refugees and asylum seekers benefits not only the individual but the host nation, as it improves the chances of successful reintegration, which has long-term benefits for the social and economic capital of that country, which will likely impact not only the displaced generation but the second generation as well [15]. Bringing together the global literature on the prevalence of mental illness in refugee and asylum-seeker populations would also enable the research community to move ahead and focus on different components of the mental health needs of this population, for example, on interventions, on less well-understood mental health conditions, or longitudinal mental health trajectories.

This systematic review aims to establish the current overall prevalence of mental illnesses in refugee and asylum-seeker populations by summarising the current global body of evidence and overcoming some methodological limitations of individual studies.

Methods

Search strategy and selection criteria

We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement (S1 Prisma Checklist) [16] and registered the protocol with PROSPERO (record CRD42016046349) (https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=46349). The search was based on that used in the earlier systematic review by Fazel and colleagues [6] but expanded to increase the range of databases searched, number of search terms, and stricter criteria regarding study inclusion. This review also placed no restrictions on resettlement countries. In total, eight databases were searched: MEDLINE, MEDLINE In-Process, EBM Reviews, Embase, PsycINFO, CINAHL, PILOTS, Web of Science. The search strategy included terms for refugees and asylum seekers and terms related to mental illness, diagnosis, and trauma. An example of a complete search string is provided in S1 Table. The date limits of the search were 1 January 2003 to 4 February 2020. This start date reflects the end date of the search conducted by Fazel and colleagues [6], in order to provide a contemporary estimate of mental illness within this population. The reference lists of 92 relevant systematic reviews identified during the search were also screened, resulting in an additional 37 articles to review.

Studies were included if (1) the sample solely comprised adult refugees and/or asylum seekers residing outside their country of origin, (2) had a sample size larger than 50, and (3) reported quantitative prevalence estimates of a mental illness as classified by the Diagnostic and Statistical Manual of Mental Disorders (DSM) [17] or the International Classification of Disease (ICD) [18]. This diagnosis must have resulted from a clinical interview using a validated diagnostic assessment measure. The interview needed to be conducted either by a mental health professional (psychiatrist, psychologist, psychiatric nurse) or trained paraprofessional (psychology research assistant, trained researcher). In studies administering the WHO World Mental Health Composite International Diagnostic Interview (WMH-CIDI) [19], nonclinicians who had completed official WHO training were accepted, as this fully structured interview measure is intended for use by trained lay interviewers. If multiple articles reported data from the same study, the article providing data best meeting the selection criteria was included. Randomised controlled trials (RCTs), longitudinal cohort, and cross-sectional studies were considered for inclusion, whereas retrospective registry reviews, medical records audits, and qualitative studies were excluded. Case-control studies were excluded if cases were selected based on the presence of our outcomes of interest.

Studies were excluded if they met the following criteria:

Participants were recruited from psychiatric or mental health clinics (to reduce selection bias). However, those studies that recruited participants from primary healthcare clinics were still included.

The sample included asylum seekers whose applications had been rejected and the results were not disaggregated or the assessment was not conducted prior to rejection (when the individuals met the definition of asylum seekers).
Diagnoses were based solely on self-report questionnaires or symptom rating scales.

Two reviewers (RB and MG-H or GF) independently assessed the title, abstract, and keywords of every article retrieved against the selection criteria. Full text was then assessed if the title and abstract suggested the study met the selection criteria. We contacted 31 study authors for further information regarding methodology and data and received 28 responses. Studies in languages other than English were assessed first by a native speaker when possible or via Google translate and then professionally translated if assessed as potentially eligible.

Data analysis

Using a fixed protocol, two review authors (RB and MG-H) independently extracted statistical data and study characteristics: host country, publication year, sample size, country or region of origin, sampling method, diagnostic tool and criteria, use of interpreter, age, proportion of female participants, visa status, duration of displacement, and prevalence of mental illness (numerator and denominator). Data regarding the sex distribution of samples were extracted separately for males and females, when possible.

Meta-analysis results (Stata software version 14.1 [StataCorp]) were expressed as prevalence estimates of mental illness calculated with 95% confidence intervals (CIs) in the pooled data. Random-effects meta-analyses using a DerSimonian and Laird estimator based on inverse variance weights were employed [20]. Random-effects meta-analysis was chosen, as heterogeneity was anticipated because of between-study variations in clinical factors due to the heterogenous nature of refugees and asylum seekers (e.g., country of origin, language, host nations, etc.). The DerSimonian and Laird method incorporates a measure of the heterogeneity between studies. Heterogeneity was assessed using the I² statistic [21]. In the case of five or more studies being available, publication bias was assessed by visual inspection of funnel plots and applying Egger’s test set at a threshold of a p-value less than 0.05 to indicate funnel plot asymmetry [22]. Prevalence rates were for current diagnoses, except studies reporting 1-year prevalence as assessed by the WHO WMH-CIDI [23–25].

Sources of heterogeneity between studies were investigated, when reported data allowed, by subgroup analyses. This included sex, sample size, displacement duration, visa status, country or region of origin, current residence, type of interview (interpreter-assisted or native language), and diagnostic measure. As prevalence of mental illness is related to sample size [6], the subgroup analysis for sample size compared studies with more or less than 200 participants.

Risk of bias assessment

Methodological quality was independently assessed by two reviewers (RB and JAB) using an assessment template for risk of bias, developed a priori according to study design, which meant the criteria to assess an RCT were different from the criteria of an observational study (S1 Risk of Bias) [26]. These templates are based upon the Newcastle-Ottawa Scale (NOS) [27], with the addition of further risk of bias components assessing internal and external validity such as use of appropriate study design, explicit and appropriate use of inclusion criteria, reporting bias, confounding, sufficient power for analyses, and any apparent conflicts of interest, as has been used in international evidence-based guidelines and other systematic reviews [28–30]. Using a descriptive approach, studies were assigned a rating of low, moderate, or high risk of bias. Any disagreement was resolved by discussion with other reviewers (MG-H and MF) to reach a consensus. Such discussions occurred on two occasions, both times regarding papers assigned at high risk of bias [31,32].

Results

The entire search yielded 21,842 records (Fig 1). After removing duplicates, 12,517 records were excluded based on title and abstract and a further 1,186 records were selected for full text review. Twenty-six studies met the inclusion criteria, providing data for 5,143 adult refugees and asylum seekers (Fig 1). Characteristics of the included studies are provided in Table 1. All were observational, except one RCT from which we included baseline prevalence data [24]. Studies were undertaken in 15 countries: Australia (652 refugees) [33–37], Austria (150) [38], China (65) [32], Germany (1,104) [39–44], Italy (297) [39], Lebanon (646) [45,46], Nepal (574) [25], Norway (64) [23], South Korea (200) [47], Sweden (86) [48], Switzerland (164) [49,50], Turkey (238) [51], Uganda (77) [24], UK (420) [39,52], and the US (406) [31,53]. Participants were from four geographic regions: the Middle East (43%), Europe (29%), Asia (20%), and Africa (5%), with two studies reporting refugee samples coming from 18 different countries (3%) [26, 41] (97% of total sample due to unreported countries of origin).

Table 1. Characteristics of included studies.

Study	Country or Region of Origin	Sampling	Instrument and Criteria	Interview in Native Language	N	Age: Years M (SD)	Female: %	PTSD (%)	DEP (%)	ANX (%)	PSY (%)	Risk of Bias
Bogic et al., 2012 [39] (Germany, Italy, and UK)	Former Yugoslavia	In Germany and Italy, refugees contacted via resident registry lists. In UK, refugees contacted via community organizations and snowball techniques.	M.I.N.I. DSM-IV	Yes	854	41.6 (10.8)	51.29	283 (33.14)	292/851 (34.31)	74/854 (7.36)	11 (1.29)	Mod.
Charney and Keane, 2007 [31] (USA)	Former Yugoslavia	Advertised psychological treatment study for Bosnian refugees suffering the effects of the Balkans’ civil war.	SCID DSM-IV	Yes	115	46 (13.78)	67	NA	NA	NA	9 (8)	High
Eckart et al., 2011 [40] (Germany)	Albania, Serbia, Romania, and Turkey	Recruited participants from shelters for asylum seekers and Kurdish recreational facilities.	CAPS and M.I.N.I. DSM-IV	No	52	PTSD group: 36.2 (7.7) Trauma controls: 34.1 (9.9) Nontrauma controls: 29 (7.2)	0	20 (38.46)	17 (32.69)	NA	NA	Low
Heeren et al., 2012 [49] (Switzerland)	Europe, Africa, and Asia	Two groups sampled consecutively from lists provided every 2 weeks for 6 months from the national register of adult asylum seekers in Switzerland.	M.I.N.I. DSM-IV	No	86	Group 1: 26.7 (7.2) Group 2: 32.9 (9.6)	30.23	20 (23.25)	27 (31.39)	7 (8.13)	NA	Low
Hocking et al., 2018 [36] (Australia)	Africa and Asia	Consecutive sample populations of ‘general-access-listed’ clients at ASRC and Refugee Health Clinic, Dental Clinic in Victoria, Australia.	M.I.N.I. DSM-IV	No	185	33	30.3	38 (20.7)	56 (30.3)	6 (3.2)	2 (1)	Mod.
Jakobsen et al., 2011 [23] (Norway)	Middle East, North Africa, Somalia, and former Yugoslavia	12 reception centres, all eligible asylum seekers (i.e., stay in Norway 4 months, age > 18 years, and speakers of one of the included languages).	WHO-CIDI DSM-IV	No	64	33 (11.6)	46.88	29 (4.31)	21 (32.81)	17 (26.56)	1 (1.56)	Low
Jeon et al., 2005 [47] (South Korea)	North Korea	All North Korean refugees living in Seoul (July 1998–November 2000) were contacted via telephone and asked to participate.	SCID DSM-III	Yes	200	34.7 (10.3)	41.5	59 (29.50)	NA	NA	NA	Low
Kazour et al., 2017 [46] (Lebanon)	Syria	Household survey on refugees between 18 and 65 years old in six Central Bekaa camps in Lebanon.	M.I.N.I. DSM-IV	Yes	452	35.05 (12.35)	55.75	123 (27.21)	NA	NA	NA	Low
Kizilhan, 2018 [42] (Germany)	Iraq	Participants were part of special quota project in Baden-Wuerttemberg to support women escaped from IS.	SCID DSM-IV	Yes	296	23.72 (2.6)	100	144 (48.6)	158 (53.4)	116 (39.1)	NA	High
Llosa et al., 2014 [45] (Lebanon)	Palestine	Selected households chosen from the Burj el-Barajneh camp in southern Beirut, Lebanon.	M.I.N.I. DSM-IV	Yes	194	41.5 (15)	71.13	9 (4.64)	31 (15.98)	15 (7.73)	5 (2.58)	Low
Maier et al., 2010 [50] (Switzerland)	18 different countries: Asia, Africa, and Europe	List provided by Swiss Federal Office for Migration, all adult (18+ years old) asylum seekers applying after 1 August 2007 and assigned to the Zurich canton.	M.I.N.I. DSM-IV	No	78	29.9 (8.4)	26.92	19 (24.36)	26 (33.33)	8 (10.26)	NA	Low
Momartin et al., 2004 [33] (Australia)	Former Yugoslavia	The Bosnian Resource Centre provided a list of names. In order to obtain additional participants, a snowball technique was also utilised.	CAPS and SCID DSM-IV	No	126	47 (NR)	61.11	79 (62.70)	58 (46.03)	NA	NA	Mod.
Neuner et al., 2004 [24] (Uganda)	Sudan	Participants randomly chosen from list of respondents who had previously been randomly selected in a hut-to-hut survey at the Imvepi Settlement in Uganda.	WHO-CIDI DSM-IV	No	77	NR (NR)	NR	43 (55.84)	NA	NA	NA	Low
Rees et al., 2019 [37] (Australia)	Middle East, Sri Lanka, and Sudan	The study was conducted at three public antenatal clinics in Sydney and Melbourne, Australia. At first appointment, women were identified by clinic records through requests for interpreters, culturally recognizable surname, and country of birth data.	M.I.N.I. DSM-IV	Yes	289	30 (5.8)	100	NA	94 (32.5)	NA	NA	Low
Renner et al., 2006 [38] (Austria)	Chechnya, West Africa, Afghanistan	All participants had applied for political asylum in Austria.	CAPS DSM-IV	No	150	Chechnya: 32.4 (10.7) West Africa: 32.5 (7.1) Afghanistan: 27.5 (9)	26.67	38 (25.33)	NA	NA	NA	Low
Richter et al., 2018 [43] (Germany)	Middle East, Russia, Azerbaijan	Asylum seekers from an admission centre in southern Germany. Two samples; help seekers, those responding to flyers regarding psychiatric services, and random sample, randomly selected residents of the centre.	M.I.N.I. ICD-10	Yes	283	31.9 (10.6)	44	58 (20.5)	62 (21.9)	11 (3.8)	3 (1)	High
Silove et al., 2010 [34] (Australia) Data obtained from same refugee population used by Momartin et al., 2004 [33]	Former Yugoslavia	The Bosnian Resource Centre provided a list of names. In order to obtain additional participants, a snowball technique was also utilised.	ASA-SI DSM-IV	No	126	47 (NR)	61.11	NA	NA	22 (17.46)	NA	Mod.
Sondergaard and Theorell, 2004 [48] (Sweden)	Iraq	Recently resettled refugees from Iraq.	CAPS DSM-IV	No	86	34.7 (7.7)	37.21	32 (37.21)	NA	NA	NA	Low
Tay et al., 2013 [35] (Australia)	Refugees in Australia from 18 different countries covering Middle East, Africa, Asia	Participants selected using cluster-probabilistic sampling method. Randomly approached 87 migration agents who had represented asylum seekers during a 12-month period (2001–2002).	SCID DSM-IV	No	52	39 (13.5)	34.61	31 (59.61)	30 (57.69)	NA	NA	Low
Tekin et al., 2016 [51] (Turkey)	Iraq	Yazidi refugees displaced from Shengal region in Iraq and entered Turkey between July and September 2014 and living in camp (February–April 2015) in the Cizre district of Turkey.	SCID DSM-IV	Yes	238	32.7 (11.87)	55.88	102 (42.86)	94 (39.50)	NA	NA	Mod.
Turner et al., 2003 [52] (UK)	Kosovo	Participants recruited from five reception centres in the north of England for refugees from Kosovo (November 1999–January 2000).	CAPS DSM-IV	Yes	118	37.1 (14.7)	53.33	46 (38.98)	NA	NA	NA	Mod.
Van Ommeren et al., 2004 [25] (Nepal)	Bhutan	Participants randomly selected from United Nations camp list of Bhutanese refugees.	WHO-CIDI ICD-10	Yes	574	Shamans: 51.3 (11.7) Nonhealers: 43.7 (12.9)	0	154 (26.8)	11 (1.92)	27 (4.70)	NA	Mod.
von Lersner et al., 2008 [41] (Germany)	Bosnia, Serbia, Kosovo, Iraq, Turkey	Participants recruited by advertisements posted in refugee centres, language schools, and doctors’ offices. Organizations involved in the return of refugees were contacted.	M.I.N.I. DSM-IV	No	100	43.2 (14.9)	50	NA	42 (42.00)	2 (2.00)	NA	Mod.
Wright et al., 2017 [53] (USA)	Iraq	Adult Iraqi refugees randomly selected from population who arrived in Michigan between October 2011 and August 2012. Recruited with collaboration of three resettlement agencies.	SCID DSM-IV	Yes	291	34.30 (11.37)	45.7	11 (3.78)	8 (2. 75)	NA	NA	Low
Wulfes et al., 2019 [44] (Germany)	Middle East and Sudan	Asylum seekers living in refugee accommodation (Braunschweig) Residents were asked to participate by staff at centre, social workers, research team, and flyers.	SCID DSM-5	No	118	32.9 (13.1)	35.6	35 (29.7)	39 (33.1)	NA	NA	Mod.
Yu and Jeon, 2008 [32] (China)	North Korea	Refugees over 15 years of age who were in protective facilities in China under the South Korean government protection.	SCID DSM-IV	Yes	65	NR (NR)	70.77	3 (4.61)	NA	NA	NA	High

