Screening for Mental Health Problems Among Refugees: Validation of an Online Tiered Screening Procedure (i-TAP) (Preprint)

BACKGROUND Refugees 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 under-utilized by refugees, and various barriers compromise access. Digital, efficient screening, adapted for refugees, 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, anxiety disorders, post-traumatic stress disorder (PTSD) and insomnia disorder among refugees. The i-TAP is an adaptive procedure with three tiers aiming to identify general mental distress in tier 1, differentiate between symptoms in tier 2, and assess severity of symptoms in tier 3. Each tier additionally functions as a gateway to further assessment, as a negative outcome terminates the procedure. OBJECTIVE The purpose of the this study was to evaluate the diagnostic test accuracy of the i-TAP, using structured clinical assessments as reference standard. METHODS 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. RESULTS Results show that the i-TAP could identify 91.7% of individuals assessed with any psychiatric disorder, and correctly identified 82.1% of all positive cases of depression, anxiety, PTSD and insomnia, 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 with maintained accuracy. A vast majority of participants rated the user-experience as positive. In this sample, 36 (51.4%) individuals were assessed with one or more psychiatric disorders and comorbidity was high. CONCLUSIONS The i-TAP may be a valid, efficient and feasible screening tool for identification of common psychiatric disorders among refugees. The i-TAP could be implemented as a first screener in various settings, including online and in-person clinical practices. The digital, adaptive, multilanguage format could facilitate early assessment and increase the availability of mental health services for refugees.