Predictors of the 10 year course of mental health and quality of life for trauma-affected refugees after psychological treatment

Figures & data

Table 1. Literature findings regarding pretreatment demographics and trauma load as predictors of treatment outcome in clinical groups of adult refugees.

Study details							Potential predictors that are also included in the present study (covariates included)
Authors (year)	N	Sample, treatment setting, country of origin (largest cohort); treatment study type	Participants’ gender, age; trauma load; length of stay in host country at study intake	No. of assessment time-points used in analyses	Time from first to last measure	Predictor variables studied	Outcome variables studied; statistical method	Gender	Age	Education	Time in host country	Host country language competence	Employment	War- and flight-related trauma exposure
van Wyk et al. (2012)	62	Refugees from Burma (now Myanmar) in assessment, therapy and social assistance provided by a resettlement organization in Australia; naturalistic study	43% males, age 18–80 (M = 34.1) years; HTQ Trauma Events: mean number = 6.2 (SD = 3.2); Stay in Australia: 1–15 (M = 3.1) months at initial assessment	2	1–14 (M = 6.9) months	7 potential predictor variables: baseline PTSD, anxiety, depression, somatization scores, number of trauma events, postmigration living difficulties, total number of service contacts, and number of therapy sessions	4 outcome variables: postintervention PTSD, anxiety, depression, and somatization scores; multiple linear regression + Bonferroni correction	Not examined/not reported	Not examined/not reported	Not examined/not reported	Not examined/not reported	Not examined/not reported	Not examined/not reported	The number of traumas experienced was unrelated to all mental health outcomes
Stenmark et al. (2014)	54	Multi-ethnic refugees and asylum seekers (31% Iraqi) who had completed a treatment programme for PTSD (10 sessions of 90 min) in Norway; multicentre RCT (here explored independently of type of treatment)	66.7% males, mean age 35.7 (SD = 10.2) years; number of trauma events recorded by CAPS = 8.2 (SD = 2.6); length of stay in Norway: not provided	2	Around 8.5 months (estimated by us from text)	10 potential predictor variables: gender, torture status, offender status, and initial level of anger and depression (+ age, education, time spent in exile, asylum status, pretreatment PTSD)	1 outcome variable: PTSD symptom severity; non-responders (n = 10), i.e. with same or higher level of symptoms after therapy, compared with responders (n = 44); t-tests and exact unconditional homogeneity/independence test for 2 × 2 tables	Male gender predicted non-response to treatment	No significant difference in age between non-responders and responders	No significant difference in level of education between non-responders and responders	No significant difference in time spent in exile between non-responders and responders	Not examined/not reported	Not examined/not reported	Self-reported experiences of torture did not predict treatment outcome. No significant difference in number of reported traumatic events between non-responders and responders
Buhmann et al. (2015)	85	Multi-ethnic refugee patients (77% from the Middle East) with PTSD and/or depression in a psychiatric trauma clinic for refugees in Denmark; treatment: M = 9 medical consultations + M = 14 psychotherapy sessions; mean duration = 8 months	47% males, age 21–57 (M = 43.4) years; 54% tortured, 86% experienced war; length of stay in Denmark: 2–30 (M = 14.5) years	3	Around 9 months (estimated by us from text)	A large number of potential predictor variables were entered into linear univariate regression models to investigate associations with outcome variables. The following were found to be significantly associated with outcome and thus included in multivariate regression models: employment, pain in the arms, use of a translator, patient suitability score, use of various therapy tools/interventions, and number of sessions with a psychologist	5 outcome variables: change between initial assessment and treatment termination in symptoms of PTSD, anxiety/depression, and level of functioning (3 scales); multivariate regression	Assumed from text: gender not significantly associated with outcome	Assumed from text: age not significantly associated with outcome	Assumed from text: education not significantly associated with outcome	Assumed from text: time in Denmark not significantly associated with outcome	Assumed from text: need for an interpreter not significantly associated with outcome	Receiving financial support, as opposed to being self-supported through employment, was associated with poorer treatment outcome in PTSD symptoms	Assumed from text: experienced war and torture not significantly associated with outcome
