Validation of the Protect Questionnaire: A tool to detect mental health problems in asylum seekers by non-health professionals
DOI:
https://doi.org/10.7146/torture.v28i2.106884Abstract
Introduction: Prevalence rates of trauma-related mental disorders such as posttraumatic stress disorder (PTSD) or major depression (MD) are high in asylum seekers. The PROTECT Questionnaire (PQ) was designed to detect indications of those disorders in asylum seekers. Empirical data are needed to evaluate the PQ psychometrically. The objective of this study is to investigate the reliability, validity, sensitivity, and specificity of the PQ.
Method: The PQ and validated questionnaires for PTSD (Posttraumatic Diagnostic Scale, PDS) and depression (Patient Health Questionnaire-9, PHQ- 9) were filled in by a sample of recently arrived asylum seekers in Germany (n=141). A sub-sample of 91 asylum seekers took part in a structured clinical interview to diagnose PTSD or MD (SCID-I).
Results: The PQ showed a one-factor structure and good reliability (Cronbach’s ⍺= .82). It correlated highly with the PDS and the PHQ-9 (rs=.53-.77; ps≤.001). Diagnostic accuracy with regard to PTSD (AUC=.74; SE=.06; p<.001; 95%-CI=.63-.84) and MD (AUC=.72; SE=.06; p<.001; 95%-CI=.61- .83) was adequate, suggesting an optimal cut-off of 8 or 9. By categorizing participants into a low- and high-risk category, the PQ differentiated well between asylum seekers who fulfilled a PTSD or MD diagnosis and those who did not.
Discussion: The results support the use of the PQ as a reliable and valid instrument for the purpose of detecting signs and symptoms of the two most common mental disorders in asylum seekers. Persons found to be at risk of mental disorders should be referred to a clinical diagnostic procedure.
References
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Knaevelsrud, C., & Müller, J. (2008). MultiCASI (Multilingual Computer Assisted Self Interview). Berlin: Springer.
Kroenke, K., Spitzer, R. L., & Williams, J. B. (2001). The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med, 16(9), 606-613. https://doi.org/10.1046/j.1525- 1497.2001.016009606.x
Kroenke, K., Spitzer, R. L., Williams, J. B., & Lowe, B. (2010). The Patient Health Questionnaire Somatic, Anxiety, and Depressive Symptom Scales: a systematic review. Gen Hosp Psychiatry, 32(4), 345-359. https://doi.org/10.1016/j. genhosppsych.2010.03.006
Laban, C. J., Gernaat, H. B., Komproe, I. H., Schreuders, B. A., & De Jong, J. T. (2004). Impact of a long asylum procedure on the prevalence of psychiatric disorders in Iraqi asylum seekers in The Netherlands. J Nerv Ment Dis, 192(12), 843-851. https://doi. org/10.1097/01.nmd.0000146739.26187.15
Löwe, B., Grafe, K., Zipfel, S., Witte, S., Loerch, B., & Herzog, W. (2004). Diagnosing ICD- 10 depressive episodes: superior criterion validity of the Patient Health Questionnaire. Psychother Psychosom, 73(6), 386-390. https://doi. org/10.1159/000080384
Löwe, B., Spitzer, R. L., Grafe, K., Kroenke, K., Quenter, A., Zipfel, S., Buchholz, C., Witte, S., Herzog, W. (2004). Comparative validity of three screening questionnaires for DSM-IV depressive disorders and physicians’ diagnoses. J Affect Disord, 78(2), 131-140. https://doi.org/10.1016/ S0165-0327(02)00237-9
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Meltzer-Brody, S., Churchill, E., & Davidson, J. R. (1999). Derivation of the SPAN, a brief diagnostic screening test for post-traumatic stress disorder. Psychiatry Res, 88(1), 63-70. https://doi. org/10.1016/S0165-1781(99)00070-0
Memon, A. (2012). Credibility of Asylum Claims: Consistency and Accuracy of Autobiographical Memory Reports Following Trauma. Applied Cognitive Psychology, 26, 677-679. https://doi. org/10.1002/acp.2868
Miller, K. E., Omidian, P., Quraishy, A. S., Quraishy, N., Nasiry, M. N., Nasiry, S., Yaqubi, A. A. (2006). The Afghan symptom checklist: a culturally grounded approach to mental health assessment in a conflict zone. Am J Orthopsychiatry, 76(4), 423-433. https://doi. org/10.1037/0002-9432.76.4.423
Mollica, R. F., Caspi-Yavin, Y., Bollini, P., Truong, T., Tor, S., & Lavelle, J. (1992). The Harvard Trauma Questionnaire. Validating a crosscultural instrument for measuring torture, trauma, and posttraumatic stress disorder in Indochinese refugees. J Nerv Ment Dis, 180(2), 111-116.
