Shocked into Tears: Depression and Posttraumatic Stress Disorder in a Sample of Syrian Refugees

Shocked into Tears 1

Shocked into Tears:

Depression and Posttraumatic Stress Disorder in a

Sample of Syrian Refugees

Amanda Aoun, Lea Debal, and Amanda Raidy

Notre Dame University


Abstract

This study examined the levels of depression and posttraumaticstress disorder in Syrian refugees in Lebanon using the BeckDepression Inventory (21 items) and the PTSD Checklist (17items). 94 acceptable participant responses were considered inthe study. All participants were above the age of 18. High levelsand an existing correlation between the two disorders wereexpected as well as greater scores and correlations for womencompared to men. Moderate levels of depression were found whilehigh degrees of PTSD were recorded. Males scored higher thanfemales in both scales but females had a higher correlationbetween the disorders. The study suggests that: refugees areprone to develop both posttraumatic stress disorder anddepression; a positive correlation exists between the disorders;male refugees develop higher degrees of PTSD and depression thanfemales and females have a greater possibility of developing oneof the disorders when the other is present.


Shocked into Tears: Depression and Posttraumatic Stress Disorderin a

Sample of Syrian Refugees

“You do not need papers to tell you how depressed we are,

you can see it on our faces” said a refugee woman cradling her

infant boy (13/12/2013).

“I’m sorry, it upsets me too much to think of these

questions” said various refugee men and women across the field

(23/12/2013).

Depression is a common and significant mood disorder which

impairs daily functioning in various ways. As with most

psychiatric illnesses, depressed people rarely seek treatment. In

the cases of patients who pursue treatment, the combination of

medication and psychotherapy is usually effective (World Health

Organization, n.d.). Depression is characterized via various

symptoms. According to the text revised fourth edition of the

Diagnostic and Statistical Manual (DSM-IV-TR), the symptoms of

depression are: “depressed mood most of the day, diminished

interest or pleasure in all or most activities, significant

unintentional weight loss or gain, insomnia or sleeping too much,

agitation or psychomotor retardation noticed by others, fatigue


or loss of energy, feelings of worthlessness or excessive guilt

and diminished ability to think or concentrate, or

indecisiveness” (American Psychiatric Association, 2000).

A person develops Posttraumatic Stress Disorder (PTSD) after

surviving a traumatic incident which may have involved physical

harm. The disorder was brought to light due to its context in

war-related events. However, it was then also found in people who

suffered from other terrifying events such as rape or accidents

(National Institute of Mental Health, n.d.). It is indicated by

symptoms such as repetitive intrusive thoughts and memories of a

traumatic event, nightmares, avoidance of situations or people

related to the event, and emotional numbing (American Psychiatric

Association, 2000). Similarly to depression, both

psychopharmacology and psychotherapy are combined in the

treatment of patients with post-traumatic stress disorder (The

National for PTSD).

According to the United Nations, a person who was obligated

to leave their country due to the presence of maltreatment, war,

or violence is coined a refugee (UN refugees, 2013).

Specifically, refugees of Syrian nationality found shelter in


Turkey, Jordan, Iraq, Egypt and Lebanon mainly. The Lebanese

government estimates that there are around one million Syrian

refugees in Lebanon. According to the UNHCR, over 857 thousand

refugees have been recorded to this date while almost 56 thousand

await registration. In 2013 alone, over 700 thousand refugees

were registered in Lebanon (UNHCR, 2013).

The results found across various studies were all

complementary in the sense of concept. Refugees are expected to

have an elevated level of depression (Cummings, Sull, Davis &

Worley, 2011). Studies done on PTSD and depression in refugee

children showed a significant correlation between them

(Heptinstall, Sethna & Taylor, 2004). In South Lebanon, the

prevalence of PTSD in Lebanese ranged from 17.6 % to 33.3% across

six villages, while the prevalence of depression varied from 9.2%

to 19.7% (Farhood & Dimassi, 2011). According to the Psychosocial

Assessment of Displaced Syrians in Lebanon, the most cited impaired

tasks were self-neglect, less productivity, isolation, fatigue,

inability to communicate, and self alienation ranging from 25% to

60% of the sample. The most mental health related problems

recorded are anxiety, depressed feelings, lethargy, eating


problems, and sleeping problems across 33% to 70% of the sample

(International Medical Corps, 2011).