Sonne, Carlsson, Bech, Vindbjerg et al. (2016)	158 (195)	Refugees with PTSD (34.5% Iraqi) enrolled in a 6–7 month treatment programme in a specialized transcultural psychiatric outpatient clinic in Denmark as part of an RCT (both treatment conditions were combined)	60.2% males, age provided in Sonne, Carlsson, Bech, Elklit, and Mortensen (2016); trauma: 49% tortured, 94% had war experiences; length of stay in Denmark provided in Sonne, Carlsson, Bech, Elklit, and Mortensen (2016): M = 14.6 (SD = 7.3) years	2	Around 7–8 months (estimated by us from text)	15 potential predictors (background, mental and physical health, social situation, and motivation for therapy) studied in a single index and separately	12 outcome variables: changes in PTSD, self-reported anxiety/depression, observer-rated anxiety/depression, well-being, disability, somatization, pain scores (4), and GAF (2); correlation between predictors and changes in outcome scores, and multiple regression analysis	Not examined/not reported	Not examined/not reported	Higher levels of education correlated negatively with improvement in anxiety and depression	Not examined/not reported	Not examined/not reported	Employment was the only predictor of improvement in PTSD symptoms	Not examined
Haagen et al. (2017)	72	Refugees and asylum seekers (35% from the Middle East) with PTSD, having received treatment in two Dutch specialist psychotrauma treatment and research centres; RCT (here explored independently of type of treatment); number of treatment sessions = 10.7 (SD = 2.8)	72% males, age 41.5 (SD = 11.1) years; trauma: number of PTEs: 12 (SD = 5.0); 66% tortured, rape or sexual abuse in 23%; length of stay in the Netherlands: 9.4 (SD = 5.2) years	3	Around 5–6 months (estimated by us from text)	15 potential predictors [gender, refugee status, interpreter use, number and 6 kinds of traumatic events (including torture), pretreatment PTSD severity, comorbid depression diagnosis, and severity of depression, number of psychotherapy sessions, and treatment dropout]	2 PTSD outcome variables (frequency and severity of PTSD symptoms); longitudinal multilevel modelling	Gender was not a significant predictor of PTSD outcome	Not examined/not reported	Not examined/not reported	Not examined/not reported	Interpreter presence during therapy was not a significant predictor of PTSD outcome	Not examined/not reported	Number and nature (including torture) of traumatic events were not significant predictors of PTSD outcome
Stammel et al. (2017)	76	Refugees (32.3% from Iran) in outpatient multidisciplinary treatment over a mean of 18 months, in a psychosocial centre for traumatized refugees in Germany; naturalistic study	61.8% males, age 25.4 (SD = 10.6) years; trauma: victims of torture and/or war (numbers not specified); length of stay in Germany: not provided	3	M = 14 months	7 potential predictors: gender, age, and country of origin (5 countries/regions investigated)	3 outcome variables, i.e. dependent variables with significant variances in the slopes (PTSD and QoL thus not included): anxiety, depression, and somatoform symptoms were investigated for predictor effects; multilevel analysis of longitudinal data with different time intervals	Gender did not significantly predict the course of anxiety, depression, or somatoform symptoms	Age predicted significantly the course of somatoform symptoms, but not the course of anxiety and depression	Not examined/not reported	Not examined/not reported	Not examined/not reported	Not examined/not reported	Not examined/not reported
Buhmann et al. (2018)	217	Refugees with war-related traumatic experiences and PTSD (36% Iraqi) after 6 months’ therapy in a specialized transcultural psychiatric outpatient clinic in Denmark; RCT	59% males, age 44.9 (SD = 9.0) years; trauma: 43% subjected to torture, 23% with combat experience; length of stay in Denmark (at 6 month follow-up): 14.7 (SD = 6.1) years	4	24 months	11 potential predictors: age, gender, personality change after catastrophic experience (ICD-10 F62.0), depression, somatic disease, country of origin, and new positive (1) and negative life events (4)	9 outcome variables: PTSD, anxiety (2), depression (2), somatization, pain, functioning/disability, and QoL; mixed models, linear regression, growth curve models	Gender significantly predicted somatization and pain, and was marginally significant for anxiety and depression; women improved more than men	No significant effects of age	Not examined/not reported	Not examined/not reported	Not examined/not reported	Not examined/not reported	Not examined/not reported; however, negative and positive life events during the course of follow-up affected the outcome in opposite directions
