# Does country of residence matter? A cross-sectional comparison of PTSD and depression among traumatized, treatment-seeking Syrians residing in Syria and Syrian refugees in Germany and Turkey

## TL;DR

This study compares PTSD and depression rates among Syrians in Syria and refugees in Germany and Turkey, finding similar mental health burdens but higher trauma exposure among refugees.

## Contribution

The study provides cross-country evidence that being a refugee does not uniquely determine mental health outcomes, as trauma exposure plays a key mediating role.

## Key findings

- PTSD and depression rates were similar between Syrians in Syria and refugees in Germany and Turkey.
- Refugees reported significantly higher trauma exposure compared to Syrians in Syria.
- Trauma exposure partially explained differences in mental health outcomes between groups.

## Abstract

Refugees, including Syrians, exhibit higher rates of posttraumatic mental disorders than non-refugee populations, partly due to traumatic events and stressors before, during, and after displacement. However, differences in symptom load cannot solely be attributed to being a refugee, as comparison groups vary in other characteristics, such as country of residence and origin. Using a cross-country comparative design, the present study examined mental health outcomes associated with being a refugee by contrasting Syrian refugees with Syrian residents.

Syrians residing in Syria (SRS) were compared with Syrian refugees in Germany (RSG) and Turkey (RST) regarding posttraumatic stress disorder (PTSD; using the PTSD Checklist for DSM-5), depression (using the Patient Health Questionnaire-9 (PHQ-9)), and traumatic event exposure (using a curated list of traumatic events). Participants (n = 689 total, n = 236 SRS, n = 254 RSG, n = 199 RST) were recruited from an open-label dissemination study between 2021 and 2024. Prevalence rates and trauma exposure were compared between groups, and mediation models examined trauma exposure as a potential mechanism underlying group differences, adjusting for employment, education, family status, age, and gender.

Prevalence rates were calculated for depression (SRS: 90%, RSG: 91%, RST: 86%) and PTSD (SRS: 75%, RSG: 81%, RST: 72%), with no significant differences between refugees and Syrian residents. However, both refugee groups reported significantly more trauma load (SRS vs. RSG: t = -5.94, p < 0.001; SRS vs. RST: t = -4.87, p < 0.001). Mediation models indicated that trauma load partly explained existing differences in mental health outcomes between refugees and Syrian residents (Indirect effects - SRS vs. RSG for PTSD: β = 0.040, 95% CI [0.015, 0.065], p = 0.002; SRS vs. RST for depression: β = 0.028, 95% CI [0.003, 0.053], p < 0.03; SRS vs. RST for PTSD: β = 0.059, 95% CI [0.028, 0.090], p < 0.001).

PTSD and depression rates did not differ between refugees and Syrian residents from Syria, emphasizing the high mental health symptom burden in treatment-seeking Syrians regardless of their country of residence. Notably, though trauma exposure was higher among refugees and explained existing differences in symptom load, underscoring the need for psychosocial support across host countries.