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date: 17 November 2018

Mental Health of Refugees

Summary and Keywords

People who are forcibly displaced are forced to flee by serious threats to fundamental human rights, caused by factors such as persecution, armed conflict, and indiscriminate violence. Contemporary drivers of forced displacement are increasingly complex and interrelated. They include population growth, food insecurity, and water scarcity, at times compounded and multiplied by the effects of climate change. A refugee is someone who fled his or her home and country owing to “a well-founded fear of persecution because of his/her race, religion, nationality, membership in a particular social group, or political opinion,” according to the United Nations 1951 Refugee Convention. Internally displaced persons (IDPs) are people who have not crossed an international border but were forced to move to a different region than the one they call home within their own country. People who cannot return home without serious risk to their human rights have specific needs.

Forced displacement, both within a country and to other countries, is a major life event that abruptly changes environmental living conditions, such as social networks, language, and cultural environment of the displaced populations. The changes in environmental living conditions and disruptions in life challenge both the individual and the families of the displaced persons. Both types of forced displacement challenge adaptational mechanisms of individuals and families. Accordingly, the challenges can contribute to changes in mental health and mental disorders. However, estimates of mental health, mental disorders, and mental health determinants vary across and between forcibly displaced persons. This heterogeneity in estimates is associated with differences between refugee groups and with methodological difficulties in assessing refugees’ mental health. Instruments to assess mental health need to be culture-grounded and gender-sensitive to capture the scope and extent of refugees’ mental health and mental disorders. Based on reliable and valid instrument needs for assessing mental health and mental disorders, determinants can be identified and intervention can be developed and evaluated.

Keywords: refugees, mental disorder, anger, depression, anxiety

Forced displacement (within a country or to another country) is a major life event that changes abruptly the living conditions of the displaced populations. This article will focus on refugees moving to other countries. It will first provide definitions of and facts about refugees. This will be followed by a section investigating theoretical models, which have been developed to better understand refugees’ mental health, mental disorders, and resilience. Then one of the major challenges in the research about and care for refugees will be described: the cultural grounded assessment of refugees’ mental health, mental disorders, and resilience. Despite the difficulties in assessing refugees’ mental health and mental disorders, a variety of studies provide estimates on these factors. A description of both individual and socio-cultural-political determinants of refugees’ mental health and mental disorders will be provided. Then an overview on interventions to promote mental health in refugees will be given.

Facts and Definitions of Refugees

Displacement of people can be of a voluntary or a forced nature. Forced displacement can be external (refugees) or internal (internally displaced persons). Instances of both internal and external forced displacement are rising across the world, particularly due to conflicts, wars, genocides, natural disasters, and environmental changes. In 2017, an estimated 65.3 million people were forcibly displaced and on the move, fleeing unrest, conflict, natural disasters, and persecution (United Nations High Commissioner for Refugees, 2017). It is expected that in the coming years millions of people will become so-called “climate refugees” as some areas will become unlivable. Included among these are refugees, asylum seekers, and internally displaced people (Burrows & Kinney, 2016; Wennersten & Robbins, 2017). More than 80% of these refugees are displaced internally or have fled across national borders to neighboring countries, the majority being located in low- and middle-income countries. The United Nations High Commissioner for Refugees (UNHCR) defines a refugee as “someone who has been forced to flee his or her country because of persecution, war, or violence. A refugee has a well-founded fear of persecution for reasons of race, religion, nationality, political opinion or membership in a particular social group. Most likely, they cannot return home or are afraid to do so” (UNHCR, 2017).

Many refugees die during passage. Most of the surviving refugees have been exposed to tremendous suffering before and during the flight. Each forcibly removed population has unique characteristics due to being exposed to both acute and chronic stressors and coming from different cultures. Accordingly, these refugees represent diverse ethnic, cultural, religious, socioeconomic, and educational backgrounds. Moreover, they represent different age groups—greater numbers of children are on the move than ever before (United Nations High Commissioner for Refugees, 2017; Zwi et al., 2007). In 2017, nearly one third of forcibly displaced persons were children (United Nations High Commissioner for Refugees, 2017).

Despite this heterogeneity, there are commonalities in the experience of being a forcibly displaced person, being a refugee. By definition, refugees have experienced persecution and often severe traumatic events. The negative mental health impact of persecution and severe traumatic events has been widely researched and documented. However, evidence suggests that persecution and violence differ across groups and that the mental health of refugees is compounded by experiences of violence before the flight, during the flight, and after the flight (Ackerman, 1997; Aspinall & Watters, 2010; Haroon, 2008). After the flight, refugees may face limited work opportunities, discrimination, difficulties communicating due to language barriers, unfamiliarity with the local environment and health and social care system, cultural differences, and restricted access to the health care system (Kirmayer et al., 2011). These pre-, during-, and after-flight conditions may have an impact on mental health and mental disorders. Although the majority of refugees adapt successfully to their new living conditions and integrate into the communities, many face long-term mental health challenges due to exposure to traumatic events before, during, and after flight.

