The United Nations Refugee Agency estimates that there are currently 22.5 million refugees worldwide, most of whom are fleeing conflict and persecution in their homeland. A further 28,300 more are displaced from their homes every day. There is a large body of evidence that suggests a correlation between psychopathology and exposure to armed conflict and targeted persecution. While needs such as physical health, safety, food and shelter often take precedence over psychological concerns, the sheer scarcity of mental health services means that most refugees who develop mental illness will never receive appropriate care. This adversely affects overall psychosocial wellbeing and has demonstrable long-term implications on refugee mental health. This paper seeks to examine the factors that contribute to mental illness in refugees fleeing conflict and persecution, identify refugee subpopulations at high risk of long-term mental health issues, and provide evidence-based recommendations by reviewing the literature on interventions.
Common mental illnessess among refugees exposed to conflict and persecution
Psychological disturbance is a common consequence of exposure to traumatic events. However, a disturbance may only be classified as a ‘mental disorder’ if it continues to inflict psychological distress over an extended period of time and causes dysfunction in daily life. The degree of the disorder will vary according to the level of exposure to potentially traumatic events (PTEs) and other ongoing stressors.
The most common mental illness among refugees exposed to violence and persecution is Post-Traumatic Stress Disorder (PTSD), where sufferers experience flashbacks of traumatic experiences, as well as heightened levels of anxiety and reactivity to sensory stimuli. The rate of PTSD in refugees can be up to ten times more than the general population. Refugees exposed to PTEs also had an overall rate of 30.8% for depression, with some populations reporting rates as high as 85.5%. Furthermore, a survey of over 16,000 war-affected refugees found prevalence rates of unspecified anxiety disorders between 20 and 88%.
Other mental conditions include psychosis (9-16%) and somatization disorders, which often manifest as chronic pain or other medically unexplained somatic complaints. Most refugees have several co-morbidities in addition to their primary psychopathology. For example, a Danish study showed that virtually all war-refugees who sought psychiatric treatment at the Competence Center for Transcultural Psychiatry in Copenhagen had depression, pain and somatic complaints in addition to PTSD.
In the absence of proper health services, many refugees afflicted by mental illness turn to substance and alcohol abuse, in turn, creating an addiction problem. Research involving 64 refugees with PTSD showed that most had suicidal ideations and half had a history of suicide attempts.
The diagnosis of mental disorders among refugees is often impeded by language barriers and cultural variance in its manifestations and conceptualisation. In some cultures, mental illness is stigmatised, leading to the suppression of verbal and emotional expressions of distress. For example, among Rohingya refugees, psychological distress is expressed idiomatically and often attributed to spirit possession. Somali refugees conceptualize mental illness as Murug, Waali and Gini – sadness, craziness due to spirits and craziness due to trauma. These terms did not exist in pre-war Somalia, however have come to fruition in recent years. Understanding these cultural differences, in contrast to Western conceptualizations of mental disorders, and having a degree of cultural competence can prove helpful to clinicians working with traumatized refugees and in devising appropriate interventions.
Factors associated with mental illness
1. Direct exposure to violence
Refugees exposed directly to violence are predisposed to mental illness. This violence can come in the form of witnessing shooting and bombardment, the destruction of their homes and significant loss of life such as the injury or death of friends and family. Violence can also be targeted directly at individuals. Persecution for racial, religious or other reasons are prime examples. Being subject to torture as a means of persecution is one of the strongest contributing factors to the development of PTSD in refugees. Often times, the victimised individuals find the sheer atrocity of the actions inflicted on them to be incomprehensible, and may assign supernatural or religious meaning to their experiences or mental illness. In other cases, they are unable to conceptualise their experience within their traditional framework for handling crises, leading to distress, depression, anxiety, guilt or shame. In understanding the impact of PTEs and targeted violence on refugee mental health, it is important to take into account the traditional interpretive frameworks used to comprehend trauma and mental illnesses.
2. Gender and sexual orientation
Female refugees are known to have higher rates of both depression and PTSD than their male counterparts, as well as a greater propensity to rely on psychotropic drugs post-migration. Women are particularly vulnerable due to pre-migration trauma such as sexual or gender-based violence during war as well as ongoing stressors. Post-migration stressors include safety concerns in refugee camps as well as discrimination following resettlement in a different country. Cultural differences in internalised gender roles may also explain why male and female refugees are affected differently by post-migration stress. Blight and colleagues found that while job occupancy was important to the mental health of male refugees in Sweden, job occupancy and living in an urban environment appeared to adversely affect the mental health of female refugees. However, research on this topic is limited.
