Mental Health: Global Challenges Journal

https://reference-global.com/journal/MHGCJ

ISSN 2612-2138

RISK AND RESCUE: PSYCHOMETRIC TOOLS FOR

TRAUMA-RELATED IN REFUGEES IN EUROPE (2014–

2024)

Anna Jaeger1, Ryan Govender2, Sandra Figueiredo2

1Osnabrueck University, Osnabrueck, Germany

2Universidade Autónoma de Lisboa Luís de Camões, Lisbon, Portugal

Abstract

Introduction:

Refugees in Europe face significant psychological burdens resulting from trauma,

displacement, and post-migration stressors. This review examines the tools used to assess PTSD and

related mental health conditions, highlighting the lack of standardization and the need for

culturally sensitive approaches.

Purpose: This systematic review examined psychometric instruments used to assess mental health

among adult refugees in Europe, focusing on trauma-related disorders, particularly post-traumatic

stress disorder (PTSD).

Methodology: Peer-

reviewed studies published between 2014 and 2024 were retrieved from

major databases (APA PsycInfo, PsycArticles, MEDLINE, among others) following PRISMA guidelines.

Forty-six studies met inclusion criteria. Data extraction included assessed domains, instruments, and

sample characteristics, and methodological quality was evaluated using the Joanna Briggs Institute

(JBI) Critical Appraisal Checklist.

Results:

Germany was the most frequent host country, followed by Norway, Sweden, and the

Netherlands. A total of 99 instruments were identified, with the Harvard Trauma Questionnaire (HTQ),

Hopkins Symptom Checklist (HSCL-25), and PTSD Checklist for DSM-5 (PCL-

5) most commonly

applied. PTSD (n=32), depression (n=30), and anxiety (n=19) were the predominant disorders

assessed. Considerable variability in tool selection, limited cultural and linguistic adaptation, and

frequent reliance on self-report measures were observed. Instruments addressing post-migration

stressors (e.g., RPMS, PMLD) and resilience factors provided broader clinical insights.

Conclusions: No standardized European approach exists for refugee mental health assessment. A

multifaceted strategy integrating validated tools, clinician-

administered interviews, and culturally

adapted measures is recommended. Future research should develop context-sensitive,

multidimensional, and potentially digital assessment models to enhance diagnostic accuracy and

care accessibility.

Keywords

Mental health, Refugees, PTSD, Assessment Tools, Systematic Review.

Address for correspondence:

Sandra Figueiredo,

Universidade Autónoma de Lisboa Luís de Camões,

Lisbon, Portugal

E-mail: sfigueiredo@autonoma.pt

This work is licensed under a Creative Commons Attribution- 4.0

International License (CC BY 4.0).

©Copyright: Figueiredo et al, 2026

Publisher: Paradigm (De Gruyter)

DOI: https://doi.org/10.56508/mhgcj.v9i1.340

Submitted for

publication: 04

December 2025

Revised: 18 January 2026

Accepted for

publication: 02 February

2026

Mental Health: Global Challenges Journal

https://reference-global.com/journal/MHGCJ

ISSN 2612-2138

Introduction

The Ukraine-Russia war, which began with

Russia's invasion in February 2022, has triggered

one of the biggest refugee crises Europe has

seen since World War II (Ellison et al., 2023). In the

course of this mass displacement, as of May

2024, 6.5 million Ukrainian civilians have fled their

homes to their neighbouring countries and other

EU states (UNHCR, 2024). Already starting with the

refugee crisis in 2015/16, European countries

have been taking in many refugees over the last

years, but even with the ongoing stream of

incoming refugees, data from the United Nations

Refugee Agency (UNHCR, 2025a) clearly

indicates a surge in the magnitude of migration

due to the crisis in Ukraine (United Nations, 2013).

This magnitude persists because other forcibly

displaced populations are also fleeing other

different countries affected by war or ongoing

human rights violations. Most of these countries

have a long history of permanent conflict, such

as Syria, Afghanistan, Iraq, and the Democratic

Republic of the Congo (UNHCR, 2025). These

populations are arriving in Europe primarily in

search of asylum or refugee status.

In a Refugee Convention by the UN in 1951,

refugees were defined as people who were

forced to flee their home country in order to find

safety somewhere else (UNHCR, 2025b). This can

be due to different reasons like fear of

persecution, because of race, religion,

nationality, their belonging to a particular social

group and more, as well as war and violence

(UNHCRc). People who are seeking international

protection and are still awaiting a decision on

their asylum claim are referred to as asylum

seekers (AS) (Amnesty International, 2025). It is

important to note that not every migrant is

considered a refugee or AS. People might just

choose to leave their home country because of

work or joining family. Other migrants do not fit

the legal definition of refugees but might still feel

forced to leave their home country due to

reasons like poverty or natural disasters. This

seems legally simple, but society lacks in literacy

regarding these differences, also research stands

with that gap when assessing for migrants with no

separate groups and clear definitions. The

present study aims to examine through a

systematic review which instruments are being

used to assess mental health of adult refugees

and AS, in Europe, in what regards specifically

trauma related to the forced displacement.

