Assessments for Trauma and Mental Health in Refugees*

Refugee’s experience many stressful experiences including war-trauma, migration stress, and post-migration stress. They also suffer from many physical and psychological symptoms and disorders, partly owing to the stressful experiences they have.  Assessing the stressful experiences and the symptoms and disorders is challenging, partly because the sheer number of events and symptoms can be overwhelming to discover for investigators and to hear and process by clinicians.  Most of the assessments available are thus not comprehensive, but rather assess parts of experiences and/or symptoms and disorders.  Refer to Table 1 below.

The Harvard Trauma Questionnaire (HTQ), developed by Mollica and colleagues is a self-report questionnaire with 4 parts.  The purpose of part 1 is to measure 17 war-related traumatic experiences.  The scale was conceptualized by expert, consensus methods from clinical experience, and was designed to allow respondents to check as many of 4 responses for each experience that apply to them (“did not happen,” “experienced,” “witnessed,” or “heard about).  The HTQ manual describes its development, although it is not clear how items were chosen and designed.  The trauma scale is reliable in clinical samples, although some items may not be reliable.  It was rationally rather than empirically developed from clinical rather than community samples and description about the construct and item development is scant.  There is one item that subjectively assesses torture, which has not been found to be reliably measured in test-retest approaches.

The purpose of the Post Migration Living Difficulties Scale (PMLD), developed by Silove and colleagues, is to assess current life stressors of asylum seekers.  Each of the 23 items of this administered survey is rated on a 5-point scale from “no problem” to “a very serious problem,” with a composite score determined.  Its construct, development and design are not further discussed.  Principal component analyses yielded 5 factors accounting for 69.8% of the variance of the 23 items: refugee determination process; health, welfare and asylum problems; family concerns; general adaptation stressors; and social and cultural isolation.  The PMLD is valid in discriminating between refugees, asylees, and immigrants in the one study completed.  The PMLD is an important concept measuring life experiences other than war, but its usefulness may be limited because of the lack of description about its design, development, reliability and validity, and scoring.

The 32-item Resettlement Stressor Scale (RSS), developed by Clarke, Sack, and Goff from their experience with Cambodian adolescents, is intended to measure stress due to resettlement.  In one study with 38 adolescents, the RSS score discriminated between those who had psychiatric illness and those who did not using diagnostic interviews, and accounted for 11.7% of PTSD score variance but did not account for the depression score variance.

The War Trauma Scale (WTS), also developed by Clarke and colleagues from their clinical experience, consists of 42-items in both an interview and self-report format, measuring traumatic experiences inflicted by the Pol Pot regime.  The WTS full-scale score had adequate internal consistency and inter-rater reliability and accounted for 15.4% of PTSD score variance and 6.7% of depression score variance.  Both the RSS and the WTS demonstrated modest predictive validity of psychiatric disorder, and the WTS demonstrated acceptable reliability.

The Comprehensive Trauma Inventory – 104 (CTI-104) was developed by Hollifield and colleagues using both qualitative and quantitative methods to capture the broad range of events experienced by Vietnamese and Kurdish refugees living in the U.S.1  These combined methods identified over 200 traumatic events experienced by refugees in these two groups.  Analyses allowed the investigators to identify the 104 events that best captured the full range of traumatic experience and that accounted for over 50% of the variance in symptoms and impairment.  Twelve types of trauma were identified in this work, including psychological violence, physical injury, detention and intentional violence, sexual violence, witnessing various forms of violence, hearing about various forms of violence, deprivation of basic needs or being discriminated against, having been betrayed, domestic discord, displacement, separation and isolation from family and friends, and problems during fleeing and migration.

Part 4 of the self-report HTQ, developed from clinical experience by Mollica and colleagues, lists 30 symptom items, 16 generated from the DSM-III-R PTSD criteria, and 14 which are “presumably, culture-specific symptoms associated with PTSD.”  Possible responses are “not at all,” “a little,” “quite a bit,” or “extremely.”  In a convenience sample of 91 patients, the symptom prevalence ranged from 44% to 92%, and the 1-week item test-retest reliability ranged from poor to excellent (r=.32-.85; median r=.59).  An average item score of > 2.5 was predictive of a PTSD diagnosis by clinical interview (78% sensitive, 65% specific).  Modest reliability and fair validity in diagnosing PTSD was demonstrated in clinical populations. However, in a community study the sensitivity and specificity of the > 2.5 cutoff score in diagnosing PTSD was 16% and 100%, respectively, and the most efficient score for diagnosis was 1.17 (S/S = 98%/100%).

The Vietnamese Depression Scale (VDS), a self-report questionnaire developed by Kinzie and colleagues to screen Vietnamese refugees for depression, was developed using a well described rational, consensus approach from extensive clinical experience.  Culturally appropriate terms were added to existing Western symptoms of depression, and designed with items on a 3-point Likert scale.  After pilot testing, the final 15-item scale measures 3 symptom types: physical symptoms associated with depression in the West, western psychological symptoms of depression, and symptoms unrelated to western concepts.  The VDS is valid in discriminating between refugee patients with depression and those with anxiety or schizophrenia, and a cutoff score of 13 out of a possible 34 points demonstrated 91% sensitivity and 96% specificity for diagnosing DSM-III Major Depression in a community sample.