Refugees who are lesbian, gay, bisexual, transgender or intersex also have higher rates of mental illness. Although acts of violence towards LGBTI individuals may increase during times of conflict, many LGBTI refugees have endured years of persecution at the hands of their families or communities. This abuse includes beatings, corrective rape and honour killings. War can exacerbate pre-existing mental illnesses and prompt many LGBTI refugees to flee from their communities.
3. Socioeconomic background and educational status
Refugees from relatively higher socioeconomic and educational statuses in their countries of origin had poorer mental health outcomes. Researchers had previously assumed that these factors would act as a buffer against mental illness, but found that greater social and intellectual status prior to displacement resulted in greater distress and depression when those statuses were reduced to nought. Previously affluent refugees often lose their possessions and homes as a result of persecution and war, while the well-educated found that their degrees and prior work experience were not recognised in the countries they resettled in.
Long-term mental health issues in refugee sub-populations
Even many years after traumatic events and resettlement, mental illness may continue to persist in refugee populations. Vietnamese refugees exposed to 3 or more traumatic events continued to have a 12% risk of mental illness 10 years after resettlement. Furthermore, refugees resettled in western countries continued to exhibit rates of PTSD that are ten times higher than the general population(s). These are consequences of long-term non-treatment, pre-migration trauma and unresolved post-migration stressors.
Refugees who are subject to protracted periods of detention represent a sub-population that is particularly prone to long-term mental health issues. Living conditions and further exposure to violence and PTEs while in detention often re-traumatise refugees.[22, 23] Following detention, adults experience a threefold increase in mental illness, while a tenfold increase was observed in children. The deprivation of freedom of movement and independence following escape from collective violence and persecution is known to be a major post-migration stressor for refugees. Even several years after resettlement and release from detention, refugees continued to experience high levels of PTSD, anxiety and depression, which they associated with feelings of insecurity and injustice resulting from their experiences in detention. Longer periods of detention were associated with greater degrees of long-term psychological disturbance following follow-up with refugee children in Sweden indicated a gradual improvement in mental illness over time, children who had been exposed to violence and conflict displayed persisting psychological disturbances. This was similarly observed in Cambodian refugees over a 12-year period, with specific regard to PTSD. The most common types of PTEs experienced by children during times of conflict include funerals, witnessing armed conflict and seeing injured or dead strangers and family members. Adult refugees who experienced PTEs as children had worse long-term mental health. Indeed, the extent of childhood PTEs was found to be more strongly related to mental illness than the degree of exposure to more recent violence and human rights violations. This suggests that child refugees fleeing conflict have a high risk of long-term mental illness, which may persist even into adulthood.
There remains a pressing need for diagnostic tools to conduct large-scale screening for mental illness in refugees. This is essential for early intervention, to prevent deterioration of mental health and to halt the progression to long-term mental illness. The Kessler Psychological Distress Scale (K10) has shown potential as a screening instrument for mental illness, particularly PTSD. However, it may have limited effectiveness in culturally diverse populations, likely due to interpretative complications. Nevertheless, until further research into transcultural diagnostic tools, K10, used in conjunction with other conventional instruments such as PTSD-8, has utility in initial screening for mental illness. The effective translation of these diagnostic tools into the primary languages used by large and potentially diverse refugee populations, while taking into consideration cultural and linguistic nuances, is an intervention that must be explored. Collaboration between healthcare professionals, interpreters and ‘culture brokers’ is crucial for this intervention to be successful and for the subsequent treatment of diagnosed mental illnesses.
Where there is access to psychiatric services, Narrative Exposure Therapy (NET), which helps individuals contextualise their experiences of persecution and violence, has been shown to alleviate mental illness in refugees from a diverse range of backgrounds and with varying traumatic experiences.[32, 33] Psychopharmacological treatments involving antidepressants and antipsychotics are also known to be effective. However, due to a lack of data, no specific pharmacological regimens can be recommended at this juncture. Nevertheless, if available and deemed appropriate by a clinician, pharmacological interventions should be used in conjunction with psychotherapy. For instance, Sertraline used with Trauma-Focused Cognitive Behavioural Therapy (TFCBT) is known to be efficacious in the treatment of PTSD. In addition, clinicians should take into account cultural variations in the conceptualisation and expression of psychological distress when conducting conventional psychotherapy.
