The Role of Comorbidity in Understanding Traumatic Sequelae Among Ukrainian War Refugees

Abstract

Limited research exists regarding the impact of the Ukrainian War on mental distress among refugees or the presentation of post-traumatic stress disorder (PTSD) as a co-morbidity. This study analyzes the mental distress experienced by displaced Ukrainian refugees, including exposure to war-related trauma, PTSD, psychological distress based on socio-demographic factors, prevalence of concurrent mental illnesses, and associated risk factors. Ukrainian refugees in Israel were included in the study shortly after their arrival. Participants completed questionnaires on socio-demographic information, exposure to war-related events, presence of PTSD, depression, anxiety, and current life satisfaction. The 128 participants reported an average of 6.4 traumatic events (SD = 2.97). Among them, 69.5% (n = 89) met the criteria for probable PTSD, 36.7% (N = 47) for depression, and 53.1% (N = 68) for anxiety. The “comorbidity” cohort, consisting of refugees with PTSD and depression/anxiety or both, included 65 participants (53.3%), the “only PTSD” group was 24 participants (19.7%), and 33 (27%) had “no probability”. Women and those who had left family members behind were 2.9 and 3.2 times more likely to experience comorbidity, respectively. Refugees with comorbidity reported higher distress and functional impairments compared to the “only PTSD” group, and lower life satisfaction than those with “no probability”. This study highlights the significant traumatology experienced by Ukrainian refugees, with attention to the unique impact of comorbidity on functional and subjective well-being among refugees. Therefore, a comprehensive approach is necessary to appropriately diagnose and support refugees, considering the interconnected impact of PTSD, anxiety, and depression.

Keywords:

• Anxiety
• PTSD
• co-morbidity
• PTSD phenomenology
• family
• refugees

Introduction

The Russian-Ukrainian conflict, which intensified significantly with a major attack on Ukraine in February 2022, has resulted in the destruction of Ukrainian cities, loss of life, and forced displacement of millions of people (Leon et al., 2022; McKee & Murphy, 2022). In fact, this conflict has resulted in the largest exodus of refugees and internally displaced persons since World War II, with approximately 10.3 million refugees and 6.6 million internally displaced people, including 1.5 million children (Poberezhets, 2022). However, fleeing the conflict does not shield individuals from experiencing mental and social difficulties that can arise due to the evacuation experience or witnessing distressing events (Alibudbud, 2022; Bryant et al., 2022). It is well known that people exposed to war, terrorism, and natural disasters are at heightened risk of developing acute stress reactions, anxiety disorders, depressive episodes, and post-traumatic stress disorder (PTSD) (Bisson et al., 2015; Johnson et al., 2022; Vermetten et al., 2014). A recent study among civilians being displaced inside and outside Ukraine during the 2022 Russian invasion reported that 30.8% had an elevated risk for PTSD (Ben-Ezra et al., 2023). Yet there is still a paucity of data on the mental health status of this large population of displaced persons in the host countries (Lee et al., 2023).

A recent meta-analysis of pooled data on 5100 refugees residing in countries all over the globe, reported PTSD diagnosis of 31%, 31% with a diagnosis of depression, and 11% for anxiety disorders (Blackmore et al., 2020). No differences in the prevalence of PTSD and depression were found in the length of living in host countries, except in the case of anxiety, with a higher prevalence among those displaced for less than four years. Furthermore, a systematic review of Syrian refugees resettled in ten countries found a prevalence of 43% for PTSD, 40% for depression, and 26% for anxiety (Peconga & Høgh Thøgersen, 2020). Interestingly, as arising from two studies, Syrian refugees who settle in developed countries present lower distress.

Refugees residing in Turkey present higher levels of PTSD symptoms and psychiatric co-morbidity than those living in Sweden; while refugees who fled alone were more likely to endorse PTSD symptoms than those who came with family members (Chung et al., 2018). In addition, internally displaced Syrians had significantly higher PTSD prevalence rates than Syrian refugees resettled in the Netherlands (Al Ibraheem et al., 2017).

