Main findings and interpretation

The present study aimed to examine and compare the self-reported rates of depression, anxiety and PTSD among Syrian and Afghan refugees in Türkiye. We found high rates of symptoms among both groups. More than half of the participants in both groups (56.7% for Syrians and 67.8% for Afghans) reported at least one of these mental health problems. The current estimates for Syrians were higher than those reported among Syrian refugees in Türkiye and Western countries.^{Reference Acarturk, McGrath, Roberts, Ilkkursun, Cuijpers and Sijbrandij12,Reference Nguyen, Guajardo, Sahle, Renzaho and Slewa-Younan35} However, they are comparable with the reported estimates in a recent study conducted among Syrian refugees during the COVID-19 pandemic.^{Reference Kurt, Ilkkursun, Javanbakht, Uygun, Karaoglan-Kahilogullari and Acarturk15} In that study, the prevalence rates of depression and anxiety were 51.9% and 42.9% among the participants. Thus, the observed increase in the prevalence rates might be due to the additional difficulties during the pandemic, such as lack of access to hygiene materials, losing jobs and being unable to pay rent.

Estimated prevalence rates for Afghans were higher than those reported in Western countries,^{Reference Gerritsen, Bramsen, Devillé, van Willigen, Hovens and van der Ploeg36,Reference Slewa-Younan, Yaser, Guajardo, Mannan, Smith and Mond37} but were similar to those reported following the conflict in Afghanistan and in neighbouring countries. Scholte et al^{Reference Scholte, Olff, Ventevogel, Jansveld and Crawford38} and Cardozo et al^{Reference Cardozo, Crawford, Wolfe, Gerber and Anderson39} found prevalence rates of 38.5% and 67.7% for depression, 51.8% and 72.2% for anxiety and 20.4% and 42.1% for PTSD among Afghans in different areas of Afghanistan. A systematic review reported that mental health problems are highly prevalent among Afghan refugees in Iran, with at least one-third suffering from one mental health problem.^{Reference Hosseini Divkolaye and Burkle40}

In line with our initial assumption, Afghans reported a higher number of potentially traumatic events and displacement-related stressors than Syrians. Entrenched war and conflict in Afghanistan over 40 years and the dangerous migration route from Afghanistan to Türkiye might explain the higher level of potentially traumatic events reported by Afghans. A recent in-depth study with 50 Afghans in Istanbul sheds light on the precarious conditions of Afghans before, during and after migrating to Türkiye. The travel from Afghanistan to Türkiye was often perilous and could take several months.^{Reference Karadağ41} Although both Syrians and Afghans live in the same displacement context, the degree to which they experience post-displacement difficulties evidently varies. Mental health problems, mainly anxiety, were higher among Afghans than Syrians even after controlling for the effect of traumatic events and displacement-related stressors. The disparities in post-displacement experiences and probable anxiety might be explained by legal status. Their temporary protection status opens the doors for Syrians to utilise basic services even if in practice access may still be challenging. Unlike Syrians, many Afghans live as asylum seekers waiting for the decision or as irregular migrants, which hampers their access to basic services.^{Reference Eryurt and Koç4} Within Türkiye many Afghans live under constant fear of deportation, which prompts them to live as invisibly as possible in order to stay under the radar of the authorities and obliges them accept the hardest and the most unstable jobs.^{Reference Karadağ41} The uncertainty of their legal status is likely to create hardships for them and hinder their ability to look ahead,^{Reference Li, Liddell and Nickerson32} which might explain the substantial differences in displacement experiences and mental health conditions among Afghans and Syrians in the present study.

As for the second aim of the study, we investigated the risk factors for mental health problems in both groups. Consistent with the existing evidence, female gender appeared as a significant risk factor for all three mental health problems among Syrians and Afghans.^{Reference Alemi, James, Cruz, Zepeda and Racadio10,Reference Acarturk, McGrath, Roberts, Ilkkursun, Cuijpers and Sijbrandij12} The higher risk for females to develop mental health problems might be explained by gender roles and experiences of gender-based violence such as intimate partner violence, early or forced marriages and social isolation.^{Reference Hassan, Ventevogel, Jefee-Bahloul, Barkil-Oteo and Kirmayer42,Reference Omidian and Miller43} Further, we found that higher education level was associated with increased risk of having mental health problems among Syrians only. Since qualifications in their home country are not easily transferable to the new setting, they are likely to be either unemployed or underemployed (working below the level of education or training that they completed in Syria).^{Reference von Haumeder, Ghafoori and Retailleau44} Therefore, higher education level poses a profound risk for mental illness because those with higher education might have more to lose from conflict and displacement.^{Reference Porter and Haslam45} Older age was associated with higher risk of anxiety only among Afghans. Previous studies with Afghans also showed that older Afghans have more mental health problems.^{Reference Slewa-Younan, Yaser, Guajardo, Mannan, Smith and Mond37,Reference Scholte, Olff, Ventevogel, Jansveld and Crawford38} Legal status was another important risk factor among the Afghan refugees. Compared with legal status holders, asylum-seeking applicants and those with no legal status (including those whose applications were rejected and those who did not apply for protection) reported higher levels of mental health problems. This is in line with research highlighting the adverse impacts of prolonged and uncertain asylum-seeking processes.^{Reference Li, Liddell and Nickerson32,Reference Hajak, Sardana, Verdeli and Grimm46} Being an asylum seeker is a potent risk factor for mental illness among Afghans in Western countries^{Reference Alemi, James, Cruz, Zepeda and Racadio10} and in neighbouring countries such as Iran.^{Reference Hosseini Divkolaye and Burkle40} Even after a long process of asylum-seeking, permanent residency status is not guaranteed to the applicants. In Türkiye, the asylum-seeking process is complicated, with the possibility of withdrawal of the residency if the home country becomes safe to return to, which hinders individual's ability to look ahead and adapt to the new life.^{Reference Li, Liddell and Nickerson32} This situation, unfortunately, puts Afghans in an even more vulnerable position.