Although more research needs to be done to develop precise, culturally-adapted therapeutic interventions, the Delphi Method has been proven to be useful in creating mental health interventions for culturally diverse groups and Iraqi refugees in Australia. It is a type of consensus method which allows a panel of mental health experts to devise comprehensive mental health interventions through multiple rounds of anonymous input and feedback. This method should be adopted and tested with other refugee populations and may prove successful in creating refined interventions.
In low-resource settings, mental health interventions may need to be community-based, delivering mental health support within schools, peer-systems and families, rather than between individuals and mental health professionals. This is especially important for refugee children exposed to violence and traumatic events. One of the primary protective factors against long-term mental illness in trauma-exposed refugee children is stable social support in schools. With a shortage of mental health professionals equipped to deal with this specific type of trauma, community-based aid workers can successfully be trained in mental health first aid and provide initial assistance to refugees. The World Health Organisation’s scalable psychological interventions, such as Problem Management Plus (PM+), can be delivered face-to-face, in a group sessions, or with a smartphone by non-professionals. Healthcare institutions may serve as training-providers for government or non-government organisations (NGOs) which are providing the community-based care.
Electronic-mental health interventions are another promising way of reaching refugees who do not have access to mental health professionals or are afraid of stigmatisation. Although there is limited research in low-resource settings, internet-delivered Cognitive Behavioural Therapy was found to significantly improve PTSD in war-traumatised Arab individuals. The internet and development of new technology can allow clinicians to administer psychotherapy without being there in-person, such as via video-call.
It is essential that these psychological interventions take place as soon as mental illness is diagnosed or an individual is determined to be at risk. Untreated mental illness can lead to long-term issues following resettlement or further deterioration of mental health following repatriation, whether voluntary or involuntary. Mental illness may persist for many years, and successful resettlement may not necessarily lead to the resolution of pre-existing mental disorders. There is therefore a need for longitudinal interventions to help refugees through the stages of resettlement and acculturation. This involves making mental healthcare accessible and affordable locally in the countries they are resettled in, so that continued care in the form of psychotherapy and/or medication is readily available. Discharge from care or a decreased frequency of checkups can be considered once a pre-existing mental illness is resolved and deemed unlikely to recur.
Social interventions are necessary to address ongoing stressors, particularly for refugees in the process of resettlement or confined in closed camps for extended periods. Social interventions must address socioeconomic concerns which are commonly associated with long-term depression, such as the lack of gainful employment. The present nature of detention, including its re-traumatising effects, level of safety, extent of restriction of movement and overall duration needs to be addressed as well. Social interventions for refugee mental illness falls in grey area between healthcare and politics, therefore requiring significant dialogue between both healthcare professionals and policymakers. Potential interventions would include job opportunities, recognition of academic accreditations, social support for resettlement and legislation pertaining to the harmful duration and conditions of detention.
Refugees fleeing conflict and persecution are prone to developing mental illness, which if left untreated can have long-term implications on psychosocial wellbeing. There is presently a major lack of resources being allocated to refugee mental health. Research pertaining to culturally-adapted diagnostic tools and transcultural psychotherapy is only just beginning to emerge. This paper examined the factors associated with mental illness in refugees exposed to PTEs, as well as identified refugee subpopulations at a high risk of long-term mental health problems. The literature regarding psychiatric interventions was then reviewed and recommendations were made based on the evidence gathered. Areas where further research is required, or where current research is limited, were noted. Social interventions were addressed as well but may be potentially limited by non-medical factors (e.g. political and economic concerns). Assessing the practicality of social or socioeconomic interventions would likely fall outside the purview of medical literature and was therefore not attempted. Further research into methods for alleviating mental illness in traumatised refugees is still desperately needed.
Image 1: public domain, accessed from https://www.shutterstock.com/image-photo/syrian-refugees-families-who-came-kobani-353855087?src=zFmLNzGPxpTxDnsWrgrieA-1-23
Conflicts of interest
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