Another systematic review based on clinical interviews and validated diagnostic systems indicated that 31.5% of refugees had PTSD, 31.5% had depressive disorders, 11.1% had anxiety disorders, and 1.5% had psychoses (Patane et al., 2022). These rates clearly surpass PTSD diagnosis in the general population, 3.9% (Koenen et al., 2017), although it is less clear regarding depression and anxiety disorder prevalence since there is such a range among countries (Liu et al., 2021). However, these reviews did not take comorbidity of psychiatric diagnoses into account. In the general population, individuals with comorbid depression and PTSD experience more severe symptoms of both disorders, encounter greater difficulties in adjustment, and reduced quality of life (Pagotto et al., 2015). Comorbidity has also been associated with increased disability, greater impairments in daily functioning and increased suicide rates (Forchuk et al., 2020; Pejuskovic et al., 2020). The impact of comorbidity underscores the need for comprehensive care and support for trauma survivors in order to facilitate their recovery and enhance their well-being.

Although refugees are already a vulnerable population at high risk of developing mental health problems such as depression, anxiety, and PTSD, limited research has been conducted on the prevalence and impact of psychiatric comorbidity among them. A recent review and meta-analysis among refugees who had resettled permanently in their new host country indicate higher rates of comorbidity compared to PTSD alone among refugees who resettled in developed countries (Henkelmann et al., 2020), with attention to the effect of post-migration factors, such as life-threatening journeys, long-lasting asylum procedures, family separation, unemployment, and discrimination, on the prevalence of mental disorders.

Among Ukrainian civilians residing in the conflict-affected regions of Donbas, where the armed conflict has persisted since 2014, 37% reported suffering from PTSD in 2019 (Fel et al., 2022). Yet, despite international agreement about the need to investigate and treat possible mental health sequelae among this population (Bai et al., 2022; Cai et al., 2022) and recent findings on higher risk of PTSD among Ukrainian refugees abroad compared to Ukrainian people who are not displaced or those who internally displaced (Lushchak et al., 2024), there is limited literature exploring mental health outcomes among Ukrainian refugees, temporarily living in a developed country.

Buchcik et al. (2023) found that 40.5% of Ukrainian refugees in Germany reported severe general psychological distress, and 44.7% and 51% reported depressive and anxiety symptoms, respectively. It was found that refugees’ quality of life was affected by mental health problems, and that gender played a role when women reported significantly higher rates of mental health difficulties, as reported also among women living in Ukraine, six months into the war (Kurapov et al., 2023). Another study among Ukrainian refugees in Poland reported that 73% of them suffered from symptoms of anxiety, depression and PTSD, and 66% reported psychological distress, whereas women scored higher on the scale of mental health disorders compared men, and active strategies were the most effective way to cope with mental health problems (Długosz, 2023).

To the best of our knowledge, our study is the first to investigate mental health comorbidity among Ukrainian refugees, with attention to the co-occurrence of PTSD with anxiety and/or depression, which presents a particularly challenging condition for trauma survivors and may complicate the recovery process. The specific goals of our research are to investigate (a) the prevalence and patterns of PTSD, depression, and anxiety symptomology, (b) the comorbidity between PTSD, depression, and anxiety, and the associations with various sociodemographic characteristics. (c) the implications of comorbidity status on refugees’ psychological distress, functioning, and well-being.

Methods

Participants and procedure

The research entailed a cross-sectional, population-based survey. Participants were Ukrainian refugees evaluated soon after arriving in Israel between April and May 2022. Participants were recruited by convenience and snowball sampling as the most cost-efficient methods to recruit individuals from an otherwise hard-to-reach study population (Atkinson & Flint, 2001). The study was approved by the Ethics Committee of the sponsoring institution [AU-SOC-RA-20220621], and participants provided consent before completing the study.

Based on records of the Israeli Ministry of Integration, we contacted three hotels, where the majority of refugees were being housed after their arrival to Israel. The inclusion criteria of the study were: (1) at least 18 years of age; (2) having been born and living in Ukraine; (3) literate in Ukrainian, and (4) having refugeed in Israel after fleeing Ukraine.

An information sheet outlined the study aims and methods and provided contact details of the study team along with a list of local service providers. Participants were informed that completing the questionnaire was voluntary and anonymous. Before their participation, all gave written informed consent to participate in this study. Each subject was offered $15 to participate; payment was made even when the participant did not complete the entire questionnaire.