Theoretical Models of Trajectories of Mental Health, Mental Disorders, and Resilience

It can be assumed that mental health and mental disorders have a history (contingency) and a geography (context) in that they occur in a given time and place. Mental health and mental disorders are therefore contingent and contextual. Accordingly, investigations of mental health and mental disorders of refugees must necessarily examine the historical and sociocultural contexts. The sociocultural context is a complicated concept and is the subject of various disciplines. From the perspective of cross-cultural psychiatry, culture is a boundary and a relationship:

One must not . . . imagine the realm of culture as some sort of spatial whole, having boundaries but also having internal territory. The realm of culture has no internal territory: it is entirely distributed along the boundaries, boundaries pass everywhere, through its very aspect, the systematic unity of culture extends into the very atoms of cultural life. . . . Every cultural act lives on the boundaries: in this is its seriousness and its significance; abstracted from boundaries . . . it disintegrates and dies.

(Bakhtin, 1981)

Accordingly, culture influences the experience and expression of suffering from its inception. Moreover, culture is increasingly perceived as dynamic. By meeting and encountering people from other places, people go through a process of acculturation, acquiring other ways of living in the world with other rules and other symptoms. A key term, therefore, to better understand refugees’ mental status is cultural interpenetration, a reciprocal process whereby the mental health of refugees is accompanied by accommodation of the host society. Accordingly, the adverse effects of exposure to violence and traumatic events before and during flight are compounded by stressors in the host country, e.g., unemployment and lack of opportunities, insecure visa status, distance from family, and discrimination.

Based on the premise that mental health and mental disorders are both contingent and contextual, various models have been developed to understand the process of refugees and their adaptation to host societies. One model is the Adaption and Development After Persecution and Trauma (ADAPT) model (Silove, 1999b). This model identifies four core adaptive systems which are disrupted by forced displacement and violence. The four adaptive systems serve the functions of safety and security, interpersonal bonds and attachment, justice, and identity roles and existential meaning. In support of the ADAPT model, a recent study showed that a measure of the ADAPT construct moderated the effects of past trauma and ongoing adversity in shaping mental disorders (Tay, Rees, Chen, Kareth, & Silove, 2013). Herewith, the ADAPT model provides a framework to better understand the social ecology of the refugee experience and might give options to contextualize interventions beyond purely medical or therapeutic models. Furthermore, the ADAPT model offers the potential to make an assessment of the adaptive systems and potential resource losses.

Another model suggests that forced relocation is associated with mixed emotions either under the overall theme of dislocation and loss or under the theme of growth (Table 1).

Table 1. Negative and Positive Conceptions of Forced Placement

Negative Conceptions

Positive Conceptions

Shock

Surprise

Trauma

Learning

Anxiety

Delight

Mourning

Hope

Overall theme: Dislocation and loss

Overall theme: Growth and hope

Source: Adapted from Di Nicola, 1997.

Assessment of Refugees’ Mental Health

The results of epidemiological studies among displaced populations should be interpreted with caution (Kirmayer, Bennegadi, & Kastrup, 2016; Kirmayer & Sartorius, 2007; Mezzich, Caracci, Fabrega, & Kirmayer, 2009). Epidemiological research suggests that core mental syndromes can be identified across cultural contexts (Kirmayer, Gomez-Carrillo, & Veissière, 2017; Kirmayer & Swartz, 2013; Kleinman & Good, 1985). However, there is substantial cross-cultural variation in the prevalence and symptom presentation of disorders and mental health (Ferrari et al., 2013; Kessler & Bromet, 2013). These representations of distress are culture grounded (Kirmayer, 1989).

Therefore, the first challenge in understanding refugees’ mental health is culture-grounded assessment (Lewis-Fernandez et al., 2014). According to research on idioms of distress, culturally sanctioned and socially shared idioms of distress (IDs) channel the way experiences and suffering are expressed, and explanatory models govern how they are understood and discussed (Kirmayer et al., 2016).

Part of the challenge in assessing the burden of mental disorders in refugees is identifying and classifying mental disorders that may not fit into Western paradigms. Standard instruments usually do not assess local cultural symptoms or idioms of distress and have not been validated for use in displaced populations. Therefore, not only the specific language but also idioms of distress are crucial. Language in itself is a significant barrier to accurately describing the signs and symptoms of mental disorders. Culture-sensitive assessment refers to language as well as perceptions of mental disorders.

