/ Recent Iraqi Refugees: Association Between Ethnic Identification and Psychological Distress

Journal of Muslim Mental Health

Author Note: The authors wish to thank the Arab American and Chaldean Council, Samaritas, the volunteers and the Iraqi refugees who participated without whom this project could not have been conducted. This research was supported in part by a grant from the State of Michigan (Lyckai/Young Funds) and clinical money from Detroit Wayne Mental Health Authority.

Correspondence concerning this paper should be addressed to Cynthia Arfken, Department of Psychiatry and Behavioral Neurosciences, Wayne State University, 3901 Chrysler Service Drive, Detroit, MI 48201. Email: cynthia.arfken@wayne.edu


Abstract

Psychological distress may differ by ethnic affiliation among recent Iraqi refugees due to a combination of risk and resiliency factors. To explore this hypothesis, data were collected from a study conducted over the course of a year (June 2016 to May 2017) of Iraqi refugees screened within one month of arrival to the United States; the screening used the PTSD Checklist Civilian for trauma symptoms and the Hopkins Symptoms Checklist for anxiety and depression, and these markers were analyzed. Of the 52 Iraqi refugees (59.6% women, mean age=38.4), 18 identified as Chaldean or Christian and 34 as Arab, presumably Muslim. Mean scores on trauma, anxiety, and depression symptoms were significantly elevated with moderate effect sizes (d=0.51 for trauma and d=0.63 for depression) and large effect size (d=0.80 for anxiety) in Arab compared to Chaldean refugees. All measures of psychological distress and a one-item self-rating of the impact of war and migration were correlated. These findings suggest that among recently resettled Iraqi refugees in the U.S., Arabs had higher psychological distress than Chaldeans. To maximize resettlement success, we need to examine ways to reduce their distress.

Keywords: refugees, Arab, PTSD, anxiety, depression, Iraq


For more than four decades, Iraqis have been exposed to almost continuous warfare or violence, most recently from the upheaval caused by the still-ongoing invasion and occupation by the United States; the vacuum of power facilitated the creation of local militias and the Islamic State of Iraq and Syria (ISIS). ISIS follows a fundamentalist heterodox Sunni doctrine and prioritizes the purification of Islamic society within Iraq and later Syria (Byman, 2015). Between 2014 and November 2017, ISIS violently enforced their belief on an estimated 2.8 to 8 million people (Byman, 2015).

This constant threat of violence has resulted in many Iraqi refugees. The United Nations High Commissioner on Refugees (2015) reported 261,107 international refugees from Iraq and 4,400,000 internally displaced people. Nearly half of Iraqi refugees have reported exposure to unnatural death or murder of a family member or a friend, and more than 40% reported personal experiences of being close to death (Hengst, Smid & Laban, 2018; Nickerson, Bryant, Steel, Silove & Brooks, 2010). The prevalence of these specific events underestimate the ongoing stress (Kira, Amer, & Wrobel, 2014) and indirect exposure to traumatic events through mass and social media felt by the population.

A recent review found a prevalence of between 8% and 37.2% for posttraumatic stress disorder among resettled Iraqis from six studies, and 28.3% and 75% for depression from seven studies (Slewa-Younan, Uribe-Guadjardo, Heriseaun & Hasan, 2015). Although the range is large, these prevalence estimates are higher than the U.S. general adult population for 12-month prevalence (3.7% for PTSD and 8.6% for depression; Kessler, Petukhova, Sampson, Zaslavsky & Wittchen, 2012). Importantly, the studies in the review were conducted before the emergence of ISIS, which may have inflicted yet more trauma and may have triggered clinically significant responses (Kira et al., 2014). More recent studies continue to document high distress among Iraqi refugees. Al-Smadi and colleagues (2017) reported elevated anxiety in more than half of adult Iraqis in Jordan. Hengst and colleagues (2018) reported high rates of PTSD (36.7%), major depression (34.7%), and generalized anxiety disorder (22.4%) among Iraqi refugees in the Netherlands.

The high prevalence of psychological distress among Iraqis may not be uniformly distributed. For context, it is estimated that 95-98% of Iraqis are Muslim and 1% Christian with ethnic Chaldeans forming the majority of them (Central Intelligence Agency, n.d.). Muslim Iraqi refugees resettled in the U.S. may show more distress than Christian refugees due to differences in stressors and resiliency factors in Iraq and the U.S. (Abu-Ras, Suarez, & Abu-Bader, 2018; Allen, 2010; Awad, 2010). ISIS acts of violence affect all Iraqis but may be more focused on Muslim civilians, leading to greater exposure to trauma, and perhaps fear of it. Another stressor is that Muslims are a minority in the U.S. after being a majority in Iraq, a change that can be stressful. Lastly, with recent changes in the political atmosphere, the Muslim refugees arriving to the United States may feel less welcome due to political statements and actions such as travel bans on people from Muslim-majority countries.