Measurements

According to “World Health Organization” standards (Harkness et al., 2008), questionnaires were translated into study language (Ukrainian) and blind back translated. First, two translators, fluent in Ukrainian, translated the trauma exposure inventory and single items from English into Ukrainian. The translations were performed independently, resulting in two preliminary Ukrainian versions. Next, the questionnaires were translated back into English by a native English speaker fluent in Ukrainian. There were no discrepancies between the two versions, probably due to the short and uncomplicated wording of the questionnaires. In addition, the Ukrainian PCL-5 version (Bezsheiko, 2016) adapted and validated by previous studies (e.g., Lushchak et al., 2024). The Ukrainian BSI-53 version was provided directly by Sereda and Dembitskyi (2016), who validated the scale among the general population in Ukraine. The translators verified these versions and worked closely with the research team during the study period. It is worth noting that this approach is a widely accepted and established method in research (Brislin, 1986).

Socio-demographic variables

Age, marital status, gender, years of education, place of residence and employment status in Ukraine, and status of who came with their whole family members (parents, children, wife/husband).

Trauma exposure

We measured exposure to war-related trauma with a shortened version of the Communal Traumatic Events Inventory (CTEI) (Weine et al., 1995), which is based on other screening instruments for refugees (Mollica et al., 1987; Mollica and Caspi-Yavin, 1991). According to previous research on Kosovo refugees (Ai et al., 2002), we included events most likely to have occurred in this population and excluded four items that were irrelevant to the study sample (e.g., forced marches, Kidnapped). Respondents indicated with a yes or no answer whether they had experienced any of the 20 war-related traumatic events according to the current war. Overall trauma exposure was a total count of the number of traumatic event types experienced (range: 0–20).

Post traumatic stress disorder symptom presence

The Posttraumatic Stress Disorder (PTSD) Checklist (PCL-5) (Weathers et al., 2013), is a 20-item self-assessment questionnaire using a rating scale of 0–4 (0 = not at all, − 4 = extremely), includes new elements of PTSD diagnosis of the DSM-5. According to the PCL-5 manual, a total score of 33 or higher is required for probable PTSD. In addition, symptom rates ≥2 is considered validated symptom. According to DSM-5 at least one out of five endorsed symptom from cluster B (“re-experiencing”); one out of two symptoms of Cluster C (“avoidance”); two out of seven symptoms from cluster D (“negative alterations in cognitions and mood”), and two out of six symptoms from Cluster E (“Marked alterations in arousal and reactivity”) suggested diagnosing of PTSD. Finally, 1 item assesses the duration time from a traumatic event.

Importantly, the Ukrainian version of the PCL-5 questionnaire conducted on a large sample (N = 3173) showed very high reliability of the total scale (α = 0.944) and good reliability for subscales (0.784–0.885)(Lushchak et al., 2024). In our study, we obtained Cronbach’s α of 0.88 for the complete questionnaire, 0.83 for the reexperiencing symptoms cluster, 0.75 for the avoidance cluster, 0.76 for the negative alterations in cognitions and mood cluster, and 0.80 for marked alterations in the arousal and reactivity cluster.

Depression and anxiety were measured using the Depression and Anxiety subscales of the Brief Symptom Inventory (BSI) (Derogatis & Melisaratos, 1983), a standardized measure of psychopathology, used also among refugee populations (Geiling et al., 2022; Lor et al., 2022) in order to evaluate depression and anxiety as well as diverse psychological distress. The BSI is comprised of 53 items that are rated on a 5-point scale ranging from “Not at All” to “Extremely” for symptoms experienced within the past month. By converting raw scores to T-scores, a cutoff of ≥ 63 is considered indicative of presumable clinical depression/anxiety for the current study (Derogatis, 1993). In the current study, we used two subscales: BSI-Depression and BSI-Anxiety which included 12 items, six items for each subscale, showing high internal consistency in this sample (Cronbach’s alpha = 0.85 for both sub-scales). Similarly, the Ukrainian version of the BSI-53 conducted on a large sample (N = 2069) showed high reliability for BSI-Depression (α = 0.82) and BSI-Anxiety (0.87) (Sereda & Dembitskyi, 2016).

Additional variables

Life satisfaction was measured using a single item from the European Social Survey, on a 7-point scale ranging from “completely dissatisfied” to “completely dissatisfied”. The use of single-item scales of life satisfaction has been widely supported (Jovanović & Lazić, 2020), and the current measurement has been used in numerous studies across different countries and cultures and has been shown to have good reliability and validity (Huppert et al., 2009). In addition, we asked participants using a rating scale of 0 to 4 (0 = not at all, − 4 = extremely) about their general distress and functioning in the last month (“How much have you been bothered by your mental distress?" and “Have your mental distress affected your work, relationships with other people or any other important part of your life?”). These items based on the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5)(Weathers et al., 2018) and administrated in the context of trauma (Goral et al., 2021).