Open in a new tab

Abbreviations: ANX, anxiety; ASA-SI, Adult Separation Anxiety Semistructured Interview; ASRC, Asylum Seeker Resource Centre; CAPS, Clinician Administered PTSD Scale; DEP, depression; DSM-IV, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition; ICD-10, International Classification of Disease, 10th Edition; IS, Islamic State; M, mean; Mod., moderate; M.I.N.I., the Mini-International Neuropsychiatric Interview; N, number; NA, not assessed in study; NR, not reported PSY, psychosis; PTSD, posttraumatic stress disorder; SCID, Structured Clinical Interview for DSM; SD, standard deviation; WHO-CIDI, World Health Organization–Composite International Diagnostic Interview

Five diagnostic measures were used (S1 Table): Structured Clinical Interview for DSM (SCID) [54], Mini-International Neuropsychiatric Interview (M.I.N.I.) [55], Clinician Administered PTSD Scale (CAPS) [56], and WHO WMH-CIDI [18]. None of these instruments were developed specifically for refugee populations but have been widely used in different cultural contexts. Nine studies mentioned the reliability or validity of the used instruments [23,35,36,39,41,44–46,51]. Thirteen studies conducted the assessment in the refugee’s native language [25,31,32,37,39,42,43,45–47,51–53]. Thirteen studies were conducted with assistance from interpreters [23,24,33–36,38,40,41,44,48–50].

Twenty-two studies of PTSD were identified (n = 4,639) [23–25,32,33,35,36,38–40,42–53]. Participants had a weighted mean age of 35.2 years and 44% were women. Overall, 31.46% (95% CI 24.43–38.50) were diagnosed with PTSD (1,376/4,639) (Fig 2). There was substantial heterogeneity between studies (Fig 2), and subgroup analyses indicated PTSD prevalence was significantly higher for women (34.02%, 95% CI 31.12–37.01, p = 0.02), in the smaller studies (n < 200) (37.35%, 95% CI 34.86–39.90, p < 0.001), those with refugee status (31.01%, 95% CI 29.52–32.54, p < 0.001), and those originating from Africa (48.25%, 95% CI 39.82–56.75, p < 0.001) (Fig 3). In the eight largest studies with 200 participants or more, PTSD prevalence was significantly lower (29.30%, 95% CI 27.72–30.91, p < 0.001) [25,39,42,43,46,47,51,53]. Duration of displacement had no significant impact on PTSD prevalence (p = 0.11). The prevalence of PTSD for those displaced less than 4 years was 30.17% (95% CI 28.24–32.14) compared to 33.14% (95% CI 29.99–36.41) for those displaced longer than 4 years. The PTSD prevalence for interpreter-assisted interviews was 35.75% (95% CI 33.80–39.70) compared to 27.82% (95% CI 26.40–29.30) for interviews conducted in the native language (p < 0.001). There was a statistically significant difference across diagnostic measures (p < 0.001) with the CAPS yielding a higher prevalence of PTSD (40.41%, 95% CI 36.20–44.70), followed by the WHO-CIDI (31.6%, 95% CI 28.20–35.20), the SCID (30.55%, 95% CI 28–33.20), and the M.I.N.I. (25.8%, 95% CI 24–27.70).

Fig 2 — *Study with sample size of ≥200. Horizontal lines indicate 95% CIs; horizontal points of the open diamond are the limits of the overall 95% CIs; and the red dashed line shows the position of the overall prevalence. AF, Afghanistan; AZR, Azerbaijan; CI, confidence interval; Frmr Yug, former Yugoslavia; ME, Middle East; PTSD, posttraumatic stress disorder; W Afr, West Africa.

Fig 3 — p-Values derived from random-effects models; horizontal lines indicate 95% CIs. CAPS, Clinician Administered PTSD Scale; CI, confidence interval; M.I.N.I., the Mini-International Neuropsychiatric Interview; PTSD, posttraumatic stress disorder; SCID, Structured Clinical Interview for DSM; WHO-CIDI, World Health Organization–Composite International Diagnostic Interview.

Seventeen studies of depression were identified (n = 3,877) [23,25,33,35–37,39–45,49–51,53]. Participants had a weighted mean age of 35.7 years and 48% were women. Overall, 31.51% (95% CI 22.64–40.38) were diagnosed with depression (1,066/3,877) (Fig 4). Three studies provided separate data for dysthymia (n = 1,135) [39,41,45]. The overall prevalence of dysthymia was 6.72% (95% CI 3.63%–9.81%) with moderate heterogeneity between studies (I² = 65.6%, p = 0.055). There was considerable heterogeneity between the studies (Fig 4). Subgroup analyses indicated depression prevalence was significantly higher in the smaller studies 32.89% (95% CI 30.06–35.82, p < 0.001), for those deemed asylum seekers 30.14% (95% CI 27.10–33.32, p = 0.04), those originating from Europe 35.82% (95% CI 32.81–38.92, p < 0.0001), and for those living in the community 30.70% (95% CI 28.74–32.72, p < 0.0001) (Fig 5). The subgroup analysis for sex could not be conducted, owing to a lack of reported data. In the seven larger studies with 200 or more participants [25,37,39,42,43,51,53], the reported depression prevalence was 20.65% (95% CI 18.88–22.51), which was significantly lower (p < 0.001) than in the smaller studies, 32.89% (95% CI 30.06–35.82). Duration of displacement had no significant impact on depression prevalence (p = 0.17). The prevalence of depression for those displaced less than 4 years was 32.44% (95% CI 30.00–34.95) and 35.12% (95% CI 32.08–38.25) for those displaced longer than 4 years. The depression prevalence for interpreter-assisted interviews was 35.35% (95% CI 32.05–38.76) compared to 24.87% (95% CI 23.33–26.45) for interviews conducted in the native language (p < 0.0001). There was a statistically significant difference across type of diagnostic measures (p < 0.0001) with the SCID yielding a higher prevalence of depression (34.52%, 95% CI 31.74–37.39), followed by the M.I.N.I. (30.55%, 95% CI 28.59–32.56) and the WHO-CIDI (5.02%, 95% CI 3.46–7.01).

Fig 4 — *Study with sample size of ≥200. Horizontal lines indicate 95% CIs; horizontal points of the open diamond are the limits of the overall 95% CIs; and the red dashed line shows the position of the overall prevalence. AZR, Azerbaijan; CI, confidence interval; Frmr Yug, former Yugoslavia; ME, Middle East.

Fig 5 — p-Values derived from random-effects models; horizontal lines indicate 95% CI. Subgroup analysis for sex could not be conducted, owing to a lack of reported data. CI, confidence interval; M.I.N.I., the Mini-International Neuropsychiatric Interview; SCID, Structured Clinical Interview for DSM; WHO-CIDI, World Health Organization–Composite International Diagnostic Interview.

Eleven studies of anxiety disorders were identified (n = 2,840) [23,25,34,36,39,41–43,45,49,50]. Participants had a weighted mean age of 36.8 years and 31% were women. Four studies reported prevalence for generalised anxiety disorder [25,39,41,45], six reported any anxiety disorder [23,36,42,43,49,50], and one study diagnosed adult separation anxiety disorder [34]. Overall, 11.09% (95% CI 6.75–15.43) were diagnosed with an anxiety disorder (305/2,840) (Fig 6). There was substantial heterogeneity between studies (Fig 6). Subgroup analyses indicated anxiety prevalence was higher for those displaced less than 4 years (21.72%, 95% CI 18.74–24.94, p < 0.0001), those granted formal refugee status (11.44%, 95% CI 10.12–12.87, p = 0.0009), those originating from the Middle East (26.73%, 95% CI 22.86–30.89, p < 0.0001), and those living in temporary refugee accommodation (13.18%, 95% CI 11.46–15.06, p < 0.0001) (Fig 7). The subgroup analysis for sex could not be conducted, owing to a lack of reported data. Sample size had no significant impact on anxiety disorder prevalence (p = 0.21). The prevalence of anxiety disorders in the smaller studies (N < 200) was 9.24% (95% CI 7.36–11.42), and in the larger studies (N ≥ 200), the prevalence was 10.83% (95% CI 9.50–12.27). The use of an interpreter to conduct assessments had no significant impact on the reported prevalence of anxiety disorders (p = 0.34). The prevalence of anxiety for interpreter-assisted interviews was 9.70 (95% CI 7.50–12.30) and 11.04% (95% CI 9.76–12.40) for those interviews conducted in the native language. The subgroup analysis for diagnostic measure could not be conducted, owing to insufficient studies for each measure.

Fig 6 — *Study with sample size of ≥200. Horizontal lines indicate 95% CIs; horizontal points of the open diamond are the limits of the overall 95% CIs; and the red dashed line shows the position of the overall prevalence. AZR, Azerbaijan; CI, confidence interval; Frmr Yug, former Yugoslavia; ME, Middle East.

Fig 7 — p-Values are derived from random-effects models; horizontal lines indicate 95% CI. Subgroup analysis for sex could not be conducted, owing to a lack of reported data. Subgroup analysis for diagnostic measure could not be conducted, owing to insufficient studies for each measure. CI, confidence interval.

Six studies of psychotic illness were identified (n = 1,695) [23,31,36,39,43,45]. Participants had a weighted mean age of 37.6 years and 51% were female. Overall, 1.51% (95% CI 0.63–2.40) were diagnosed with psychosis (31/1,695), with low heterogeneity between studies (Fig 8).

Fig 8 — Horizontal lines indicate 95% CIs. Horizontal points of the open diamond are the limits of the overall 95% CIs; and the red dashed line shows the position of the overall prevalence. AZR, Azerbaijan; CI, confidence interval; Frmr Yug, former Yugoslavia; ME, Middle East.

Publication bias

There was no evidence of publication bias for PTSD, depression, anxiety, or psychosis (S1–S4 Egger’s Tests).

Risk of bias

Thirteen studies were assigned a low risk of bias and determined to be of high quality [23,24,35,37,38,40,45–50,53]. Nine studies demonstrated moderate risk of bias [25,33,34,36,39,41,44,51,52]. A moderate rating was assigned to studies that had issues with the representativeness of their sample or used nonrandom sampling techniques. Additionally, in one study, only male psychologists conducted the diagnostic assessments, and this was associated with fewer than expected reports of sexual assault [51]. Four studies were assigned a high risk of bias [31,32,42,43]. One study, providing data for PTSD and depression, assessed the mental health consequences of captivity by the Islamic State (IS) militant group on a sample of Yazidi women. It was reported that some of the women were not yet ready to receive psychotherapy for their symptoms [42]. This may have impacted upon the reported prevalence rates, particularly PTSD, as some women may have been reluctant and not ready to disclose trauma details during the research interviews. Another study, providing PTSD data, conducted diagnostic assessments in nonconfidential areas of a detention facility [32]. The reported PTSD prevalence was low but similar to two other studies assigned a low risk of bias. Two studies recruited help-seeking populations through the use of advertisements or flyers offering psychological treatment for those affected by war [31,43]. One of these studies compared their help-seeking population to a randomly recruited sample, and there was a difference in prevalence rates, with higher rates in the help-seeking population [43].

Discussion

Our results indicate that refugees and asylum seekers experience high rates of mental illness, in particular PTSD and depression. PTSD and depression appear to persist for many years post displacement, as there was no difference in prevalence between those displaced less than 4 years and those displaced longer. However, this was not the case for the prevalence of anxiety disorders, which we found to be higher among those displaced less than 4 years.

PTSD and depression in refugees and asylum seekers appear to be more prevalent than in the general population. According to data from the World Mental Health Surveys, lifetime prevalence in the general population is 3.9% for PTSD [57] and 12% for any depressive disorder [58], compared to our findings of 31% for PTSD and 31.5% for depression. However, the prevalence of anxiety disorders (11%) and psychosis (1.5%) in refugees and asylum seekers appears to be less than the lifetime prevalence in general population samples: 16% [58] and 3% [59], respectively. Only 11 studies reporting data on anxiety prevalence met the inclusion criteria for this review, and of those 11, only six assessed the full range of DSM anxiety disorders. With a heavy emphasis on PTSD and depression, the full breadth of anxiety disorders is less frequently examined and reported in the literature. It was only recently, with the release of DSM-5, that PTSD was no longer classified as an anxiety disorder but in a separate category of trauma and stressor-related disorders [60]. Further research on the prevalence of the full range of anxiety disorders and comorbidities is needed.

With the aim of including all possible refugee populations that have been studied, this systematic review placed few restrictions on characteristics of refugee experiences (region of origin or resettlement, duration of displacement, etc.). As a result, the review’s criteria could in fact have been a contributing factor to the resulting substantial statistical heterogeneity. Despite this high heterogeneity, which is expected when investigating and analysing prevalence across global refugee populations, knowledge of current prevalence estimates provides a foundation for the field to build on. Researchers can progress with this knowledge and focus their attention on addressing the critical need for immediate, appropriate, and ongoing mental health support and interventions. Without the progression of further high-quality research that explores the different components of mental health needs, culturally appropriate and effective interventions, and longitudinal mental illness trajectories, untreated mental illnesses will severely impact upon successful integration into host communities. For host countries and humanitarian agencies, current prevalence estimates of mental illness within this ever-growing population can be used in advocacy and health service planning to strengthen mental health services for refugees and asylum seekers, in line with WHO priorities and objectives [14].

Subgroup analysis for sex was only possible for PTSD, owing to a lack of sex data for the other outcomes, and this is a major limitation of the current literature. The subgroup analysis indicated a higher PTSD prevalence for women, consistent with studies of sex differences and PTSD within general populations [61–63]. During times of conflict, women face not only an increased risk of sexual violence [64–66], which is considered to confer a high risk for developing PTSD, but other risks associated with migration trauma such as safety concerns, child-rearing pressures, and exploitation and trafficking [67]. Although trauma type in relation to PTSD diagnosis was not adequately described in the studies, many of the studies included participants from countries such as the former Yugoslavia, Syria, and Iraq, areas with conflicts reported to have perpetrated systematic sexual violence [68]. In line with best-practice research reporting, future research in the field must ensure outcome measures are disaggregated by sex.