Emotional effects on refugees and AS

In short, refugees and AS never leave their

country voluntarily. Most of the time the decision

to become a refugee is a last resort for those

facing pain and fear in their home countries and

is based on an interaction of psychological,

social and environmental factors (Jesuthasan et

al., 2018; Killikelly et al., 2021; Lambert, 2017; Li

et al., 2016; Watters et al., 2022). Those affected

experience trauma, violence and go through

severe anxiety and loss, which has a huge

impact on their psychological health and people

who experience extreme violence such as armed

attacks and bombs are bearing the impact of

those memories for their whole lives (Figueiredo &

Petravičiūtė, 2025; Figueiredo et al., 2023; Volkan,

2018). Trying to navigate unfamiliar situations and

reconstructing their lives creates even more stress,

anxiety and uncertainty (Hameed et al., 2019).

Forced migration creates a unique set of trauma

with specific implications for the individuals that

are impacted by it. Refugees are at a constant

risk of violence, persecution, discrimination and

violations of human rights by armed groups and

governmental actors deepen the already existing

psychological scars (Schlaudt et al., 2020; Taylor

et al., 2024). Refugees and AS often also not only

experience discrimination in their home countries

but in their hosting countries as well (Taylor et al.,

2024; Wylie et al., 2018).

Additionally, the impact witnessing death and

the devastation of whole communities likely has

on a person’s mental health (Schlaudt et al.,

2020). The feelings of helplessness and

hopelessness created by this are further

intensified by the immense psychological impact

of the loss of their homes, their belongings and

frequently their family (Watters et al., 2022). Post-

traumatic stress disorder (PTSD) may result from

direct exposure to violence, including armed

attacks, the sudden and forced displacement

from one's home, and witnessing the death of

family members and animals. It is one of the

most common forms of trauma experienced by

refugees (Ben-Ezra et al., 2022; Bilewicz et al.,

2024; Bryant et al., 2023). This often manifests

itself in the form hypervigilance or paranoia,

emotional detachment, nightmares and

flashbacks (Bryant et al., 2023; Figueiredo &

Petravičiūtė, 2025; Istiaque et al., 2023).

Apart from this emotional trauma these

individuals may carry, it can also be the root

cause for a loss of identity, belonging and

security, the effects of which are even more far-

reaching (Dromgold-Sermen, 2022; Fuchs eta al.,

2021). Being removed from the familiar structures

of their daily lives, refugees and AS find

themselves in a situation characterized by

uncertainty and creating a sense of

disempowerment (Figueiredo et al., 2024;

Figueiredo et al., 2025; Procter et al, 2017). This is

especially relevant, since having a solid social

network is a protective factor against mental

health problems (Długosz, 2023; Sundvall et al.,

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2021). Since anterior research, it is well known the

negative condition of being separated from their

loved one’s, their familiar surroundings and

routines especially considering the

circumstances, which creates a sense of

isolation, disorientation and vulnerability which

exacerbates the impact of the trauma

experienced (Długosz, 2023; Evans Cameron,

2008; Zepinic et al., 2012).

This loss of identity is also connected to cultural

trauma (Im & Swan, 2021). Pressured migration

can change a group's collective identity. Being in

a foreign country and culture, in forcible way,

having lost their homes and familiar environment,

refugees and AS are forced into a position where

they have little control (Giordano et al., 2024;

Zeno, 2021). These groups experience feelings of

alienation and a serious identity crisis can result

from the loss of a sense of belonging, community

and home (KoŚĆ-RyŻko, 2022; Wehrle et al.,

2018; Zeno, 2021). Language barriers and

unfamiliar norms in the hosting countries may

increase these effects even more (Figueiredo,

2016; 2022; Wylie et al., 2018). Looking at the

situation in the hosting countries, refugees are

often forced to endure long stays in refugee

accommodations with hazardous and

unfavorable conditions (ACNUR, 2025a; Volkan,

2018). Having lost their means to provide for

themselves and their loved ones, having lost

family members and facing many other

vulnerabilities, a better life often seems

impossible to achieve (Ellis et al., 2019; Jones et

al., 2024).

Effects of forcible populations on the hosting

communities

Rapid migration even increases the risks of

exploitation, abuse and trafficking, especially of

vulnerable groups, such as children, women and

elderly and beyond that, has negative effects on

the social and cultural life of the hosting

communities as well (Freccero et al., 2017;

Schneiderheinze & Lücke, 2020; Tambini et al.,

2024). The existing cultural norms and values are

threatened, and this creates cultural conflicts and

identity problems within the hosting communities,

which is somewhat similar to some of the

experiences of the refugee populations (Stevens

et al., 2024). Apart from that, the hosting

communities only have limited resources to help

all incoming refugees and local services like

education, housing and healthcare can quickly

reach their limits. As a result, both refugees and

hosting communities are unable to receive the

care and services they need. The rapid income

of refugees and AS can easily overwhelm the

local communities tasked with dealing with those

people in need. Due to all this the social

cohesion can be weakened, social inequities

can be worsened and it is cause for tension and

disputes over resources (Łukasiewicz et al., 2023;

Maystadt et al., 2019).