Sample size

To calculate the sample size for testing our hypotheses, a priori power analysis was performed using G*Power statistical power analysis software (G*Power 3.1.7; Kiel University, Germany) for F test; ANOVA: Fixed effects, omnibus, one-way. In the calculation, a two-tailed test was used, and we assumed a significance level of 0.05, a medium effect size of r = 0.30 and a statistical power of 0.8, resulting in a required sample size of 111 participants.

Statistical Analysis

We analyzed the data using SPSS (IBM, Chicago, v. 26) to perform descriptive and inferential analyses. We described categorical variables in frequencies and percentages and continuous variables in terms of means ± standard deviation. We conducted a multinomial logistic regression to investigate predictors of comorbidity status, and to investigate the differences between the groups; we conducted one-way ANOVA with Tukey’s Test post-hoc. The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy restrictions.

Results

We enrolled 150 participants, 22 of whom were eventually excluded from the analysis following incomplete questionnaires: lack of time (n = 6), difficulty understanding the questions due to being native Russian speakers (n = 6), and missing data on PTSD measurement (n = 10). Of the remaining 128 participants (91 women and 37 men), (ages 22–83 years, [M = 49.16; SD = 16.5], (Table 1) all of them had previously lived in Ukraine and reported a mean number of 6.4 traumatic events (SD = 2.97), with the most frequent being evacuation (80.8%), ill health (63.0%) and lack of adequate shelter (61.1%) (Figure 1).

Figure 1. Frequencies (n, %) of exposure according to traumatic events (N = 128).

Table 1. Mean and standard deviations of PTSD, anxiety and depression (N = 128).

Variable	Total Sample (N=128)
	Mean	SD
PTSD
Total score	39.34	14.67
Clusters (Average per item)
Reexperiencing	2.33	0.99
Avoidance	1.88	1.08
Negative alterations in cognitions and mood	1.66	0.87
Marked alterations in arousal and reactivity	1.87	0.93
Psychological distress
Depression	63.69	18.03
Anxiety	69.60	20.76

PTSD, depression and anxiety

According to the PCL-5 cutoff ≥ 33, 69.5% (n = 89) of the refugees met the criteria for probable PTSD, with a mean score of 39.34 (SD = 14.7). Moreover, based on the DSM-5 four clusters diagnosis, 59.4% (n = 76) of the sample met the clinical criteria for PTSD, which includes at least one intrusion symptom, two negative alterations in cognition and mood symptoms, one avoidance symptom, and two arousal and reactivity symptoms. Specifically, 98.4% (n = 126) of the sample suffered from at least one intrusion symptom; 85.9% (n = 110) from at least two negative alterations in cognition and mood symptoms; 78.9% (n = 101) from at least one avoidance symptom; 78.9% (N = 101) from at least two arousal and reactivity symptoms (Table 1).

According to BSI-Depression and BSI-Anxiety, a T score ≥ 63 was found among 36.7% (n = 47) for depression with a mean of 63.69 (SD = 18.03); 53.1% (n = 68) participants showed significant anxiety, with a mean score of 69.6 (SD = 20.76).

Comorbidity of PTSD, anxiety and depression

In order to examine the comorbidity among PTSD, anxiety, and depression, we computed three groups according to the clinical cutoff of PTSD, anxiety, and depression (0-no probability, 1-only PTSD, 2- PTSD with one or more conditions [comorbidity]). We excluded six cases that had only a diagnosis of depression or anxiety or both, so they were not included in the resultant analysis. The “only PTSD” group included 24 (19.7%) participants, while the comorbidity group included 65 (53.3%) refugees with PTSD and depression or anxiety or both. Thirty-three (27.0%) participants did not meet the clinical cutoff for any condition (Figure 2).

Figure 2. Comorbidity prevalence percentages of PTSD, anxiety and depression (N = 128).

No significant differences were found in socio-demographics according to comorbidity status, except in family migration status (Table 2). Refugees who had to leave family behind were more likely to be part of the comorbidity group (66.7%) as compared to those who came with family intact (40.38%) [χ²(2, n = 106) =7.64, p = .022]. We included family migration status as a covariate as well as gender according to its near significance. Furthermore, no significant differences were found in exposure to war-related trauma [F(2,119) = 2.00, p < .139].

Table 2. Socio-demographic characteristics.