The studies with populations from Africa reported the highest prevalence of PTSD. This result likely reflects how countries within Africa are consistently ranked at the highest levels of the Political Terror Scale [69]. This scale is a five-point rating system based on data from Amnesty International and the US State Department and measures the levels of extensive human rights violations and violence within nations. In our review, the refugee populations from Europe, which mostly consisted of individuals from the former Yugoslavia, had the highest prevalence of depression, and the Middle East refugee populations had the highest prevalence of anxiety.

The prevalence of PTSD and depression appeared to be higher in studies that utilised interpreter-assisted diagnostic assessments. However, this was not the case for anxiety disorders, for which we did not find evidence for a difference between the interpreter-assisted interviews and those conducted in the native language. This difference could be due to a number of factors, such as language fluency, which plays an important role in the diagnosis of mental illness because the clinician relies heavily on the self-reported symptoms of the individual [70]. However, further research is required to understand the differences in diagnosis rates between interpreter-assisted interviews and clinicians conducting the assessment in the native language and whether there are cultural and linguistic nuances that can impact on diagnostic rates that might only be accessible to native interviewers. Even though the different diagnostic measures are considered comparable in performance and diagnosis precision [71], our results suggest some differences, which highlight the importance of careful consideration of the method and instrument used in the mental health assessments of refugee populations. Although beyond the scope of this review, further investigation is required to understand potential differences in case identification between diagnostic measures.

Our findings suggest that the prevalence of PTSD and depression persists for many years post displacement, suggesting ongoing suffering from mental illnesses in the postmigration environment. This environment can include complexities of social and cultural isolation, reconfigured family relationships, difficulties adjusting to life in a foreign country, and often limited opportunities to contribute economically and socially to their new communities. Previous longitudinal studies have demonstrated how these hallmarks of the postmigration environment, alongside poor social support and acculturation difficulties, may contribute to a deterioration in mental health [5,72–74]. In contrast to the findings for PTSD and depression, anxiety prevalence was higher for those individuals recently displaced. Factors contributing to anxiety might be influenced by the uncertainty of the resettlement process and participation in the refugee determination process, which might have a detrimental effect on psychological well-being; however, robust longitudinal research is needed in this field.

We found that the prevalence of PTSD and depression is higher than in the review by Fazel and colleagues [6]. This could reflect the fact that this current systematic review included refugee populations from low- and middle-income countries or that the more recent refugee flows might be exposed to higher numbers of risk factors. In contrast, the results for anxiety disorders and psychosis are comparable with previously reported prevalence rates [6]. The influence of sample size is further supported, with the larger studies reporting lower prevalence rates for PTSD and depression. However, this was not the case for anxiety, for which sample size did not influence prevalence. The results for PTSD and depression are comparable to the findings by Steel and colleagues [7] and slightly lower than other systematic reviews, which have reported PTSD prevalence in the range of 36%–43% and depression 40%–44% [12,75].

Two phenomena currently affecting refugee and asylum-seeker populations should be considered when interpreting the results of this review. First is the increased targeting of civilian populations in areas of mass conflict. Second is the postmigration environment in countries with increasingly harsh immigration policies including detention, deportation, and delayed granting of refugee status—possibly mirroring local population shifts against immigration and heightened hostility towards refugee populations [76,77]. Investigation of these situations and their impact on mental health is warranted.

Limitations and strengths

Some statistical heterogeneity is to be expected as a result of the review’s design, which set no exclusion criteria for host country, country of origin, sex, or duration of displacement. We addressed this by using random-effects models to calculate more conservative 95% CIs. The conventional method to investigate potential sources of heterogeneity is to conduct a meta-regression; however, this was not possible, because of the limited covariates reported in the studies. We conducted subgroup analyses to investigate potential sources heterogeneity, but some subgroup analyses were also not possible, and some studies were excluded from subgroup analyses because of a lack of reported data. There are many challenges to conducting research with refugee populations, one of which is sampling. Ideally, this review would have restricted the inclusion criteria to studies that incorporated multistage representative sampling. However, such a restriction in this field would have yielded so few studies that the prevalence estimates could not have been made. In fact, only two of the included studies in this review would have met this criterion. Other limitations were imposed when studies combined illnesses to form diagnostic groups and/or reported only the number of comorbidities rather than the actual diagnoses. Although many of the diagnostic measures had been widely used in different cultural contexts, none had been specifically developed for refugee populations or cross-cultural use. Although the DSM-5 attempts to enhance cultural validity, all of the included studies used the DSM-IV, DSM-III-R, or ICD-10 criteria, previously criticized for limited recognition of cultural perspectives [78]. In particular, the diagnostic framework for PTSD has largely been investigated using military personnel and single-incident trauma survivors from high-income nations [79]. Somatic symptoms and related disorders were outside the scope of this review but warrant specific investigation and characterization.

As far as we are aware, this is the only systematic review to implement strict inclusion criteria regarding the diagnosis of mental illness in current refugee and asylum-seeker populations. This allowed for the selective analysis of higher-quality studies reporting the prevalence of mental illness based on clinical interviews with trained assessors using validated diagnostic measures. This review also expands the current evidence base by not only focusing on PTSD but also reporting depression, anxiety, and psychosis. To the best of our knowledge, this is the first systematic review to place no restrictions on language or on countries of origin or settlement. The majority of studies in this field are undertaken in high-income countries, which are often not countries of first asylum. Although most studies in this review came from countries such as the UK, Germany, Switzerland, and Australia, it also included studies from key refugee host nations such as Lebanon, Turkey, Uganda, and Nepal.

The ever-growing refugee and asylum-seeker populations pose a major global public health crisis with serious implications for mental health. This review provides current prevalence estimates for PTSD, depression, anxiety, and psychosis and suggests that both short-term and ongoing mental health services, beyond the period of initial resettlement, are required to promote the health of refugees.

Supporting information

S1 Prisma Checklist. From [16].

For more information, visit: www.prisma-statement.org.

(DOCX)

Click here for additional data file.^{(20.7KB, docx)}

S1 Table. *Truncation symbol.

MeSH term, Medical Subject Headings.

(DOCX)

Click here for additional data file.^{(18.2KB, docx)}

S1 Risk of Bias

(DOCX)

Click here for additional data file.^{(24.7KB, docx)}

S1 Egger’s Test PTSD

Figure: Funnel plot using data from 22 studies providing data for the prevalence of posttraumatic stress disorder. Each dot represents a study. ES, effect size; s.e, standard error. Table: Egger’s test set at a threshold of a p-value less than 0.05 to indicate funnel plot asymmetry. Coef., coefficient; Conf. Interval, confidence interval; Std_Eff, standard effect; Std. Err, standard error; Test of HO, test of null hypothesis.

(DOCX)

Click here for additional data file.^{(29.7KB, docx)}

S2 Egger’s Test Depression

Figure: Funnel plot using data from 17 studies providing data for the prevalence of depression. Each dot represents a study. ES, effect size; s.e, standard error. Table: Egger’s test set at a threshold of a p-value less than 0.05 to indicate funnel plot asymmetry. Coef., coefficient; Conf. Interval, confidence interval; Std_Eff, standard effect; Std. Err, standard error; Test of HO, test of null hypothesis.

(DOCX)

Click here for additional data file.^{(29.8KB, docx)}

S3 Egger’s Test Anxiety

Figure: Funnel plot using data from 11 studies providing data for the prevalence of anxiety disorders. Each dot represents a study. ES, effect size; s.e, standard error. Table: Egger’s test set at a threshold of a p-value less than 0.05 to indicate funnel plot asymmetry. Coef., coefficient; Conf. Interval, confidence interval; Std_Eff, standard effect; Std. Err, standard error; Test of HO, test of null hypothesis.

(DOCX)

Click here for additional data file.^{(29.2KB, docx)}

S4 Egger’s Test Psychosis

Figure: Funnel plot using data from six studies providing data for the prevalence of psychosis. Each dot represents a study. ES, effect size; s.e, standard error. Table: Egger’s test set at a threshold of a p-value less than 0.05 to indicate funnel plot asymmetry. Coef., coefficient; Conf. Interval, confidence interval; Std_Eff, standard effect; Std. Err, standard error; Test of HO, test of null hypothesis.

(DOCX)

Click here for additional data file.^{(28.9KB, docx)}

Acknowledgments

We thank the following authors for providing additional information regarding their studies: C. Acarturk, M. Aoun, C. Eckart, E. Kaltenbach, C. J. Laban, A. Nickerson, F. Neuner, A. Rasmussen, Z. Steel, and S. Thapa. We would also like to thank A. Young from the Monash University library for her assistance with conducting the database search. We sincerely thank the Monash University staff and students and non-Monash colleagues who assisted with the screening of articles across a number of languages: R. Goldstein, C. Tay, C. Pickett (Edith Cowan University and Victoria University), D. Coles, K. Petersen, N. Pekin, K. Hammarberg, K. Stanzel, and R. Hasanov.

Abbreviations

ASA-SI: Adult Separation Anxiety Semistructured Interview
CAPS: Clinician Administered PTSD Scale
CI: confidence interval
DSM: Diagnostic and Statistical Manual of Mental Disorders
ICD: International Classification of Disease
IS: Islamic State
M.I.N.I.: the Mini-International Neuropsychiatric Interview
NA: not assessed in study
NOS: Newcastle-Ottawa Scale
NR: not reported
PTSD: posttraumatic stress disorder
RCT: randomised controlled trial
SCID: Structured Clinical Interview for DSM
SD: standard deviation
WHO: World Health Organization
WMH-CIDI: World Mental Health Composite International Diagnostic Interview

Data Availability

All relevant data are within the manuscript and its Supporting Information files.

Funding Statement

The authors received no specific funding for this work. MG-H and JAB are supported by fellowships from the National Health and Medical Research Council. RB is supported by scholarships from Australian Rotary Health, Windermere Foundation, and Monash Centre for Health Research and Implementation (MCHRI).