Our finding showing that exposure to potentially traumatic events increases the risk of having common mental health problems dovetails with the large body of research among forcibly displaced communities.^{Reference Bogic, Njoku and Priebe17,Reference Steel, Chey, Silove, Marnane, Bryant and van Ommeren47} As for the post-displacement stressors, we found that socioeconomic displacement stressors (e.g. discrimination, isolation, financial difficulties) were a more consistent predictor of mental health problems among Syrians and Afghans. Those who experienced higher levels of socioeconomic stressors were two to three times more likely to develop mental health problems. Compared with traumatic events, this increased risk might be related to the characteristics of socioeconomic stressors that are proximal in time and ubiquitous in daily life.^{Reference Miller and Rasmussen48} Structural displacement stressors were associated with higher risk of anxiety among both Syrians and Afghans and higher risk of PTSD among Afghans. Considering the nature of structural stressors, such as difficulties related to the asylum process and being fearful of being sent back to the country of origin, it is imperative to assume that these stressors fuel a feeling of uncertainty, which provides grounds for anxiety and related disorders.^{Reference Gentes and Ruscio49} These findings are of particular importance in showing that stressors encountered in different areas of life affect mental health to a different degree.^{Reference Hou, Liu, Liang, Ho, Kim and Seong13}

Strengths, limitations and implications

To the best of our knowledge, this study is the first to provide a comparative picture of the hardships of two major refugee groups in Türkiye. Since the onset of the Syrian war, there have been several studies investigating the mental health conditions of Syrians in the neighbouring and Western countries.^{Reference Nguyen, Guajardo, Sahle, Renzaho and Slewa-Younan35,Reference Hendrickx, Woodward, Fuhr, Sondorp and Roberts50} Several international collaborations are undertaking studies testing the effectiveness of psychosocial interventions on mental health among Syrians.^{Reference Acarturk, Uygun, Ilkkursun, Carswell, Tedeschi and Batu21,Reference Sijbrandij, Acarturk, Bird, Bryant, Burchert and Carswell51} However, despite the conflict in their country and continuing displacement, Afghans’ displacement conditions and mental health have received relatively scant attention. With the withdrawal of foreign military forces and Taliban takeover of the country, the humanitarian situation in Afghanistan further deteriorated, putting approximately 25 million people in need. Owing to the dire conditions in Afghanistan – the conflict, natural disasters, the COVID-19 pandemic, economic collapse – almost 1 million people were displaced inside the country and thousands of them sought refuge in Iran and Pakistan,⁵² with the possibility of many more people fleeing the country in the near future. It is likely therefore that more Afghans will find their way to Türkiye to either stay or pass through to European countries. We hope that the findings of the high mental health needs of Afghans in Türkiye will lead to more academic work on this group and to improved humanitarian programming.

Our findings reveal the impacts of potentially traumatic conflict-related events and post-displacement stressors, highlighting vulnerable groups among Syrians and Afghans, such as females, the highly educated and older individuals. Although resources might be limited to directly working with the traumatic events, especially in low- and middle- income countries that are short of mental health resources,⁵³ efforts might be spent on improving life circumstances for refugees and asylum seekers living in displacement through, for example, less restrictive asylum policies, better access to education and the labour market and cash-based interventions.^{Reference Miller and Rasmussen48} Further, our findings suggest that socioeconomic stressors might be more proximal and pervasive than structural ones, further increasing susceptibility to mental health problems. We assume therefore that structural barriers or stressors influence mental health via precipitating socioeconomic stressors, but this assumption requires further inquiry.

The present study has number of limitations. First, owing to the COVID-19 pandemic, we conducted online surveys, which might restrict our ability to extrapolate the current findings to Syrians and Afghans in Türkiye in general. Second, this study was based on self-report of mental health problems. A recent systematic review and meta-analysis showed that self-report measurements might yield overestimated prevalence rates.^{Reference Charlson, van Ommeren, Flaxman, Cornett, Whiteford and Saxena16} Therefore, it is important to be cautious in making inferences about the prevalence rates of common mental health problems among Syrians and Afghans in Türkiye. Further, we utilised the most commonly used measures to assess mental health problems among these groups. Consequently, we might have overlooked idiosyncratic ways of expressing mental health problems.^{Reference Ventevogel and Faiz54}