As a result, sentiments of being overpowered

may arise and lead to feelings of anger,

xenophobia and consequently discrimination

towards displaced persons (Aldamen et al., 2023;

Obeid et al., 2019). How the hosting country

structures their response, dictates how well or if at

all refugees and AS are able to receive the care

and support they need to deal with pre-existing

health issues and also the emotional and

psychological impact of forced migration

(Figueiredo & Petravičiūtė, 2025; Kronick et al.,

2021; Morina et al., 2017). Having a secure

surrounding is tremendously important to stabilize

the mental health of trauma victims (Buchcik et

al., 2023; Ballard-Kang, 2021). Without the proper

support it is almost impossible to cope with the

toll the experiences associated with forced

migration take on the people concerned.

Therefore, it is absolutely essential to provide

access to mental health services, psychological

support and trauma-informed care to promote

healing and recovery (Kronick, 2018; O’Donnell et

al., 2020).

Protective factors and need for action in

mental health assessment

However, it is important to also point out the

resiliency and strengths refugees and AS display

despite all those hardships (Derya et al., 2020;

Łukasiewicz et al., 2023; O’Donnell et al., 2020).

This is especially true regarding both the

psychological and social effects of displacement

(Newman et al., 2017; Taylor et al., 2024). Many

demonstrate an exceptional degree of

endurance, ingenuity and flexibility and are

frequently able to reconstruct their lives and

communities despite the challenges they are

facing (Giordano et al., 2024; Strang & Quinn,

2021; Walther et al., 2021). In order to support this

resiliency and well-being among refugees in their

effort to rebuild their lives in a new environment,

providing a secure and supportive surrounding

that helps to empower, restore dignity and create

a sense of belonging is crucial (Ballard-Kang,

2021; Buchcik et al., 2023; Krause & Schmidt,

2019).

As can be seen, forced migration has a

significant impact on both refugees and hosting

communities (Das & Chowdhary, 2020;

Łukasiewicz et al., 2023). It is indisputable that

there needs to be a better way to support those

seeking refuge. This requires a coordinated

response from governments, humanitarian

organizations and civil societies (Łukasiewicz et

al., 2023). In accordance with the problems

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ISSN 2612-2138

pointed out, measures to strengthen the social

support system, promote social cohesion, and

ensure the protection and rights of both refugees

and hosting populations are required (Greenberg

et al., 2018; Kronick et al., 2021; Morina et al.,

2017). Assessing the mental health state of the

refugees is a key step in assuring the needs as

quickly as possible and the right assistance can

be distributed (Hanewald et al., 2023; Kronick et

al., 2021; Volkan, 2018). This systematic review

aimed to identify, synthesize, and critically

appraise psychometric instruments used between

2014 and 2024 to assess trauma-related mental

health disorders—particularly post-traumatic stress

disorder (PTSD)—among adult refugees and

asylum seekers in European host countries. The

review compared assessment domains,

methodological approaches, and cultural

adaptations to inform the development of

standardized, context-sensitive evaluation

frameworks.

Purpose

This review aims to systematically examine the

domains of mental health that are assessed and

the psychometric instruments employed by

European countries to evaluate the mental health

status of refugees, as well as to compare the

methodologies adopted across different national

contexts. European hosting countries have made

significant strides in promoting the social and

psychological well-being of refugees mainly with

origin in current war conflicts in Middle East,

Africa, Latin America (Venezuela and Colombia)

and in Ukraine (Europe). Government initiatives

apparently have facilitated rapid access to

healthcare services, housing, education, and

employment opportunities, thereby supporting

smoother integration into society.

Despite these efforts, substantial challenges

persist, particularly in the provision of timely and

effective mental health assessment and

treatment for individuals with clinical needs.

Psychological support remains essential for many

refugees who are experiencing trauma related to

armed conflict, displacement, and uncertainty

regarding their future. As part of this research

project, a comprehensive literature review will be

conducted to evaluate existing studies on the

assessment of mental health among asylum

seekers and refugee populations, in European

soil. The study will address several sub-questions,

including:

•What specific assessment procedures

and validated mental health instruments

are employed in European countries?

•What are the characteristics of these

instruments (e.g., version, date of

publication, cultural and linguistic

adaptations) used over the past decade

(2014-2024) across European contexts?

•What are the socio-demographic

characteristics (e.g., age, sex,

occupational status) of the refugee

populations assessed in these studies?

