Background: Post-traumatic stress disorder (PTSD) is highly prevalent among refugees due to their exposure to traumatic events; however, many demonstrate resilience that mitigates its impact. Given the ethnocultural diversity of refugee populations, questions remain regarding whether their symptom presentation aligns with diagnostic and therapeutic frameworks developed in Western contexts. Furthermore, evidence is limited on how resilience relates to PTSD symptom clusters.Objective: We examined (a) the contribution of PTSD symptom clusters to the overall PTSD construct in traumatized individuals with a refugee background, and (b) the structural relationships between PTSD symptom clusters and psychological resilience.Method: The study included 267 (61% male) young adults (Mage = 25.21) with a refugee background who had experienced trauma. Questionnaires measured PTSD symptoms, psychological resilience and socio-demographic characteristics. Confirmatory factor analyses (CFA) and structural equation modeling (SEM) were utilized.Results: Hyperarousal, negative alterations in cognition and mood (NACM), and re-experiencing symptom clusters were stronger indicators of PTSD, compared to avoidance symptoms. Additionally, resilience exhibited a stronger association with hyperarousal and NACM than re-experiencing, while its association with avoidance was not significant.Conclusions: Hyperarousal represents an important symptom cluster within this population, possibly reflecting the impact of migration-related ongoing stressors. The findings also suggest patterns that may be related to ethnocultural differences in symptom expression and coping strategies. Higher resilience is associated with lower PTSD symptoms, but this association is contingent upon the strength of individual PTSD symptom clusters. Further research is warranted to replicate and extend these results.

BACKGROUND:Mental health conditions such as depression, anxiety, and post-traumatic stress disorder (PTSD) are highly prevalent among forcibly displaced populations. Prevalence rates of common mental health conditions have been studied in refugee groups. However, research is sparse regarding the heterogeneity of psychiatric symptoms and quality of life (QoL) profiles among individuals with recent displacement experiences. METHODS:The current study employed Latent Profile Analysis (LPA) to identify profiles of psychopathology and QoL in a sample of 510 recently arrived refugees in Sweden. The associations of profile membership with socio-demographic factors were thereafter investigated. RESULTS:Three distinct profiles were identified: a severe psychopathology/low QoL profile (36.27%), a PTSD-dominant/preserved QoL profile (33.14%) and a mild psychopathology/high QoL profile (30.59%). Nationality and residence status were moderately associated with profile membership. Individuals with Afghan nationality were over-represented, and those with Syrian nationality under-represented, in the severe psychopathology/low QoL profile. This association is likely explained by residence status: 82% of individuals in the severe psychopathology/low QoL profile lacked a residence permit, with only 3.6% of Afghans having received a residence permit, compared to 59.1% of Syrians. CONCLUSIONS:The results underscore the heterogeneity of psychopathological symptoms and QoL in individuals with recent displacement experiences, as well as a significant influence of contextual factors like residence status on their mental health and QoL. These findings may have implications for informing psychological treatments and migration policies.

Background Perceived stress is a key indicator of mental health, and Afghanistan’s ongoing social and economic challenges underscore the need for a reliable, validated self-report instrument specifically adapted to accurately assess stress levels among Afghan populations. Objective The present study aimed to translate and validate the Dari/Farsi version of the Perceived Stress Scale (PSS-10) in a sample of Afghan students. Method The statistical population of this study consisted of 200 undergraduate students at Herat University, Afghanistan, who were enrolled in the 2024-25 academic year. In this study, students were selected using convenience sampling and completed an online survey. To calculate test-retest reliability, 35 individuals were also selected and completed the PSS-10 within two weeks. In this study, the PSS-10 and the Depression Anxiety Stress Scale- 21 Items (DASS-21) were administered. Results The two-factor model demonstrated better fit than the single-factor model. The single-factor model showed poor fit (CFI = .863, TLI = .824, RMSEA = .095, 90% CI [.072, .117]), whereas the two-factor model showed improved but partial adequacy of fit (CFI = .902, TLI = .870, RMSEA = .081, 90% CI [.057, .105]). Furthermore, PSS-10 showed a moderate positive association with depression, anxiety, and stress (r(198) = .58, .57, and .59, all p < .01), an acceptable test-retest reliability (r(33) = .72, p < .01), and excellent internal consistency (α = .78; ω = .82). Conclusion Given its strong psychometric properties, the Dari/Farsi version of the PSS-10 can be considered a reliable tool for both research purposes and clinical assessment. Its use is highly recommended for psychologists and mental health practitioners in investigative and applied studies.