There may be also important resiliency factors that differ by ethnic identification or religious affiliation. For example, Christian refugees to Southeast Michigan move to an area with a large population of Christian Arabs (Detroit Area Arab American Study Team, 2009), including Chaldean Iraqis (Chaldean American Chamber of Commerce, n.d.). Resiliency factors among Chaldeans include the prominence and general community acceptance of Chaldean churches.

Based upon these risk and resiliency factors, it is not surprising that a brief report found higher distress among Arab-Muslim Iraqis than Chaldean Iraqis (Jamil & Arnetz, 2017). However, the analysis included refugees who had lived in the U.S. for different lengths of time making interpretation difficult. We know of no report comparing psychological distress between Muslim and non-Muslim Iraqi refugees controlling for time in the U.S. and resettlement site.

In this work, we report on recently arrived U.S. Iraqi refugees in southeast Michigan screened for PTSD, depression, and anxiety, and explored the hypothesis that symptoms of possible psychological distress would be higher among Arab (presumed to be Muslim) Iraqi refugees compared to Chaldean (Christian) Iraqi refugees.

Methods

Study Design and Participants

This cross-sectional study was approved by the Wayne State University institutional review board, and conducted in collaboration between the Stress, Trauma, and Anxiety Research Clinic of Wayne State University Department of Psychiatry and Behavioral Neurosciences and the Arab American and Chaldean Council, a nonprofit social service agency. The latter agency held the contract to conduct the local primary care screening mandated for refugees which are scheduled within one month of arriving in the country.

Recruitment was piloted at one of the four contracted primary care clinics with later expansion to another clinic. These two clinics had been identified by the social service agency as receiving most of the Syrian refugees resettling in the area and also many Iraqi refugees (Javanbacht, Rosenberg, Haddad, & Arfken, 2018). This analysis reports only on the Iraqi refugees. Inclusion criteria for screening of adults were: participants must be between the ages of 18 and 65, provided informed consent, and able to understand English or Arabic. Recruitment occurred from June 2016 to May 2017.

Procedures

At the mandatory primary health screening, the primary care provider introduced the research project. Those who were interested in learning about the project were then provided with more information by bilingual, graduate-level research assistants. Those who agreed to participate were guided to a private room to provide informed consent and complete the survey. The survey was self-administered although the research assistants were available for answering questions and reading the questions if preferred by the participant. The length of the survey varied from a few minutes to 20 minutes, in some cases unduly abbreviated due to pressure from drivers waiting to return the participants to their homes.

The survey covered demographics, self-reported English proficiency, substance use, and past medical and mental history. To screen for current symptoms of psychological distress, we used the PTSD Checklist Civilian version (PCL-C) for DSM-IV to assess for past-month trauma symptoms and the Hopkins Symptom Checklist 25 items (HSCL-25) to assess past-week anxiety and depression symptoms. Both scales have been used extensively across multiple settings and cultures (Carlson & Rosser-Hogan, 1994; Cepeda-Benito & Gleaves, 2000; Hesbacher, Rickels, Morris, Newman, & Rosenfeld, 1980; Hollifield et al., 2002; Terhakopian, Sinaii, Engel, Schnurr, & Hoge, 2008). No inventory of traumatic exposure was included, though one question asked “how would you score your experience with the war and migration?” The item responses were anchored at “mildly traumatic” (1) and “worst thing in my life” (7).

For the analysis, total symptom severity scores and percentage with possible PTSD, anxiety, and depression were calculated. The total sum of the PCL was calculated for those who completed at least 15 of the 17 items, with the missing values imputed by mean scores of items if the 2 items were not in the same criterion to measure trauma symptoms. Determination of possible PTSD was based upon the DSM-IV criteria (excluding Criterion A), and not the total PTSD score. For anxiety, the mean score for the 10 items on the HSCL (with mean imputed values for those with 2 or fewer missing items) was calculated. For depression, the mean score for the 15 items on the HSCL (with mean imputed values for those with 3 or fewer missing items) was calculated. For both anxiety and depression, scores of 1.75 or higher were considered possible diagnosis (Derogatis, Lipman, Rickels, Uhlenhuth, & Covi, 1974). The internal reliability of the scales in this sample was excellent (PCL α=0.90, anxiety α=0.89 and depression α=0.93).

Statistical Analysis

Descriptive statistics were used to summarize the psychological distress among the recently resettled Iraqi refugees. Chi-square and t-tests were used to test if there were differences by ethnic identification, and the magnitude of effect was summarized using Cohen’s d (Cohen, 1988) for continuous measures and odds ratios (OR) for dichotomous measures (Fleiss & Berlin, 2009). The OR are reported with 95% confidence intervals (CI).