Methodology

The evaluation of the mental health of

refugees for disorders stemming from trauma

involves a number of particular obstacles (Uphoff

et al., 2020). Both language limitations and

cultural differences can make it difficult for

refugees and mental health specialists to

effectively communicate with one another

(Morrice et al., 2019). Cultural variations can have

an impact on how mental health disorders are

presented and perceived (Kirmayer et al., 2021).

It is also possible that the stigma that is

associated with mental disorders in certain

cultures may discourage refugees from seeking

assistance, which would make the evaluation

process more difficult (Ahad et al., 2023). This

systematic review will explore practices in several

key areas, focusing on which specific mental

health aspects are assessed, the instruments

employed, and the methods of their

administration. The objective is to gain insight into

how the countries in Europe that receive the

largest numbers of refugees assess mental

health, in order to identify best practices and

optimize approaches.

The research team, comprising three authors

of this study, followed a rigorously structured,

multi-phase protocol consistent with systematic

review standards. Each member contributed to

distinct yet overlapping stages to ensure

methodological transparency and reliability.

•Planning and Protocol Development: All

three authors jointly defined the research

objectives, formulated the core thematic

domains, and established explicit

inclusion and exclusion criteria. A

comprehensive search strategy, including

the selection of keywords (see Section

2.2), was collaboratively designed to

optimize retrieval from academic

databases.

•Literature Search and Study Selection: Two

authors independently conducted the

systematic search and screened titles,

abstracts, and full texts according to the

predefined criteria. Any discrepancies

were resolved through discussion with the

third author, who acted as an

adjudicator.

•Data Extraction and Quality Assessment:

Data from eligible studies were

Mental Health: Global Challenges Journal

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independently extracted by two authors

and verified by the third to ensure

accuracy. The risk of bias for each study

was assessed using the Joanna Briggs

Institute (JBI) Critical Appraisal Tool. Risk of

bias was systematically evaluated using

the Joanna Briggs Institute (JBI) Critical

Appraisal Checklist, applying nine core

domains encompassing sample

adequacy, methodological

transparency, analytical robustness, and

clarity of outcome reporting (Figure 2).

•Data Analysis and Synthesis: All authors

participated in qualitative synthesis and

thematic analysis, applying the PRISMA

(Preferred Reporting Items for Systematic

Reviews and Meta-Analyses) guidelines

throughout.

•Interpretation and Finalization: The final

discussion, including the resolution of

disagreements and critical reflection on

findings, was collaboratively developed

by all three authors.

This structured approach ensured

methodological rigor, minimized bias, and

provided a transparent account of each phase

of the review.

Inclusion/exclusion criteria

To be included in this review, studies had to

meet the following inclusion criteria: published

between 2014 and 2024; peer-reviewed; written

in English; report mental health assessments

carried out on adult (above the age of 18)

refugees or asylum seekers in European countries.

Non-empirical studies, PhD theses, grey literature,

as well as studies where the country of reception

was not part of the European Union (EU) were

excluded.

Data source and search strategy

The MeSH terms selected for this critical

literature review on mental health assessments of

adult refugees in Europe were strategically

chosen to comprehensively represent relevant

thematic areas and enable an exhaustive search

within key academic databases. Keywords were

designed to capture the core elements of the

research: variations of mental disorders

investigated, specific assessment instruments

utilized, and the European geographical context.

Additionally, broader and related terms were

included to increase the sensitivity of the search

and ensure retrieval of applicable studies.

Specific MeSH terms such as “refugee mental

health”, “asylum seekers mental health”, “adult

refugee assessment,” and “psychological testing

for refugees” focus the search on the target

population. Complementary broader terms like

“mental health screening” and “psychological

evaluations” allow inclusion of studies addressing

assessment methodologies applicable to

refugees, even if the population is not explicitly

stated.

Disorder-specific terms, including “Post-

Traumatic Stress Disorder (PTSD)”, “anxiety

disorders,” and “depression,” were selected due

to their high prevalence among refugee

populations, thereby facilitating identification of

literature centered on commonly evaluated

conditions.

Terms such as “trauma assessment” and

“psychological trauma in refugees” underscore

the significant impact of forced displacement on

mental health, reflecting the clinical emphasis on

trauma-informed care.

Cultural dimensions were addressed through

terms like “culturally sensitive assessments” and

“cultural competence in mental health,”

recognizing the importance of culturally adapted

diagnostic approaches within both refugees’

countries of origin and host European contexts.

The inclusion of “Europe” refined the search to the

study’s geographical scope.

Furthermore, diagnostic frameworks such as

“DSM-5” and “ICD-11” were included to ensure

retrieval of studies employing standardized and

validated diagnostic criteria.

The databases searched comprised APA

PsycInfo, APA PsycArticles, Psychology and

Behavioral Sciences Collection, Humanities

International Complete, and MEDLINE.