Nordin & Perrin (2019)	276/171	Refugees (38% Iraqi) exposed to torture and organized violence, waiting for, in, or having completed multimodal treatment in a specialized outpatient clinic for tortured refugees in Denmark; average treatment sessions = 72.8 (SD = 44.3) over about 1 year	61.6% males, age 44.8 (SD = 9.4) years; trauma: 82% subjected to torture, 18% to other forms of organized violence; length of stay in Denmark: 56% around 20 years, 13.7% > 20 years, 25.7% < 20 years, and 6% < 2–3 years (our estimate from text)	2 (for the analysis of predictors)	M = 39 months (estimated by us from text)	5 potential predictors: gender, age, pretreatment pain severity, pain interference with different areas in life, and number of treatment sessions. N = 276 for pretreatment predictors	3 outcome variables: PTSD, depression, and anxiety (health-related disability was omitted, as there was no significant pretreatment to post-treatment difference); N = 171 for post-treatment data; multilevel linear mixed modelling; analyses of whether the predictor variables predicted scores at post-treatment	Gender did not significantly predict outcomes	Age did not predict outcomes except for a small negative effect of (older) age on PTSD	Not examined/not reported	Not examined/not reported	Not examined/not reported	Not examined/not reported	Not examined/not reported
Sander et al. (2019)	436–598	Trauma-affected refugees and family-united individuals with PTSD (33.3% Iraqi), having received multidisciplinary treatment and M = 10.4 sessions of CBT over M = 10.4 months in a specialized outpatient centre for transcultural psychiatry in Denmark	52.3% males, age 45.2 (SD = 9.1) years; trauma: 43.6 subjected to torture, 47.4% imprisonment; length of stay in Denmark: 15.4 (SD = 7.2) years	2	Around 11–12 months (estimated by us from text)	1 potential predictor: interpreter use in therapy. Comparison of two subsamples who used or did not use an interpreter during treatment. (A large number of covariates were controlled for. Those significantly associated with at least one outcome variable and with interpreter use were included in the final analyses: being Muslim, being married, income, length of stay in Denmark, time in multidisciplinary treatment, number of psychotherapy sessions, and coming from Iraq, former Yugoslavia, and Lebanon. The direction of their effect is not reported)	10 outcome variables: severity of PTSD, anxiety (2), and depression (2) symptoms, somatization and disability/functioning scores, QoL, GAF-F, and GAF-S; covariate multiple linear regression model + full information maximum likelihood estimation	Gender was not significantly associated with interpreter use or any outcome variable	Age was not significantly associated with interpreter use or any outcome variable]	Education was not significantly associated with interpreter use or any outcome variable	Length of stay in Denmark was significantly associated with interpreter use and at least one outcome variable (which one is not reported)	Interpreter use in therapy predicted poorer treatment outcomes in PTSD, anxiety, depression, somatization, disability/functioning, and QoL	Not examined/not reported (although income was entered as a covariate, but had no significant effect)	Exposure to torture and imprisonment were not significantly associated with interpreter use or any outcome variable
Sonne et al. (2021)	321/256–265	Refugees or reunited family members with PTSD (34.1% Iraqi), in 6–7 months’ (in practice, often longer) multimodal treatment, including 16 sessions with a psychologist, in a specialized transcultural centre in Denmark; pooled data from two RCTs	59.5% males, age 43.4 (SD = 9.5) years; trauma: subjected to torture 48.9%, imprisonment 50.9, combat experience 27.4%; length of stay in Denmark: 14.8 (SD = 7.0) years	2	Around 7–9 months (estimated by us from text)	17 candidate predictors were analysed for significant association with change in outcomes, which resulted in 7 potential predictors: age, time since arrival in Denmark, occupation, Muslim faith, combat experience, refugee status, and level of functioning (GAF-F) (not: torture, imprisonment, stay in refugee camp outside host country, length of stay in asylum centres, marital status, living alone, or trauma-related psychotic symptoms)	5 outcome variables: pretreatment to post-treatment changes in symptoms of PTSD, anxiety (2), and depression (2); candidate predictors significantly related to pre–post symptom change were included in hierarchical multiple regression analyses	Gender was not significantly associated with change in outcome variables in preliminary analyses	Younger age was associated with greater improvement in both PTSD and depression	Education was not significantly associated with change in outcome variables in preliminary analyses	Short time in the host country was associated with symptom improvement in PTSD	Not examined/not reported	Full-time occupation was associated with improvement in anxiety and depression	Less exposure to traumatic events (assumed from status as family reunited in contrast to refugee status) was associated with improvement in PTSD