References

1.United Nations High Commissioner for Refugees. Global trends—forced displacement in 2018. United Nations High Commissioner for Refugees. 2019. Available from: https://www.unhcr.org/en-au/statistics/unhcrstats/5d08d7ee7/unhcr-global-trends-2018.html [Google Scholar]
2.Kéri S. Suffering has no race or nation: The psychological impact of the refugee crisis in Hungary and the occurrence of posttraumatic stress disorder. Soc Sci. 2015;4(4). [Google Scholar]
3.Beiser M. Longitudinal research to promote effective refugee resettlement. Transcult Psychiatry. 2006; 43(1): 56–71. [DOI] [PubMed] [Google Scholar]
4.Porter M, Haslam N. Predisplacement and postdisplacement factors associated with mental health of refugees and internally displaced persons—a meta-analysis. JAMA. 2005;294(5): 602–12. [DOI] [PubMed] [Google Scholar]
5.Bogic M, Njoku A, Priebe S. Long-term mental health of war-refugees: a systematic literature review. BMC Int Health Hum Rights. 2015;15: 29 10.1186/s12914-015-0064-9 [DOI] [PMC free article] [PubMed] [Google Scholar]
6.Fazel M, Wheeler J, Danesh J. Prevalence of serious mental disorder in 7000 refugees resettled in western countries: a systematic review. Lancet. 2005;365(9467): 1309–14. [DOI] [PubMed] [Google Scholar]
7.Steel Z, Chey T, Silove D, Marnane C, Bryant RA, van Ommeren M. Association of torture and other potentially traumatic events with mental health outcomes among populations exposed to mass conflict and displacement: a systematic review and meta-analysis. JAMA. 2009; 302(5): 537–49. [DOI] [PubMed] [Google Scholar]
8.Peconga EK, Hogh Thogersen M. Post-traumatic stress disorder, depression, and anxiety in adult Syrian refugees: what do we know? Scand J Public Health. 2019; 10.1177/1403494819882137 [DOI] [PubMed] [Google Scholar]
9.Steel JL, Dunlavy AC, Harding CE, Theorell T. The psychological consequences of pre-emigration trauma and post-migration stress in refugees and immigrants from Africa. J Immigr Minor Health. 2017;19(3): 523–532. [DOI] [PubMed] [Google Scholar]
10.Slewa-Younan S, Uribe Guajardo MG, Heriseanu A, Hasan T. A systematic review of post-traumatic stress disorder and depression amongst Iraqi refugees located in western countries. J Immigr Minor Health. 2015;17(4): 1231–1239. [DOI] [PubMed] [Google Scholar]
11.Tay AK, Riley A, Islam R, Welton-Mitchell C, Duchesne B, Waters V, et al. The culture, mental health and psychosocial wellbeing of Rohingya refugees: a systematic review. Epidemiol Psychiatr Sci. 2019;28(5): 489–94. 10.1017/S2045796019000192 [DOI] [PMC free article] [PubMed] [Google Scholar]
12.Mahmood HN, Ibrahim H, Goessmann K, Ismail AA, Neuner F. Post-traumatic stress disorder and depression among Syrian refugees residing in the Kurdistan region of Iraq. Confl Health. 2019;13(1): 51. [DOI] [PMC free article] [PubMed] [Google Scholar]
13.de Jong JTVM Komproe IH, Van Ommeren M. Common mental disorders in postconflict settings. Lancet. 2003; 361(9375): 2128–30. [DOI] [PubMed] [Google Scholar]
14.World Health Organization. Promoting the health of refugees and migrants: draft global action plan. Seventy Second World Health Assembly; 2019. Available from: https://apps.who.int/gb/ebwha/pdf_files/WHA72/A72_25-en.pdf. [Google Scholar]
15.Schick M, Morina N, Mistridis P, Schnyder U, Bryant RA, Nickerson A. Changes in post-migration living difficulties predict treatment outcome in traumatized refugees. Front Psychiatry. 2018;9: 476–476. [DOI] [PMC free article] [PubMed] [Google Scholar]
16.Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. 2009; 6(7): e1000097 10.1371/journal.pmed1000097 [DOI] [PMC free article] [PubMed] [Google Scholar]
17.American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. Arlington: American Psychiatric Publishing; 2013. [Google Scholar]
18.World Health Organization. The ICD-10 classification of mental and behavioural disorders: Clinical descriptions and diagnostic guidelines. Geneva: World Health Organization; 1992. [Google Scholar]
19.Kessler RC, Ustun TB. The world mental health (WMH) survey initiative version of the World Health Organization (WHO) Composite International Diagnostic Interview (CIDI). Int J Methods Psychiatr Res. 2004; 13(2):93–121. [DOI] [PMC free article] [PubMed] [Google Scholar]
20.DerSimonian R, Laird N. Meta-analysis in clinical trials. Control Clin Trials. 1986;7(3): 177–188. [DOI] [PubMed] [Google Scholar]
21.Higgins JPT, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. BMJ. 2003;327(7414): 557–560. [DOI] [PMC free article] [PubMed] [Google Scholar]
22.Egger M, Smith GD, Schneider M, Minder C. Bias in meta-analysis detected by a simple, graphical test. BMJ. 1997;315(7109): 629–634. [DOI] [PMC free article] [PubMed] [Google Scholar]
23.Jakobsen M, Thoresen S, Johansen LEE. The validity of screening for post-traumatic stress disorder and other mental health problems among asylum seekers from different countries. J Refug Stud. 2011; 24(1):171–86. [Google Scholar]
24.Neuner F, Schauer M, Klaschik C, Karunakara U, Elbert T. A comparison of narrative exposure therapy, supportive counseling, and psychoeducation for treating posttraumatic stress disorder in an african refugee settlement. J Consult Clin Psychol. 2004;72(4): 579–87. [DOI] [PubMed] [Google Scholar]
25.van Ommeren M, Komproe I, Cardena E, et al. Mental illness among Bhutanese shamans in Nepal. J Nerv Ment Dis. 2004;192(4): 313–7. [DOI] [PubMed] [Google Scholar]
26.Monash Centre for Health Research and Implementation. Evidence synthesis program template for critical appraisal of a cohort study. Melbourne: Monash Centre for Health Research and Implementation; 2014. [Google Scholar]
27.Wells G, Shea B, O’Connell D, et al. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses. 2009. Available from: http://www.ohri.ca/programs/clinical_epidemiology/oxford.asp. [Google Scholar]
28.Balen AH, Morley LC, Misso M, et al. The management of anovulatory infertility in women with polycystic ovary syndrome: an analysis of the evidence to support the development of global WHO guidance. Hum Reprod Update. 2016;22: 687–708. [DOI] [PubMed] [Google Scholar]
29.Teede HJ, Misso ML, Costello MF, et al. Recommendations from the international evidence-based guideline for the assessment and management of polycystic ovary syndrome. Clin Endocrinol. 2018; 89: 251–68. [DOI] [PMC free article] [PubMed] [Google Scholar]
30.Goldstein RF, Abell SK, Ranasinha S, et al. Association of gestational weight gain with maternal and infant outcomes: A systematic review and meta-analysis. JAMA. 2017;317: 2207–25. [DOI] [PMC free article] [PubMed] [Google Scholar]
31.Charney ME, Keane TM. Psychometric analyses of the Clinician-Administered PTSD Scale (CAPS)—Bosnian translation. Cultur Divers Ethni Minor Psychol. 2007;13(2): 161–8. [DOI] [PubMed] [Google Scholar]
32.Yu SE, Jeon WT. Mental health of North Korean refugees in protective facilities in china. Psychiatry Investig. 2008;5(2): 70–7. [DOI] [PMC free article] [PubMed] [Google Scholar]
33.Momartin S, Silove D, Manicavasagar V, Steel Z. Comorbidity of PTSD and depression: associations with trauma exposure, symptom severity and functional impairment in Bosnian refugees resettled in Australia. J Affect Disord. 2004;80(2–3):231–8. [DOI] [PubMed] [Google Scholar]
34.Silove D, Momartin S, Marnane C, Steel Z, Manicavasagar V. Adult separation anxiety disorder among war-affected Bosnian refugees: comorbidity with PTSD and associations with dimensions of trauma. J Trauma Stress. 2010;23(1): 169–72. [DOI] [PubMed] [Google Scholar]
35.Tay K, Frommer N, Hunter J, Silove D, Pearson L, San Roque M, et al. A mixed-method study of expert psychological evidence submitted for a cohort of asylum seekers undergoing refugee status determination in Australia. Soc Sci Med. 2013;98: 106–15. [DOI] [PubMed] [Google Scholar]
36.Hocking DC, Mancuso SG, Sundram S. Development and validation of a mental health screening tool for asylum-seekers and refugees: the STAR-MH. BMC Psychiatry. 2018;18. [DOI] [PMC free article] [PubMed] [Google Scholar]
37.Rees SJ, Fisher JR, Steel Z, Mohsin M, Nadar N, Moussa B, et al. Prevalence and risk factors of major depressive disorder among women at public antenatal clinics from refugee, conflict-affected, and Australian-born backgrounds. JAMA Netw Open. 2019;2(5): e193442. [DOI] [PMC free article] [PubMed] [Google Scholar]
38.Renner W, Salem I, Ottomeyer K. Cross-cultural validation of measures of traumatic symptoms in groups of asylum seekers from Chechnya, Afghanistan, and West Africa. Soc Behav Pers. 2006; 34(9):1101–14. [Google Scholar]
39.Bogic M, Ajdukovic D, Bremner S, Franciskovic T, Galeazzi GM, Kucukalic A, et al. Factors associated with mental disorders in long-settled war refugees: refugees from the former Yugoslavia in Germany, Italy and the UK. Br J Psychiatry. 2012; 200(3):216–23. [DOI] [PubMed] [Google Scholar]
40.Eckart C, Stoppel C, Kaufmann J, Tempelmann C, Hinrichs H, Elbert T, et al. Structural alterations in lateral prefrontal, parietal and posterior midline regions of men with chronic posttraumatic stress disorder. J Psychiatry Neurosci. 2011;36(3): 176–86. [DOI] [PMC free article] [PubMed] [Google Scholar]
41.von Lersner U, Wiens U, Elbert T, Neuner F. Mental health of returnees: refugees in Germany prior to their state-sponsored repatriation. BMC Int Health Hum Rights. 2008; 8:8 10.1186/1472-698X-8-8 [DOI] [PMC free article] [PubMed] [Google Scholar]
42.Kizilhan JI. PTSD of rape after IS ("Islamic State") captivity. Arch Womens Ment Health. 2018;21(5): 517–524. [DOI] [PubMed] [Google Scholar]
43.Richter K, Peter L, Lehfeld H, Zaske H, Brar-Reissinger S, Niklewski G. Prevalence of psychiatric diagnoses in asylum seekers with follow-up. BMC Psychiatry. 2018;18 10.1186/s12888-018-1783-y [DOI] [PMC free article] [PubMed] [Google Scholar]
44.Wulfes N, del Pozo MA, Buhr-Riehm B, Heinrichs N, Kröger C. Screening for posttraumatic stress disorder in refugees: comparison of the diagnostic efficiency of two self-rating measures of posttraumatic stress disorder. J Trauma Stress. 2019;32(1): 148–155. [DOI] [PubMed] [Google Scholar]
45.Llosa AE, Ghantous Z, Souza R, Forgione F, Bastin P, Jones A, et al. Mental disorders, disability and treatment gap in a protracted refugee setting. Br J Psychiatry. 2014;204(3): 208–13. [DOI] [PubMed] [Google Scholar]
46.Kazour F, Zahreddine NR, Maragel MG, Almustafa MA, Soufia M, Haddad R, et al. Post-traumatic stress disorder in a sample of Syrian refugees in Lebanon. Compr Psychiatry. 2017;72: 41–7. [DOI] [PubMed] [Google Scholar]
47.Jeon W, Hong C, Lee C, Kim DK, Han M, Min S. Correlation between traumatic events and posttraumatic stress disorder among North Korean defectors in South Korea. J Trauma Stress. 2005; 18(2): 147–54. [DOI] [PubMed] [Google Scholar]
48.Sondergaard HP, Theorell T. Alexithymia, emotions and PTSD; findings from a longitudinal study of refugees. Nord J Psychiatry. 2004;58(3): 185–91. [DOI] [PubMed] [Google Scholar]
49.Heeren M, Mueller J, Ehlert U, Schnyder U, Copiery N, Maier T. Mental health of asylum seekers: a cross-sectional study of psychiatric disorders. BMC Psychiatry. 2012;12: 114. [DOI] [PMC free article] [PubMed] [Google Scholar]
50.Maier T, Schmidt M, Mueller J. Mental health and healthcare utilisation in adult asylum seekers. Swiss Med Wkly. 2010; 140. [DOI] [PubMed] [Google Scholar]
51.Tekin A, Karadag H, Suleymanoglu M, Tekin M, Kayran Y, Alpak G, et al. Prevalence and gender differences in symptomatology of posttraumatic stress disorder and depression among Iraqi Yazidis displaced into Turkey. Eur J Psychotraumatol. 2016;7: 28556 10.3402/ejpt.v7.28556 [DOI] [PMC free article] [PubMed] [Google Scholar]
52.Turner SW, Bowie C, Dunn G, Shapo L, Yule W. Mental health of Kosovan Albanian refugees in the UK. Br J Psychiatry. 2003;182: 444–448. 10.1192/bjp.01.458 [DOI] [PubMed] [Google Scholar]
53.Wright A, Talia YR, Aldhalimi A, Broadbridge CL, Jamil H, Lumley MA, et al. Kidnapping and mental health in Iraqi refugees: the role of resilience. J Immigr Minor Health. 2017;19(1): 98–107. [DOI] [PMC free article] [PubMed] [Google Scholar]
54.First MB, Williams JBW, Karg RS, Spitzer RL. Structured clinical interview for DSM-5—research version. Arlington: American Psychiatric Association; 2015. [Google Scholar]
55.Sheehan DV, Lecrubier Y, Sheehan KH, Amorim P, Janavs J, Weiller E, et al. The Mini-International Neuropsychiatric Interview (M.I.N.I.): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. J clin psychiatry. 1998; 59 Suppl 20:22–33; quiz 4–57. [PubMed] [Google Scholar]
56.Weathers FW, Bovin MJ, Lee DJ, Sloan DM, Schnurr PP, Kaloupek DG, et al. The Clinician-Administered PTSD Scale for DSM-5 (CAPS-5): development and initial psychometric evaluation in military veterans. Psychol assess. 2018;30(3): 383–95. [DOI] [PMC free article] [PubMed] [Google Scholar]
57.Koenen KC, Ratanatharathorn A, Ng L, McLaughlin KA, Bromet EJ, Stein DJ, et al. Posttraumatic stress disorder in the World Mental Health Surveys. Psychol Med. 2017;47: 2260–74. [DOI] [PMC free article] [PubMed] [Google Scholar]
58.Kessler RC, Aguilar-Gaxiola S, Alonso J, Chatterji S, Lee S, Ormel J, et al. The global burden of mental disorders: An update from the WHO World Mental Health (WMH) Surveys. Epidemiol Psichiatr Soc. 2009;18: 23–33. [DOI] [PMC free article] [PubMed] [Google Scholar]
59.Perälä J, Suvisaari J, Saarni SI, Kuoppasalmi K, Isometsa E, Pirkola S, et al. Lifetime prevalence of psychotic and bipolar I disorders in a general population. Arch Gen Psychiatry. 2007;64: 19–28. [DOI] [PubMed] [Google Scholar]
60.Pai A, Suris AM, North CS. Posttraumatic stress disorder in the DSM-5: controversy, change, and conceptual considerations. Behav Sci (Basel). 2017;7(1): 7 10.3390/bs7010007 [DOI] [PMC free article] [PubMed] [Google Scholar]
61.Kessler RC, Sonnega A, Bromet E, Hughes M, Nelson CB. Posttraumatic stress disorder in the National Comorbidity Survey. Arch Gen Psychiatry. 1995;52: 1048–60. 10.1001/archpsyc.1995.03950240066012 [DOI] [PubMed] [Google Scholar]
62.Christiansen DM, Hansen M. Accounting for sex differences in PTSD: A multi-variable mediation model. Eur J Psychotraumatol. 2015;6: 26068–26068. [DOI] [PMC free article] [PubMed] [Google Scholar]
63.Tolin DF, Foa EB. Sex differences in trauma and posttraumatic stress disorder: a quantitative review of 25 years of research. Psychol Bull. 2006;132: 959–92. [DOI] [PubMed] [Google Scholar]
64.Sidebotham E, Moffatt J, Jones K. Sexual violence in conflict: a global epidemic. The Obstet Gynaecol. 2016;18: 247–50. [Google Scholar]
65.Vu A, Adam A, Wirtz A, Pham K, Rubenstein L, Glass N, Beyrer C, Singh S. The prevalence of sexual violence among female refugees in complex humanitarian emergencies: a systematic review and meta-analysis. PLoS Curr. 2014; 18. [DOI] [PMC free article] [PubMed] [Google Scholar]
66.Mohammadi D. Help for Yazidi survivors of sexual violence. Lancet Psychiatry. 2016;3: 409–410. [Google Scholar]
67.Ditlevsen DN, Elklit A. Gender, trauma type, and PTSD prevalence: a re-analysis of 18 Nordic convenience samples. Ann Gen Psychiatry. 2012;11: 26–26. [DOI] [PMC free article] [PubMed] [Google Scholar]
68.Baker A. The Secret War Crime: How Do You Ask Women to Relive Their Worst Nightmares. TIME. 2016. March 10 [cited 2019 Nov 12]. Available from: http://time.com/war-and-rape/. [Google Scholar]
69.Gibney M, Cornet L, Wood R, Haschke P, Arnon D, Pisanò A, et al. The Political Terror Scale 1976–2018. The Political Terror Scale Website. 2019. Available from: http://www.politicalterrorscale.org. [Google Scholar]
70.Bauer AM, Alegría M. Impact of patient language proficiency and interpreter service use on the quality of psychiatric care: a systematic review. Psychiatr serv. 2010;61(8), 765–773. 10.1176/ps.2010.61.8.765 [DOI] [PMC free article] [PubMed] [Google Scholar]
71.Levis B, McMillan D, Sun Y, He C, Rice DB, Krishnan A, et al. Comparison of major depression diagnostic classification probability using the SCID, CIDI, and MINI diagnostic interviews among women in pregnancy or postpartum: an individual participant data meta-analysis. Int J Methods Psychiatr Res. 2019;28(4): e1803. [DOI] [PMC free article] [PubMed] [Google Scholar]
72.Fazel M, Betancourt TS. Preventive mental health interventions for refugee children and adolescents in high-income settings. Lancet Child Adolesc Health. 2018;2: 121–32. [DOI] [PubMed] [Google Scholar]
73.Beiser M. Resettling refugees and safeguarding their mental health: lessons learned from the Canadian Refugee Resettlement Project. Transcult Psychiatry. 2009;46: 539–83. [DOI] [PubMed] [Google Scholar]
74.Carlsson JM, Olsen DR, Mortensen EL, Kastrup M. Mental health and health-related quality of life: a 10-year follow-up of tortured refugees. J Nerv Ment Dis. 2006;194: 725–31. [DOI] [PubMed] [Google Scholar]
75.Lindert J, Ehrenstein OS, Priebe S, Mielck A, Brahler E. Depression and anxiety in labor migrants and refugees—a systematic review and meta-analysis. Soc Sci Med. 2009;69(2): 246–257. [DOI] [PubMed] [Google Scholar]
76.Fitzgerald DS, Arar R. The sociology of refugee migration. Annu Rev Sociol. 2018;44: 387–406. [Google Scholar]
77.Crawley H, Skleparis D. Refugees, migrants, neither, both: categorical fetishism and the politics of bounding in Europe’s ‘migration crisis’. J Ethn Migr Stud. 2018;44: 48–64. [Google Scholar]
78.Alarcón RD. Culture, cultural factors and psychiatric diagnosis: review and projections. World Psychiatry. 2009; 8:131–39. [DOI] [PMC free article] [PubMed] [Google Scholar]
79.Specker P, Liddell BJ, Byrow Y, Bryant RA, Nickerson A. A factor analytic investigation of DSM-5 PTSD symptoms in a culturally diverse sample of refugees resettled in Australia. Confl Health. 2018;12: 26. [DOI] [PMC free article] [PubMed] [Google Scholar]

PLoS Med. doi: 10.1371/journal.pmed.1003337.r001

Decision Letter 0

Caitlin Moyer

4 Nov 2019

Dear Dr. Gibson-Helm,

Thank you very much for submitting your manuscript "The Prevalence of Mental Illness in Refugees and Asylum Seekers: a systematic review and meta-analysis" (PMEDICINE-D-19-02869) for consideration in PLOS Medicine's Special Issue on Refugee and Migrant Health.