Selected MeSH Terms:

•Refugee mental health

•Mental disorders in refugees

•Anxiety disorders in refugees

•Depression in refugees

•Mental health assessment tools refugees

•Europe refugee mental health

•Diagnostic criteria for refugees

•Mental health evaluation methods

•Refugee psychology

•Mental health outcomes in refugees

•Psychological trauma in refugees

•Screening tools for refugees

•Mental health services for refugees

•DSM-5 and refugees

•Cross-cultural psychology

•Trauma-informed care refugees

•Psychosocial assessments refugees

•Clinical assessments in refugees.

Study selection and data extraction

The initial database search yielded 6332

studies, of which 6028 studies were removed due

to being marked as ineligible by the automation

tools. The remaining 304 studies were then

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screened and the full text of 109 studies was

retrieved. After duplicates and studies that did not

fit the inclusion criteria or met the exclusion

criteria were removed, 46 studies remained and

were analyzed for this systematic review.

The screening process was conducted in two

sequential phases in accordance with

established systematic review protocols. Initially,

titles and abstracts retrieved from the database

search were screened against predefined

inclusion and exclusion criteria. Articles meeting

these criteria proceeded to a full-text eligibility

assessment to establish the final corpus of studies

addressing the associations among mental

health, particularly PTSD, of refugees and asylum

seekers in Europe. Both the title–abstract and full-

text screening procedures were conducted

independently by two reviewers (co-authors). To

enhance completeness, the reference lists of all

eligible studies were subjected to manual citation

tracking by two co-authors.

Data extraction was performed using a

standardized template by two reviewers and

independently validated by a third reviewer to

ensure accuracy and internal consistency.

Extracted variables included: publication year,

geographic origin, exposure and outcome

measures, study design, sample size and

characteristics, and key findings relating to the

interaction between sleep routines, chronotype,

geographic positioning, and ethnicity.

Discrepancies in extracted data were resolved

through consensus-based discussion among all

reviewers.

Figure 1. Flowchart of Study Identification and Inclusion

Ethical considerations

Approval of the study obtained by Ethical

Committee of Research Psychology Centre (CIP)

of Universidade Autónoma de Lisboa (UAL),

Portugal, with code: refª 2/2023. Despite the

compliance of the study with the ethical

principles outlined in the Declaration of Helsinki,

ensuring integrity, transparency, is was not

applicable the informed consent regarding the

type of investigation (systematic review) with no

direct contact with human participants.

This is a systematic review, does not involve

directly research with human participants. All

procedures are in accordance with the ethical

standards of the institutional research committee

and with the 1964 Helsinki Declaration and its

later amendments or comparable ethical

standards.

Results

A total of 46 studies were included for this

review (Table 1), covering 18 different hosting

countries. 18 of those studies were conducted in

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Germany, while Norway, Sweden and the

Netherlands were the second most common

hosting countries mentioned in the included

studies. In this systematic review a wide variety of

psychological assessment instruments were used

to evaluate various elements of refugee mental

health. Considering the focus of this review, the

results are going to be presented in three

separate points: the (1) areas of mental health

that were assessed, the (2) instruments used for

assessment and (3) the comparison of the

different tools to each other.

The assessed areas of mental health

As mentioned, many different aspects of

mental health were assessed in the included

studies, PTSD and depression being mentioned

the most frequently with 32 and 30 studies having

their focus on those disorders respectively. This is

followed by anxiety which was assessed 19 times.

Next to these frequent assessments, many other

aspects of mental health were examined. Some

examples include somatization, functional

impairment, several measures of stress and

subjective well-being.

In regards to sex differences, there were

noticeable disparities in mental health results and

the efficacy of assessment instruments. Male

reported less psychological suffering, while

showing more avoidance behaviors. Female,

especially those with children, showed more

expressed sadness and anxiety.

The tools used for assessment

This systematic review showed a wide range of

psychological assessment tools that were used in

those 46 studies. In total 99 different tools could

be identified, not including demographic

measures. The Harvard Trauma Questionnaire

(HTQ), the Hopkins Symptom Checklist (HSCL-25)

and the Posttraumatic Stress Disorder Checklist for

DSM-5 (PCL-5) were most often used to measure

PTSD, depression and anxiety. Some broader

assessments of anxiety and functional

impairment used other tools, including the Patient

Health Questionnaire (PHQ-9), General Health

Questionnaire (GHQ-28), and Refugee Health

Screener (RHS-15).

Overall, a significant variance can be noted in

instrument choice across studies. Many studies

that chose self-report measures such as the

HSCL-25 and PHQ-9 did so due to the simplicity of

administration and accessibility. Clinician-

administered interviews and culturally customized

assessments on the other hand provide a more

complete picture of refugee psychological

health. Vignette-based semi-structured interviews

helped lower the possibility of misdiagnosis due to

showing more sensitivity to cultural variations in

symptom manifestation. Functional impairment

metrics, such as the WHO Disability Assessment

Schedule (WHODAS 2.0), were used in some

studies to reflect the influence of mental health

disorders on everyday living. Conventional

symptom-based surveys do not usually cover this

aspect of mental health disorders.