Norris, A. E., & Aroian, K. J. (2008). Assessing reliability and validity of the Arabic language version of the Post-traumatic Diagnostic Scale (PDS) symptom items. Psychiatry Res, 160(3), 327-334. https://doi.org/10.1016/j. psychres.2007.09.005
Prins, A., Ouimette, P., Kimerling, R., Cameron, R. P., Hugelshofer, D., S., Shaw-Hegwer, J., Thrailkill, A., Gusman, F.D., Sheikh, J. I. (2003). The Primary Care PTSD Screen (PC-PTSD): Development and operating characteristics. Primary Care Psychiatry, 9, 9-14. https://doi. org/10.1185/135525703125002360
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Rogers, H., Fox, S., & Herlihy, J. (2014). The importance of looking credible: the impact of the behaviourial sequelea of post-traumatic stress disorder on the credibility of asylum seekers. Psychology, Crime & Law, (21(2), 139-155. doi.or g/10.1080/1068316X.2014.951643
Rohlof, H. G., Knipscheer, J. W., & Kleber, R. J. (2014). Somatization in refugees: a review. Soc Psychiatry Psychiatr Epidemiol, 49(11), 1793-1804. DOI 10.1007/s00127-014-0877-1
Silove, D., Sinnerbrink, I., Field, A., Manicavasagar, V., & Steel, Z. (1997). Anxiety, depression and PTSD in asylum-seekers: assocations with premigration trauma and post-migration stressors. Br J Psychiatry, 170, 351-357. https://doi. org/10.1192/bjp.170.4.351
Steel, Z., Chey, T., Silove, D., Marnane, C., Bryant, R. A., & van Ommeren, M. (2009). Association of torture and other potentially traumatic events with mental health outcomes among populations exposed to mass conflict and displacement: a systematic review and meta-analysis. JAMA, 302(5), 537-549. https://doi.org/10.1001/jama.2009.1132
Steel, Z., Silove, D., Brooks, R., Momartin, S., Alzuhairi, B., & Susljik, I. (2006). Impact of immigration detention and temporary protection on the mental health of refugees. Br J Psychiatry, 188, 58-64. https://doi.org/10.1192/bjp. bp.104.007864
Van de Vijver, F.J.R., & Hambleton, R. K. (1996). Translating Tests - Some Practical Guidelines. European Psychologist, 1(2), 89-99. https://doi. org/10.1027/1016-9040.1.2.89
Wittchen, H. U., Schramm, E., Zaudig, M., & Unland, H. (1997). SKID. Stukturiertes klinisches Interview für DSM-IV, Achse I, deutsche Version. [Structured clinical interview for DSM-IV, German Version]. Göttingen: Hogrefe.
Brewin, C. R. (2005). Systematic review of screening instruments for adults at risk of PTSD. Journal of Traumatic Stress, 18(1), 53-62. https://doi. org/10.1002/jts.20007
Bundesamt für Migration und Flüchtlinge (2014). Migrationsbericht des Bundesamtes für Migration und Flüchtlinge im Auftrag der Bundesregierung [Migration Report of the Federal Office for Migration and Refugees on behalf of the Federal Government] (Migrationsbericht 2014).
Cameron, H. E. (2010). Refugee Status Determinations and the Limits of Memory. International Journal of Refugee Law, 22, 469-511. https://doi.org/10.1093/ijrl/eeq041
Chou, F. H., Su, T. T., Ou-Yang, W. C., Chien, I. C., Lu, M. K., & Chou, P. (2003). Establishment of a disaster-related psychological screening test. Aust N Z J Psychiatry, 37(1), 97-103.
European Asylum Support Office (EASO) (2015). EASO Practical Guide: Evidence Assessment.
European Asylum Support Office (EASO) (2016). EASO tool for identification of persons with special needs.
European Union (2013). Directive 2013/32/ EU and Directive 2013/33/EU of the European Parliament and the Council of 26 June 2013. Official Journal of the European Union, 29.6.2013 (L 180/60). https://doi. org/10.3000/19770677.L_2013.180.eng
European Union Agency for Fundamental Rights (FRA) (2016). FRA Opinion on fundamental rights in the ‘hotspots’ set up in Greece and Italy, 2016, 5.
Foa, E. (1995). Posttraumatic Stress Diagnostic Scale Manual. United States of America: National Computer Systems Inc.