		Total-N(%)	No Diagnose	PTSD	Comorbidity	Chi-Square test	Effect size
N		122	33	24	65
Gender	Men	37(28.9%)	15	5	16	χ^2(2) = 5.56 p = .054	.22
	Women	91(71.1%)	18	19	49
Education	Elementary-middle school	2(1.6%)	0	1	1	χ^2(10) = 9.32 p = .502	.20
	High School	17(13.4%)	5	1	9
	Associate’s Degree	11(8.7%)	2	4	5
	Bachelor’s Degree	22(17.3%)	7	5	10
	Master’s Degree/Higher	75(59.1%)	19	13	40
	Missing Value	1	0	0	0
Place of residence (in Ukraine)	City	100 (79.4%)	23	19	52	χ^2(6) = 3.25 p = .0776	.12
	Town	20 (15.9%)	7	4	9
	Village	5(4.0%)	2	0	3
	Other	1(0.8%)	0	0	1
	Missing Value	2	1	1	0
Marital Status	Single	8(6.7%)	4	0	4	χ^2(10) = 8.77 p = .554	.19
	Married or in a relationship	87(68.0%)	22	16	45
	Divorced	22(17.2%)	3	7	10
	Widow(er)	8(6.3%)	3	1	4
	Other	3(2.3%)	1	0	2
Children	Yes	107(86.3%)	22	23	57	χ^2(2) = 6.58 p = 0.087	.24
	No	17(13.7%)	8	1	7
	Missing Value	4	3	0	1
Employment status in Ukraine	Employed	91(77.1%)	25	20	44	χ^2(2) = 4.43 p = .109	.20
	Unemployed	27(22.9%)	5	2	18
	Missing Value	10	3	2	3
Migration with family	Yes	57 (51.4%)	18	13	21	χ^2(2) = 7.64 p = .022*	.27
	No	54 (48.6%)	9	9	36
	Missing Value	17	6	2	8

* p<.05.

We conducted multinomial logistic regression with gender and family migration status. As can be seen in Table 3, the overall model was found to be significant (χ²(4) = 13.91, p = .008), demonstrating that refugees who left family behind were 3.2 times more likely to suffer from comorbidity versus no probability, when compared with those who arrived with the family intact. Additionally, women were 2.9 times more significant to have comorbidity versus no probability compared to men, and 4.2 times more likely to have “only PTSD” than “no probability”, when compared to men. Interestingly, gender and family migration status are significantly associated when comparing “PTSD only” versus “no probability”, but no longer significant when comparing “comorbidity” versus “PTSD only” groups.

Table 3. Multinominal logistic regression analysis between comorbidity, PTSD and no probability.

Variable	B	SE	Sig.	OR	95% CI
No probability^a vs. PTSD only^b
Intercept	−1.26	0.61	0.038*
Gender (male vs female)	1.41	0.67	0.036*	4.12	[1.10, 15.46]
Family migration	0.25	0.61	0.681	1.28	[0.39, 4.26]
No probability vs. Comorbidity^c
Intercept	−0.52	0.46	0.261
Gender (male vs female)	1.07	0.51	0.037*	2.92	[1.07, 8.01]
Family migration	1.17	0.50	0.020*	3.23	[1.20, 8.66]
PTSD only vs. Comorbidity
Intercept	0.74	0.65	0.228
Gender (male vs female)	−0.34	0.65	0.596	0.71	[0.19, 2.37]
Family migration	0.92	0.51	0.074	2.51	[0.92, 6.89]

^a No probability, n = 33; ^bPTSD only, n = 24; ^cComorbidity, n = 65.

* p < .05.

In order to examine the implications of comorbidity status (no probability/PTSD only/comorbidity) on refugees’ distress, functioning, and well-being, we conducted a one-way ANOVA, controlling family migration status and gender as covariates (Table 4) and Post-hocs comparisons (Table 5). We found a significant in (1) general distress (F(2,119) = 27.13, p < .001). Post-hoc comparisons with Tukey’s Test showed that refugees with comorbidity reported more significant distress compared to refugees with “PTSD only” (t(119)= −4.48, p < .001, d = −1.07) and those with “no probable condition” [t(119)= −6.93, p < .001, d = −1.48)]. (2) impairment in social, occupational, or other areas of functioning [F(2,119) = 18.60, p < .001]. Post-hoc comparisons with Tukey’s Test showed that refugees with comorbidity experienced more functional difficulties compared to the “PTSD only” group and to “no probable condition” groups, respectively [t(119)= −3.82, p < .001, d = −0.91); (t(119)= −5.68, p < .001, d = −1.21]; and (3) life satisfaction [F(2,117) = 6.44, p < .002]. Post-hoc comparisons with Tukey’s Test showed that refugees with comorbidity reported lower satisfaction with life than those with “no probable condition” (t(117)= 3.40, d = 0.74, p < .003). No significant differences were found between the “PTSD only” status and the “comorbidity” status.