Some studies used tools that also assessed

post-migration stress variables, which offered an

increased understanding of refugee mental

health outside the direct influence of trauma.

Examples of these tools include the Refugee Post-

Migration Stress scale (RPMS) and the Post-

Migration Living Difficulties Checklist (PMLD). They

showed that refugees often struggled with

housing insecurity, legal status, social integration,

and financial problems, which greatly affected

their psychological well-being.

The increased use of multidimensional

assessment techniques can be observed as a

growing trend in the literature. Some of the

included studies paired the assessment of

psychological distress indicators with the

evaluations of social well-being and quality of life

in order to respond to the interaction between

mental health and social functioning. Well-being

was measured using the EUROHIS Quality of Life

Scale and the WHO-5 Well-Being Index. Resilience

and coping strategies were investigated using the

General Self-Efficacy Scale and the Brief COPE.

Comparison of the different tools

Some studies voiced critique on Western tools,

like the PHQ-9 and HSCL-25 in regards to their

relevance for different groups, as translated

versions with psychometric validation or modified

tools to fit particular cultural settings showed

greater dependability and validity. Including

interpreters and cultural mediators in evaluation

processes further improved the accuracy of

mental health assessments.

While the direct comparison is made difficult

by the high number of different tools, there were

some clear recommendations: For trauma

exposure and PTSD symptoms, the HTQ and PCL-5

were deemed useful; for depression and anxiety,

the HSCL-25 and PHQ-9; for functional

impairment the WHODAS 2.0 and the PMLD for

post-migration stress.

Concerning Joanna Briggs Institute (JBI) Critical

Appraisal Checklist, the assessment was

performed for each included study, with explicit

documentation of judgments as “Yes,” “No,”

“Unclear,” or “Not Applicable.” Studies receiving

“No” or “Unclear” ratings—typically due to

incomplete methodological reporting, reliance

on self-reported measures, or inadequate

procedural detail—were classified as having a

moderate risk of bias. The JBI risk-of-bias

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assessment for all 46 included studies was

finalized by the lead reviewer, with all evaluations

cross-validated by the research team prior to

synthesis. Domains refer to the following

questions: D1: Was the sample frame

appropriate to address the target population?;

D2: Were study participants sampled in an

appropriate way?; D3: Was the sample size

adequate?, D4: Were the study subjects and the

setting described in detail?; D5: Was the data

analysis conducted with sufficient coverage of

the identified sample?; D6: Were valid methods

used for the identification of the condition?; D7:

Was the condition measured in a standard,

reliable way for all participants?; D8: Was there

appropriate statistical analysis?; D9: Was the

response rate adequate, and if not, was the low

response rate managed appropriately? See

Figure 2.

In summary, the overall risk of bias was

determined to range from low to moderate, with

no substantial concerns identified regarding the

content of the studies included in this systematic

review.

Figure 2. Traffic-light table using the JBI critical appraisal tool for each included study

Study

Aarethun et al.,

2021

        

Alexander et

al., 2021

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Mental Health: Global Challenges Journal

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ISSN 2612-2138

Study

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        

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Pandya, 2018

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Zinfandel &

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        

Note: D = Domains corresponding to JBI items (1–9);

Colors: green indicates a “Yes” response to each question/domain, representing low risk of bias for the

specific study; red indicates “No” representing high risk of bias; yellow indicates “NA” (not applicable),

representing moderate risk; and grey indicates “unclear“ information, meaning it was excluded from the

assessment.

Discussion

The majority of the analyzed studies were

published between 2019 and 2024, showing an

increased interest in the topic of mental health

among refugees in recent years. The observed

variance of the chosen evaluation tools among

the included studies suggests that there are

differences in the assessment emphasis, cultural

suitability and therapeutic relevance. This also

shows that assessing mental health in refugee

communities is still a complex and difficult job

Mental Health: Global Challenges Journal

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ISSN 2612-2138

(Kiselev et al., 2020). This systematic review

revealed that PTSD was the most extensively

assessed mental health outcome, with 32 studies

incorporating its evaluation. The domains most

frequently investigated included trauma exposure

history, intrusive symptoms (flashbacks,

nightmares), hyperarousal, emotional numbing,

and avoidance behaviors, often measured

through instruments such as the Harvard Trauma

Questionnaire (HTQ) and the PTSD Checklist for

DSM-5 (PCL-5). Several studies also explored

complex PTSD manifestations, including

disturbances in self-organization, affect

dysregulation, and interpersonal difficulties,

though these were less consistently addressed.

Functional impairment and comorbid depressive

or anxiety symptoms were frequently assessed

alongside PTSD, highlighting its multidimensional

clinical burden. Despite this focus, heterogeneity

in tools, lack of standardized cut-off scores, and

limited cultural adaptation restricted cross-study

comparability and may have led to under- or

overestimation of trauma-related disorders in

refugee populations.