The New Mexico Refugee Symptom Checklist – 121 (NMRSCL-121) was developed by Hollifield and colleagues from a community sample of Vietnamese and Kurdish refugees using qualitative and quantitative methods.2  Refugees identified 121 symptom items, and factor and reliability analyses showed that these symptoms clustered into 12 subscales: (1) PTSD and Depression, (2) Musculoskeletal, (3) Sensory, (4) Cardiopulmonary, (5) Gastrointestinal, (6) Anxiety, (7) Urinary, (8) Posttraumatic Vulnerability, (9) Neurological and Bleeding, (10) Skin Sensation, (11) Menstrual, and (12) Constitutional.  Symptoms were highly correlated with both war trauma and impairment.  The NMRSCL-121 is very good to assess the broad range of symptoms in refugees, but its length limits its utility in day-to-day clinical settings.

The Refugee Health Screener – 15 (RHS-15) is an efficient instrument to screen for distress, anxiety, and depression in refugees.3  The RHS-15 is valid for predicting diagnostic level anxiety, depression and PTSD in at least three refugee groups.  It has been translated into eleven languages.

Other instruments that have been used in general populations have been adapted for use with refugees.  The Hopkins Symptom Checklist-25 (HSCL-25), a self-administered questionnaire originally designed to measure change in 15 anxiety and 10 depression symptoms in psychotherapy, has been validated in the general US population and used in many refugee studies.  The content and design on a 4-point severity scale is acceptable to Indochinese refugees, and reviews in the cultural psychiatry literature consider the measure valid.  An average-item score >1.75 indicates “clinically significant distress,” and is used as a diagnostic proxy in general U.S. studies and now in some refugee studies as well.

The Impact of Events Scale (IES) has been used in a handful of refugee studies.  The 15-item measure has 7 intrusion and 8 avoidance items on 3-point descriptive scales measuring intrusive thoughts and body sensations and avoidance behaviors after trauma.  It has been proven valid and reliable, and its development is well described.  The 2 scales had satisfactory internal consistency, although a principal component analysis suggests a third scale named “numbing,” which requires further validation.  Higher intrusion and total scores in children with more trauma events demonstrated validity, although trauma events did not predict avoidance scores.  The IES scores also distinguish between 3 groups of adult refugees who have experienced torture, non-torture trauma, and migrants who have not experienced war trauma.

The Symptoms Checklist-90 (SCL-90), a well-developed and described 90-item self-report questionnaire consisting of 10 symptom scales, has been used in a few refugee studies. The SCL-90 depression scale was valid in classifying depressed from non-depressed Hmong refugees who were either patients in a psychiatric clinic or who were from a community sample, and the depression scale correlated well with the Zung Depression scale (r=.67), demonstrating concurrent validity.  The depression scale of a translated Vietnamese version of the SCL-90 correlated well with the VDS (r=.81).

The Posttraumatic Symptom Scale – Self Report (PSS-SR) has been used in at least two refugee studies.  The PSS-SR predicts PTSD diagnosis in U.S. populations. Cronbach alpha is 0.91, and one-month test-retest reliability is 0.74.  The 17 items on the scale, each scored from 0 to 3 for symptom frequency, are DSM-IV PTSD diagnostic items.  The PSS-SR may be scored as continuous or a dichotomous diagnostic proxy.  PSS-SR continuous scores and the DP are highly correlated with war-related trauma and impairment in Kurdish and Vietnamese refugees, and Cronbach alpha in these samples was 0.95.

Other existing instruments have been tested in one or two studies.  Refer to Table 2 below.  The anxiety and depression scales from the Health Opinion Survey were interview administered to a community sample of 2,180 Southeast Asian refugees from 3 countries.  A factor analysis demonstrated that anxiety and depression were common and had the same meaning for all 3 groups.  Further analyses reported in a subsequent paper demonstrated that a single factor resembling the concept of neurasthenia accounted for 40% of the distress scores on the HOS.  A community sample of Vietnamese refugees demonstrated high and persistent levels of physical and psychological symptoms on the Cornell Medical Index (CMI), a health-status questionnaire, compared to normative data from the United States and Britain.  The Posttraumatic Symptom Scale-10, a 10-question survey, was found to have excellent internal consistency (alpha=.92) and test-retest reliability (r=.89) in Bosnian refugees.  The Beck Depression Inventory demonstrated excellent internal consistency (alpha =.93), excellent test-retest reliability (r=.92) and distinguished depressed vs. non-depressed Hmong refugees against a clinician interview (sensitivity 94%, specificity 78%).  The Norbeck Social Support Questionnaire (NSSQ), which measures dimensions of support that demonstrate excellent test-retest reliability and moderate concurrent validity in Western studies, was adapted to study the relationship of 3 kinds of support (social network size, emotional support, esteem support) to health in Namibian refugees.  The authors found that support and coping style moderated the relationship between chronic stress (years in exile) and health status (anxiety, physical symptoms, physical signs, and hospitalization in the previous year), demonstrating a form of predictive validity.  The NSSQ showed good internal consistency (alpha =.83), but no further adaptations or statistical testing has been conducted in refugees.