Research has demonstrated reduced emotional reactivity in a second- (L2) compared to a first language (L1). One explanation for this states that L2 use is more cognitively demanding and thus leaves fewer resources available for emotion processing. Here, we specifically investigated this notion of differences in cognitive load during L1 and L2 use. EEG was used to investigate mismatch negativity during an auditory oddball paradigm. Native Swedish speakers with L2 English were asked to read text excerpts in their L1 and L2, whilst simultaneously listening to standard and deviant auditory tones to be ignored. The results showed significant oddball effects (i.e., mismatch negativity) in L1 but not in L2. Together with a lower accuracy in the L2 condition, these results imply a higher cognitive load during L2 reading. These findings are explained within a resource allocation framework and are suggested as a possible explanation of the underlying mechanisms of the foreign language effect.

BackgroundRefugees and asylum-seekers commonly experience numerous adverse and traumatic events and are therefore at increased risk of mental health problems. Despite the high need for mental health interventions, services tend to be underused by refugees and asylum-seekers, and various barriers compromise access. Digital, efficient screening, adapted for these groups, could facilitate initial assessment and increase accessibility to mental health services. We developed an internet-based tiered screening procedure (i-TAP) aiming to identify clinically relevant symptoms of major depressive disorder (MDD), anxiety disorder, posttraumatic stress disorder, and insomnia disorder among individuals with a refugee background. The i-TAP is an adaptive procedure with 3 tiers aiming to identify general mental distress in Tier 1, differentiate between symptoms in Tier 2, and assess the severity of symptoms in Tier 3. Each tier additionally functions as a gateway to further assessment, as a negative outcome terminates the procedure. ObjectiveThe purpose of this study was to evaluate the diagnostic test accuracy of the i-TAP, using structured clinical assessments as the reference standard. MethodsIn this prospective study, 70 adult participants with a refugee background, literate in Arabic, Dari, Farsi, or Swedish, and residing in Sweden, completed the i-TAP on tablets and participated in a subsequent structured diagnostic interview. ResultsIt has been shown that the i-TAP could identify 91.7% (33/36) of individuals assessed with any psychiatric disorder, and correctly identified 82.1% of all positive cases of MDD, anxiety disorder, posttraumatic stress disorder, and insomnia disorder, with few false negative assessments. Overall test accuracy of the i-TAP ranged between 77.1% and 84.3%, depending on disorder. The tiered design could reduce item burden while maintaining accuracy. A vast majority of participants rated the user experience as positive. In this sample, 36/70 (51.4%) individuals were assessed with one or more psychiatric disorders and comorbidity was high. ConclusionsThe i-TAP may be a valid, efficient, and feasible screening tool for the identification of common psychiatric disorders among individuals with a refugee background in Sweden. The i-TAP could be implemented as a first screener in various settings, including online and in-person clinical practices. The digital, adaptive, multilingual format could facilitate early assessment and increase the availability of mental health services for refugees and asylum-seekers.