Your paper was evaluated by a senior editor and discussed among all the editors here. It was also discussed with the Guest Editors, and sent to three independent reviewers, including a statistical reviewer. The reviews are appended at the bottom of this email and any accompanying reviewer attachments can be seen via the link below:

[LINK]

In light of these reviews, I am afraid that we will not be able to accept the manuscript for publication in the journal in its current form, but we would like to consider a revised version that addresses the reviewers' and editors' comments. Obviously we cannot make any decision about publication until we have seen the revised manuscript and your response, and we plan to seek re-review by one or more of the reviewers.

In revising the manuscript for further consideration, your revisions should address the specific points made by each reviewer and the editors. Please also check the guidelines for revised papers at http://journals.plos.org/plosmedicine/s/revising-your-manuscript for any that apply to your paper. In your rebuttal letter you should indicate your response to the reviewers' and editors' comments, the changes you have made in the manuscript, and include either an excerpt of the revised text or the location (eg: page and line number) where each change can be found. Please submit a clean version of the paper as the main article file; a version with changes marked should be uploaded as a marked up manuscript.

Due to the fact that you have a manuscript under consideration elsewhere describing findings related to those reported here, we ask that you submit your unpublished manuscript as supporting information and describe in your cover letter the differences between the two papers. The editorial team will discuss any potential overlap between the two reports, and consult with the Special Issue Guest Editors, and this will be taken into account when considering the revised manuscript.

In addition, we request that you upload any figures associated with your paper as individual TIF or EPS files with 300dpi resolution at resubmission; please read our figure guidelines for more information on our requirements: http://journals.plos.org/plosmedicine/s/figures. While revising your submission, please upload your figure files to the PACE digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email us at PLOSMedicine@plos.org.

We expect to receive your revised manuscript by Nov 25 2019 11:59PM. Please email us (plosmedicine@plos.org) if you have any questions or concerns.

***Please note while forming your response, if your article is accepted, you may have the opportunity to make the peer review history publicly available. The record will include editor decision letters (with reviews) and your responses to reviewer comments. If eligible, we will contact you to opt in or out.***

We ask every co-author listed on the manuscript to fill in a contributing author statement, making sure to declare all competing interests. If any of the co-authors have not filled in the statement, we will remind them to do so when the paper is revised. If all statements are not completed in a timely fashion this could hold up the re-review process. If new competing interests are declared later in the revision process, this may also hold up the submission. Should there be a problem getting one of your co-authors to fill in a statement we will be in contact. YOU MUST NOT ADD OR REMOVE AUTHORS UNLESS YOU HAVE ALERTED THE EDITOR HANDLING THE MANUSCRIPT TO THE CHANGE AND THEY SPECIFICALLY HAVE AGREED TO IT. You can see our competing interests policy here: http://journals.plos.org/plosmedicine/s/competing-interests.

Please use the following link to submit the revised manuscript:

https://www.editorialmanager.com/pmedicine/

Your article can be found in the "Submissions Needing Revision" folder.

To enhance the reproducibility of your results, we recommend that you deposit your laboratory protocols in protocols.io, where a protocol can be assigned its own identifier (DOI) such that it can be cited independently in the future. For instructions see http://journals.plos.org/plosmedicine/s/submission-guidelines#loc-methods.

Please ensure that the paper adheres to the PLOS Data Availability Policy (see http://journals.plos.org/plosmedicine/s/data-availability), which requires that all data underlying the study's findings be provided in a repository or as Supporting Information. For data residing with a third party, authors are required to provide instructions with contact information for obtaining the data. PLOS journals do not allow statements supported by "data not shown" or "unpublished results." For such statements, authors must provide supporting data or cite public sources that include it.

We look forward to receiving your revised manuscript.

Sincerely,

Caitlin Moyer, Ph.D.

Associate Editor

PLOS Medicine

plosmedicine.org

-----------------------------------------------------------

Requests from the editors:

1.Abstract: Please structure your abstract using the PLOS Medicine headings (Background, Methods and Findings, Conclusions). Please report your abstract according to PRISMA for abstracts, http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1001419 .

2. Abstract: Background (second sentence): Please revise to “...has reported wide variation in mental illness prevalence data....”

3. Abstract: Methods and Findings: Please provide the data sources, types of study designs included, eligibility criteria, and the synthesis and appraisal methods.

4. Abstract: Methods and Findings: In the last sentence of the Abstract Methods and Findings section, please describe the main limitation(s) of the study's methodology.

5. Author Summary: At this stage, we ask that you include a short, non-technical Author Summary of your research to make findings accessible to a wide audience that includes both scientists and non-scientists. The Author Summary should immediately follow the Abstract in your revised manuscript. This text is subject to editorial change and should be distinct from the scientific abstract. Please see our author guidelines for more information: https://journals.plos.org/plosmedicine/s/revising-your-manuscript#loc-author-summary

6. Methods: Please update your search to the present time. We require that SRs are updated to within roughly six months of the expected publication date. Your search has not been re-run since February of 2018.

7. Methods (Lines 144-145): Please describe the evaluation of study quality. Specifically, it is stated in the methods that: “Individual items related to study quality such as internal and external validity, reporting bias, and conflict of interest were assessed.” Please describe how these items were analyzed, and how this assessment factored into the results of the review and meta-analysis.

8. Methods (Lines 128-130): Please describe the random effects model used in the meta-analysis.

9. Methods: Please remove the section titled: “Role of the Funding Source” as this information is extracted from the manuscript submission system automatically.

10. Results: Please provide 95% CIs and p values for the results discussed for the subgroup analyses for each mental illness described (e.g. PTSD paragraph, depression paragraph, etc.).

11. Results: Please provide numerators and denominators for overall prevalence rates, if not in the text then at a minimum present these in the appropriate tables.

12. Discussion: Please expand on your Discussion as follows: Please increase the discussion of the existing research on prevalence of mental illnesses in the refugee and asylum seeking population, extending the depth of your discussion beyond the 2005 Fazel et al. and 2009 Steel et al. reviews if possible. Please expand on your discussion of subgroup analysis findings regarding why PTSD prevalence may be higher in individuals originating from Africa.

13. Discussion (Line 144-145, second to last paragraph): Please avoid assertions of primacy and add “To the best of our knowledge…” or similar to the following sentence: “It is also the first systematic review to place no restrictions on language or on countries of origin or settlement.”

14. Figures 2, 4, 6, 8, and 9: Please describe in the figure legend the meaning of the vertical dashed red line.

15. Figures 2-9: Please provide an X-axis label for these graphs.

16. References: Please use brackets for in-text reference numbers, e.g. [1].

17. Supporting Information: Please provide separate labels and titles (e.g. S1 Text, S1 Table, S1 Figure), and legends for all figures and tables. This includes the material included in your Appendix (Checklist, example search string, bias assessment template, and the three Egger plots for PTSD, Depression, and Anxiety). Please refer to our guidelines at:

https://journals.plos.org/plosmedicine/s/submission-guidelines#loc-supporting-information

18. Supporting information: Please define all abbreviations used within the figures and tables in the accompanying legends.

19. Supporting information: In your cover letter, you mentioned that the findings related to children and adolescents have been written up separately and that report is under consideration at another journal. Please include a copy of the unpublished manuscript as part of the supporting information with your revised submission, and also include a paragraph in your cover letter describing the key differences and any overlap between the two papers.

20. Checklist: Thank you for providing the PRISMA checklist. Instead of page numbers, please use sections and paragraphs when referring to locations within the article.

Comments from the reviewers:

Reviewer #1: Thank for the opportunity to review this paper. Blackmore and colleagues report findings from a systematic review which synthesizes mostly survey-based studies to describe the prevalence of mental illness in adult refugees and asylum seekers, reporting pooled results in post-traumatic stress disorder, depression and anxiety. All prevalence figures were higher in refugees than in the general population, which in itself not surprising. This paper adds updated figures that are more recent compared to some previous reviews done completed previously. I do, however, have some suggestions/comments primarily on the methodology.

Abstract - in general the abstract needs a bit more detail when reporting the methods and findings, in particular

Lines 38-39: What "strict" inclusion criteria was described here? This is presented in the main text but the abstract should also explicitly state this directly

Lines 40-41: Study quality assessed should be stated/assessed by the specific tool used.

Abstract methods in general: Methods don't specify what type of meta-analyses was utilised? Random-effects and type of weighting method should be stated. Specify also this was combining aggregate prevalence measures reported in each study.

Line 44: This jumps out without any context - meta-analyses performed in just larger studies, then this needs to pre-specified in the methods section of the abstract or it just looks like selective reporting of a particular sub-analyses.

Methods

Firstly, my main concern on the methods is that as stated in Lines 93-96, the search strategy was not entirely the same as the earlier review performed by Fazel et al., and thus I question whether the rationale to limit the date to 1 Jan 2003 onwards appropriate. Because the search strategy is in fact different in this current review, it is not a "pure" an update on the Fazel et al review. The expanded search, with different criteria, pre-2003 may in fact pick up slightly different composition of studies from Fazel et al. because the authors imposed stricter criteria on mental health diagnoses and expanded the range of databases searched, number of search terms, and no restriction on geography or language.

Second, even if the rationale was purely to update the Fazel et al. review, using the exact search strategy, any evidence synthesis and meta-analyses performed should also include the studies identified in the previous date for the update. Normally, Cochrane Review updates would in fact include both the previous studies combined with new studies. Here, the focus is only on new studies, but I'm not sure this is entirely rationale approach or at least has not been rationalised strongly enough.

Line 103: Clarify if there were any restrictions on study design: i.e. cohort, case-control, cross-sectional surveys (though it looks like most studies were surveys)

Lines 129-130: What weighting methods was utilised in the random-effects model

Lines 134-135: This is the primary concern with the weighting methods. The authors state earlier they used a random-effects model to account for heterogeneity but then describe here that "prevalence rates were combined by direction summation of numerators and denominators". This would suggest that the prevalence rates were simply combined by direct summation across studies, which of course does not account for unequal weighting given from various studies due to sample size and heterogeneity in study design. The definition of prevalence implies a standard statistical assumption following a binomial distribution. Hence, the pooling of prevalence needs to consider the variance derived from the binomial distribution, accounting for the size of the study: var(p) = p(1-p)/N, p is the prevalence and N is the population size

Then the pooled prevalence can be combined using the inverse variance method and the model should be specified with a random-effects term to account for heterogeneity. 95% CI can be appropriately be computed using either the exact method, score method, Wald's method. see for the methodology: https://jech.bmj.com/content/67/11/974

It can be implemented in STATA using metaprop command: see https://archpublichealth.biomedcentral.com/articles/10.1186/2049-3258-72-39

Lines 138-139: Limiting studies stratified by participant number: This shouldn't be necessary with proper weighting methods when pooling (such as Inverse-variance or DerSimonian and Laird method), as small study effects will have large 95% CI and contribute fairly small effects to the overall pooled results. Doing this arbitrary stratification in the primary analyses actually introduces some bias itself.

Lines 142-143: The NOS scale is useful but really designed for Cohort and Case-control studies, hence most of the questions refer to selection bias, control for confounding, and selection of comparators, which all cross-sectional studies are not designed to capture. AXIS-tool is more relevant for assessing quality of cross-sectional studies https://bmjopen.bmj.com/content/6/12/e011458

Overall impression: The study does has it's merits and appreciate the authors hard work in an important area which has a strong rationale to undertake this research. However, there are some aspects the authors should address and clarify. In my opinion, the rationale for limiting the start date with an altered set of search criteria from a previous review is not strong enough. This would have been far more comprehensive as a review to also include studies pre-2003. In fact, there was an opportunity to present a time-stratified sub-analyses to look if the prevalence of mental illness have increased or decreased over time. There also some questions I have on the method which the prevalence figures were synthesized, including how the prevalence figures were pooled - so it's a bit difficult interpret how robust the results are without these factors in clarified and considered.

Reviewer #2: Thank you for your work on this systematic review and meta-analysis on the Prevalence of Mental Illness in Refugees and Asylum Seekers.

Strengths of your manuscript include:

- expanding the evidence base on psychosis among refugees and asylum seekers

- This work continues to demonstrate that refugees experience long term psychiatric sequelae of traumatic events experienced as a result of refugee status and as you note call for long-term health care beyond the initial period of resettlement- very important to ensure funding and programmatic planning.

- Very important finding on:"We found that PTSD and depression were higher for those displaced longer than four years, suggesting a possible deterioration of mental health in the post-migration environment".

I am suggesting several points that should be addressed prior to publication that can improve the utility of this work:

- My main concern is that although it is noted that there is some novel information in this review, besides the interesting information on psychotic symptoms, this review essentially replicates what we know from the literature on PTSD for the past 20 years. The problem is a political one that translates to underfunded programs and poor to no policies based on the evidence base, globally. The majority of refugees and asylum seekers do not live in high income countries- they face significant challenges in settings where there is little to no mental health care. As such, it would be good if you could address, even very briefly, the broader context for having up to date estimates of poor mental health among refugees and asylum seekers globally. Chronic PTSD prevents integration into new societies and reintegration. Funding such programs now makes good economic sense as well as having a human rights imperative.

- It is discussed that it's a strength that results from medical settings were included (excluding survey results) but I'm not sure that's a strength. While in some settings, it can be "assumed" that this means that a diagnosis of say, PTSD, is likely more accurate, it still depends on the clinician, their level of training, need for a quick diagnosis etc etc. It also has a potential country setting bias- biased towards places that may have higher capacity to diagnose and treat PTSD. This should be clearly stated.

- It's concerning that there is such heterogeneity among study results, even though the authors admirably sought to address this. It could be due to your review's criteria and that the results are drawn from such different settings and populations- these populations have experienced such different experiences and culturally may manage them differently. THe authors state that this means that "The results of the meta-analysis yielded high statistical heterogeneity, which is evidence of the critical need for research in this field that is large-scale, uses rigorous diagnostic methods, and characterizes the study sample in detail." but this is highly unlikely as the reason, given the 20 years of replicable results already clear in the literature. Again, this is likely the result of the review's criteria.