Repeated calls have been made to develop reliable and valid measures to assess mental disorders. Lack of those measures may result in transcultural measurement error (Wells, Wells, & Lawsin, 2015). Such an error might fail to include local expressions or idioms of distress, which also can lead to the underenumeration or the overenumeration of mental health problems (Lewis-Fernandez et al., 2017). The development of such instruments includes four features: linguistic equivalence, functional equivalence, cultural equivalence, and metric equivalence (Pena, 2007). Despite the challenges in assessing mental health and mental disorders among refugees, it is critical to improve assessments. Responding to the calls to develop reliable and valid measures, the American Psychiatric Association offers in the Diagnostic and Statistical Manual (DSM-5) the Cultural Formulation Interview to assist researchers and mental health practitioners in this aspect of assessment (Aggarwal et al., 2014).

Mental Disorders and Mental Health

The extent and course of mental disorders in refugees have shown wide variation across studies (Steel et al., 2014). Research conducted over the past three decades has documented a dose-response relationship between violence exposure and mental health and mental disorders in refugees (Mollica, McInnes, Poole, & Tor, 1998; Steel et al., 2009). This research suggests that the greater the number of types of trauma participants were exposed to, the more violence-associated mental disorders such as PTSD, anxiety, depression, and emotion dysregulation they experienced. Systematic reviews suggested heterogeneity in prevalence rates (Table 2), noting that lower prevalence rates were found among the more rigorously designed studies (Bogic, Njoku, & Priebe, 2015; Fazel, Wheeler, & Danesh, 2005; Lindert, Ehrenstein, Priebe, Mielck, & Brahler, 2009).

Table 2. Prevalence Rates of Anxiety, Depression, and PTSD in Reviews of Studies on Refugees

Authors

Year

Prevalence Rate

Anxiety

Depression

PTSD

Bogic et al.

2015

8–37

28–75

4–86

Lindert et al.

2009

39–64

5–90

20–74

Lindert et al.

2018

11–54

5–71

Slewa-Younan

2015

28–75

8–37

An earlier review of studies of refugees already resettled in Western countries found an aggregate prevalence of 9% for PTSD and 5% for depression (Fazel et al., 2005). Another systematic review found that the high prevalence of mental disorders persisted even 5 years after displacement (Bogic et al., 2015). This review reported PTSD rates varying from 8 to 37% and depression from 28 to 75% in refugees (Bogic et al., 2015); another review on long-term health consequences including 29 studies with a total of 16,010 refugees suggested prevalence rates of depression in the range of 2 to 80%, of PTSD in the range of 4 to 86%, and unspecified anxiety disorder in the range of 20 to 88%. A further review, published in 2009, identified 181 surveys undertaken among 81,866 refugees and other conflict-affected populations from 40 countries. The prevalence rates of PTSD and depression were similar, approximately 30%, although there was substantial heterogeneity in prevalence rates across studies.

More recently, the prevalence ranged from 20 to 74% for PTSD and 39 to 64% for depression (Lindert, von Ehrenstein, Wehrwein, Brahler, & Schafer, 2018). This review suggests that prevalence rates are associated with type of human rights violation experienced in the countries of origin (Lindert et al., 2018). Accordingly, in this review exposure to human rights violations and the total number of traumatic events experienced emerged as the strongest predictors of mental disorders among refugees.

For Slewa-Younan, Uribe Guajardo, Heriseanu, and Hasan (2015), this variation in prevalence rates, methodological differences, and difficulties such as the challenges of culturally grounded assessment and contingency and context-related factors are responsible (Kirmayer et al., 2017; Lindert et al., 2018). The methodological factors might be refugee specific (e.g., transcultural measurement error due to lack of validated measures) or generic (e.g., biases related to non-probabilistic sampling, use of non-validated screening measures). Another review, based on studies that included comparison groups, suggests that refugees have a modestly elevated risk (effect size of 0.41) of a range of adverse mental health outcomes.

These findings provide a corrective to the tendency of single studies to find that all refugees are affected by mental disorders. It might be that rates of mental disorders in refugees differ according to the cohort investigated. In the case of severe human rights violations, prevalence rates of mental disorders might be higher than in cohorts with less severe human rights violations. Therefore, it might be misleading to try to provide an overall picture of scope and extent of mental health and mental disorders in refugees without carefully investigating and understanding cohort effects. It seems to be necessary to differentiate between forcibly and not-forcibly-displaced persons as one of the main risk factors, exposure to violence, might not be prevalent among the latter.

For example, high rates of mental disorders were found among refugees from Syria. In the catchment area of Verona, all male asylum seekers and refugees aged 18 or above included in the Italian protection system for asylum seekers and refugees during a period of 1 year were screened for psychological distress and psychiatric disorders (n = 109) using validated questionnaires. In this study, more than one-third of the participants (36%) showed clinically relevant psychological distress, and one-fourth (25%), met the criteria for a psychiatric diagnosis, mainly PTSD and depressive disorders (Nose et al., 2017). Yet effects of past exposure might be compounded with effects of current living conditions, such as living in refugee camps (Acarturk et al., 2017) or in detention centers (Silove, 1999b; Storm & Engberg, 2013).

