Four decades of war, political upheaval, economic deprivation and forced displacement have profoundly affected both in-country and refugee Afghan populations.

We reviewed literature on mental health and psychosocial well-being, to assess the current evidence and describe mental healthcare systems, including government programmes and community-based interventions.

In 2022, we conducted a systematic search in Google Scholar, PTSDpubs, PubMed and PsycINFO, and a hand search of grey literature (N = 214 papers). We identified the main factors driving the epidemiology of mental health problems, culturally salient understandings of psychological distress, coping strategies and help-seeking behaviours, and interventions for mental health and psychosocial support.

Mental health problems and psychological distress show higher risks for women, ethnic minorities, people with disabilities and youth. Issues of suicidality and drug use are emerging problems that are understudied. Afghans use specific vocabulary to convey psychological distress, drawing on culturally relevant concepts of body–mind relationships. Coping strategies are largely embedded in one's faith and family. Over the past two decades, concerted efforts were made to integrate mental health into the nation's healthcare system, train cadres of psychosocial counsellors, and develop community-based psychosocial initiatives with the help of non-governmental organisations. A small but growing body of research is emerging around psychological interventions adapted to Afghan contexts and culture.

We make four recommendations to promote health equity and sustainable systems of care. Interventions must build cultural relevance, invest in community-based psychosocial support and evidence-based psychological interventions, maintain core mental health services at logical points of access and foster integrated systems of care.

Long-term efficacy of brief psychotherapies for refugees in low-resource settings is insufficiently understood. Integrative adapt therapy (IAT) is a scalable treatment addressing refugee-specific psychosocial challenges.

We report 12-month post-treatment data from a single-blind, active-controlled trial (October 2017–August 2019) where 327 Myanmar refugees in Malaysia were assigned to either six sessions of IAT (n = 164) or cognitive behavioral treatment (CBT) (n = 163). Primary outcomes were posttraumatic stress disorder (PTSD), depression, anxiety, and persistent complex bereavement disorder (PCBD) symptom scores at treatment end and 12-month post-treatment. Secondary outcome was functional impairment.

282 (86.2%) participants were retained at 12-month follow-up. For both groups, large treatment effects for common mental disorders (CMD) symptoms were maintained at 12-month post-treatment compared to baseline (d = 0.75–1.13). Although participants in IAT had greater symptom reductions and larger effect sizes than CBT participants for all CMDs at treatment end, there were no significant differences between treatment arms at 12-month post-treatment for PTSD [mean difference: −0.9, 95% CI (−2.5 to 0.6), p = 0.25], depression [mean difference: 0.1, 95% CI (−0.6 to 0.7), p = 0.89), anxiety [mean difference: −0.4, 95% CI (−1.4 to 0.6), p = 0.46], and PCBD [mean difference: −0.6, 95% CI (−3.1 to 1.9), p = 0.65]. CBT participants showed greater improvement in functioning than IAT participants at 12-month post-treatment [mean difference: −2.5, 95% CI (−4.7 to −0.3], p = 0.03]. No adverse effects were recorded for either therapy.

Both IAT and CBT showed sustained treatment gains for CMD symptoms amongst refugees over the 12-month period.

We investigate the prevalence and risk factor profiles of Intermittent Explosive Disorder (IED) and comparison between two diagnostic measures for IED in a large population-based study of three ethnic groups of refugees (Chin, Kachin and Rohingya) from Myanmar resettled in Malaysia.

Trained field personnel interviewed in total 2058 refugees, applying a clustered, probabilistic, proportional-to-size sampling framework and using the DSM-IV and DSM-5 criteria to diagnose IED. We used descriptive and bivariate analyses to explore associations of IED (using DSM IV or DMS 5) with ethnic group membership, sociodemographic characteristics and exposure to premigration traumatic events (TEs) and postmigration living difficulties (PMLDs). We also examined associations of IED with other common mental disorders (CMDs) (depression, anxiety and posttraumatic stress disorder) and with domains of functional impairment. Finally, we compared whether IED measured using DSM IV or DSM 5 generated the same or different prevalence.

For the whole sample (n = 2058), the 12-month prevalence of DSM-IV IED was 5.9% (n = 122) and for DSM-5, 3.4% (n = 71). Across the three ethnic groups, 12-month DSM-5 IED prevalence was 2.1% (Chin), 2.9% (Rohingya) and 8.0% (Kachin), whereas DSM-IV defined IED prevalence was 3.2% (Chin), 7% (Rohingya) and 9.2% (Kachin). Being single, and exposure to greater premigration TEs and PMLDs were each associated with IED. Over 80% of persons with IED recorded one or more comorbid CMDs. Persons with IED also showed greater levels of functional impairment compared with those without IED.

The pooled IED prevalence was higher than global norms but there was substantial variation in prevalence across the three study groups.