- The lower anxiety results is puzzling. PTSD and anxiety disorders are highly comorbid. More explanation needs to be given for this including whether the review's strategy led to potentially inaccurate results.

Given all of the above, the review needs major revisions but could still be a helpful publication if strengthened.

Reviewer #3: The authors have undertaken a systematic review and meta-analysis of epidemiological studies reporting the prevalence of mental disorder amongst refugee and asylum seekers. The review reported is very closely modelled on an earlier review undertaken by Fazel et al (2005). As with that review the authors have restricted their review to research studies that have used structured or semi-structured diagnostic instruments and have excluded studies that report prevalence estimates derived from screening or self-report measures.

The prevalence estimates cited on page 3, line 72-74 are not so relevant to the current review given the inclusion of post-conflict country surveys in that review. It may be possible to cite more specific displaced population estimates.

At line 101, page 4 the authors should clarify the number of systematic reviews examined and include citations for these.

A difference between the Fazel et al study and this research which should be highlighted or corrected is that the authors have included LMI countries of first asylum studies of refugees and asylum seekers. The Fazel et al study was restricted to resettled refugees or asylum seekers in Western or HIC country settings.

It is not clear that the search criteria are optimised to identify those displaced with the region as other terms are often applied. There are a number of studies amongst displaced populations that appear to have used structured diagnostic measures that may be relevant to stated inclusion criteria. I have included a list of studies that the authors should consider. If some of these do meet inclusion criteria then there may be problems with the search strategy applied.

It is not clear what data was extracted by the authors - the manuscript lists sample size, publication year, and country or region of origin. Meta-analytic stratification suggest that other data was extracted such as, sex specific prevalence rates; duration of displacement, and living circumstance. Additional information should be provided on this and whether data on sex especially was extracted as a percentage distribution of extracted separately for makes and females, the later being preferable.

It is a shame that information on the prior trauma and torture exposure given the importance of these as determinants of MH outcomes, although noted that this was not undertaken by Fazel but has been undertaken by subsequent reviews.

Page 28, I agree a strength to limit to diagnostic measures, probably should also limit to multi-stage representative sampling. The study by Fazel especially suggested that study with a sample of over 200 may be the lowest number to reach stable population estimates.

Banal, R., J. Thappa, et al. Psychiatric morbidity in adult Kashmiri migrants living in a migrant camp at Jammu.Indian J Psychiatry 52: 154-158; 2010).

Amowitz LL, Heisler M, Iacopino V. A population-based assessment of women's mental health and attitudes toward women's human rights in Afghanistan. Journal of Women's Health. 2003;12(6):577-587.

Eytan A, Durieux-Paillard S, Whitaker-Clinch B, Loutan L, Bovier PA. Transcultural validity of a structured diagnostic interview to screen for major depression and posttraumatic stress disorder among refugees. Journal of Nervous & Mental Disease. 2007;195(9):723-728.

Fenta H, Hyman I, Noh S. Determinants of depression among Ethiopian immigrants and refugees in Toronto. Journal of Nervous & Mental Disease. 2004;192(5):363-372.

Marshall GN, Schell TL, Elliott MN, Berthold SM, Chun C-A. Mental health of Cambodian refugees 2 decades after resettlement in the United States. JAMA. 2005;294(5):571-579.

Renner W, Salem I, Ottomeyer K. Cross-cultural validation of measures of traumatic symptoms in groups of asylum seekers from Chechnya, Afghanistan, and West Africa. Social Behavior and Personality. 2006;34(9):1101-1114.

Renner W, Salem I. Post-traumatic stress in asylum seekers and refugees from Chechnya, Afghanistan, and West Africa: gender differences in symptomatology and coping. International Journal of Social Psychiatry. 2009;55(2):99-108.

Toscani L, Deroo LA, Eytan A, Gex-Fabry M, Avramovski V, Loutan L, Bovier P. Health status of returnees to Kosovo: do living conditions during asylum make a difference? Public Health. 2007;121(1):34-44.

Any attachments provided with reviews can be seen via the following link:

[LINK]

PLoS Med. 2020 Sep 21;17(9):e1003337. doi: 10.1371/journal.pmed.1003337.r002

Author response to Decision Letter 0

24 Apr 2020

Attachment

Submitted filename: Response to reviewers_PLOS Medicine vers 3.pdf

Click here for additional data file.^{(267.8KB, pdf)}

PLoS Med. doi: 10.1371/journal.pmed.1003337.r003

Decision Letter 1

Caitlin Moyer

17 Jun 2020

Dear Dr. Gibson-Helm,

Thank you very much for submitting your revised manuscript "The Prevalence of Mental Illness in Refugees and Asylum Seekers: a systematic review and meta-analysis" (PMEDICINE-D-19-02869R1) for consideration in PLOS Medicine's Special Issue on Refugee and Migrant Health.

I apologize for the delay in review. Your paper was evaluated by a senior editor and discussed among all the editors here. It was also discussed with the Special Issue Guest Editors, and was re-reviewed by the statistical reviewer. The reviews are appended at the bottom of this email and any accompanying reviewer attachments can be seen via the link below:

[LINK]

In light of these reviews, I am afraid that we will not be able to accept the manuscript for publication in the journal in its current form, but we would like to consider a revised version that addresses the reviewers' and editors' comments. Mainly, we request that you please be sure to address the first comment of Reviewer 1, regarding the analysis comparing studies with native language vs. interpreter-assisted assessments. There were also a few points raised during the previous round of reviews that we would like to see further clarified (please see the Editor's list of requests below).

Obviously we cannot make any decision about publication until we have seen the revised manuscript and your response, and we plan to seek re-review by one or more of the reviewers.

We expect to receive your revised manuscript by Jun 24 2020 11:59PM. Please email us (plosmedicine@plos.org) if you have any questions or concerns.

Please use the following link to submit the revised manuscript:

https://www.editorialmanager.com/pmedicine/

Your article can be found in the "Submissions Needing Revision" folder.

We look forward to receiving your revised manuscript.

Sincerely,

Caitlin Moyer, Ph.D.

Associate Editor

PLOS Medicine

plosmedicine.org

-----------------------------------------------------------

Requests from the editors:

1. Reviewer 1, point #1: Please do address this point raised by the reviewer, perhaps conducting a quick analysis to determine if there was any difference between native language and interpreter-assistance studies.

2. Response to Reviewers: Reviewer 2, point #2: In response to reviewer 2’s second point, I think please explicitly clarify in the text that you have included studies that recruited individuals from general refugee health/ primary health care clinics.

3. Response to Reviewers: Reviewer 2, point # 3: Please discuss ways in which the review's criteria could be a potential contributing factor to the heterogeneity observed.

4. Response to Reviewers: Reviewer 3, point #1: Please more clearly discuss that a limitation of some of the cultural/nation specific prevalence estimates (such as those that were cited) is that some estimates focus on internally displaced/conflict-affected populations and a global refugee comprehensive review is needed.

5. Response to Reviewers: Reviewer 3: final point: Please discuss that restricting inclusion criteria to studies which used multi-stage representative sampling is a limitation (perhaps discuss within the discussion section), and please report in the manuscript how many of their studies would have been excluded based on this restriction.

6. Abstract: Line 48-49: Please clarify this sentence: “Random effects, based on inverse variance weights, were conducted.” Do you mean “random effects models” were conducted?

7. Abstract: Please make some mention of the countries, or at least number of countries, represented by the review, such as described in your results (or similar): “Studies were undertaken in 15 countries with participants from four geographical regions: the Middle East (43%), Europe (29%), Asia (20%), Africa (5%).”

8. Abstract: Methods and Findings: Please revise this sentence to clarify as follows: “The prevalence of post traumatic stress disorder (PTSD) was 31.46% (95% CI 24.43-38.5), the prevalence of depression was 31.5% (95% CI 22.64-40.38), the prevalence of anxiety disorders was 11% (95% CI 6.75-15.43), and the prevalence of psychosis was 1.51% (95% CI 0·63-2·40).” or similar.

9. Abstract: Limitations statement: Thank you for including a statement of limitations, please revise to: “A limitation of the study is that substantial heterogeneity was present in the prevalence estimates of PTSD, depression, and anxiety, and limited covariates were reported in the included studies.”

10. Abstract: Line 59: Please remove the subjective term “rigorous”

11. Author summary: What do these findings mean? Line 77: Should this read “increased prevalence” in the first bullet point?

12. Introduction: Line 94, and throughout manuscript where applicable: Please refer to low or middle income countries rather than "developing countries" or "the Global South". Please refer to high income countries rather than "developed" or "Western" countries.

13. Results Line 232-233: Please also provide 95% CIs for duration of displacement results.

14. Results Line 247-249: Please clarify “significantly lower” than which comparison group in the following sentence: “In the seven larger studies with 200 or more participants, depression prevalence was significantly lower, 20.65% (95% CI 18.88-22.51).” If statistical significance is meant, please include associated p values in addition to CIs.

15. Results Line 249-250: Please also provide 95% CIs for duration of displacement results.

16. Results Line 271: Please also provide 95% CIs for the sample size and anxiety disorder analysis.

17. Results Line 295-297: Please clarify that you meant “resulting in” and not “...and this was associated with fewer than expected…” in the following sentence: “Additionally, in one study only male psychologists conducted the diagnostic assessments, resulting in fewer than expected reports of sexual assault. [51]”

18. Discussion: Line 314: Please indicate that you mean “anxiety prevalence” here.

19. Discussion: Line 344-346: Please revise this sentence to clarify: Although trauma type in relation to PTSD diagnosis was not adequately described in the studies, many studies reported on participants from countries such as the former Yugoslavia, Syria, and Iraq, areas with conflicts reported to have perpetrated systematic sexual violence.” or similar depending on your intended meaning here.

20. Discussion: Line 353: Please revise this sentence, without overreaching what can be concluded from the data- we suggest: “Our findings suggest that the prevalence of PTSD and depression persists for many years post-displacement…” Similarly at line 363, we suggest beginning this sentence with “We found that…”

21. References: In-text citations should be in regular text (not superscript), with numbers in brackets appearing before punctuation, like this: [1].

22. Reference List: Please use the "Vancouver" style for reference formatting, and see our website for other reference guidelines: https://journals.plos.org/plosmedicine/s/submission-guidelines#loc-references

23. Supporting information: S1 Table, S3-S6 Eggers test results: Please provide titles and descriptive legends for each individual table and figure in the Supporting Information.

Comments from the reviewers:

Reviewer #1: The revised version of the manuscript is much approved by the authors. The authors have spent significant effort addressing review amendments and suggestions. The responses were appropriate and the corresponding manuscript has reflected the suggested changes.

Two final additional points that I felt could potentially enhance this nice piece of work to consider:

1) There were thirteen studies conducting assessment in native language compared to thirteen with assistant from interpreters. I wonder if there was any influence on prevalence figures - which would have implications on the mode of assessment in native languages.

2) The authors picked up five diagnosis measures - were there enough studies in any one of those diagnostic measures to conduct a sub-group that were diagnostic measure specific. Again - if possible the results could indicate what particular measures may be contributing to the heterogeneity and whether there is any indication that certain diagnostic measures may be more sensitive towards picking up higher levels of the outcomes of interest.

Apart from these comments - I think the manuscript is publishable.

Any attachments provided with reviews can be seen via the following link:

[LINK]

PLoS Med. 2020 Sep 21;17(9):e1003337. doi: 10.1371/journal.pmed.1003337.r004

Author response to Decision Letter 1

2 Jul 2020

Attachment

Submitted filename: Response to Reviewers_3 July 2020.docx

Click here for additional data file.^{(29.2KB, docx)}

PLoS Med. doi: 10.1371/journal.pmed.1003337.r005

Decision Letter 2

Caitlin Moyer

23 Jul 2020

Dear Dr. Gibson-Helm,

Thank you very much for re-submitting your manuscript "The Prevalence of Mental Illness in Refugees and Asylum Seekers: a systematic review and meta-analysis" (PMEDICINE-D-19-02869R2) for review by PLOS Medicine.

I have discussed the paper with my colleagues and the academic editor and it was also seen again by one of the reviewers. I am pleased to say that provided the remaining editorial and production issues are dealt with we are planning to accept the paper for publication in the journal.

The remaining issues that need to be addressed are listed at the end of this email. Any accompanying reviewer attachments can be seen via the link below. Please take these into account before resubmitting your manuscript:

[LINK]

Our publications team (plosmedicine@plos.org) will be in touch shortly about the production requirements for your paper, and the link and deadline for resubmission. DO NOT RESUBMIT BEFORE YOU'VE RECEIVED THE PRODUCTION REQUIREMENTS.

In revising the manuscript for further consideration here, please ensure you address the specific points made by each reviewer and the editors. In your rebuttal letter you should indicate your response to the reviewers' and editors' comments and the changes you have made in the manuscript. Please submit a clean version of the paper as the main article file. A version with changes marked must also be uploaded as a marked up manuscript file.

Please also check the guidelines for revised papers at http://journals.plos.org/plosmedicine/s/revising-your-manuscript for any that apply to your paper. If you haven't already, we ask that you provide a short, non-technical Author Summary of your research to make findings accessible to a wide audience that includes both scientists and non-scientists. The Author Summary should immediately follow the Abstract in your revised manuscript. This text is subject to editorial change and should be distinct from the scientific abstract.

We expect to receive your revised manuscript within 1 week. Please email us (plosmedicine@plos.org) if you have any questions or concerns.

We ask every co-author listed on the manuscript to fill in a contributing author statement. If any of the co-authors have not filled in the statement, we will remind them to do so when the paper is revised. If all statements are not completed in a timely fashion this could hold up the re-review process. Should there be a problem getting one of your co-authors to fill in a statement we will be in contact. YOU MUST NOT ADD OR REMOVE AUTHORS UNLESS YOU HAVE ALERTED THE EDITOR HANDLING THE MANUSCRIPT TO THE CHANGE AND THEY SPECIFICALLY HAVE AGREED TO IT.

If you have any questions in the meantime, please contact me or the journal staff on plosmedicine@plos.org.

We look forward to receiving the revised manuscript by Jul 30 2020 11:59PM.

Sincerely,

Caitlin Moyer, Ph.D.

Associate Editor

PLOS Medicine

plosmedicine.org

------------------------------------------------------------

Requests from Editors:

1.Results Line 289-290: Please provide 95% CIs to accompany the p value reported here: “The use of an interpreter to conduct assessments had no significant impact on the reported prevalence of anxiety disorders (p = 0.34).”

2.Discussion: first paragraph, lines 334-335: Please revise this sentence: “However, this was not the case for the prevalence of anxiety disorders, which we found to be higher among those displaced less than four years.” or similar, to clarify.”

3.Discussion: Line 340: Should this read “...less than the lifetime prevalence…”?