*Most of this material was adapted from: Hollifield M, Warner T, Lian N, Krakow B, Jenkins JH, Kesler J, Stevenson J, Westermeyer J. Measuring trauma and health status in refugees: a critical review. JAMA. 288:611-621, 2002.  References may be found in this publication.

1. Hollifield M, Warner T, Jenkins J, Sinclair-Lian N, Krakow B, Eckert V, et al. Assessing War Trauma in Refugees: Properties of the Comprehensive Trauma Inventory-104 (CTI-104). Journal of Traumatic Stress. 2006; 19(4): 527-40.
2. Hollifield M, Warner TD, Krakow B, Jenkins J, Westermeyer J. The range of symptoms in refugees of war: the New Mexico Refugee Symptom Checklist-121. J Nerv Ment Dis. 2009; 19(2): 117-25.
3. Hollifield M, Verbillis-Kolp S, Farmer B, Toolson EC, Woldehaimanot T, Yamazaki J, et al. The Refugee Health Screener-15 (RHS-15): development and validation of an instrument for anxiety, depression, and PTSD in refugees. General Hospital Psychiatry. 2013; 35(2): 202-9.

Table 1. Instruments developed about trauma or health status in refugee populations.

Author, year Instrument Trauma Health Status Method Validity testing Reliability testing
Developed and described instruments – published, accessible and useable
Kinzie, 1982, 1987 Vietnamese Depression Scale, Published No Culturally Valid Depression Scale Qualitative + Quantitative, Rational + consensus Yes No
Mollica, 1992 Harvard Trauma Questionnaire, Published 17 Trauma Items, one is Torture 30 symptoms: PTSD and Depression Quantitative, Rational + Consensus Yes Yes
Hollifield, 2006 Comprehensive Trauma Inventory-104, Published 104 Trauma items; 12 types No Qualitative and Quantitative Yes Yes
Hollifield, 2009 New Mexico Refugee Symptom Checklist – 121, Published No 121 symptoms; 12 clusters Qualitative and Quantitative Yes Yes
Hollifield, 2013 Refugee Health Screener – 15, Published No 14 symptoms and distress thermometer Qualitative and Quantitative Yes Yes
Developed and described instruments – not published or easily useable
Clarke, Sack, 1993 Resettlement Stressor Scale, Unpublished Yes No Quantitative, Rational + Consensus Yes No
Clarke, Sack, 1993 War Trauma Scale, Unpublished Yes No Quantitative, Rational + Consensus Yes Yes
Silove, 1998 Post-Migration Living Difficulties, Unpublished Difficult Life Events in Resettlement No Quantitative, Rational + Consensus Yes No
Potentially useful instruments (either in development, not described well, or not tested well)
Beiser, 1986 Unnamed, Unpublished No 4 Mental Health Factors Quantitative and rational, from existing scale items Yes No
McCloskey, 1995 Unnamed, Unpublished Yes PTSD Inventory Combined Qualitative/ Quantitative, No No
Van Velsen, 1996 Survivor of Torture Assessment Record, Unpublished 7 Trauma Events 9 Health Symptoms/Losses Combined Qualitative/ Quantitative Yes No
Cunningham, 1997 Unnamed, Unpublished Trauma Types by PCA Symptom Types by PCA Quantitative and Statistical No No
Ekblad, 1999 Unnamed, Unpublished No Quality of Life Qualitative Yes No
Bolton, 2001 Unnamed, Published No 2 Mental Health Factors Qualitative, Empirical Yes Yes
Weine, 2001 Unnamed, Unpublished No Quality of Care: Providers Rational + Qualitative Yes No


Table 2. Instruments about trauma or health status whose statistical properties have been evaluated in refugee populations.

Author, year of evaluation Instrument and Author Trauma Health Status Validity testing Reliability testing
Lin et al., 1979 Cornell Medical Index; Brodman, 1956 No Symptoms List No No
Chung et al., 1995 Health Opinion Survey; Leighton, 1963 No Anxiety and Depression Scales No No
Mollica et al., 1987 Hopkins Symptom Checklist – 25; Derogatis, 1974 No Anxiety, Depression Yes Yes
Westermeyer et al, 1983; 1986; 1989 Symptom Checklist – 90; Derogatis, 1977 No 10 Symptom Scales Yes No
Dyregov et al, 1996; Schwartzwald et al., 1987 Impact of Events Scale; Horowitz, 1979 No Intrusion, Avoidance, Total score Yes No
Westermeyer et al, 1983 Beck Depression Scale; Beck, 1961 No Depression Yes Yes
Shishana et al, 1987 Norbeck Social Support Questionnaire; Norbeck, 1981 No Support as a moderator to health status Yes No
Thulesius, et al., 1999 Posttraumatic Symptom Scale – 10; Raphael, 1989 No Posttraumatic Stress Symptoms No Yes