Network analysis of changes in post-migration stressors during treatment for refugees with PTSD

Background: Refugees resettled in high-income countries are at high risk of post-traumatic stress disorder (PTSD) and often face multiple post-migration stressors that can influence symptom severity. While individual and cumulative effects of these stressors have been examined, little is known about how they interact and change during treatment. Objective: To investigate changes in the structure and interconnections of post-migration stressors among refugees with PTSD before and after mental health treatment. Method: Participants were refugees with PTSD receiving multidisciplinary treatment at a specialised mental health clinic in Denmark, as part of a randomised controlled trial. The Post-Migration Living Difficulties Checklist (17-item Danish version) (PMLD) was completed pre- and post-treatment. Partial correlation networks were estimated for each time point, with network comparison test assessing changes in global network connectivity. Predictability of individual stressors and paired-sample t-tests for item-level change were also conducted. Results: Global network connectivity increased significantly from pre- to post-treatment (p =.004), suggesting stronger interrelations among stressors over time. Overall PMLD score did not change from pre- to post-treatment, but on item-level, financial and housing-related stress decreased (p =.006; p =.028), while concerns about returning to the country of origin in an emergency increased (p =.028). Discussion: Post-migration stressors became more interconnected during treatment, underscoring the need to address them not as isolated issues but as interdependent, mutually reinforcing challenges shaped by cultural and structural contexts. Clinically, effective support for trauma-affected refugees requires multi-level interventions that integrate legal, social, and economic determinants alongside mental health care.