Background: The Childhood Trauma Questionnaire-Short Form (CTQ-SF) is a widely used and standardized questionnaire designed to assess five types of childhood abuse. The CTQ-SF demonstrates good validity and reliability. The aim of this study was to assess the validity and reliability of a Dari-translated version of the CTQSF. Method: A convenience sample of 240 undergraduate Dari-speaking students at Herat University, Afghanistan, completed an online survey that included the CTQ-SF and the Depression Anxiety Stress Scale (DASS-21). To calculate test-retest reliability, a sub-sample of 44 individuals completed the CTQ-SF again within two weeks. Results: The results from a confirmatory factor analysis indicated that the five-factor structure of the CTQ-SF demonstrated acceptable fit to the data (chi 2/df = 1.98, CFI = .90, RMSEA = .06). Furthermore, CTQ-SF showed a moderate positive association with depression, anxiety, and stress (r(238) = .43 - 0.49, p < .05), a strong test-retest reliability, (r(42) = .74, p < .05), and excellent internal consistency (alpha = .92). Conclusion: The results support the five-factor structure of the CTQ-SF and, together with strong psychometric properties, suggest that the Dari version is reliable for assessing childhood maltreatment.

Refugees often experience multiple losses. Despite this, and even though the loss is often due to unnatural causes and violent killings, the presence of Prolonged Grief (PG) among refugees may be obscured by other diagnoses such as depression and post-traumatic stress disorder (PTSD). In this cross-sectional study, we assessed the prevalence of PG and its comorbidity with depression and PTSD among 679 adult refugees in Sweden. Results showed that 401 (59.06 %) individuals had lost someone close to them, whom they were grieving intensely. Of these, 76 individuals (18.95 % of 401) fulfilled the criteria for PG. In the full sample, 304 individuals fulfilled the criteria for depression and 56 (18.42 % of 304) of these individuals also fulfilled the criteria for PG. Similarly, 315 fulfilled the criteria for PTSD. Among these individuals, 201 reported loss and 64 (20.32 % of 315) also fulfilled the criteria for PG. The results indicate that behind symptoms of depression and PTSD, there may be a layer of grief. This needs to be considered if we are to provide accurate and effective assessments and interventions for refugees.

BACKGROUND:Many refugees suffer from mental health problems due to stressful and traumatic events before, during, and after migration. However, refugees are facing a wide variety of barriers, limiting their access to mental health care. Internet-based tools, available in several languages, could be one way to increase the availability of mental health services for refugees. The present study aimed to develop and test a screening tool to screen for clinically relevant symptoms of psychiatric disorders common among refugees (i.e. Depression, Anxiety, Post-traumatic stress disorder, and Insomnia). We, designed, translated, and adapted an internet-based tiered screening procedure suitable for use with the largest refugee populations residing in Sweden. The tool aims to accurately identify symptoms of mental distress (Tier 1), differentiate between symptoms of specific psychiatric disorders (Tier 2), and assess symptom severity (Tier 3). We tested the overall efficiency of using a tiered screening procedure. METHODS:Seven hundred fifty-seven refugees residing in Sweden, speaking any of the languages Arabic, Dari, Farsi, English, or Swedish, completed an online questionnaire following a three-tiered procedure with screening instruments for each tier. In this study, the Tier 3 scales were used as reference standards for clinically relevant symptoms, to evaluate screening efficiency in terms of accuracy and reduction of item burden in previous tiers. RESULTS:The results show that the tiered procedure could reduce the item burden while maintaining high accuracy, with up to 86% correctly assessed symptoms and few false negatives with moderate symptoms and above (at most 9%), and very few with severe symptoms (at most 1.3%). DISCUSSION:This study generated an accurate screening tool that efficiently identifies clinically relevant symptoms of common psychiatric disorders among refugees. Using an adapted online tiered procedure to screen for multiple mental health issues among refugees has the potential to facilitate screening and increase access to mental health services for refugees. We discuss the utility of the screening tool and the necessity of further evaluation.