The growing application of multidimensional

assessment techniques also shows that various

tools could lead to better results, when applied

together. Combining standardized tests like the

HTQ and HSCL-25 for diagnosis with different

qualitative methods might yield better results.

Those qualitative methods like interviews with

clinicians and tools tailored to a person’s culture

can help to obtain more accurate information,

since there is still the general problem in cross-

cultural validity in psychiatric examinations

(Shiraev & Levi, 2020).

The culturally unique symptoms of refugees

are not always captured well by standardized

Western diagnostic tools, even if their validity was

high in previous clinical settings (Kitayana &

Salvador, 2023). This shows that mental health

evaluations can be influenced by cultural and

contextual factors and using methods that do not

take into account these cultural factors could

lead to misdiagnosis and underreporting (Shiraev

& Levi, 2020). As an example, there is evidence

of mental distress typically presenting itself in

culturally subtle forms like physical symptoms,

spiritual distress or community-based displays of

suffering among refugee groups (Zbidat et al.,

2020). In order to improve the sensitivity in

detecting mental health issues in refugees, using

culturally adapted evaluations, including

qualitative approaches such as vignette-based

semi-structured interviews, has been found

effective (Van & Leung, 2021). Including

interpreters and cultural mediators ensures a

more accurate understanding of refugees’

experiences and suffering.

With regard to this topic, it is also important to

mention that self-diagnostic tools are often not

reliable in depicting the psychological disorders

or the facets of mental health they are meant to

assess. For these tools to be accurate, the person

to whom these tests are applied needs to be

able to correctly understand and describe their

psychological suffering (Hogan, 2019). Other

factors like low literacy, language barriers and

differences in cultural views on mental health can

also negatively impact the accuracy of those

tools (Shiraev & Levy, 2020). By giving more

nuanced insights, interviews and observations led

by therapists can possibly counteract these

problems to some extent (Dunwoodie et al.,

2022). To highlight further difficulties, it is important

to be aware of differences between women and

men, when it comes to assessing the outcomes

of mental health evaluations. One of the studies

in this review found that male refugees tend to

not report their symptoms due to the social

stigmas surrounding mental health (Brabender &

Mihura, 2016), while female refugees tend to

report higher levels of anxiety and sadness

(Buchcik et al., 2023). Based on these findings, it

is reasonable to assume that traditional self-report

questionnaires might not work as well for men as

they do for women.

To have a full understanding of the

psychological well-being of refugees a holistic

approach is required that includes for example,

assessments of functional impairment and stress

elements, with which refugees and AS are

confronted in the respective hosting countries

after migration (Hogan, 2019). This systematic

review emphasizes the importance of

establishing post-migration stressors as part of the

evaluation of refugee mental health, since the

psychological suffering does not stop on arrival in

a hosting country (James et al., 2019). The use of

the Post-migration Living Difficulties Checklist

(PMLD) and the Refugee Post-Migration Stress

Scale (RPMS) are good examples of useful tools

for assessment of these aspects. As previously

mentioned, refugees’ and AS’ resources like

resilience and protective factors should not be

neglected when assessing refugee mental health

evaluations. Including resilience-based measures

in the evaluations can help offer a more

balanced view, an increased understanding of

refugee mental health outside the direct

influence of trauma and aid in creating a

strengths-based approach. Many studies focus

on capturing the extent of psychological suffering

in refugees, but more recent research has begun

to bring focus on the need of assessing social

support systems, coping strategies and resilience

(Derya Güngör & Strohmeier, 2020). The Brief

COPE and the General Self-Efficacy Scale have

Mental Health: Global Challenges Journal

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ISSN 2612-2138

been used to measure refugee’s adaptation

capacity (Fino et al., 2022) and based on the

results, a strong social support system and active

coping techniques seem to play a crucial role in

having better control over the psychological

suffering (Oviedo et al., 2022).

Strengths and Limitations of the study

Limitations and future perspectives

This systematic review should be considered

with some limitations to this study in mind. A direct

comparison between evaluation tools is made

difficult by the large quantity of different

instruments used in the included studies.

Additionally, while some instruments have been

culturally adapted, they have been developed

for the Western context. Therefore, they might not

accurately reflect the specific symptom

presentation and manifestations of different

groups. This may have a negative impact on the

cultural validity and sensitivity of these tests.

Language barriers and low literacy may have

a negative effect on the validity of instruments.

While many tests were administered as translated

versions, this can cause prejudice and the

meaning of psychological concepts may have

been altered. Stigma, mistrust of mental health

care and cultural or trauma-related avoidance

can cause underreporting of symptoms.