Fullerton, C. S., Ursano, R. J., Epstein, R. S., Crowley, B., Vance, K. L., Craig, K. J., & Baum, A. (2000). Measurement of posttraumatic stress disorder in community samples. Nordic Journal of Psychiatry, 54(1), 5-12. https://doi. org/10.1080/080394800427519
Gäbel, U., Ruf, M., Schauer, M., Odenwald, M., & Neuner, F. (2006). Prävalenz der Posttraumatischen Belastungsstörung (PTSD) und Möglichkeiten der Ermittlung in der Asylverfahrenspraxis. [Prevalence of posttraumatic stress disorder among asylum seekers in Germany and its detection in the application process for asylum] Zeitschrift für Klinische Psychologie und Psychotherapie, 35(1), 12- 20. https://doi.org/10.1026/1616-3443.35.1.12
Heeren, M., Wittmann, L., Ehlert, U., Schnyder, U., Maier, T., & Muller, J. (2014). Psychopathology and resident status - comparing asylum seekers, refugees, illegal migrants, labor migrants, and residents. Comprehensive Psychiatry, 55(4), 818-825. https://doi.org/10.1016/j. comppsych.2014.02.003
Herlihy, J., Jobson, L., & Turner, S. (2012). Just tell us what happened to you: Autobiographical memory and seeking asylum. Applied Cognitive Psychology, 26(5), 661-676. https://doi. org/10.1002/acp.2852
Hollifield, M., Toolson, E. C., Verbillis-Kolp, S., Farmer, B., Yamazaki, J., Woldehaimanot, T., & Holland, A. (2016). Effective Screening for Emotional Distress in Refugees: The Refugee Health Screener. J Nerv Ment Dis, 204(4), 247-253. https://doi.org/10.1097/ NMD.0000000000000469
Hollifield, M., Verbillis-Kolp, S., Farmer, B., Toolson, E. C., Woldehaimanot, T., Yamazaki, J., SooHoo, J. (2013). The Refugee Health Screener-15 (RHS-15): development and validation of an instrument for anxiety, depression, and PTSD in refugees. Gen Hosp Psychiatry, 35(2), 202-209. https://doi.org/10.1016/j. genhosppsych.2012.12.002
Ikram, U., & Stronks, K. (2016). Preserving and Improving the Mental Health of Refugees and Asylum Seekers. Den Haag: bijlage bij Briefadvies Geestelijke gezondheid van vluchtelingen [The Hague, attachment with Advisory letter mental health of refugees].
Jakobsen, M., Thoresen, S., & Johansen, L. (2011). The Validity of Screening for Post-traumatic Stress Disorder an Other Mental Health Problems among Asylum Seekers from Different Countries. Journal of Refugee Studies, 24(1), 171-186. https:// doi.org/10.1093/jrs/feq053
Knaevelsrud, C., & Müller, J. (2008). MultiCASI (Multilingual Computer Assisted Self Interview). Berlin: Springer.
Kroenke, K., Spitzer, R. L., & Williams, J. B. (2001). The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med, 16(9), 606-613. https://doi.org/10.1046/j.1525- 1497.2001.016009606.x
Kroenke, K., Spitzer, R. L., Williams, J. B., & Lowe, B. (2010). The Patient Health Questionnaire Somatic, Anxiety, and Depressive Symptom Scales: a systematic review. Gen Hosp Psychiatry, 32(4), 345-359. https://doi.org/10.1016/j. genhosppsych.2010.03.006
Laban, C. J., Gernaat, H. B., Komproe, I. H., Schreuders, B. A., & De Jong, J. T. (2004). Impact of a long asylum procedure on the prevalence of psychiatric disorders in Iraqi asylum seekers in The Netherlands. J Nerv Ment Dis, 192(12), 843-851. https://doi. org/10.1097/01.nmd.0000146739.26187.15
Löwe, B., Grafe, K., Zipfel, S., Witte, S., Loerch, B., & Herzog, W. (2004). Diagnosing ICD- 10 depressive episodes: superior criterion validity of the Patient Health Questionnaire. Psychother Psychosom, 73(6), 386-390. https://doi. org/10.1159/000080384
Löwe, B., Spitzer, R. L., Grafe, K., Kroenke, K., Quenter, A., Zipfel, S., Buchholz, C., Witte, S., Herzog, W. (2004). Comparative validity of three screening questionnaires for DSM-IV depressive disorders and physicians’ diagnoses. J Affect Disord, 78(2), 131-140. https://doi.org/10.1016/ S0165-0327(02)00237-9
McDonald, T. W., & Sand, J. N. (2010). Post- Traumatic Stress Disorder in Refugee Communities: The Importance of Culturally Sensitive Screening, Diagnosis, and Treatment. New York: Nova Science Publishers.