Table 4. Means (SD) and ANOVA among the groups of comorbidity.

	No probability (n = 33)	PTSD only (n = 24)	Comorbidity (n = 65)	F	p	η^2
Life Satisfaction	4.97(0.79)	4.75(1.19)	4.29(0.84)	6.44	.002**	.099
Functioning impairment	1.88(0.86)	2.25(1.07)	3.21(0.86)	27.13	.001***	.313
General distress	1.09(1.07)	1.42(1.06)	2.40(1.07)	18.60	.001***	.238

**p < .01, ***p ≤ .001.

Discussion

This study represents a pioneering attempt to examine the mental health burden of displacement on Ukrainian refugees. Our findings not only provide insight into the experiences and challenges faced by this specific group of refugees, but also contribute to the growing body of research on psychosocial distress among displaced populations.

Table 5. Post-hoc comparisons for life satisfaction, functioning impairment and general distress.

	Mean difference	SE	t	Cohen’s d	p
Life Satisfaction
No probability- PTSD only	0.218	0.247	0.880	0.239	.654
No probability- Comorbidity	0.675	0.199	3.40	0.742	.003**
PTSD only- Comorbidity	0.458	0.217	2.105	0.503	.093
Functioning impairment
No probability- PTSD only	−0.371	0.242	−1.533	−0.411	.279
No probability- Comorbidity	−1.337	0.193	−6.926	−1.480	.001***
PTSD only- Comorbidity	−0.965	0.216	−4.477	−1.069	.001***
General distress
No probability- PTSD only	−0.326	0.289	−1.127	−0.302	.499
No probability- Comorbidity	−1.309	0.230	−5.684	−1.215	.001***
PTSD only- Comorbidity	−0.983	0.257	−3.821	−0.913	.001***

**p<.01, ***p ≤ .001.

Our study found a high rate of probable PTSD (68%) based on DSM-5 criteria among this population. This aligns with other studies reporting overall rates of PTSD ranging from 31% to 72% among treatment-seeking refugees resettled in Europe (Henkelmann et al., 2020; Mesa-Vieira et al., 2022), yet is higher than a study conducted among Ukrainian citizens (37.3% prevalence of PTSD) living in towns in the Donbass region, where armed conflict had been ongoing since 2014 (Fel et al., 2022).

The high rates of traumatic distress observed in our study may be explained by the close proximity of the traumatic event (one to three months after the flight) and the fact that many had to leave family members behind in the conflict. Refugees who flee with intact families appeared to be less vulnerable to PTSD and psychological distress compared to those who are separated from family (Gebresilassie et al., 2022; Walther et al., 2020). Lastly, the high level of exposure to traumatic events experienced by the study subjects, with an average of 6.3 events, likely contributed to more severe symptom scores and higher prevalence rates of probable PTSD. According to the Conservation of Resources (COR) theory, when individuals are exposed to high levels of trauma and PTSD, they can deplete an overwhelming number of public resources, resulting in greater impairment (Hobfoll, 2011).

Methodological differences may also account for the variations between this study and the meta-analysis mentioned above (Mesa-Vieira et al., 2022). The present study utilized self-report scales and did not employ interviews as an assessment tool. While self-report questionnaires are commonly used in this type of research, it is worth considering that they may overestimate symptomatology (Steel et al., 2009; De Jong et al., 2003).

Additionally, our study found a significantly higher occurrence of PTSD in women compared to men, supporting existing literature on gender differences in trauma. Similar results along the gender divide have been seen among other refugee populations (Mohwinkel et al., 2018; Roberts et al., 2017; Stevanovic et al., 2016). Higher levels of PTSD have also been found among women in the general population as well (Jacobi et al., 2014; Liu et al., 2021). This may be explained by the possibility that women may be more prone to report intrusion symptoms such as intrusive thoughts, flashbacks, and nightmares, as well as higher levels of emotional distress and greater psychological impairment, resulting in avoidance patterns (Taha and Sijbrandij, 2021; Alpak et al., 2015). Furthermore, women with PTSD have been found to experience higher levels of somatization and anxiety compared to men with PTSD (Husky et al., 2018; Richardson et al., 2017).