Due to the little or no research done on Syrian Refugees in

Lebanon and in other countries of the region, our current study

aims at examining the levels of PTSD and depression in Syrian

Refugees found in Lebanon.

Hypothesis 1: Refugees will show high levels of depression and Post-

traumatic stress disorder.

Hypothesis 2: Depression will correlate positively with PTSD.

Hypothesis 3: Females will have higher levels of depression and PTSD

than males.

Hypothesis 4: Females will have a higher correlation between

depression and PTSD than males.

Methods

The scales were distributed to a total of 130 Syrian

refugees waiting for registration at the UNHCR branch found in

Jnah. A total of 94 acceptable questionnaires were completed. All

participants were above the age of 18 and varied in gender with a

ratio of 9:11 males to females. Some of the chosen participants


were illiterate and were read to. The questionnaire required

approximately 10 minutes to complete. It involved an informed

consent form, two scales testing the levels of depression and

PTSD, and inquiry about the participants’ age and gender.

The chosen scale to test depression was the Beck Depression

Inventory (BDI). The used version was a previously translated and

validated scale. A former study done to test the validation of

the Arabic BDI showed internal consistency and stability

affirming its reliability. The scale results were also compared

to the diagnoses of Arab clinicians which confirmed the high

degree of validity of the chosen BDI (West, 1985). The BDI

consists of 21 items covering the various symptoms of depression.

Each item provided the participant with four options specific to

the item. The options were presented in increasing order of

intensity and numbered 1 through 4.The sum of the BDI answers are

put into a range of normal, slight depression, moderate

depression, and severe depression according to ranges of 0 to 11,

12 to 19, 20 to 27, and 28 to 63 respectively.

As for the scale chosen to test PTSD, the PTSD Checklist

(PCL) was used. The PCL’s reliability was tested in a previous


study proving high internal consistency (International Society

for Traumatic Stress Studies, 1993). The PCL is formed of 17

items testing the symptoms of PTSD. A Likert scale was used

ranging from 1 to 5 (1 being “Not at all” and 5 being

“Extremely”). The scoring of the PCL is also based on the sum of

the chosen numbers and is split into four categories. People

having little or no symptoms of PTSD scored between 17 and 27.

Participants who scored either 28 or 29 have some PTSD symptoms.

Scores between 30 and 44 imply moderate to moderately high

severity of PTSD symptoms and scores between 45 and 85 represent

a high severity of symptoms.

Participants were given consent forms which they read

carefully and agreed to. Each consent form contained an

identification number. The consent form thoroughly explained the

purpose, content and confidentiality of the study. It also

included the freedom to refuse or withdraw, the possible

disadvantages of taking part in the study and the use of the

filled information. It provided the participants with the

required contact information in the case of further inquiries.

The participants kept a copy of the consent form which was


presented in Arabic. The form was both translated and back-

translated from an English version prior to distribution by the

authors of this article. Since no deception was used throughout

the study, debriefing was not necessary. The two scales were

counterbalanced in order to test if the chronology of the scales

would affect the answers of the participants. They were coined as

Version A, PCL before BDI, and Version B, BDI before PCL. In

contrast to the BDI scale that was already translated, the PCL

scale was retrieved in English, translated and back-translated by

the authors of this article. The freedom to withdraw was highly

emphasized when approaching the participants. In case any

difficulties came up when filling the scales, participants were

explained to. However, if participants faced emotional

disturbances, they were informed that they had the freedom to

skip the item or the entire scale or even withdraw from the

entire study.

The answers of each participant were then entered

into the IBM Statistical Package for the Social Sciences (SPSS)

version 21 along with the gender and age.


The data was then checked for normality via the formation of

histograms and tests of skewness and kurtosis. Finally, data

analysis was done to retrieve frequencies (mean, median mode,

range, minimum, maximum) and to test correlations and t-testing

following the standardization of the results.

Results

Before the initiation of analysis the data was checked for

accuracy of entry and missing values. Missing values on both

scales exceeded 5% of the cutoff and they were replaced using

expectation maximization. All scores were standardized across the

items of both scales. Univariate Outlier Analysis using z-scores

found no outliers on both scales. All scores were therefore

retained. Normality of the data for all continuous variables was

checked and confirmed through the standardized kurtosis

statistics, standardized skew statistics (z skew) and histograms.

There was no significant difference between the two

counterbalanced versions. This implies that the order of the

scales does not affect the scores. Reliability of the scales was


tested. Cronbach’s alpha was calculated to be 0.81 which confirms

that the study is reliable.