Current literature on mental health symptoms

in refugees consists largely of cross-sectional

studies. The development of psychological

distress over time would provide a better inside in

changes in the mental health status post-

migration or in response to treatments. Moreover,

there is a great variety in demographic data and

sample sizes across the included studies to be

noted, which, in addition to small sample sizes

and sex imbalances in some studies, restricts

generalization of results.

Finally, this systematic review is limited by a

possible publication bias, since studies with highly

significant results could be more likely to be

published than those without.

Future studies should concentrate on creating

more holistic approaches to mental health

assessments and encourage the development of

improved culturally sensitive assessment tools.

Pre-migration trauma evaluations combined with

post-migration stress assessments could provide a

more comprehensive view on the mental health

of forcibly displaced people.

To make mental health evaluations in

refugees more accessible and accurate, future

research should also focus on new ways of

carrying out those assessments, including for

example digital mental health screenings and

tools using AI to counteract the problems of self-

reports in populations with background of

international displacement. The development of

gender-sensitive evaluation methods of these

populations could be another focus of future

studies.

Strengths of the study

Comprehensive scope: The study reviews a full

decade (2014–2024) of research, offering an up-

to-date and exhaustive overview of mental-

health assessment tools used with refugees in

Europe.

Methodological rigor: It follows PRISMA

guidelines and applies the JBI Critical Appraisal

Checklist, ensuring transparent screening, quality

evaluation, and reduced bias.

Comparative insight: By mapping 99

instruments across 46 studies, it provides a rare

comparative analysis of assessment domains,

methodologies, and cultural adaptations.

Focus on cultural validity: The study highlights

how cultural and linguistic factors affect tool

accuracy, filling a critical gap in cross-cultural

assessment literature.

Relevance to policy and practice: Findings

inform clinicians, researchers, and policymakers

seeking more reliable, harmonized approaches

to refugee mental-health assessment.

Identification of emerging trends: It captures

the shift toward multidimensional, culturally

adapted, and resilience-oriented assessment

methods.

Practical and social value

Improves clinical practice: The review

identifies reliable and culturally appropriate

assessment tools, helping clinicians choose

instruments that better capture refugees’ mental-

health needs.

Guides policy development: By exposing the

lack of standardization across Europe, it supports

policymakers in creating coherent, evidence-

based assessment frameworks for refugee care.

Enhances service accessibility: Highlighting

barriers such as language and cultural mismatch

encourages the design of more inclusive,

adapted mental-health services.

Supports better resource allocation:

Understanding which tools are effective enables

more targeted interventions, reducing

misdiagnosis and unnecessary treatment.

Promotes social integration: More accurate

mental-health assessments contribute to

improved well-being, resilience, and integration

outcomes for forcibly displaced populations.

Mental Health: Global Challenges Journal

https://reference-global.com/journal/MHGCJ

ISSN 2612-2138

Conclusion

The present study aimed to provide an up-to-

date overview of the literature on which methods

and tools are currently applied in European

countries for mental health evaluation in refugee

populations. Results showed that the instruments

used are very diverse and there is currently no

standardized approach. While self-report

assessments are widely used, the accuracy of

those assessments is compromised due to

cultural differences and inaccuracies in self-

perceptions among others. This systematic review

highlights the need for a consistent, yet

adaptable method for assessing refugee mental

health. An emergent trend for the use of

multidimensional evaluation techniques could be

observed in the literature. Based on these results,

a multifaceted method including culturally

adapted instruments, clinician-administered

interviews, as well as self-report assessments is

proposed for a proper understanding of refugee

mental health.

The results of this systematic review also

emphasize the importance of including post-

migration stressors in mental health evaluations.

Language barriers, problems with social

integration, financial struggles and housing

uncertainties can have a significant impact on

the psychological health of refugees and AS.

Tools like the Refugee Post-Migration Stress Scale

(RPMS) and the Post-Migration Living Difficulties

Checklist (PMLD) can help mental health

professionals to better understand the situation of

those forcibly displaced people. Combined with

resilience-based measures, mental health

treatments could be increased in their

effectiveness due to a more balanced view on

refugees’ psychological health.

Future studies should focus on developing

more accurate means of evaluation with an

emphasis on cultural-sensitive measurements that

include post-migration stressors, as well as pre-

migration trauma in an integrated model. It is

important to understand that a flexible yet

consistent approach is essential to be able to

provide the proper care for a refugee population

whose needs are constantly changing due to the

diverse backgrounds of these individuals.

By focusing on these measures, the accuracy

of diagnosis could be enhanced and overall

mental health care for refugee populations can

be improved.

Acknowledgments

The authors wish to thank to Anna Jaeger for

the careful contribution in the review of research

data and the outstanding work.

Funding statement

This work was funded by national funds

through Foundation for Science and

Technology/Agency for Research and Innovation

(AI2), as part of the project CIP/UAL – Ref.

UIDB/04345/2020 integrated in the University

Research Centre in Psychology (CUIP) of Portugal.

Conflict of interest

The authors declare no conflicts of interest.

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