Anger and irritability are common expressions of distress in many cultures that can occur in response to stress and conflicts. Accordingly, emotion dysregulation and anger appear to play an important role in the psychopathology of refugees (Berkowitz, 1999; DiGiuseppe & Tafrate, 2007; Fava & Rosenbaum, 1998). The massive disruptions to family in the context of extreme human rights violations undermines the fundamental sense of coherence of refugees, trust in others, and trust in authority structures. In one study, Southeast Asian refugees with PTSD had significantly higher scores on the Anger Reaction Index, including higher levels of both expressed and experienced anger (Abe, Zane, & Chun, 1994). In a study of Vietnamese refugees using the Symptom Checklist (SCL), of the 9 items that were able to differentiate between patients with and without PTSD, 3 were anger items (Hauff & Vaglum, 1994). Likewise, in a study of Cambodian refugees attending a psychiatric clinic, the refugees from Cambodia had elevated rates of anger and anger-associated autonomic arousal, with 58% of the patients with PTSD having anger episodes causing enough somatic arousal symptoms (e.g., palpitations) to meet panic attack criteria; they also had many catastrophic cognitions about the somatic symptoms induced by anger, including culturally specific concerns, such as that the neck vessels might rupture (Hinton, Hsia, Um, & Otto, 2003). For example, among West Papuan refugees, a constellation of mistrust, resentment, and anger is embodied in an idiom of distress, Sakit Hati, literally meaning “sick heart” (Rees & Silove, 2011). A focus on states of uncontrollable anger in survivors of extreme human rights violations creates an important bridge that links individual symptoms to the stability of the family and the wider social network.

Accordingly, war-related trauma exposure is linked to anger and to aggression and enhanced levels of community and family violence, suggesting a cycle of violence (Rogler, Cortes, & Malgady, 1994). Reactive aggression—an aggressive reaction to a perceived threat—is associated with PTSD.

In contrast, appetitive aggression—a hedonic, intrinsically motivated form of aggression—seems to be negatively related to PTSD in offender and military populations. Studies suggested an association between exposure to violence, trauma-related symptoms, and aggression in refugees. In semi-structured interviews, 290 Congolese refugees were questioned about trauma exposure, PTSD symptoms, and aggression. War-related trauma exposure correlated positively with exposure to family and community violence in the past month (r = .31, p < .001) and appetitive (r = .18, p = .002) and reactive aggression (r = .29, p < .001). The relationship between war-related trauma exposure and reactive aggressive behavior was mediated by PTSD symptoms and appetitive aggression. In a multiple sequential regression analysis, trauma exposure (β‎ = .43, p < .001) and reactive aggression (β‎ = .36, p < .001) were positively associated with PTSD symptoms, whereas appetitive aggression was negatively associated (β‎ = −.13, p = .007) with PTSD symptoms (Hecker, Fetz, Ainamani, & Elbert, 2015).

Likewise, anger is often directed toward spouses and family (Taft, Street, Marshall, Dowdally, & Riggs, 2007). Anger is one of the DSM-5 diagnostic criteria for PTSD (American Psychiatric Association, 2016), and trauma's main impact on local social worlds may be through anger. The few studies that have examined the effect of anger among trauma victims at the level of the family have only investigated anger directed toward a spouse (Taft et al., 2007); none have examined anger directed toward children. The lack of studies of anger's effect on the family unit of traumatized populations represents a major gap in the literature. In a sample of refugees from Cambodia, 49% (n = 70) had PTSD (Hinton, Rasmussen, Noi, Pollak, & Mary-Jo, 2009). Anger in families might be looked at as generating a multiplier effect of mental health problems in intimate partners and, potentially, children. This social outcome may have profound effects on children of refugees. Examination of these transactional effects within conjugal couples and families might broaden the understanding of the mental health of refugees (Nickerson et al., 2011). An extensive literature documents that anger attacks are common among depressed patients (Fava & Rosenbaum, 1998). To meet anger attack criteria, the person must have experienced four or more of several symptoms (these include somatic and psychological symptoms and acting-out behaviors) upon becoming angry in the last month, and the person must be irritable and overreactive to minor annoyances.

In addition, emotion dysregulation represents mechanisms associated with exposure to traumatic events. Emotion regulation can be defined as the individual’s capacity to monitor, evaluate, and modify emotional reactions in a manner that facilitates adaptive functioning. Apparently, the relationship between emotion dysregulation and mental disorders can be identified in survivors of repeated interpersonal traumatization.