Although post-traumatic stress is prevalent among unaccompanied refugee minors (URM), there are few evidence-based psychological interventions for this group. Teaching Recovery Techniques (TRT) is a brief, manualised intervention for trauma-exposed youth, which has shown promising results in exploratory studies. The aim of the present study was to assess the feasibility of conducting a randomised controlled trial (RCT) evaluating the use of TRT among URM by investigating key uncertainties relating to recruitment, randomisation, intervention delivery and data collection. A 3-month long non-blinded internal randomised pilot trial with a parallel-group design assessed the feasibility of a planned nationwide multi-site RCT. URM with or without granted asylum were eligible if they were 14 to 20 years old, had arrived in Sweden within the last 5 years and had screened positive for symptoms of post-traumatic stress disorder (PTSD). Quantitative data were collected pre- and post-intervention, and 18 weeks after randomisation. On-site individual randomisation (1:1) followed directly after pre-intervention assessment. Participants allocated to the intervention were offered seven weekly group-based TRT sessions. Quantitative pilot outcomes were analysed using descriptive statistics. Qualitative information was gathered through on-site observations and follow-up dialogue with group facilitators. A process for Decision-making after Pilot and feasibility Trials (ADePT) was used to support systematic decision-making in moving forward with the trial. Fifteen URM (mean age 17.73 years) with PTSD symptoms were recruited at two sites. Three of the youths were successfully randomised to either TRT or waitlist control (TRT n = 2, waitlist n = 1). Fourteen participants were offered TRT for ethical reasons, despite not being randomised. Six (43%) attended ≥ 4 of the seven sessions. Seventy-three percent of the participants completed at least two assessments, with a response rate of 53% at both post-intervention and follow-up. The findings demonstrated a need for amendments to the protocol, especially with regard to the procedures for recruitment and randomisation. Upon refinement of the study protocol and strategies, an adequately powered RCT was pursued, with data from this pilot study excluded. ISRCTN47820795 , prospectively registered on 20 December 2018

Previous self-report measures of attachment have used different assessment approaches, and a common conceptualization is using a dimensional perspective in which attachment is measured with two factors: attachment anxiety and attachment avoidance. The Experiences in Close Relationships-Relationship Structures Questionnaire (ECR-RS) has, prior to this study, been assessed for psychometric properties regarding specific relationships, but not in a shorter version for close relationships in general. In this paper, we present a Swedish translation of the ECR-RS Global nine-item version assessed for factor structure and psychometric properties by using a crossvalidation approach with two separate adult samples. In Study 1 (N = 492), participants were randomly split into two subsamples. Using an exploratory factor analysis (EFA), the first subsample was used for finding the best-fitting model while the second subsample was used to test the a priori model using confirmatory factor analysis (CFA). In Study 2 (N = 806), we set out to validate the factor structure yet again by using CFA. Results from the EFA supported a two-factor structure with six items for attachment avoidance and three items for attachment anxiety. In the validation of the factor structure using CFA, both studies showed that all model-fit indices were good only after some modification, including removal of one avoidance item. Methodological reasoning and implications are discussed. The final eight-item model showed good internal consistency, as well as good convergent and discriminant validity, and multi-group invariance tests for gender and age showed no violations to invariance. Findings are encouraging to use this short global attachment self-report instrument, but further validation is advised.

In this cross-sectional study we aimed to assess symptoms of depression and anxiety at an early stage of the COVID-19 pandemic, and to explore factors predictive of these mental health outcomes. A sample of 1,503 participants, recruited from the general Swedish population, completed an online survey distributed through social media. In this sample, 22.2% reported clinically significant levels of depressive symptoms (PHQ-9 ≥ 10) and 10.9% indicated possible major depression using the PHQ-9 algorithm. Moreover, 28.3% reported clinically significant levels of anxiety (GAD-7 ≥ 8) and 9.7% severe anxiety and possible GAD (GAD-7 ≥ 15). Multiple linear regression analyses identified some common predictors for both outcomes. Age, having a stable income, and sufficient social stimulation, sleep, and recovery showed negative associations, whereas worry about the economy and overall burden showed positive associations. These results suggest an impact on mental health already at an early stage of the COVID-19 pandemic.