Note: PTSD, post-traumatic stress disorder; RCT, randomized controlled trial; CBT, cognitive behavioural therapy; HTQ, Harvard Trauma Questionnaire; CAPS, Clinician-Administered PTSD Scale; PTE, potentially traumatic event; QoL, quality of life; GAF-F and GAF-S, Global Assessment of Functioning – Function and Symptoms.

The wording in the table is kept close to the original wording in the articles.

Table 2. Demographics, traumatic experiences, mental health, and quality of life at T1.

Male gender	35 (64.8)
Age (years)	39.3 ± 8.2
Married/cohabiting	35 (64.8)
Participants with children	44 (81.5)
Years of education in country of origin	9.7 ± 4.5
Years living in host country	10.5 ± 6.5
Host country language competence	27 (50.0)
Employment	12 (22.2)
Childhood Family Violence^a	0.6 ± 1.0
Childhood External Violence^b	2.4 ± 1.9
HTQ Trauma Events^c	16.3 ± 6.3
Torture^d	28 (51.9)
Sexual Abuse^e	16 (29.6)
Anxiety^f	2.89 ± 0.59
Depression^f	2.94 ± 0.54
PTSD Total^f	2.82 ± 0.47
PTSD Reexperencing^f	2.89 ± 0.69
PTSD Arousal^f	3.12 ± 0.49
PTSD Avoidance^f	2.56 ± 0.57
Diagnostic level anxiety (> 1.75)	51 (96.2)
Diagnostic level depression (> 1.75)	52 (98.1)
Diagnostic level PTSD (≥ 2.5)	41 (78.8)
QoL Physical Health^g	28.5 ± 13.8
QoL Psychological Health^g	25.6 ± 15.9
QoL Social Relationships^g	36.6 ± 23.4
QoL Environmental Conditions^g	45.2 ± 18.2

Note: Data are shown as n (%) or M ± SD.

T1, time of first assessment and approximate time of therapy start; HTQ, Harvard Trauma Questionnaire; PTSD, post-traumatic stress disorder; QoL, quality of life.

Demographics and traumatic experiences: n = 54; anxiety and depression: n = 53; PTSD: n = 52; QoL: n = 52.

Scoring range: ^a0–3 and ^b0–7 (subscales of Childhood Trauma) (Opaas & Varvin, 2015).

^c 37 items related to war and persecution, scoring range 0–37 (HTQ Part 1) (Mollica et al., 2004).

^d An item in the HTQ Part 1.

^e Two items in the HTQ Part 1, combined.

Instruments: ^fMollica et al. (2004); ^gWHOQOL Group (1998).

Figure 1. Prediction of the long-term course of mental health symptoms and quality of life (QoL) by gender. Mixed effects modelling of the trajectories of mental health symptoms and QoL based on the interaction between gender and time. Symptoms of post-traumatic stress disorder (PTSD) were measured by the Harvard Trauma Questionnaire (Mollica et al., 2004); anxiety and depression were measured by the Hopkins Symptom Checklist-25 (Mollica et al., 2004); QoL was measured by the World Health Organization Quality of Life BREF questionnaire (WHOQOL-BREF) (WHOQOL Group, 1998). The plot illustrates the trajectories over the 10 years of follow-up.

Figure 2. Prediction of the long-term course of anxiety and depression by trauma experiences. Mixed effects modelling of the trajectories of mental health symptoms and quality of life (QoL) based on the interaction between trauma variables and time. HTQ Trauma Events and symptoms of post-traumatic stress disorder (PTSD) were measured by the Harvard Trauma Questionnaire (Mollica et al., 2004); anxiety and depression were measured by the Hopkins Symptom Checklist-25 (Mollica et al., 2004); childhood family violence was assessed for this sample by Opaas & Varvin (2015). The plot illustrates the trajectories over the 10 years of follow-up.

van Wyk, S., Schweitzer, R., Brough, M., Vromans, L., & Murray, K. (2012). A longitudinal study of mental health in refugees from Burma: The impact of therapeutic interventions. Australian & New Zealand Journal of Psychiatry, 46(10), 995–1003. doi: 10.1177/0004867412443059

 PubMed Web of Science ®Google Scholar

Stenmark, H., Guzey, I. C., Elbert, T., & Holen, A. (2014). Gender and offender status predicting treatment success in refugees and asylum seekers with PTSD. European Journal of Psychotraumatology, 5(1), 20803. doi:10.3402/ejpt.v5.20803

 PubMed Web of Science ®Google Scholar

Buhmann, C. B., Mortensen, E. L., Nordentoft, M., Ryberg, J., & Ekstrøm, M. (2015). Follow-up study of the treatment outcomes at a psychiatric trauma clinic for refugees. Torture, 25, 1–16.

