Summary
Aim
This study explores the possibility of developing an assessment instrument based on self-report that would be sufficiently sensitive and practically applicable to detect mental illness and need for treatment among asylum seekers. A questionnaire consisting of different standardized psychometric instruments were assembled and translated into the asylum seekers native language: Harvard Trauma Questionnaire (HTQ), Hopkins Symptoms Checklist (HSCL-25), Positive State of Mind Scale (PSOM) and Somatoform dissociation scale (SDQ- 20). A questionnaire mapping demographical variables and four items with the asylum seekers’ own evaluation of their life situation were included as well. The results from the questionnaires were analyzed and validated through the results from a diagnostic interview, the Composite International Diagnostic Interview (CIDI). The study was conducted among relatively newly arrived residents in a number of asylum reception centers in Southern Norway. A total of 85 adult asylum seekers completed the questionnaire, and 65 of these underwent the diagnostic interview.
The study’s participants
Based on differences with regard to linguistic and cultural affiliation in the study, two main groups were defined in the analysis: A Somalian group (n=39) and a group from Middle-East and North-Africa (n=39). The study also included a small group with background from the Balkans (n=7), too few to detect significant statistical differences within the group, and because of this left out of some of the analysis. Around 60 % of the Somali group report that they do not have any formal education, while 30 % report primary school, and only 5 % report any education on high school level. Ten percent in the group from the Middle-East and North-Africa region report no formal schooling, whereas 20 % has primary school as their highest level of education. Forty per cent report secondary school and 30 % higher education. Lack of education and low level of literacy were the main reasons why a large part of the study group needed assistance from interpreter during the completion of the questionnaire, even though the questionnaire was translated into their native language.
Results
The results from the self-report questionnaire shows the following: In our sample 59 % had anxiety symptoms and 46 % had depressive symptoms that exceeded what is normally regarded as a limit for clinically relevant findings when applying HSCL-25. Thirty three percent had a score exceeding what is considered clinically relevant when using HTQ, and thereby indicating a PTSD-diagnosis. Based on the subscales of HTQ consisting of items related to events that are considered very stressful and potentially traumatizing, 76.5 % report that they have been “close to being killed” and as many as 67 % have experienced family and/or friends being killed. As much as 31.4 % of the women reported that they had been raped, and the corresponding number among men was 13.6 % (in the total sample 21.5 % report having been raped). With regard to experiences of torture, there was no significant difference between men and women, but the total number was high: 57.3 % reported that they had been subjected to torture. In addition a major part of the interviewed report that they have experienced that basic needs have not been met, such as a place to live, access to food and water and necessary assistance in case of illness.
Results from CIDI-interviews show that among the 65 persons that were interviewed 46% met the criteria for a post-traumatic stress disorder, while 34% fulfil the criteria for a depressive disorder, and 26% can be diagnosed with anxiety. Furthermore, 29% has a somatoform disorder (a physical disorder without proven physical cause), whereas 1 person was diagnosed with an ongoing psychotic disorder. Some met the criteria for more than on disorder at the same time, mainly post-traumatic stress disorder combined with depression.
No clear relation can be seen between the number or nature of traumatic events and psychiatric diagnoses in this investigation. The one-year prevalence of PTSD in our sample is relatively high; 46%, but the PTSD part of HTQ distinguishes rather poorly between people with and people without a PTSD diagnosis. If one looks at the whole sample, HTQ-16 has a sensitivity of 0.48. This means that it can help us find 48% of the persons who qualify for the PTSD diagnosis according to the CIDI-interview. The specificity of HTQ is 0.83. This implies that of those that do not have a PTSD diagnosis according to the CIDI-interview, 83% of the cases were correctly identified. HSCL-25 gives a somewhat better result, but distinguishes poorly between anxiety and depression. In this study we find that persons from Somalia report much fewer symptoms than persons from the Middle East and North Africa region. The validity of the psychometric instruments seems to be extra weak when we are focusing on the Somali asylum seekers. An explanation can be the enormous differences in education between the groups. While most of the participants from the Middle East and North Africa region had the resources needed to fill in the questionnaire on their own, the majority of the Somalis needed assistance from an interpreter.
Conclusion
Based on the results from this investigation we can conclude that the translated instruments based on self-report are valid for recent asylum seekers with some education, i.e. that they can read and write in their own mother tongue. The questionnaire is not helpful finding the PTSD-cases, but is somewhat better regarding anxiety and depression, although it distinguishes poorly between the disorders. This implies that one at best can identify asylum seekers that are in need of further evaluation applying HSCL-25 to this literate group. Questionnaires filled in by asylum seekers with little or no education – assisted by interpreters – do not correspond well with the psychiatric disorders that are diagnosed in this study. At the same time we know that persons with little or no formal education constitute a relatively large part of the asylum seekers to Norway.