Refugees’ Resilience

It has been established that many refugees do not develop mental disorders. However, most studies focus on mental disorders, with little or no attention to resilience. However, a narrow focus on mental disorders may not capture the diversity of mental health symptoms of displaced populations.

Resilience can be conceptualized as individual resilience, e.g., as better-than-expected trajectories of healthy functioning over time (Bonanno, Westphal, & Mancini, 2011; McEwen, 2016; Panter-Brick & Leckman, 2013; Ungar, 2011); as the harnessing of resources to overcome adversity, to cope with adversities; or as the capacity of a system to adapt successfully. However, resilience can be conceptualized as well as a multidimensional dynamic outcome that incorporates personal skills and qualities together with social environments and a supportive environment, rather than as an individual characteristic. Building on these concepts it can be assumed that the main pursuit after traumatic life disruptions is to restore resources that have been lost. The guiding assumption is that all humans aim to obtain, retain, foster, and protect resources, defined widely to include a range of domains, including the personal (health, well-being, positive sense of self), familial, and social (preservation of peace, capacity to work, access to facilities and services). Maintaining resources is essential to fulfilling the task of self-regulation and a sense of control (Jayasuriya, 2014).

Despite some of the worst horrors imaginable, there are indeed many who manage to show mental health and interpersonal functioning despite substantial exposure to violence. For instance, in a study of 529 war-affected youth followed for more than 6 years since the end of Sierra Leone’s civil war, it was observed that while average mental health symptoms are higher than US clinical thresholds, most are on an improving or low symptom trajectory over time despite nearly nonexistent access to mental health care (Betancourt, McBain, Newnham, & Brennan, 2014). In a review on resilience in adolescents based on qualitative studies, six sources of resilience were identified: social support, acculturation strategies, education, religion, avoidance, and hope (Sleijpen, Boeije, Kleber, & Mooren, 2016).

Data suggest that refugees’ mental health needs to be studied together with their resilience. Mental disorders and resilience vary over time and may exist in the same person. Attention to resilience and resilience trajectories is widening the scope of refugee mental health understanding beyond a focus on psychopathology (Betancourt, Frounfelker, Mishra, Hussein, & Falzarano, 2015; Betancourt et al., 2010; Hobfoll, 2012; Hobfoll, Stevens, & Zalta, 2015). We might need to conceptualize resilience not as the polar opposite of vulnerability and psychopathology but as an attribute of refugees living in new contexts.

Mental Health and Mental Disorders of Refugee Women

While the majority of refugees arriving have been men, there are increasing numbers of women and children among the arrivals (Usta & Masterson, 2015). It is impossible to give an accurate figure for the women refugees arriving in Europe due to the lack of gender disaggregated data, but the UNHCR estimates that among those arriving in the EU, about 20% are women. According to UNHCR, the proportion of women refugees has been increasing since 2015, and a greater proportion of women are now traveling alone or just with their children. Women are traveling alone because they are single or because they have lost their husbands during war. In some cases, families become separated, either by smugglers or by officials. There have been cases, for example, where a sea rescue has been carried out by Greek and Turkish coast guards together, with some refugees being brought to Greece and others taken back to Turkey.

Women are exposed to gender-based violence (GBV) before, during, and after flight (Freedman, 2016; Jefee-Bahloul, Bajbouj, Alabdullah, Hassan, & Barkil-Oteo, 2016; Warren, Post, Hossain, Blanchet, & Roberts, 2015). Studies on refugee populations from Bosnia (Hynes, Ward, Robertson, & Crouse, 2004), Serbia (Avdibegović & Sinanović, 2006; Djikanovic, Jansen, & Otasevic, 2010), East Timor (Hynes et al., 2004), the Democratic Republic of Congo (DRC) (Johnson et al., 2010), and Somalia (Byrskog, Olsson, Essén, & Allvin, 2014) found prevalence rates of violence against women ranging from 24.8 to 75.9%. Another source of GBV are the smugglers or traffickers who facilitate their journeys to reach Europe.

Women traveling alone or just with children are particularly vulnerable to attacks. As well as the insecurities of their journey, these women suffered abuse from their own husbands, who not only did not protect them but posed a threat. Women in this situation find it almost impossible to leave their abusive husbands or partners because of the challenge of continuing the journey alone or with just their children. So they find themselves stuck in a violent relationship with no hope of escaping. Respondents in Serbia also said that they had noted cases where husbands were violent to their wives, but again they felt that there was little that they could do to help these women who were determined to continue their journey as quickly as possible. The vulnerability of refugee women to GBV is exacerbated by the inadequacy of the reception and accommodation conditions in many countries. The situation in the Greek islands where refugees are currently arriving in large numbers is catastrophic, with no accommodation available for most refugees, meaning that they are left to sleep in the open air in parks, fields, or on the streets (Freedman, 2016).