 PubMedGoogle Scholar

Sonne, C., Carlsson, J., Bech, P., Vindbjerg, E., Mortensen, E. L., & Elklit, A. (2016). Psychosocial predictors of treatment outcome for trauma-affected refugees. European Journal of Psychotraumatology, 7, 1. doi:10.3402/ejpt.v7.30907

 Web of Science ®Google Scholar

Sonne, C., Carlsson, J., Beck, P., Elklit, A., & Mortensen, E. L. (2016). Treatment of trauma-affected refugees with venlafaxine versus sertraline combined with psychotherapy – A randomised study. BMC Psychiatry, 16(383), 3–13. doi:10.1186/s12888-016-1081-5

 Google Scholar

Haagen, J. F. G., ter Heide, F. J. J., Mooren, T. M., Knipscheer, J. W., & Kleber, R. J. (2017). Predicting post-traumatic stress disorder treatment response in refugees: Multilevel analysis. British Journal of Clinical Psychology, 56, 69–83. doi: 10.1111/bjc.12121

 Web of Science ®Google Scholar

Stammel, N., Knaevelsrud, C., Schock, K., Walther, L. S., Wenk-Ansohn, M., & Böttche, M. (2017). Multidisciplinary treatment for traumatized refugees in a naturalistic setting: Symptom courses and predictors. European Journal of Psychotraumatology, 8(sup2), 1377552. doi:10.1080/20008198.2017.1377552

 PubMed Web of Science ®Google Scholar

Buhmann, C. B., Nordentoft, M., Ekstroem, M., Carlsson, J., & Mortensen, E. L. (2018). Long-term treatment effect of trauma-affected refugees with flexible cognitive behavioural therapy and antidepressants. Psychiatry Research, 264, 217–223. doi: 10.1016/j.psychres.2018.03.069

 Web of Science ®Google Scholar

Nordin, L., & Perrin, S. (2019). Pre-treatment pain predicts outcomes in multimodal treatment for tortured and traumatized refugees: A pilot investigation. European Journal of Psychotraumatology, 1–10. doi:10.1080/20008198.2019.1686807

 Web of Science ®Google Scholar

Sander, R., Laugesen, H., Skammeritz, S., Mortensen, E. L., & Carlsson, J. (2019). Interpreter-mediated psychotherapy with trauma-affected refugees – A retrospective cohort study. Psychiatry Res 271, 684–692. doi:10.1016/j.psychres.2018.12.058

 Web of Science ®Google Scholar

Sonne, C., Mortensen, E. L., Silove, D., Palic, S., & Carlsson, J. (2021). Predictors of treatment outcomes for trauma-affected refugees – Results from two randomised trials. Journal of Affective Disorders, 282, 194–202. doi:10.1016/j.jad.2020.12.095

 PubMed Web of Science ®Google Scholar

Opaas, M., & Varvin, S. (2015). Relationships of childhood adverse experiences with mental health and quality of life at treatment start for adult refugees traumatized by pre-flight experiences of war and human right violations. Journal of Nervous and Mental Disease, 203, 684–695. doi:10.1097/NMD.0000000000000330

 PubMed Web of Science ®Google Scholar

Mollica, R. F., McDonald, L. S., Massagli, M. P., & Silove, D. M. (2004). Measuring trauma, measuring torture. Instructions and guidance on the utilization of Hopkins Symptom Checklist-25 (HSCL-25) & the Harvard Trauma Questionnaire (HTQ). Harvard program in refugee trauma, http://hprt-cambridge.org. CD, retrieved 2006.

 Google Scholar

WHOQOL Group. (1998). Development of the World Health Organization WHOQOL-BREF quality of life assessment. Psychological Medicine, 28, 551–558. doi: 10.1017/S0033291798006667

 PubMed Web of Science ®Google Scholar

Data availability statement

The data that support the findings of this study are available on reasonable request from the corresponding author, Marianne Opaas. The data are not publicly available owing to ethical concerns, i.e. information on open data sharing was not given to participants at inclusion in the study in 2006–2009 and ethical clearance has not been given for such sharing.