Longitudinal studies are needed to examine the association between maternal depression, trauma and childhood mental health in conflict-affected settings.

To examine maternal depressive symptoms, trauma-related adversities and child mental health by using a longitudinal path model in conflict-affected Timor-Leste.

Women were recruited in pregnancy. At wave 1, 1672 of 1740 eligible women were interviewed (96% response rate). The final sample comprised 1118 women with complete data at all three time points. Women were followed up when the index child was aged 18 months (wave 2) and 36 months (wave 3). Measures included the Edinburgh Postnatal Depression Scale, lifetime traumatic events and the Child Behaviour Checklist. A longitudinal path analysis examined associations cross-sectionally and in a cross-lagged manner across time.

Maternal depressive symptom score was associated with child mental health (cross-sectional association at wave 2, β = 0.35, P < 0.001; cross-sectional association at wave 3, β = 0.33, P < 0.001). The maternal depressive symptom score at wave 1 was associated with child mental health at wave 2 (β = 0.12, P < 0.001), and the maternal depressive symptom score at wave 2 showed an indirect association with child mental health at wave 3 (indirect standardised coefficient 0.23, P < 0.001). There was a time-lagged relationship between child mental health at wave 2 and maternal depression at wave 3 (β = 0.08, P = 0.02).

Maternal depressive symptoms are longitudinally associated with child mental health, and traumatic events play a role. Maternal depression symptoms are also affected by child mental health. Findings suggest the need for skilled assessment for depression, trauma-informed maternity care and parenting support in a post-conflict country such as Timor-Leste.

Large variations in prevalence rates of common mental disorder (CMD) amongst refugees and forcibly displaced populations have raised questions about the accuracy and value of epidemiological surveys in these cross-cultural settings. We examined the associations of sociodemographic indices, premigration traumatic events (TEs), postmigration living difficulties (PMLDs), and psychosocial disruptions based on the Adaptive Stress Index (ASI) in relation to CMD prevalence amongst the Rohingya, Chin and Kachin refugees originating from Myanmar and relocated to Malaysia.

Parallel epidemiological studies were conducted in areas where the three groups were concentrated in and around Malaysia (response rates: 80–83%).

TE exposure, PMLDs and ASI were significantly associated with CMD prevalence in each group but the Rohingya recorded the highest exposure to all three of these former indices relative to Chin and Kachin (TE: mean = 11.1 v. 8.2 v. 11; PMLD: mean = 13.5 v. 7.4 v. 8.7; ASI: mean = 128.9 v. 32.1 v. 35.5). Multiple logistic regression analyses based on the pooled sample (n = 2058) controlling for gender and age, found that ethnic group membership, premigration TEs (16 or more TEs: OR, 2.00; 95% CI, 1.39–2.88; p < 0.001), PMLDs (10–15 PMLDs: OR, 4.19; 95% CI, 3.17–5.54; 16 or more PMLDs: OR, 7.23; 95% CI, 5.24–9.98; p < 0.001) and ASI score (ASI score 100 or greater: OR, 2.19; 95% CI, 1.46–3.30; p < 0.001) contributed to CMD.

Factors specific to each ethnic group and differences in the quantum of exposure to TEs, PMLDs and psychosocial disruptions appeared to account in large part for differences in prevalence rates of CMDs observed across these three groups.

The mental health and social functioning of millions of forcibly displaced individuals worldwide represents a key public health priority for host governments. This is the first longitudinal study with a representative sample to examine the impact of interpersonal trust and psychological symptoms on community engagement in refugees.

Participants were 1894 resettled refugees, assessed within 6 months of receiving a permanent visa in Australia, and again 2–3 years later. Variables measured included post-traumatic stress disorder symptoms, depression/anxiety symptoms, interpersonal trust and engagement with refugees’ own and other communities.

A multilevel path analysis was conducted, with the final model evidencing good fit (Comparative Fit Index = 0.97, Tucker–Lewis Index = 0.89, Root Mean Square Error of Approximation = 0.05, Standardized Root-Mean-Square-Residual = 0.05). Findings revealed that high levels of depression symptoms were associated with lower subsequent engagement with refugees’ own communities. In contrast, low levels of interpersonal trust were associated with lower engagement with the host community over the same timeframe.

Findings point to differential pathways to social engagement in the medium-term post-resettlement. Results indicate that depression symptoms are linked to reduced engagement with one's own community, while interpersonal trust is implicated in engagement with the broader community in the host country. These findings have potentially important implications for policy and clinical practice, suggesting that clinical and support services should target psychological symptoms and interpersonal processes when fostering positive adaptation in resettled refugees.