Mediation models were explored using self-rating perception of war and migration as the mediator. This variable was chosen as it might integrate the impact of cumulative traumatic events during war and migration. If the mediation models were found to fit the data, it would imply that difference in psychological distress between self-identified Arab and Chaldean refugees would be at least partially due to the self-rated perception of war and migration. To determine mediation, we examined the effect size of standardized beta coefficients from regression analyses (Preacher & Kelly, 2011). We also calculated the proportion of the effect that is mediated. This summary measure is calculated as (indirect effect)/ (indirect + direct effect) with Kenny (2018) recommending that complete mediation would have a proportion of 0.80 or larger. Separate mediation models were constructed for each outcome measure.

For the analysis, SPSS (version 25) was used, along with a macro developed by Hayes to run mediation models (Hayes, 2017).

Results

Of the 104 adult Iraqi refugees who reported their ethnicity (55 Arab, 1 Kurdish, 47 Chaldean and 1 other ethnicity) only 53 answered the question on their perception of war and migration. Of those respondents, 34 identified as Arab, 18 as Chaldean and 1 as other ethnicity. For ease of interpretation, the answers for the 34 Arab and 18 Chaldean Iraqis were analyzed. This smaller sample size resulted in reduced power for bivariate analysis but did not impact effect sizes or the mediation models.

There were no significant differences in demographic variables (Table 1) by ethnic identification. Overall, 59.6% were female, 67.3% were married, and the mean age was 38.35 (SD=11.77) years. There were no significant differences in prior substance use (20.2% had ever smoked cigarettes), previous psychiatric diagnosis (10.6%), lack of spoken English (40.4%), or self-reported medical conditions (32.7%).

Table 1. Iraqi refugee characteristics by ethnic affiliation

Characteristics

Arab (n=34)

Chaldean (n=18)

Mean age (SD)

36.41 (11.83)

42.00 (11.05)

Females, %

58.8%

61.1%

Education, %

  Illiterate

  Elementary/middle school

  High school

  College

  Higher Education

  Data missing

6.1

27.3

21.2

42.4

3.0

n=1

0

44.4

11.1

38.9

5.6

Marital Status, %

  Married

  Single

  Divorced/widowed

  Data missing

72.7

15.2

12.1

n-1

61.1

27.8

11.1

Previous psychiatric diagnosis, %

  Depression

  Anxiety

  PTSD

  Psychosis

  Any

  Data missing

6.7

6.7

0

0

13.3

n=4

5.9

0

0

0

5.9

n=1

Any medical condition, %

29.4

38.9

Self-rated spoken English fluency, %

  Not at all

  Not well

  Well

  Very well

32.4

41.2

20.6

5.9

55.6

22.2

22.2

0

As hypothesized, Arab refugees as a group had elevated trauma, anxiety, and depression symptoms compared to Chaldean refugees (Table 2) with effect sizes ranging from d=0.46 for perception of war and migration to d=0.80 for anxiety symptoms. Arab refugees also had elevated odds ratios for possible PTSD (OR=3.83, 95% CI 0.75 – 19.64), anxiety (OR=3.12, 95% CI 0.90 – 10.76), and depression (OR=2.53, 95% CI 0.70 – 8.34). Results were similar for both the continuous symptom score and categorical disorder after excluding people with pre-existing psychiatric diagnoses (n=5).

Table 2. Psychological distress and perception of war and migration among Iraqi adult refugees by ethnic affiliation

Variables

Arab (n=34)

Chaldean (n=18)

Test statistic

P‑value

Effect size

Mean (SD)

Cohen’s d

Trauma symptom

44.12 (19.82)

35.99 (10.88)

t(49.89)=1.91

.062

0.51

Anxiety symptom

Data missing

2.11 (0.90)

1

1.54 (0.46)

t(49.87)=3.00

.004

0.80

Depression symptom

2.02 (0.77)

1.63 (0.41)

t(49.96)=2.41

.02

0.63

Perception of war and migration1

5.29 (1.98)

4.33 (2.22)

t(50)=1.60

.12

0.46

%

Odds Ratio

Possible PTSD diagnosis

32.4

11.1

χ2(1)=2.83

.09

3.83

Possible Anxiety diagnosis

Data missing

54.5

1

27.8

χ2(1)=3.37

.066

3.12

Possible Depression diagnosis

55.9

33.3

χ2(1)=2.40

.12

2.53

Score of 7 on perception of war and migration

47.1

27.8

χ2(1)=1.82

.18

2.31

1 measured on a Likert Scale with anchors of 1= mildly traumatic and 7 = worst thing in my life

Although trauma, anxiety, and depression have different symptoms and clinical criteria, they frequently co-occur. The bivariate correlations between the trauma, anxiety, and depression symptoms were all greater than r=0.86. The correlations of three psychological distress measures with self-rated perception of war and migration were lower (range from r=0.29 to r=0.33) but still significant.