Little is known about the psychological status of older refugees who have immigrated from war-torn areas. A study among older Kurds living in one city in the United States (n = 70) found elevated levels of depression, with 67.1% scoring above the clinical cutoff for depression and 25.7% scoring in the severe depression range. Among these older refugees, depression was associated with demographic (age), stressor (migratory grief, death of spouse, number of medical conditions, functional disability, and income), and coping (English proficiency and social support) variables. Health conditions exerted the greatest effect. Migratory grief and social support were also significant predictors of depression (Taylor et al., 2013).

Course of Mental Disorders, Mental Health, and Resilience Among Refugees

Only a small number of studies have followed up on refugees’ mental health and mental disorders longitudinally (Hauff & Vaglum, 1995; Lie, 2002; Steel et al., 2011). These longitudinal studies suggest a common pattern of trajectories: most refugees continue to show low or no symptoms, a significant minority shows a pattern of gradual recovery, and a small group shows chronic mental disorders (Silove, 1999a). This tripartite pattern of (1) low or no symptoms, (2) gradual recovery, and (3) chronicity, although tentative, has important implications from a public mental health perspective. From that perspective, refugees show both symptoms of mental disorders and resilience.

There is concern for how children and youth will fare as parents and how untreated problems with hopelessness, interpersonal difficulties, or anger will affect interpersonal relationships and quality-of-life outcomes (Betancourt, 2015). For many forced dislocation-affected youth, the aftereffects of loss and trauma can result in paradoxical behavior: even when they are given an opportunity, they squander it (Hirani, Payne, Mutch, & Cherian, 2016). For example, nongovernmental organization programs have lamented the low attendance in youth employment and education programs. Rather than reflecting laziness or culture-specific traits, these types of behavior are manifestations of the mental health consequences of forced displacement and traumatic experiences. Numerous studies of war-affected youth show that a high level of exposure to violence is often associated with a foreshortened sense of the future that can lead a young person to sell the very tools given to him or her in the hopes of promoting economic self-sufficiency.

Neuroscience has illustrated how this may occur: the prefrontal cortex is still under tremendous development in adolescence through young adulthood (McEwen, 2017; Peters, McEwen, & Friston, 2017). When an individual is exposed to extreme and repeated violence or toxic stress (Lindert et al., 2014), consequences emerge at the level of physiology and brain function, disrupting self-regulatory capacities as well as elements of executive functions and problem solving necessary for functioning.

Determinants of Refugees’ Mental Disorders and Mental Health

Adverse impacts of forced displacement on mental health are well established and are compounded in these situations by the events typically precipitating migration, as well as by events occurring during and after the flight (Guruge & Butt, 2015; Miller & Rasmussen, 2010; Roberts & Browne, 2011). A number of studies found that determinants of mental health conditions among refugees’ conditions are (1) socio-demographics, (2) socioeconomic-political determinants, and (3) social capital (Miller & Rasmussen, 2014; Rostila, 2011; Wind, Fordham, & Komproe, 2011). Social capital itself is compounded by bonding capital (e.g., between family members), bridging social capital (e.g., between groups of people that are socially heterogeneous), and linking social capital (e.g., voting and trust in social institutions) (Putnam, 2001; Rostila, 2011; Szreter & Woolcock, 2004). Some socio-demographic characteristics have been identified as risk factors, such as being older, female, from rural background, and less well educated and having a lower socioeconomic status (Rasmussen & Annan, 2010).

Table 3. Socio-Demographic Determinants of Refugees’ Mental Health

Depression

Anxiety

PTSD

Studies

Female gender

+

+

+

(Cardozo, Talley, Burton, & Crawford, 2004; Feyera, Mihretie, Bedaso, Gedle, & Kumera, 2015; Roberts, Damundu, Lomoro, & Sondorp, 2009; Roberts et al., 2008; Sabin, Cardozo, Nackerud, Kaiser, & Varese, 2003; Vonnahme, Lankau, Ao, Shetty, & Cardozo, 2015)

Being divorced

+

na

na

(Feyera et al., 2015)

Living alone

+

na

na

(Schweitzer, Melville, Steel, & Lacherez, 2006)

na = not applicable.

Importantly, violence-related factors are major determinants of refugees’ life and their mental health. Violence can occur before, during, or after resettlement (Table 4). Often these determinants are investigated. However, this focus tends to ignore political, economic, cultural, and racial aspects of the settlement experience that affect well-being, with some studies indicating that post-migration experiences are more important in undermining well-being than pre-migration physical and psychological trauma (Table 4). Among the socioeconomic-political determinants are prolonged displacement, detention, insecure residency status, challenging refugee determination procedures, restricted access to services, and lack of opportunities to work or study, combined in a way that compounded the effects of past traumas in exacerbating symptoms of PTSD and depression in a dose-response relationship.