Refugees are at risk of experiencing a combined constellation of complicated bereavement and posttraumatic stress disorder (PTSD) symptoms following exposure to complex traumas associated with personal threat and loss. Features of identity confusion are central to both complicated bereavement and PTSD and these characteristics may be particularly prominent amongst refugees from traditional cultures displaced from their homelands, families, and kinship groups. We investigate whether a combined pattern of complicated bereavement and PTSD can be identified amongst West Papuan refugees participating in an epidemiological survey (n = 486, response rate: 85.8%) in a remote town in Papua New Guinea.

Latent class analysis was applied to derive subpopulations of refugees based on symptoms of complicated bereavement and PTSD. Associations were examined between classes and traumatic loss events, post-migration living difficulties (PMLDs), and psychosocial support systems.

The four classes identified comprised a complicated bereavement class (11%), a combined posttraumatic bereavement class (10%), a PTSD class (11%), and a low symptom class (67%). Symptoms of identity confusion were prominent in the posttraumatic bereavement class. Compared with the low symptom class, the combined posttraumatic bereavement class reported greater exposure to traumatic loss events (OR 2.43, 95% CI 1.11–5.34), PMLDs (OR 2.24, 95% CI 1.01–4.6), disruptions to interpersonal bonds and networks (OR 3.3, 95% CI 1.47–7.38), and erosion of roles and identities (OR 2.18, 95% CI 1.11–4.27).

Refugees appear to manifest a combined pattern of complicated bereavement and PTSD symptoms in which identity confusion is a prominent feature. This response appears to reflect the combined impact of high levels of exposure to traumatic losses, PMLDs, and disruption of relevant psychosocial systems.

Following years of controversy, a category of complex post-traumatic stress disorder (CPTSD) will be included in the forthcoming ICD-11.

To test whether refugees with CPTSD differ from those with other common mental disorders (CMDs) in the degree of exposure to childhood adversities, adult interpersonal trauma and post-traumatic hardship.

Survey of 487 West Papuan refugees (response rate 85.5%) in Papua New Guinea.

Refugees with CPTSD had higher exposure to childhood adversities (CPTSD: mean 2.6, 95% CI 2.5–2.7 versus CMD: mean 1.15, 95% CI 1.10–1.20), interpersonal trauma (CPTSD: mean 9, 95% CI 8.6–9.4 versus CMD: mean 5.4, 95% CI 5.4–5.5) and postmigration living difficulties (CPTSD: mean 2.3, 95% CI 2–2.5 versus CMD mean 1.85, 95% CI 1.84–1.86), compared with those with CMDs who in turn exceeded those with no mental disorder on all these indices.

The findings support the cross-cultural validity of CPTSD as a reaction to high levels of exposure to recurrent interpersonal trauma and associated adversities.

None.

A key issue in need of empirical exploration in the post-conflict and refugee mental health field is whether exposure to torture plays a role in generating risk of intimate partner violence (IPV), and whether this pathway is mediated by the mental health effects of torture-related trauma. In examining this question, it is important to assess the impact of socio-economic hardship which may be greater amongst survivors of torture in low-income countries.

The study data were obtained from a cohort of 870 women (recruited from antenatal clinics) and their male partners in Dili district, Timor-Leste. We conducted bivariate and path analysis to test for associations of men's age, socioeconomic status, torture exposure, and mental disturbance, with IPV (the latter reported by women).

The path analysis indicated positive paths from a younger age, torture exposure, and lower socio-economic status amongst men leading to mental disturbance. Mental disturbance, in turn, led to IPV. In addition, younger age, lower socio-economic status, torture exposure, and mental disturbance were directly associated with IPV.

Our data provide the first systematic evidence of an association between torture and IPV in a low-income, post-conflict country, confirming that low socio-economic status, partly related to being a torture survivor, adds to the risk. The high prevalence of IPV in this context suggests that other structural factors, such as persisting patriarchal attitudes, contribute to the risk of IPV. Early detection and prevention programs may assist in reducing the risk of IPV in families in which men have experienced torture.

Little is known about explosive anger as a response pattern among pregnant and post-partum women in conflict-affected societies.

To investigate the prevalence and correlates of explosive anger among this population in Timor-Leste.

We assessed traumatic events, intimate partner violence, an index of adversity, explosive anger, psychological distress and post-traumatic stress disorder among 427 women (257 in the second trimester of pregnancy, 170 who were 3–6 months postpartum) residing in two districts of Timor-Leste (response >99%).

Two-fifths (43.6%) had explosive anger. Levels of functional impairment were related to frequency of explosive anger episodes. Explosive anger was associated with age (>35 years), being married, low levels of education, being employed, traumatic event count, ongoing adversity and intimate partner violence.

A combination of social programmes and novel psychological therapies may assist in reducing severe anger among pregnant and post-partum women in conflict-affected countries such as Timor-Leste.

Traumatic injuries affect millions of patients each year, and resulting post-traumatic stress disorder (PTSD) significantly contributes to subsequent impairment.