Research indicates that subgroups of refugees may be at increased risk for suicidal ideation, but further knowledge on this topic is needed. This study aimed to assess both prevalence and factors associated with suicidal ideation among newly arrived refugees in Sweden. Assessing suicidal ideation was part of a larger project, aiming to develop a model for assessment and treatment of mental health problems among refugees. The included data were based on a cross-sectional survey among 510 asylum seekers and refugees, all under the care of the Swedish Migration Agency. The project group visited 12 asylum accommodations and 9 other locations, asking potential participants to answer a survey with questions on mental health, suicidal ideation and quality of life. Data were analysed using logistic regression. Symptoms of depression, anxiety and posttraumatic stress disorder, low physical and psychological quality of life, and being of young age were all independently associated with suicidal ideation. This study points to the importance of identifying refugees with mental health problems and of providing them with adequate care. It also indicates the importance of assuring a decent quality of life at asylum accommodations, and it shows that the young may constitute an especially vulnerable group.

Asylum seekers suffer high levels of distress but have restricted access to mental health care. This paper constitutes an evaluation of a psycho-educational group intervention, called AMIN, which was provided at two asylum accommodation centers in Sweden. A mixed-methods approach was used. To assess potential effectiveness, acceptability, and feasibility, quantitative outcome measures were combined with qualitative information from interviews with both intervention participants and staff providing the intervention. Potential effectiveness in reducing symptoms of distress and insomnia and in increasing physical quality of life was found, even though the intervention participants suffered from more severe distress than expected. In general, the intervention seemed to be acceptable to both participants and staff, with concrete strategies seeming more meaningful than abstract psychological techniques. Finally, regardless of the asylum process itself being a complicating factor, the intervention seemed feasible to deliver to individuals with different backgrounds and conditions. Taken together, these results indicate that some sessions may need further elaboration, but also that the transition to a randomized control trial is reasonable.

Background Refugee children have often experienced traumas and are at significant risk of developing mental health problems, such as symptoms of post-traumatic stress disorder (PTSD), depression and anxiety, which can continue for years after resettlement. The Accompanied refugeeS In Sweden Trial (ASsIST) aims to evaluate a community-based intervention, called ‘Teaching Recovery Techniques’ (TRT), for accompanied refugee minors experiencing PTSD symptoms. Methods/design A cluster randomised controlled trial will be conducted in which participants will be randomly allocated to one of the two possible arms: the intervention arm (n=113) will be offered the TRT programme and the waitlist-control arm (n=113) will receive services as usual, followed by the TRT programme around 20 weeks later. Outcome data will be collected at three points: pre-intervention (T1), post-intervention (T2; c.8 weeks after randomisation) and follow-up (T3; c.20 weeks after randomisation). Ethics and dissemination Ethical approval was granted by the Regional Ethical Review Board in Uppsala (Ref. 2018/382) (24th February 2019). Results will be published in scientific journals. Trial registration details ISRCTN17754931. Prospectively registered on 4th June 2019.

Background In 2015, 162 877 persons sought asylum in Sweden, 35 369 of whom were unaccompanied refugee minors (URM). Refugee children, especially URM, have often experienced traumas and are at significant risk of developing mental health problems, such as symptoms of post-traumatic stress disorder (PTSD), depression and anxiety, which can continue years after resettlement. The Swedish UnaccomPanied yOuth Refugee Trial (SUPpORT) aims to evaluate a community-based intervention, called ‘Teaching Recovery Techniques’ (TRT), for refugee youth experiencing PTSD symptoms. Methods/Design A randomised controlled trial will be conducted in which participants will be randomly allocated to one of two possible arms: the intervention arm (n = 109) will be offered the TRT programme, and the waitlist-control arm (n = 109) will receive services as usual, followed by the TRT programme around 20 weeks later. Outcome data will be collected at three points: pre-intervention (T1), post-intervention (T2; c.8 weeks after randomisation) and follow-up (T3; c.20 weeks after randomisation). Discussion This study will provide knowledge about the effect and efficiency of a group intervention for URM reporting symptoms of PTSD in Sweden.