In mediation models (Table 3), the direct effect or standardized beta coefficient from the regression model of ethnic identification (controlling for perception of war and migration) on trauma was – 5.78, the indirect effect of perception was -2.35, and the total effect was 8.13. Thus the percentage of the effect that was mediated by the perception of war and migration was 28.9%. For anxiety, the proportion of the effect mediated was 15.8%. For depression, the proportion of the effect mediated was 20.5%.

Table 3. Results from the mediation models

Results

Trauma symptoms

Anxiety symptoms

Depression symptoms

Total effect (SE)

-8.13 (5.04)

-0.57 (0.23)

-0.39 (0.19)

Direct effect (SE)

-5.78 (5.00)

-0.48 (0.23)

-0.31 (0.19)

Indirect effect (Lower limit, Upper limit)

-2.35 (-7.83, 0.27)

-0.09 (-0.33, .004)

-0.08 (-0.29, 0.01)

 Lower limit and upper limit are bias-corrected bootstrap 95% confidence intervals obtained from 10,000 samples

Discussion

Among Iraqi refugees recently resettled in the U.S., we observed high psychological distress measured as trauma, anxiety, and depression symptoms among both Arab and Chaldean Iraqi refugees. The cumulative history of violence in the country and recent surge of violence with ISIS clearly took a toll on the refugees. This group of refugees spent approximately two years in refugee camps before arriving in the U.S., and therefore would have been exposed to ISIS and other conflicts either directly or indirectly through mass and social media. Furthermore, as hypothesized, we observed higher psychological distress among Arab, presumably Muslim, compared to Chaldean or Christian refugees. These differences were not explained by demographic characteristics or pre-existing psychiatric disorders, and effect sizes ranged from moderate to large (Cohen, 1988). These findings are strengthened by studying refugees who had been resettled in the U.S. for the same length of time and in the same region.

Other recent research on Iraqi refugees had also found elevated psychological distress (Hengst et al., 2018; Al-Smadi et al., 2017) but did not report potential differences by ethnic identification or religious affiliation. However, an earlier cohort of Iraqi refugees (10% Muslims) in southeast Michigan recruited after the Iraq War of 2003-2011 ended but prior to the arrival of ISIS found low levels of distress (LeMaster et al., 2018). The low levels of distress may have been due to low overall exposure to violence, as refugees who had been kidnapped were more likely to be diagnosed with PTSD (Wright et al., 2017), and specific traumas were associated with more distress (Arnetz et al., 2014).

Examination of why these ethnic differences existed in our sample was limited as we had time constraints excluding the possibility of a longer questionnaire or conducting qualitative interviews. One possibility was that the Arab refugees had suffered more trauma during the war. For that reason, we explored mediation models using perception of war and migration as the mediator. The findings did not support that our hypothesized mediator had a major impact. However, our proposed mediator may have suffered from reverse causation as refugees with high level of psychological distress may perceive the war and migration worse than those with low levels of distress.

Other risk and resiliency factors need to be examined for the underlying reasons for the ethnic differences. Examples from research examining other populations include the buffering effect of in-group connection and/or desires to re-strengthen this connection (Wohl, Branscombe, & Reysen, 2010; Wohl, King, & Taylor, 2014). In a one-year follow-up to the initial screening we will attempt to examine some of these reasons.

This work has several limitations. First, we had missing information due to time constraints. This pressure meant that questions on psychological distress were prioritized compared to other questions such as perception of war and migration. The smaller sample size answering the question of perception reduced our statistical power. Second, we lacked data on the type and number of traumatic exposures due to concerns about triggering distress. Third, our proposed mediator was one item with unknown reliability and validity. Fourth, we did not specifically ask about religion. This was due to concern about sensitivity of such questions in the first encounter with refugees, especially given political circumstances. For that reason, we asked about ethnicity which in other research with Iraqi refugees was shown to be associated with religious affiliation, as Chaldeans are the overwhelming majority of Christians in Iraq. Lastly, we did not have measures of resiliency. For example, the resettlement area is home to a large number of Iraqi Christians. It is possible that the Chaldean refugees might be have relatives nearby and felt less anxious after arrival.

In conclusion, our finding that anxiety, depression, and trauma symptoms are associated with ethnic identification and possibly religious affiliation has policy and clinical implications. It echoes previous work finding higher initial distress among Muslim Arab Americans than other Arab Americans (Padela & Heisler, 2010) and highlights the importance of deeper examination of this issue (Sulaiman-Hill & Thompson, 2012). To maximize resettlement success, we need to examine ways to reduce their distress.

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