To map the distinctive long-term trajectories of PTSD responses over 6 years by using latent growth mixture modelling.

Randomly selected injury patients (n = 1084) admitted to four hospitals around Australia were assessed in hospital, and at 3, 12, 24 and 72 months. Lifetime psychiatric history and current PTSD severity and functioning were assessed.

Five trajectories of PTSD response were noted across the 6 years: (a) chronic (4%), (b) recovery (6%), (c) worsening/recovery (8%), (d) worsening (10%) and (e) resilient (73%). A poorer trajectory was predicted by female gender, recent life stressors, presence of mild traumatic brain injury and admission to intensive care unit.

These findings demonstrate the long-term PTSD effects that can occur following traumatic injury. The different trajectories highlight that monitoring a subset of patients over time is probably a more accurate means of identifying PTSD rather than relying on factors that can be assessed during hospital admission.

The latent structure of the proposed ICD-11 post-traumatic stress disorder (PTSD) symptoms has not been explored.

To investigate the latent structure of the proposed ICD-11 PTSD symptoms.

Confirmatory factor analyses using data from structured clinical interviews administered to injury patients (n = 613) 6 years post-trauma. Measures of disability and psychological quality of life (QoL) were also administered.

Although the three-factor model implied by the ICD-11 diagnostic criteria fit the data well, a two-factor model provided equivalent, if not superior, fit. Whereas diagnostic criteria based on this two-factor model resulted in an increase in PTSD point prevalence (5.1% v. 3.4%; z = 2.32, P<0.05), they identified individuals with similar levels of disability (P = 0.933) and QoL (P = 0.591) to those identified by the ICD-11 criteria.

Consistent with theorised reciprocal relationships between re-experiencing and avoidance in PTSD, these findings support an alternative diagnostic algorithm requiring at least two of any of the four re-experiencing/avoidance symptoms and at least one of the two hyperarousal symptoms.

High levels of comorbidity between separation anxiety disorder (SEPAD) and panic disorder (PD) have been found in clinical settings. In addition, there is some evidence for a relationship involving bipolar disorder (BD) and combined PD and SEPAD. We aim to investigate the prevalence and correlates of SEPAD among patients with PD and whether the presence of SEPAD is associated with frank diagnoses of mood disorders or with mood spectrum symptoms.

Adult outpatients (235) with PD were assessed by the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I), the Panic Disorder Severity Scale (PDSS), the Structured Clinical Interview for Separation Anxiety Symptoms (SCI-SAS), and the Mood Spectrum Self-Report Instrument (MOODS-SR, lifetime version).

Of ther 235 subjects, 125 (53.2%) were categorized as having SEPAD and 110 (46.8%) as not. Groups did not differ regarding onset of PD, lifetime prevalence of obsessive compulsive disorder (OCD), social phobia, simple phobia, BD I and II, or major depressive disorder (MDD). SEPAD subjects were more likely to be female and younger; they showed higher rates of childhood SEPAD, higher PDSS scores, and higher MOODS-SR total and manic component scores than subjects without SEPAD.

SEPAD is highly prevalent among PD subjects. Patients with both PD and SEPAD show higher lifetime mood spectrum symptoms than patients with PD alone. Specifically, SEPAD is correlated with the manic/hypomanic spectrum component.

Our data confirm the high prevalence of SEPAD in clinical settings. Moreover, our findings corroborate a relationship between mood disorders and SEPAD, highlighting a relationship between lifetime mood spectrum symptoms and SEPAD.

There have been changes to the criteria for diagnosing post-traumatic stress disorder (PTSD) in DSM-5 and changes are proposed for ICD-11.

To investigate the impact of the changes to diagnostic criteria for PTSD in DSM-5 and the proposed changes in ICD-11 using a large multisite trauma-exposed sample and structured clinical interviews.

Randomly selected injury patients admitted to four hospitals were assessed 72 months post trauma (n = 510). Structured clinical interviews for PTSD and major depressive episode, as well as self-report measures of disability and quality of life were administered.

Current prevalence of PTSD under DSM-5 scoring was not significantly different from DSM-IV (6.7% v. 5.9%, z = 0.53, P = 0.59). However, the ICD-11 prevalence was significantly lower than ICD-10 (3.3% v. 9.0%, z =–3.8, P<0.001). The PTSD current prevalence was significantly higher for DSM-5 than ICD-11 (6.7% v. 3.3%, z = 2.5, P = 0.01). Using ICD-11 tended to show lower rates of comorbidity with depression and a slightly lower association with disability.

The diagnostic systems performed in different ways in terms of current prevalence rates and levels of comorbidity with depression, but on other broad key indicators they were relatively similar. There was overlap between those with PTSD diagnosed by ICD-11 and DSM-5 but a substantial portion met one but not the other set of criteria. This represents a challenge for research because the phenotype that is studied may be markedly different according to the diagnostic system used.