In respect to the first hypothesis, participants were

expected to show high levels of both PTSD and depression based on

our scales. The sum of each participant’s responses was

calculated per scale. A descriptive analysis of the sums was done

to calculate the mean, median, mode, standard deviation, minimum

and maximum of the results. Results are shown in Table 1. The

mean, median, and mode of the participants were all between 20

and 27 which is the range of moderate depression (Mean=25.15,

Median=24.00, Mode=25.00). As for the PCL, the mean and median of

the scores were between 45 and 85 which is the range of high

severity of PTSD symptoms (Mean=50.37, Median=51.00). However,

the mode of the scores was between 30 and 44 which is the range

of moderate to moderately high severity of PTSD symptoms

(Mode=41.00). The results show that both the average and the

majority of the participants in the study are moderately

depressed which is lesser in degree than expected in the

hypothesis. Additionally, the results prove that the average of

the participants’ scores shows a high level of PTSD severity


which confirms our hypothesis. On the other hand, the outcome of

the statistical analysis shows that the majority of the

participants had moderate to high severity of PTSD symptoms which

is subordinate to the expected level.

As for the second hypothesis, a positive correlation between

PTSD and depression was expected. A Pearson Correlation of the

scores was calculated. Results are shown in table 2. Since there

exists a correlation of 0.38, which is considered to be a weak

correlation but nevertheless a positive one, the hypothesis was

confirmed (p>0.01). Additionally, the correlation between age and

depression was calculated. Results showed a negative weak

correlation (r= -0.233, p>0.05). This means that as age

increased, the scores of our participants on the BDI decreased.

Similarly, the correlation between age and PTSD was also

calculated. Results showed an almost null correlation (r= -

0.087). This showed that there is no notable relationship between

age and PTSD scores.

The third hypothesis expected higher results on the BDI and

PCL for females compared to males. The means of both PTSD and


depression were calculated based on gender. The results are shown

in table 3. Variance t tests on depression levels found for

females and males were insignificant (Mean males = 1.20; Mean

females = 1.17). Differences on means on the PTSD levels

indicated a significant difference between means of males and

females (Mean males = 3.16; Mean females = 2.93). The results

show that male and female Syrian refugees received similar scores

on the BDI indicating similar levels of depression. To the

contrary, the results show that males scored significantly higher

than females on the PCL suggesting a higher level of PTSD in

males. This shows that this hypothesis is incorrect.

The expectation that females will have a higher correlation

between PTSD and depression than males forms the fourth

hypothesis. A Pearson Correlation was calculated. The results are

shown in Table 4. Males showed a correlation of 0.32 (p>0.05)

while females showed a correlation of 0.48 (p>0.01). The results

show that females who have one of depression or PTSD are more

likely to have the other as well than males which confirms the

hypothesis.


The sum of each participant’s scores on each scale were

calculated and put into the suitable range. 5.3% of participants

were recorded to have normal results on the BDI. 23.4% had a

slight score of depression while 31.9% had a moderate degree.

Finally, 39.4% of the participants were classified as having a

severe degree of depression. As for the PCL, 1.1% of participants

had little to no severity and 1.1% had some PTSD symptoms. 34%

were recorded to have a moderate to moderately high level of PTSD

symptoms while a total of 63.8% of participants were scored as

having a high severity of PTSD symptoms.

Discussion

The purpose of the study was to assess the levels of PTSD

and depression in a sample of Syrian refugees. Four predictions

were made prior to the study: high levels of PTSD and depression,

a positive correlation between PTSD and depression, greater

scores for females than males, and a greater correlation between

PTSD and depression for females than males.

The findings of this study are consistent with the results

of Cummings, Sull, Davis and Worley (2011) where the majority of


the refugees are considered to be depressed. The results of PTSD

are also similar to those recorded in a study conducted with

Bosnian refugees (Vojvoda, Weine, McGlashan, Becker & Southwick,

2008). However, the results are more amplified than those found

in a study done on Lebanese citizens also testing for PTSD and

depression (Farhood & Dimassi, 2011). In the study of Farhood and

Dimassi, results showed that there is a minor prevalence of PTSD

and depression in participants of the area. The findings of this

study, on the other hand, recorded that the majority of

participants were depressed and had sufficient symptoms of PTSD.