Table 4. Socioeconomic-Political Determinants of Refugees’ Mental Health (Pre-Flight, During Flight, and Post-Flight)

Determinants

Pre-flight

During Flight

Post-flight

War

Violence

Discrimination, racism

Persecution

Exploitation

Lack of access to meaningful work

Torture

Lack of access to food

Detention centers

Gender-based violence

Gender-based violence

Gender-based violence

Discrimination

Threats to physical safety

Threats to physical safety

Lack of access to services

Restricted access to services

Restricted access to services

Murder of family/friends

Separation from family/friends

Separation from family/friends

Lack of housing or shelter

Lack of housing or shelter

Violence in refugee camps

Notwithstanding these sources of heterogeneity, substantive issues of a universal nature—such as the extent of exposure to torture, the severity and number of trauma events experienced, the socio-demographic characteristics of the population, the level of eco-social threat that the community continues to face, and the nature and extent of post-migration stressors—all make a major contribution to the prevalence of disorders across populations. Likewise, social capital can explain differences between refugee groups, especially in post-flight situations. Given that refugees left a considerable share of their social network in their home country, family social capital is an important determinant for refugees’ mental health.

Given the variation in individuals, in socio-demographic-political determinants, and in social capital, it is not surprising that prevalence rate and course of mental distress differ from one displaced population to another. The interruption or the linking between refugees and the surrounding societies is a key mechanism by which forced dislocation migration may negatively impact mental health.

Family as a Major Determinant for Refugees’ Mental Health

In light of refugees’ realities, family social capital is a major determinant for refugees’ mental health. Consistent evidence documents bonding capital as important for refugees’ mental health (Johnson, Rostila, Svensson, & Engström, 2017). Accordingly, the negative impact of family separation on refugee mental health is increasingly clear. Mixed methods data from a community-based mental health intervention study reveal that family separation was a major source of distress for refugees. The distress was experienced in a range of ways: as fear for family still in the country of origin, as a feeling of helplessness, as cultural disruption, and as the greatest source of distress since resettlement (Miller, Hess, Bybee, & Goodkind, 2017).

Met and Unmet Health and Psychosocial Care Needs

Studies suggest that refugees underuse mental health services compared with non-refugees. Experiences in the country of origin—cultural, religious, linguistic, or economic factors—may contribute to this underuse (Whitley, Kirmayer, & Groleau, 2006). Best practices to overcome these factors are essential (Ventevogel, Ommeren, Schilperoord, & Saxena, 2015). In 2012, a clinic in Louisville, Kentucky, began to use the RHS-15 to screen for mental health issues among refugees. At the same time, mental health outreach programs were developed and implemented by the Mental Health Coordination program (Ballard-Kang, Lawson, & Evans, 2017). Those more likely to accept services included refugees in the United States more than 240 days and those referred by non-clinic sources. Still, there is an urgent need to provide an updated systematic review of the current best evidence for managing mental distress in refugee populations. A lack of culturally adapted treatments was apparent, and there was less evidence to support standard cognitive behavioral therapy (CBT), eye movement desensitization and reprocessing (EMDR), and multidisciplinary treatments. Studies found medium- to high-quality evidence supporting the use of narrative exposure therapy (NET) and short interventions (Slobodin & De Jong, 2015).

In a review of mental health treatment for refugees, the most often implemented activities were provided by peers and general practitioners followed by counseling (Nickerson & Hinton, 2011). These activities include basic counseling for individuals, groups, and families; facilitation of community awareness and support; child-friendly spaces and structured recreational activities; and non-pharmacologic management of mental health disorders (Patel, Kellezi, & Williams, 2014). Most models draw on evidence from Western contexts supporting trauma-focused cognitive behavioral therapies (Hinton, Ojserkis, Jalal, Peou, & Hofmann, 2013). Relatively few randomized controlled trials (RCTs) have been conducted to evaluate interventions. These evaluations suggest modest improvements in PTSD symptoms with narrative exposure therapy among adults but differing efficacy for other interventions.

Accordingly, it might be that mental health interventions should focus more on providing the supportive environments that allow refugees to set up (social) bonds again and restore their resources and become embedded in routine primary care services in a manner that is sustainable. Refugees with complex exposures may not have the motivation or capacity to engage Western-based therapies.

Questions remain, therefore, as to the best strategies to assist refugees. As indicated, research findings are consistent with contemporary ecological models in demonstrating the powerful impact that context exerts on the mental health and resilience of refugees. The impact of forced displacement is that refugees commonly lack the support of nuclear and extended families. Even in intact families, relationships can be undermined by the cumulative effects of past trauma and ongoing stressors, resulting in anger, conflict, and, at worst, intimate partner violence.