4.Discussion: Line 377: Please revise: “anxiety disorders, where there was no difference between…” to read “...anxiety disorders, where we did not find evidence for a difference between…”

5.Discussion: Line 385-386: Please revise to clarify this sentence, we suggest: “Although beyond the scope of this review, further investigation is required to understand potential differences in case identification between diagnostic measures.” or similar.

6.Discussion: line 399-400: Please revise to clarify this sentence. We suggest: “In contrast, the results for anxiety disorders and psychosis are comparable with previously reported prevalence rates [6].” or similar.

7.Discussion: Line 416: Please change to “investigate potential sources of heterogeneity”

8.Figure 2: Please define the abbreviations for PTSD and CI in the legend.

9.Figure 3: Please provide an X axis label. Please spell out abbreviations for PTSD, CI, and for the diagnostic measures MINI, CAPS, WHO-CIDI, and SCID in the legend.

10.Figure 4: Please define the abbreviation for CI in the legend.

11.Figure 5: Please spell out the abbreviations for CI, MINI, WHO-CIDI, and SCID. Please provide an X axis label.

12.Figure 6: Please spell out the abbreviation for CI in the legend.

13.Figure 7: Please spell out the abbreviation for CI in the legend, and please provide an X axis label.

14.Figure 8: Please spell out the abbreviation for CI in the legend.

15. Supporting information files S3-S6: Please provide legends for each file in which you describe all figure panels and spell out all abbreviations used within the figures.

Comments from Reviewers:

Reviewer #1: I agree that the authors have done their part in adding the additional analyses. How interesting the results!

This implication being I think being that when designing these assessments - the method of assessment and diagnostic measure had a significant bearing on the proportion of cases being detected (the direction of association seemed to be consistently one way as well).

The limitation is that we don't of course know what is closer to the true answer without a known reference standard (arguably in this population this would be difficult to achieve) but it does raise the issues that careful consideration of the method of assessment and instrument of assessment in this population.

Any attachments provided with reviews can be seen via the following link:

[LINK]

PLoS Med. 2020 Sep 21;17(9):e1003337. doi: 10.1371/journal.pmed.1003337.r006

Author response to Decision Letter 2

9 Aug 2020

Attachment

Submitted filename: Response to Reviewers_30 July 2020.docx

Click here for additional data file.^{(17.4KB, docx)}

PLoS Med. doi: 10.1371/journal.pmed.1003337.r007

Decision Letter 3

Caitlin Moyer

14 Aug 2020

Dear Dr Gibson-Helm,

On behalf of my colleagues and the academic editor, Dr. Paul Spiegel, I am delighted to inform you that your manuscript entitled "The Prevalence of Mental Illness in Refugees and Asylum Seekers: a systematic review and meta-analysis" (PMEDICINE-D-19-02869R3) has been accepted for publication in PLOS Medicine.

PRODUCTION PROCESS

Before publication you will see the copyedited word document (in around 1-2 weeks from now) and a PDF galley proof shortly after that. The copyeditor will be in touch shortly before sending you the copyedited Word document. We will make some revisions at the copyediting stage to conform to our general style, and for clarification. When you receive this version you should check and revise it very carefully, including figures, tables, references, and supporting information, because corrections at the next stage (proofs) will be strictly limited to (1) errors in author names or affiliations, (2) errors of scientific fact that would cause misunderstandings to readers, and (3) printer's (introduced) errors.

If you are likely to be away when either this document or the proof is sent, please ensure we have contact information of a second person, as we will need you to respond quickly at each point.

PRESS

A selection of our articles each week are press released by the journal. You will be contacted nearer the time if we are press releasing your article in order to approve the content and check the contact information for journalists is correct. If your institution or institutions have a press office, please notify them about your upcoming paper at this point, to enable them to help maximize its impact.

PROFILE INFORMATION

Now that your manuscript has been accepted, please log into EM and update your profile. Go to https://www.editorialmanager.com/pmedicine, log in, and click on the "Update My Information" link at the top of the page. Please update your user information to ensure an efficient production and billing process.

Thank you again for submitting the manuscript to PLOS Medicine. We look forward to publishing it.

Best wishes,

Caitlin Moyer, Ph.D.

Associate Editor

PLOS Medicine

plosmedicine.org

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

S1 Prisma Checklist. From [16].

For more information, visit: www.prisma-statement.org.

(DOCX)

Click here for additional data file.^{(20.7KB, docx)}

S1 Table. *Truncation symbol.

MeSH term, Medical Subject Headings.

(DOCX)

Click here for additional data file.^{(18.2KB, docx)}

S1 Risk of Bias

(DOCX)

Click here for additional data file.^{(24.7KB, docx)}

S1 Egger’s Test PTSD

(DOCX)

Click here for additional data file.^{(29.7KB, docx)}

S2 Egger’s Test Depression

(DOCX)

Click here for additional data file.^{(29.8KB, docx)}

S3 Egger’s Test Anxiety

(DOCX)

Click here for additional data file.^{(29.2KB, docx)}

S4 Egger’s Test Psychosis

(DOCX)

Click here for additional data file.^{(28.9KB, docx)}

Attachment

Submitted filename: Response to reviewers_PLOS Medicine vers 3.pdf

Click here for additional data file.^{(267.8KB, pdf)}

Attachment

Submitted filename: Response to Reviewers_3 July 2020.docx

Click here for additional data file.^{(29.2KB, docx)}

Attachment

Submitted filename: Response to Reviewers_30 July 2020.docx

Click here for additional data file.^{(17.4KB, docx)}

Data Availability Statement

All relevant data are within the manuscript and its Supporting Information files.

[pmed.1003337.ref001] 1.United Nations High Commissioner for Refugees. Global trends—forced displacement in 2018. United Nations High Commissioner for Refugees. 2019. Available from: https://www.unhcr.org/en-au/statistics/unhcrstats/5d08d7ee7/unhcr-global-trends-2018.html [Google Scholar]

[pmed.1003337.ref002] 2.Kéri S. Suffering has no race or nation: The psychological impact of the refugee crisis in Hungary and the occurrence of posttraumatic stress disorder. Soc Sci. 2015;4(4). [Google Scholar]

[pmed.1003337.ref003] 3.Beiser M. Longitudinal research to promote effective refugee resettlement. Transcult Psychiatry. 2006; 43(1): 56–71. [DOI] [PubMed] [Google Scholar]

[pmed.1003337.ref004] 4.Porter M, Haslam N. Predisplacement and postdisplacement factors associated with mental health of refugees and internally displaced persons—a meta-analysis. JAMA. 2005;294(5): 602–12. [DOI] [PubMed] [Google Scholar]

[pmed.1003337.ref005] 5.Bogic M, Njoku A, Priebe S. Long-term mental health of war-refugees: a systematic literature review. BMC Int Health Hum Rights. 2015;15: 29 10.1186/s12914-015-0064-9 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pmed.1003337.ref006] 6.Fazel M, Wheeler J, Danesh J. Prevalence of serious mental disorder in 7000 refugees resettled in western countries: a systematic review. Lancet. 2005;365(9467): 1309–14. [DOI] [PubMed] [Google Scholar]

[pmed.1003337.ref007] 7.Steel Z, Chey T, Silove D, Marnane C, Bryant RA, van Ommeren M. Association of torture and other potentially traumatic events with mental health outcomes among populations exposed to mass conflict and displacement: a systematic review and meta-analysis. JAMA. 2009; 302(5): 537–49. [DOI] [PubMed] [Google Scholar]

[pmed.1003337.ref008] 8.Peconga EK, Hogh Thogersen M. Post-traumatic stress disorder, depression, and anxiety in adult Syrian refugees: what do we know? Scand J Public Health. 2019; 10.1177/1403494819882137 [DOI] [PubMed] [Google Scholar]

[pmed.1003337.ref009] 9.Steel JL, Dunlavy AC, Harding CE, Theorell T. The psychological consequences of pre-emigration trauma and post-migration stress in refugees and immigrants from Africa. J Immigr Minor Health. 2017;19(3): 523–532. [DOI] [PubMed] [Google Scholar]

[pmed.1003337.ref010] 10.Slewa-Younan S, Uribe Guajardo MG, Heriseanu A, Hasan T. A systematic review of post-traumatic stress disorder and depression amongst Iraqi refugees located in western countries. J Immigr Minor Health. 2015;17(4): 1231–1239. [DOI] [PubMed] [Google Scholar]

[pmed.1003337.ref011] 11.Tay AK, Riley A, Islam R, Welton-Mitchell C, Duchesne B, Waters V, et al. The culture, mental health and psychosocial wellbeing of Rohingya refugees: a systematic review. Epidemiol Psychiatr Sci. 2019;28(5): 489–94. 10.1017/S2045796019000192 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pmed.1003337.ref012] 12.Mahmood HN, Ibrahim H, Goessmann K, Ismail AA, Neuner F. Post-traumatic stress disorder and depression among Syrian refugees residing in the Kurdistan region of Iraq. Confl Health. 2019;13(1): 51. [DOI] [PMC free article] [PubMed] [Google Scholar]

[pmed.1003337.ref013] 13.de Jong JTVM Komproe IH, Van Ommeren M. Common mental disorders in postconflict settings. Lancet. 2003; 361(9375): 2128–30. [DOI] [PubMed] [Google Scholar]

[pmed.1003337.ref014] 14.World Health Organization. Promoting the health of refugees and migrants: draft global action plan. Seventy Second World Health Assembly; 2019. Available from: https://apps.who.int/gb/ebwha/pdf_files/WHA72/A72_25-en.pdf. [Google Scholar]

[pmed.1003337.ref015] 15.Schick M, Morina N, Mistridis P, Schnyder U, Bryant RA, Nickerson A. Changes in post-migration living difficulties predict treatment outcome in traumatized refugees. Front Psychiatry. 2018;9: 476–476. [DOI] [PMC free article] [PubMed] [Google Scholar]

[pmed.1003337.ref016] 16.Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. 2009; 6(7): e1000097 10.1371/journal.pmed1000097 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pmed.1003337.ref017] 17.American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. Arlington: American Psychiatric Publishing; 2013. [Google Scholar]

[pmed.1003337.ref018] 18.World Health Organization. The ICD-10 classification of mental and behavioural disorders: Clinical descriptions and diagnostic guidelines. Geneva: World Health Organization; 1992. [Google Scholar]

[pmed.1003337.ref019] 19.Kessler RC, Ustun TB. The world mental health (WMH) survey initiative version of the World Health Organization (WHO) Composite International Diagnostic Interview (CIDI). Int J Methods Psychiatr Res. 2004; 13(2):93–121. [DOI] [PMC free article] [PubMed] [Google Scholar]

[pmed.1003337.ref020] 20.DerSimonian R, Laird N. Meta-analysis in clinical trials. Control Clin Trials. 1986;7(3): 177–188. [DOI] [PubMed] [Google Scholar]

[pmed.1003337.ref021] 21.Higgins JPT, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. BMJ. 2003;327(7414): 557–560. [DOI] [PMC free article] [PubMed] [Google Scholar]

[pmed.1003337.ref022] 22.Egger M, Smith GD, Schneider M, Minder C. Bias in meta-analysis detected by a simple, graphical test. BMJ. 1997;315(7109): 629–634. [DOI] [PMC free article] [PubMed] [Google Scholar]

[pmed.1003337.ref023] 23.Jakobsen M, Thoresen S, Johansen LEE. The validity of screening for post-traumatic stress disorder and other mental health problems among asylum seekers from different countries. J Refug Stud. 2011; 24(1):171–86. [Google Scholar]

[pmed.1003337.ref024] 24.Neuner F, Schauer M, Klaschik C, Karunakara U, Elbert T. A comparison of narrative exposure therapy, supportive counseling, and psychoeducation for treating posttraumatic stress disorder in an african refugee settlement. J Consult Clin Psychol. 2004;72(4): 579–87. [DOI] [PubMed] [Google Scholar]

[pmed.1003337.ref025] 25.van Ommeren M, Komproe I, Cardena E, et al. Mental illness among Bhutanese shamans in Nepal. J Nerv Ment Dis. 2004;192(4): 313–7. [DOI] [PubMed] [Google Scholar]

[pmed.1003337.ref026] 26.Monash Centre for Health Research and Implementation. Evidence synthesis program template for critical appraisal of a cohort study. Melbourne: Monash Centre for Health Research and Implementation; 2014. [Google Scholar]

[pmed.1003337.ref027] 27.Wells G, Shea B, O’Connell D, et al. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses. 2009. Available from: http://www.ohri.ca/programs/clinical_epidemiology/oxford.asp. [Google Scholar]

[pmed.1003337.ref028] 28.Balen AH, Morley LC, Misso M, et al. The management of anovulatory infertility in women with polycystic ovary syndrome: an analysis of the evidence to support the development of global WHO guidance. Hum Reprod Update. 2016;22: 687–708. [DOI] [PubMed] [Google Scholar]

[pmed.1003337.ref029] 29.Teede HJ, Misso ML, Costello MF, et al. Recommendations from the international evidence-based guideline for the assessment and management of polycystic ovary syndrome. Clin Endocrinol. 2018; 89: 251–68. [DOI] [PMC free article] [PubMed] [Google Scholar]

[pmed.1003337.ref030] 30.Goldstein RF, Abell SK, Ranasinha S, et al. Association of gestational weight gain with maternal and infant outcomes: A systematic review and meta-analysis. JAMA. 2017;317: 2207–25. [DOI] [PMC free article] [PubMed] [Google Scholar]

[pmed.1003337.ref031] 31.Charney ME, Keane TM. Psychometric analyses of the Clinician-Administered PTSD Scale (CAPS)—Bosnian translation. Cultur Divers Ethni Minor Psychol. 2007;13(2): 161–8. [DOI] [PubMed] [Google Scholar]

[pmed.1003337.ref032] 32.Yu SE, Jeon WT. Mental health of North Korean refugees in protective facilities in china. Psychiatry Investig. 2008;5(2): 70–7. [DOI] [PMC free article] [PubMed] [Google Scholar]

[pmed.1003337.ref033] 33.Momartin S, Silove D, Manicavasagar V, Steel Z. Comorbidity of PTSD and depression: associations with trauma exposure, symptom severity and functional impairment in Bosnian refugees resettled in Australia. J Affect Disord. 2004;80(2–3):231–8. [DOI] [PubMed] [Google Scholar]

[pmed.1003337.ref034] 34.Silove D, Momartin S, Marnane C, Steel Z, Manicavasagar V. Adult separation anxiety disorder among war-affected Bosnian refugees: comorbidity with PTSD and associations with dimensions of trauma. J Trauma Stress. 2010;23(1): 169–72. [DOI] [PubMed] [Google Scholar]

[pmed.1003337.ref035] 35.Tay K, Frommer N, Hunter J, Silove D, Pearson L, San Roque M, et al. A mixed-method study of expert psychological evidence submitted for a cohort of asylum seekers undergoing refugee status determination in Australia. Soc Sci Med. 2013;98: 106–15. [DOI] [PubMed] [Google Scholar]