The results showed that the average and the majority of the

participants in the study are moderately depressed. The average

of the participants’ scores also shows a high level of PTSD

severity. However, the majority of the participants had moderate

to high severity of PTSD symptoms. This may be caused by the

difficulties the refugees underwent in both the physical and

psychological damages caused by war and fleeing their country.

Statistical analysis of the results showed a positive correlation

between PTSD and depression. A significant comorbidity between

PTSD and depression has been previously established (Campbell et


al., 2007). Additionally, males scored higher than females on

both scales but females showed a greater correlation between PTSD

and depression than males. Males may have scored higher because

they may have been more exposed to the direct traumas of war than

females since few or no women are involved in direct battle.

Also, women are more prone than men to develop depression so

perhaps developing PTSD eases the development of depression and

thus explains the higher correlation (Noble, 2005).

There were various limitations to the study. One main

difficulty faced throughout the study was that a variety of

participants was emotionally unable to complete both scales and

decided to skip one of them. This caused the elimination of about

20 questionnaires. Also, since some of the participants were

illiterate and read to, their answers might have been compromised

by the idea of declaring their personal responses. Some of the

refugees became very emotionally touched and terminated the study

without completion or completed the study while crying however

their freedom to withdraw was repeated to them. In addition, the

participants were awaiting registration and might have been

preoccupied with the many forms they had to fill and the children


they had to care for while waiting. As for the questionnaire

itself, two main weaknesses existed. The first weakness was that

the used version of the BDI was not the most recent one. The

second limitation was the inability to find a proper Arabic

translation for an item of the PCL (item #12) which might have

been misrepresented in the scale.

In conclusion, the study provided a valid understanding

about the levels of PTSD and depression in male and female Syrian

refugees. It showed that significant degrees of both disorders

were present in the sample and had a positive correlation

relationship. This study and future studies contributed to the

understanding of refugees as a whole and their psychological

difficulties. The International Medical Corps has taken

consideration of the assistance this issue requires. “While

social and outreach workers have been deployed in the North by

other agencies, there is a need for capacity building of non-

specialized staff, including community workers, volunteers, and

NGO staff to provide basic emotional and practical support to

individuals and families crossing the border” (International

Medical Corps, 2011).


Table 1Scale Descriptives (1)

Sum of Beck Depression Inventory Scores

Sum of PTSD Checklist Scores

Mean 25.15 50.37Median 24.00 51.00Mode 25.00a 41.00a

Standard Deviation 9.68 12.34Minimum 1.00 1.00Maximum 4.00 4.00a. Multiple modes exist. The smallest value is shown.

Table 2Pearson Correlation between the BDI and the PCL

Mean of Beck Depression Inventory

Mean of PTSD Checklist

Age

Mean of Beck Depression Inventory Correlation

1.00

Mean of PTSD Checklist Correlation

0.384** 1.00

Age Correlation -0.233* -0.087 1.00**. Correlation is significant at the 0.01 level.*. Correlation is significant at the 0.05 level.

Table 3Scale Descriptives (2)

Mean of Beck Depression Inventory Scores

Mean of PTSDChecklist


Males 1.21 3.16Females 1.17 2.93


Table 4Pearson Correlation between Males and Females According to the BDI and PCL

Correlation between BDI and PCL

Males 0.32*Females 0.48****. Correlation is significant at the 0.01 level.*. Correlation is significant at the 0.05 level.


References

American Psychiatric Association. (2000). Diagnostic and Statistical Manual.

Campbell D. et al. (2008). Posttraumatic Stress Disorder Symptomsin Bosnian Refugees 3 1/2 Years After Resettlement.

Cummings S,. Sull L., Davis C., Worle N. (2011). Correlates of Depression among Older Kurdish Refugees.

Farhood L., Dimassi H. (2011). Prevalence and Predictors for Post-traumatic Stress Disorder, Depression and General Health in a Population from Six Villages in South Lebanon.

Heptinstall E., Sethna V., Taylor, E. (2004). PTSD and Depressionin Refugee Children.

International Medical Corps. (2011). Psychosocial Assessment of Displaced Syrians.

International Society for Traumatic Stress Studies. (1993). Posttraumatic Stress Disorder Checklist.

National Institute of Mental Health. (n.d.). Post-traumatic Stress Disorder.

Noble R. (2005). Depression in Women.

UN Refugees. (2013). What Is a Refugee?

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Shocked into Tears: Depression and Posttraumatic Stress Disorder in a Sample of Syrian Refugees

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