Social programs for refugees have the potential to revive resources and a sense of connectedness, re-establish social networks, and promote self-help activities. Strategies that foster community initiatives encourage engagement and attachment within families and attachment to the host communities (Mirghani, 2013).

In the refugee setting, sociotherapy is a promising psychosocial intervention (Richters, Dekker, & Scholte, 2008), the primary focus being the fostering of connections between people. The method was developed in the post-genocidal context of Rwanda and has since been applied in other settings, including among refugees (Duhumurizanye Iwacu Rwanda, 2015; Scholte et al., 2011; Verduin, Smid, Wind, & Scholte, 2014). Groups share and discuss daily problems ranging from interpersonal arguments, feelings of discrimination and anger, and strategies to deal with GBV. The restorative experience of bonding aims at repairing disrupted social relationships. Preliminary research suggests that these interventions have the effect of increasing social capital and improving refugees’ mental health (Scholte et al., 2011; van Ee, Kleber, & Mooren, 2012; Verduin et al., 2014).

Conclusion

Refugees are regarded as one of the highest-risk groups for mental disorders. However, we know that the effects of war and forced displacement are not deterministic. Sustainability of health and psychosocial services, ensuring best practice, evidence-based approaches, and promoting access to services might be the next steps. Additionally, an important direction for research is to distinguish the needs of the various refugee subpopulations of interest: those with mental disorders due to environmental factors, for whom non-clinical group interventions may be of assistance; those whose traumatic stress reactions are severe, disabling, and unlikely to resolve spontaneously and who may benefit from brief structured psychotherapies; more complex trauma-related cases who may benefit from longer-term rehabilitation; the severely mentally ill who need an array of mainstream interventions; and special groups such as women exposed to GBV who may require a cultural and a gender-sensitive intervention (Betancourt & Chambers, 2016; Murray & Jordans, 2016). A major challenge that the field confronts at a global level is that most refugee populations reside in locations where the resource base in mental health is extremely low. Listening to the voices of various refugee communities is vital. Mental health cannot be conferred, it must be regained by the communities that have lost the ability to live together.

To better mitigate the impact of forced displacement from one generation to the next, health care professionals must recognize not only the immediate effects of trauma but also its long-term implications. At the health system level, this means not only strengthening primary care systems but also building trauma-informed mental health services and ensuring inclusion of mental health in the primary package of services available for refugees. It may be true that war is as old as humanity itself; however, the intergenerational transmission of violence does not have to continue (Carta et al., 2016). After all, forced displacement and violence before, during, and after the flight are man-made and malleable to interventions.

Further Reading

Kirmayer, L. J., Bennegadi, R., & Kastrup, M. C. (2016). Cultural awareness and responsiveness in person-centered psychiatry. In J. Mezzich, M. Botbol, G. Christodoulou, C. R. Cloninger, & I. Salloum (Eds.), Person Centered Psychiatry (1st ed., pp. 77–95). Switzerland: Springer International Publishing.Find this resource:

Lindert, J., von Ehrenstein, O. S., Wehrwein, A., Brahler, E., & Schafer, I. (2018). Anxiety, depression and posttraumatic stress disorder in refugees—a systematic review. Psychotherapie, Psychosomatik, Medizinische Psychologie.Find this resource:

McEwen, B. S. (2016). In pursuit of resilience: stress, epigenetics, and brain plasticity. Annals of the New York Academy of Sciences, 1373(1), 56–64.Find this resource:

Pena, E. (2007). Lost in translation: methodological considerations in cross cultural research. Child Development, 78(4), 1255–1264.Find this resource:

Peters, A., McEwen, B. S., & Friston, K. (2017). Uncertainty and stress: why it causes diseases and how it is mastered by the brain. Progress in Neurobiology, 156, 164–188.Find this resource:

Roberts, B., & Browne, J. (2011). A systematic review of factors influencing the psychological health of conflict-affected populations in low and middleincome countries. Global Public Health, 6(8), 814–829.Find this resource:

Slobodin, O., & De Jong, J. T. (2015). Mental health interventions for traumatized asylum seekers and refugees: what do we know about their efficacy? International Journal of Social Psychiatry, 6(1), 17–26.Find this resource:

Ungar, M. (2011). The social ecology of resilience: addressing contextual and cultural ambiguity of a nascent construct. American Journal of Orthopsychiatry, 81(1), 1–17.Find this resource:

Ventevogel, P., Ommeren, M. v., Schilperoord, M., & Saxena, S. (2015). Improving mental health care in humanitarian emergencies. Bulletin of the World Health Organization, 93(10), 666–666A.Find this resource:

Wells, R., Wells, D., & Lawsin, C. (2015). Understanding psychological responses to trauma among refugees: the importance of measurement validity in cross-cultural settings. Journal and Proceedings of the Royal Society of New South Wales, 148(455/456), 60–69.Find this resource:

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