[pmed.1003337.ref036] 36.Hocking DC, Mancuso SG, Sundram S. Development and validation of a mental health screening tool for asylum-seekers and refugees: the STAR-MH. BMC Psychiatry. 2018;18. [DOI] [PMC free article] [PubMed] [Google Scholar]

[pmed.1003337.ref037] 37.Rees SJ, Fisher JR, Steel Z, Mohsin M, Nadar N, Moussa B, et al. Prevalence and risk factors of major depressive disorder among women at public antenatal clinics from refugee, conflict-affected, and Australian-born backgrounds. JAMA Netw Open. 2019;2(5): e193442. [DOI] [PMC free article] [PubMed] [Google Scholar]

[pmed.1003337.ref038] 38.Renner W, Salem I, Ottomeyer K. Cross-cultural validation of measures of traumatic symptoms in groups of asylum seekers from Chechnya, Afghanistan, and West Africa. Soc Behav Pers. 2006; 34(9):1101–14. [Google Scholar]

[pmed.1003337.ref039] 39.Bogic M, Ajdukovic D, Bremner S, Franciskovic T, Galeazzi GM, Kucukalic A, et al. Factors associated with mental disorders in long-settled war refugees: refugees from the former Yugoslavia in Germany, Italy and the UK. Br J Psychiatry. 2012; 200(3):216–23. [DOI] [PubMed] [Google Scholar]

[pmed.1003337.ref040] 40.Eckart C, Stoppel C, Kaufmann J, Tempelmann C, Hinrichs H, Elbert T, et al. Structural alterations in lateral prefrontal, parietal and posterior midline regions of men with chronic posttraumatic stress disorder. J Psychiatry Neurosci. 2011;36(3): 176–86. [DOI] [PMC free article] [PubMed] [Google Scholar]

[pmed.1003337.ref041] 41.von Lersner U, Wiens U, Elbert T, Neuner F. Mental health of returnees: refugees in Germany prior to their state-sponsored repatriation. BMC Int Health Hum Rights. 2008; 8:8 10.1186/1472-698X-8-8 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pmed.1003337.ref042] 42.Kizilhan JI. PTSD of rape after IS ("Islamic State") captivity. Arch Womens Ment Health. 2018;21(5): 517–524. [DOI] [PubMed] [Google Scholar]

[pmed.1003337.ref043] 43.Richter K, Peter L, Lehfeld H, Zaske H, Brar-Reissinger S, Niklewski G. Prevalence of psychiatric diagnoses in asylum seekers with follow-up. BMC Psychiatry. 2018;18 10.1186/s12888-018-1783-y [DOI] [PMC free article] [PubMed] [Google Scholar]

[pmed.1003337.ref044] 44.Wulfes N, del Pozo MA, Buhr-Riehm B, Heinrichs N, Kröger C. Screening for posttraumatic stress disorder in refugees: comparison of the diagnostic efficiency of two self-rating measures of posttraumatic stress disorder. J Trauma Stress. 2019;32(1): 148–155. [DOI] [PubMed] [Google Scholar]

[pmed.1003337.ref045] 45.Llosa AE, Ghantous Z, Souza R, Forgione F, Bastin P, Jones A, et al. Mental disorders, disability and treatment gap in a protracted refugee setting. Br J Psychiatry. 2014;204(3): 208–13. [DOI] [PubMed] [Google Scholar]

[pmed.1003337.ref046] 46.Kazour F, Zahreddine NR, Maragel MG, Almustafa MA, Soufia M, Haddad R, et al. Post-traumatic stress disorder in a sample of Syrian refugees in Lebanon. Compr Psychiatry. 2017;72: 41–7. [DOI] [PubMed] [Google Scholar]

[pmed.1003337.ref047] 47.Jeon W, Hong C, Lee C, Kim DK, Han M, Min S. Correlation between traumatic events and posttraumatic stress disorder among North Korean defectors in South Korea. J Trauma Stress. 2005; 18(2): 147–54. [DOI] [PubMed] [Google Scholar]

[pmed.1003337.ref048] 48.Sondergaard HP, Theorell T. Alexithymia, emotions and PTSD; findings from a longitudinal study of refugees. Nord J Psychiatry. 2004;58(3): 185–91. [DOI] [PubMed] [Google Scholar]

[pmed.1003337.ref049] 49.Heeren M, Mueller J, Ehlert U, Schnyder U, Copiery N, Maier T. Mental health of asylum seekers: a cross-sectional study of psychiatric disorders. BMC Psychiatry. 2012;12: 114. [DOI] [PMC free article] [PubMed] [Google Scholar]

[pmed.1003337.ref050] 50.Maier T, Schmidt M, Mueller J. Mental health and healthcare utilisation in adult asylum seekers. Swiss Med Wkly. 2010; 140. [DOI] [PubMed] [Google Scholar]

[pmed.1003337.ref051] 51.Tekin A, Karadag H, Suleymanoglu M, Tekin M, Kayran Y, Alpak G, et al. Prevalence and gender differences in symptomatology of posttraumatic stress disorder and depression among Iraqi Yazidis displaced into Turkey. Eur J Psychotraumatol. 2016;7: 28556 10.3402/ejpt.v7.28556 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pmed.1003337.ref052] 52.Turner SW, Bowie C, Dunn G, Shapo L, Yule W. Mental health of Kosovan Albanian refugees in the UK. Br J Psychiatry. 2003;182: 444–448. 10.1192/bjp.01.458 [DOI] [PubMed] [Google Scholar]

[pmed.1003337.ref053] 53.Wright A, Talia YR, Aldhalimi A, Broadbridge CL, Jamil H, Lumley MA, et al. Kidnapping and mental health in Iraqi refugees: the role of resilience. J Immigr Minor Health. 2017;19(1): 98–107. [DOI] [PMC free article] [PubMed] [Google Scholar]

[pmed.1003337.ref054] 54.First MB, Williams JBW, Karg RS, Spitzer RL. Structured clinical interview for DSM-5—research version. Arlington: American Psychiatric Association; 2015. [Google Scholar]

[pmed.1003337.ref055] 55.Sheehan DV, Lecrubier Y, Sheehan KH, Amorim P, Janavs J, Weiller E, et al. The Mini-International Neuropsychiatric Interview (M.I.N.I.): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. J clin psychiatry. 1998; 59 Suppl 20:22–33; quiz 4–57. [PubMed] [Google Scholar]

[pmed.1003337.ref056] 56.Weathers FW, Bovin MJ, Lee DJ, Sloan DM, Schnurr PP, Kaloupek DG, et al. The Clinician-Administered PTSD Scale for DSM-5 (CAPS-5): development and initial psychometric evaluation in military veterans. Psychol assess. 2018;30(3): 383–95. [DOI] [PMC free article] [PubMed] [Google Scholar]

[pmed.1003337.ref057] 57.Koenen KC, Ratanatharathorn A, Ng L, McLaughlin KA, Bromet EJ, Stein DJ, et al. Posttraumatic stress disorder in the World Mental Health Surveys. Psychol Med. 2017;47: 2260–74. [DOI] [PMC free article] [PubMed] [Google Scholar]

[pmed.1003337.ref058] 58.Kessler RC, Aguilar-Gaxiola S, Alonso J, Chatterji S, Lee S, Ormel J, et al. The global burden of mental disorders: An update from the WHO World Mental Health (WMH) Surveys. Epidemiol Psichiatr Soc. 2009;18: 23–33. [DOI] [PMC free article] [PubMed] [Google Scholar]

[pmed.1003337.ref059] 59.Perälä J, Suvisaari J, Saarni SI, Kuoppasalmi K, Isometsa E, Pirkola S, et al. Lifetime prevalence of psychotic and bipolar I disorders in a general population. Arch Gen Psychiatry. 2007;64: 19–28. [DOI] [PubMed] [Google Scholar]

[pmed.1003337.ref060] 60.Pai A, Suris AM, North CS. Posttraumatic stress disorder in the DSM-5: controversy, change, and conceptual considerations. Behav Sci (Basel). 2017;7(1): 7 10.3390/bs7010007 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pmed.1003337.ref061] 61.Kessler RC, Sonnega A, Bromet E, Hughes M, Nelson CB. Posttraumatic stress disorder in the National Comorbidity Survey. Arch Gen Psychiatry. 1995;52: 1048–60. 10.1001/archpsyc.1995.03950240066012 [DOI] [PubMed] [Google Scholar]

[pmed.1003337.ref062] 62.Christiansen DM, Hansen M. Accounting for sex differences in PTSD: A multi-variable mediation model. Eur J Psychotraumatol. 2015;6: 26068–26068. [DOI] [PMC free article] [PubMed] [Google Scholar]

[pmed.1003337.ref063] 63.Tolin DF, Foa EB. Sex differences in trauma and posttraumatic stress disorder: a quantitative review of 25 years of research. Psychol Bull. 2006;132: 959–92. [DOI] [PubMed] [Google Scholar]

[pmed.1003337.ref064] 64.Sidebotham E, Moffatt J, Jones K. Sexual violence in conflict: a global epidemic. The Obstet Gynaecol. 2016;18: 247–50. [Google Scholar]

[pmed.1003337.ref065] 65.Vu A, Adam A, Wirtz A, Pham K, Rubenstein L, Glass N, Beyrer C, Singh S. The prevalence of sexual violence among female refugees in complex humanitarian emergencies: a systematic review and meta-analysis. PLoS Curr. 2014; 18. [DOI] [PMC free article] [PubMed] [Google Scholar]

[pmed.1003337.ref066] 66.Mohammadi D. Help for Yazidi survivors of sexual violence. Lancet Psychiatry. 2016;3: 409–410. [Google Scholar]

[pmed.1003337.ref067] 67.Ditlevsen DN, Elklit A. Gender, trauma type, and PTSD prevalence: a re-analysis of 18 Nordic convenience samples. Ann Gen Psychiatry. 2012;11: 26–26. [DOI] [PMC free article] [PubMed] [Google Scholar]

[pmed.1003337.ref068] 68.Baker A. The Secret War Crime: How Do You Ask Women to Relive Their Worst Nightmares. TIME. 2016. March 10 [cited 2019 Nov 12]. Available from: http://time.com/war-and-rape/. [Google Scholar]

[pmed.1003337.ref069] 69.Gibney M, Cornet L, Wood R, Haschke P, Arnon D, Pisanò A, et al. The Political Terror Scale 1976–2018. The Political Terror Scale Website. 2019. Available from: http://www.politicalterrorscale.org. [Google Scholar]

[pmed.1003337.ref070] 70.Bauer AM, Alegría M. Impact of patient language proficiency and interpreter service use on the quality of psychiatric care: a systematic review. Psychiatr serv. 2010;61(8), 765–773. 10.1176/ps.2010.61.8.765 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pmed.1003337.ref071] 71.Levis B, McMillan D, Sun Y, He C, Rice DB, Krishnan A, et al. Comparison of major depression diagnostic classification probability using the SCID, CIDI, and MINI diagnostic interviews among women in pregnancy or postpartum: an individual participant data meta-analysis. Int J Methods Psychiatr Res. 2019;28(4): e1803. [DOI] [PMC free article] [PubMed] [Google Scholar]

[pmed.1003337.ref072] 72.Fazel M, Betancourt TS. Preventive mental health interventions for refugee children and adolescents in high-income settings. Lancet Child Adolesc Health. 2018;2: 121–32. [DOI] [PubMed] [Google Scholar]

[pmed.1003337.ref073] 73.Beiser M. Resettling refugees and safeguarding their mental health: lessons learned from the Canadian Refugee Resettlement Project. Transcult Psychiatry. 2009;46: 539–83. [DOI] [PubMed] [Google Scholar]

[pmed.1003337.ref074] 74.Carlsson JM, Olsen DR, Mortensen EL, Kastrup M. Mental health and health-related quality of life: a 10-year follow-up of tortured refugees. J Nerv Ment Dis. 2006;194: 725–31. [DOI] [PubMed] [Google Scholar]

[pmed.1003337.ref075] 75.Lindert J, Ehrenstein OS, Priebe S, Mielck A, Brahler E. Depression and anxiety in labor migrants and refugees—a systematic review and meta-analysis. Soc Sci Med. 2009;69(2): 246–257. [DOI] [PubMed] [Google Scholar]

[pmed.1003337.ref076] 76.Fitzgerald DS, Arar R. The sociology of refugee migration. Annu Rev Sociol. 2018;44: 387–406. [Google Scholar]

[pmed.1003337.ref077] 77.Crawley H, Skleparis D. Refugees, migrants, neither, both: categorical fetishism and the politics of bounding in Europe’s ‘migration crisis’. J Ethn Migr Stud. 2018;44: 48–64. [Google Scholar]

[pmed.1003337.ref078] 78.Alarcón RD. Culture, cultural factors and psychiatric diagnosis: review and projections. World Psychiatry. 2009; 8:131–39. [DOI] [PMC free article] [PubMed] [Google Scholar]

[pmed.1003337.ref079] 79.Specker P, Liddell BJ, Byrow Y, Bryant RA, Nickerson A. A factor analytic investigation of DSM-5 PTSD symptoms in a culturally diverse sample of refugees resettled in Australia. Confl Health. 2018;12: 26. [DOI] [PMC free article] [PubMed] [Google Scholar]

PERMALINK

The prevalence of mental illness in refugees and asylum seekers: A systematic review and meta-analysis

Rebecca Blackmore

Jacqueline A Boyle

Mina Fazel

Sanjeeva Ranasinha

Kylie M Gray

Grace Fitzgerald

Marie Misso

Melanie Gibson-Helm

Roles

Abstract

Background

Methods and findings

Conclusions

Author summary

Why was this study done?

What did the researchers do and find?

What do these findings mean?

Introduction

Methods

Search strategy and selection criteria

Data analysis

Risk of bias assessment

Results

Fig 1. Search results and selection of studies reporting prevalence of mental illness among refugees and asylum seekers.

Table 1. Characteristics of included studies.

Fig 2. Prevalence of PTSD in refugees and asylum seekers.

Fig 3. Prevalence of PTSD by various study characteristics.

Fig 4. Prevalence of depression in refugees and asylum seekers.

Fig 5. Prevalence of depression by various study characteristics.

Fig 6. Prevalence of anxiety in refugees and asylum seekers.

Fig 7. Prevalence of anxiety by various study characteristics.

Fig 8. Prevalence of psychosis in refugees and asylum seekers.

Publication bias

Risk of bias

Discussion

Limitations and strengths

Supporting information

Acknowledgments

Abbreviations

Data Availability

Funding Statement

References

Decision Letter 0

Caitlin Moyer

Roles

Author response to Decision Letter 0

Decision Letter 1

Caitlin Moyer

Roles

Author response to Decision Letter 1

Decision Letter 2

Caitlin Moyer

Roles

Author response to Decision Letter 2

Decision Letter 3

Caitlin Moyer

Roles

Associated Data

Supplementary Materials

Data Availability Statement

ACTIONS

PERMALINK

RESOURCES

Similar articles

Cited by other articles

Links to NCBI Databases