Road hazard perception is considered the most prominent higher-order cognitive skill related to traffic-accident involvement. Regional cultures and social rules that govern acceptable behavior may influence drivers’ interpretation of a traffic situation and, consequently, the correct identification of potentially hazardous situations. Here, we aimed to compare hazard perception skills among four European countries that differ in their traffic culture, policies to reduce traffic risks, and fatal crashes: Ukraine, Italy, Spain, and Sweden. We developed a static hazard perception test in which driving scenes with different levels of braking affordance were presented while drivers’ gaze was recorded. The test required drivers to indicate the action they would undertake: to brake vs. to keep driving. We assessed 218 young adult drivers. Multilevel models revealed that the scenes’ levels of braking affordance (i.e., road hazard) modulated drivers’ behavior. As the levels of braking affordance increased, drivers’ responses became faster and their gaze entropy decreased (i.e., visual search strategy became less erratic). The country of origin influenced these effects. Ukrainian drivers were the fastest and Swedish drivers were the slowest to respond. For all countries, the decrement in response times was less marked in the case of experienced drivers. Also, Spanish drivers showed the most structured (least erratic) visual search strategy, whereas the Italians had the most rigid (most constant) one. These results suggest that road hazard perception can be defined cross-culturally, with cultural factors (e.g., traffic climate, legislation) modulating response times and visual search strategies. Our results also support the idea that a multimodal assessment methodology is possible for mass testing of road hazard perception and its outcomes would be relevant to understand how different traffic cultures shape driving behavior.

INTRODUCTION:The aim of the present study was to investigate how emotions influence pain, measured by one subjective self-rated measure, the numeric rating scale (NRS), and one objective physiological measure, the number of skin conductance responses (NSCR).METHOD:Eighteen volunteers were exposed to conditions with pictorial emotional stimuli (neutral, positive, negative), authentic ICU-sound (noise, no-noise) and electrical stimulation (pain, no-pain) individually titrated to induce moderate pain. When using all combinations of picture inducing emotions, sound, and pain, each of these conditions (12 conditions lasting for 60 seconds each) were followed by pain ratings. Ratings of arousal (low to high) and valence (pleasant to unpleasant) were used as indicators of affective state for each condition. Mean NSCR was also measured throughout the experiment for each condition.RESULTS:Even though NRS and NSCR increased during painful stimuli, they did not correlate during the trial. However, NSCR was positively correlated with the strength of the electrical stimulation, r = 0.48, P = 0.046, whereas NRS showed positive correlations with the anxiety level, assessed by affective ratings (arousal, r = 0.61, P < 0.001, and valence, r = 0.37, P < 0.001).CONCLUSIONS:The NRS was strongly influenced by affective state, with higher pain ratings during more anxiety-like states, whereas NSCR correlated to the strength of electrical pain stimulation. That reported pain is moderated by anxiety, puts forward a discussion whether reduction of the anxiety level should be considered during analgesia treatment.

The high number of asylum seekers in Sweden has highlighted the need for structured assessment tools to screen for refugee mental health problems in clinical services. We examined the utility of the Refugee Health Screener (RHS) in refugee adolescents, aged 14-18, attending routine clinical examinations or staying in group homes/refugee centres (N = 29). Participants completed a survey, including the RHS, administered through iPads in their native language. The RHS showed excellent internal consistency (alpha = 0.96) and correlated moderately with symptoms of post-traumatic stress disorder (r = 0.41, p = 0.025). Mean scores and prevalence rates were comparable to a study of adult refugees in Sweden. Unaccompanied refugee minors (URMs) scored significantly higher (M = 32.0, SD = 12.9) compared to youth staying with their families (M = 7.5, SD = 8.2, p<0.001, d = 2.27). Our findings confirm that the RHS can be used in the adolescent population in Sweden. These findings moreover suggest that URMs are a particularly vulnerable group with a large burden of mental health problems.