MSF (Medecins sans Frontieres( (2017). A Dramatic Detoriation for Asylum Seekers on Lesbos.
Meltzer-Brody, S., Churchill, E., & Davidson, J. R. (1999). Derivation of the SPAN, a brief diagnostic screening test for post-traumatic stress disorder. Psychiatry Res, 88(1), 63-70. https://doi. org/10.1016/S0165-1781(99)00070-0
Memon, A. (2012). Credibility of Asylum Claims: Consistency and Accuracy of Autobiographical Memory Reports Following Trauma. Applied Cognitive Psychology, 26, 677-679. https://doi. org/10.1002/acp.2868
Miller, K. E., Omidian, P., Quraishy, A. S., Quraishy, N., Nasiry, M. N., Nasiry, S., Yaqubi, A. A. (2006). The Afghan symptom checklist: a culturally grounded approach to mental health assessment in a conflict zone. Am J Orthopsychiatry, 76(4), 423-433. https://doi. org/10.1037/0002-9432.76.4.423
Mollica, R. F., Caspi-Yavin, Y., Bollini, P., Truong, T., Tor, S., & Lavelle, J. (1992). The Harvard Trauma Questionnaire. Validating a crosscultural instrument for measuring torture, trauma, and posttraumatic stress disorder in Indochinese refugees. J Nerv Ment Dis, 180(2), 111-116.
Norris, A. E., & Aroian, K. J. (2008). Assessing reliability and validity of the Arabic language version of the Post-traumatic Diagnostic Scale (PDS) symptom items. Psychiatry Res, 160(3), 327-334. https://doi.org/10.1016/j. psychres.2007.09.005
Prins, A., Ouimette, P., Kimerling, R., Cameron, R. P., Hugelshofer, D., S., Shaw-Hegwer, J., Thrailkill, A., Gusman, F.D., Sheikh, J. I. (2003). The Primary Care PTSD Screen (PC-PTSD): Development and operating characteristics. Primary Care Psychiatry, 9, 9-14. https://doi. org/10.1185/135525703125002360
PROTECT. (2012). Project Report. Process of Recognition and Orientation of Torture Victims in European Countries to Facilitate Care and Treatment.
Rogers, H., Fox, S., & Herlihy, J. (2014). The importance of looking credible: the impact of the behaviourial sequelea of post-traumatic stress disorder on the credibility of asylum seekers. Psychology, Crime & Law, (21(2), 139-155. doi.or g/10.1080/1068316X.2014.951643
Rohlof, H. G., Knipscheer, J. W., & Kleber, R. J. (2014). Somatization in refugees: a review. Soc Psychiatry Psychiatr Epidemiol, 49(11), 1793-1804. DOI 10.1007/s00127-014-0877-1
Silove, D., Sinnerbrink, I., Field, A., Manicavasagar, V., & Steel, Z. (1997). Anxiety, depression and PTSD in asylum-seekers: assocations with premigration trauma and post-migration stressors. Br J Psychiatry, 170, 351-357. https://doi. org/10.1192/bjp.170.4.351
Steel, Z., Chey, T., Silove, D., Marnane, C., Bryant, R. A., & van Ommeren, M. (2009). Association of torture and other potentially traumatic events with mental health outcomes among populations exposed to mass conflict and displacement: a systematic review and meta-analysis. JAMA, 302(5), 537-549. https://doi.org/10.1001/jama.2009.1132
Steel, Z., Silove, D., Brooks, R., Momartin, S., Alzuhairi, B., & Susljik, I. (2006). Impact of immigration detention and temporary protection on the mental health of refugees. Br J Psychiatry, 188, 58-64. https://doi.org/10.1192/bjp. bp.104.007864
Van de Vijver, F.J.R., & Hambleton, R. K. (1996). Translating Tests - Some Practical Guidelines. European Psychologist, 1(2), 89-99. https://doi. org/10.1027/1016-9040.1.2.89
Wittchen, H. U., Schramm, E., Zaudig, M., & Unland, H. (1997). SKID. Stukturiertes klinisches Interview für DSM-IV, Achse I, deutsche Version. [Structured clinical interview for DSM-IV, German Version]. Göttingen: Hogrefe.
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2018-07-28
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Mewes, R., Friele, B., & Bloemen, E. (2018). Validation of the Protect Questionnaire: A tool to detect mental health problems in asylum seekers by non-health professionals. Torture Journal, 28(2), 56–71. https://doi.org/10.7146/torture.v28i2.106884
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