Online Tiered Screening for Mental Health Problems Among Refugees in Sweden: Validation Study

Refugees and asylum-seekers commonly experience numerous adverse and traumatic events and are therefore at increased risk of mental health problems. Despite the high need for mental health interventions, services tend to be underused by refugees and asylum-seekers, and various barriers compromise access. Digital, efficient screening, adapted for these groups, could facilitate initial assessment and increase accessibility to mental health services. We developed an internet-based tiered screening procedure (i-TAP) aiming to identify clinically relevant symptoms of major depressive disorder (MDD), anxiety disorder, posttraumatic stress disorder, and insomnia disorder among individuals with a refugee background. The i-TAP is an adaptive procedure with 3 tiers aiming to identify general mental distress in Tier 1, differentiate between symptoms in Tier 2, and assess the severity of symptoms in Tier 3. Each tier additionally functions as a gateway to further assessment, as a negative outcome terminates the procedure.

The purpose of this study was to evaluate the diagnostic test accuracy of the i-TAP, using structured clinical assessments as the reference standard.

In this prospective study, 70 adult participants with a refugee background, literate in Arabic, Dari, Farsi, or Swedish, and residing in Sweden, completed the i-TAP on tablets and participated in a subsequent structured diagnostic interview.

It has been shown that the i-TAP could identify 91.7% (33/36) of individuals assessed with any psychiatric disorder, and correctly identified 82.1% of all positive cases of MDD, anxiety disorder, posttraumatic stress disorder, and insomnia disorder, with few false negative assessments. Overall test accuracy of the i-TAP ranged between 77.1% and 84.3%, depending on disorder. The tiered design could reduce item burden while maintaining accuracy. A vast majority of participants rated the user experience as positive. In this sample, 36/70 (51.4%) individuals were assessed with one or more psychiatric disorders and comorbidity was high.

The i-TAP may be a valid, efficient, and feasible screening tool for the identification of common psychiatric disorders among individuals with a refugee background in Sweden. The i-TAP could be implemented as a first screener in various settings, including online and in-person clinical practices. The digital, adaptive, multilingual format could facilitate early assessment and increase the availability of mental health services for refugees and asylum-seekers.