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Abstract Background The link between mental health difficulties and terrorist behaviour has been the subject of debate for the last 50 years. Studies that report prevalence rates of mental health difficulties in terrorist samples or compare rates for those involved and not involved in terrorism, can inform this debate and the work of those responsible for countering violent extremism. Objectives To synthesise the prevalence rates of mental health difficulties in terrorist samples (Objective 1—Prevalence) and prevalence of mental health disorders pre‐dating involvement in terrorism (Objective 2—Temporality). The review also synthesises the extent to which mental health difficulties are associated with terrorist involvement compared to non‐terrorist samples (Objective 3—Risk Factor). Search Methods Searches were conducted between April and June 2022, capturing research until December 2021. We contacted expert networks, hand‐searched specialist journals, harvested records from published reviews, and examined references lists for included papers to identify additional studies. Selection Criteria Studies needed to empirically examine mental health difficulties and terrorism. To be included under Objective 1 (Prevalence) and Objective 2 (Temporality), studies had to adopt cross‐sectional, cohort, or case‐control design and report prevalence rates of mental health difficulties in terrorist samples, with studies under Objective 2 also needing to report prevalence of difficulties before detection or involvement in terrorism. For Objective 3 (Risk Factor) studies where there was variability in terrorist behaviour (involved vs. not involved) were included. Data Collection and Analysis Captured records were screened in DisillterSR by two authors. Risk of bias was assessed using Joanna Briggs Institute checklists, and random‐effects meta‐analysis conducted in Comprehensive Meta‐Analysis software. Results Fifty‐six papers reporting on 73 different terrorist samples (i.e., studies) (n = 13,648) were identified. All were eligible for Objective 1. Of the 73 studies, 10 were eligible for Objective 2 (Temporality) and nine were eligible for Objective 3 (Risk Factor). For Objective 1, the life‐time prevalence rate of diagnosed mental disorder in terrorist samples (k = 18) was 17.4% [95% confidence interval (CI) = 11.1%–26.3%]. When collapsing all studies reporting psychological problems, disorder, and suspected disorder into one meta‐analyses (k = 37), the pooled prevalence rate was 25.5% (95% CI = 20.2%–31.6%). When isolating studies reporting data for any mental health difficulty that emerged before either engagement in terrorism or detection for terrorist offences (Objective 2: Temporality), the life‐time prevalence rate was 27.8% (95% CI = 20.9%–35.9%). For Objective 3 (Risk Factor), it was not appropriate to calculate a pooled effect size due the differences in comparison samples. Odds ratios for these studies ranged from 0.68 (95% CI = 0.38–1.22) to 3.13 (95% CI = 1.87–5.23). All studies were assessed as having high‐risk of bias which, in part, reflects challenges conducting terrorism research. Author's Conclusions This review does not support the assertion that terrorist samples are characterised by higher rates of mental health difficulties than would be expected in the general population. Findings have implications for future research in terms of design and reporting. There are also implications for practice with regards the inclusion of mental health difficulties as indicators of risk.