In our study, we also found notable differences in the level of mental distress, functioning, and life satisfaction when comparing the group refugees with comorbidity (depression, anxiety, and PTSD) with those with “only PTSD”. This difference suggests that the presence of comorbid mental health diagnoses may exacerbate the challenges faced by refugees. A recent study on refugee experience in Uganda found that refugees with dual morbidity experienced lower levels of functioning in comparison to those with only PTSD (Bapolisi et al., 2020). This possible conflagration based on co-morbidity has been seen in other studies on refugees (Im et al., 2022; Momartin et al., 2004; Pejuskovic et al., 2020), yet the reasons for this are not clear. The presence of depression and anxiety in addition to PTSD likely contributes to a diminished sense of well-being and contentment among these individuals. This finding underscores the intricate interplay of multiple mental health disorders, which poses challenges for refugees in attaining a positive and fulfilling life in their new environment. This corroborates the notion that the coexistence of depression, PTSD, and anxiety exacerbates the negative impact on life satisfaction experienced by refugees.

These findings highlight the importance of identifying and addressing comorbid conditions in refugees with PTSD. By recognizing the coexistence of depression and anxiety, interventions should not solely focus on managing PTSD symptoms but should also target the specific needs associated with depression and anxiety. Moreover, addressing specific socio-demographic factors such as gender and family immigration status, may improve the ability to identify refugees at higher risk for comorbidity.

It is of utmost significance to comprehend that PTSD encompasses a wider spectrum of manifestations beyond the symptomatic criteria delineated in the DSM-5 diagnostic manual (Weathers et al., 2013). This assertion finds support in the substantial prevalence observed in studies investigating the coexistence of PTSD with depression and anxiety (Forchuk et al., 2020; Henkelmann et al., 2020; Pagotto et al., 2015; Pejuskovic et al., 2020). These diagnostic categories are not discrete entities in isolation but rather serve as extensions that augment the overarching disorder. Given the unclear relationship among these comorbidities (depression, anxiety and PTSD), and the probability that depression may be a consequence of PTSD, and not a parallel development (Angelakis & Nixon, 2015; Elliott et al., 2015), interventions targeting both disorders may be needed to promote resilience and improve outcomes, especially among refugee populations.

Based on ours and other’s recent findings, it is imperative to provide basic mental health training to refugee aid workers to recognize common signs of trauma-related mental consequences requiring attention. This training should also emphasize what not to do, including pressuring refugees to disclose details of their traumatic experiences (Thompson et al., 2018). In emergency medical settings, comprehensive assessment of mental health needs, individual or group counseling, medication management, and referrals to specialized services should be implemented. Additionally, addressing practical needs such as housing, job training, and language classes is crucial, as they significantly impact mental well-being (Greene et al., 2016). Refugees should also have access to information about symptoms of PTSD, anxiety, and depression, as well as available mental health support and treatment options in their current situation.

Limitations

The use of self-report measures, although common, introduces the risk of reporting bias. Moreover, the use of single items which is common in psychological science, raises arguments in referring to the lower reliability of single items and its’ problem with capturing complex constructs (Allen et al., 2022). Furthermore, the cross-sectional design limits the ability to analyze the psychological consequences of war and immigration over time. Future studies should employ longitudinal designs, incorporate multi-informant assessments, as well as using more comprehensive scales for measuring functioning such as WHODAS 2.0 that assess various aspects (Üstün, 2010). Additionally, international research collaborations are needed to deepen understanding and draw clinical conclusions regarding the mental health challenges faced by refugees.

In conclusion, the current study highlights the complex and interconnected nature of mental distress among refugees. To effectively assist refugees, a comprehensive approach that recognizes the triple effect of PTSD, anxiety, and depression is necessary. While this study has its limitations, it underscores the need for further research to better comprehend the intricacies of mental distress among refugees and develop effective interventions.

The data that support the findings of this study are available on request from the corresponding author [R.A]. The data are not publicly available due to privacy of research participants.

Acknowledgments

We appreciate Ofek Azulay, Nir Ben-Harush and Asaf Goodman, research assistants, for their precious time and goodwill in volunteering for the present study. We’d also like to thank Aviva Yoselis for her editorial assistance.