WPA guidance on mental health and mental health care in migrants

Psychological morbidity in Nepali cross-border migrants in India: a community based cross-sectional study

BACKGROUND

Since Nepali cross-border migrants can freely enter, work and stay in India, they are largely undocumented. The majority is involved in semi-skilled or unskilled jobs with limited labour rights and social security, a fact which predisposes them to psychological distress. We aimed to assess the prevalence of and factors associated with psychological morbidity among Nepali migrants upon their return from India.

METHODS

A community based cross-sectional study was conducted in six districts of Nepal between September 2017 and February 2018. A total of 751 participants who had worked at least six months in India and returned to Nepal were interviewed from 24 randomly selected clusters. The General Health Questionnaire (GHQ)-12 was used to measure the psychological morbidity. Data were analysed using Poisson regression analysis.

RESULTS

The majority was younger than 35 years (64.1%), male (96.7%), married (81.8%), had at least a primary education (66.6%), and belonged to Dalit, Janajati and religious minorities (53.7%). The prevalence of psychological morbidity was 13.5% (CI: 11.2-16.1%). Participants aged 45 years and above (adjusted prevalence ratio (aPR) = 2.74), from the Terai (aPR = 3.29), a religious minority (aPR = 3.64), who received no sick leave (aPR = 2.4), with existing health problems (aPR = 2.0) and having difficulty in accessing health care (aPR = 1.88) were more likely than others to exhibit a psychological morbidity.

CONCLUSION

This study demonstrated that psychological morbidity was prevalent in the study participants and varied significantly with individual characteristics, work conditions and health. Multifaceted approaches including psychological counselling for returnees and protection of labour and health rights in the workplace are recommended to help reduce psychological morbidity.

Mental health service users' progression from illicit drug use to schizophrenia in New Zealand

BACKGROUND

Recently, publications have hypothesised that the demonstrated increase in the incidence of schizophrenia in New Zealand is a side effect of the increased strength of available cannabis derivatives over the last 25+ years and the much more recent increase in the population's use of methamphetamine.

AIM

To compare the rates of later schizophrenia between age-matched mental health service users with initial diagnoses as alcohol abusers or illicit drug users.

METHOD

From the PRIMHD comprehensive national database, all users of the mental health services over a 5-year period who received an ICD-10 presenting diagnosis of alcohol or substance use/abuse were identified. For each person identified, the database was examined for the following 3 years to determine the numbers later diagnosed with schizophrenia.

RESULTS

For the initial alcohol problem people in their twenties, 1.7% were diagnosed as suffering from schizophrenia in the subsequent 3 years. For the initial drug problem people, the rate was 10.9%. Within that drug-using population, the indigenous Maori developed schizophrenia at a higher rate than did the remainder of the population.

CONCLUSION

These findings in New Zealand require further research into their generalisability, context and explanation.

Pathways to and Results of Psychiatric Consultation for Patients Referred from the Emergency Department. Are there Differences between Migrant and Native Patients?

The aim of this study was to compare migrants and native Italians on the pathways to care and results of psychiatric consultation (PC) in the emergency department (ED). Patients who were referred from the ED for psychiatric consultation (EDPC) at the Maggiore della Carità Hospital between March 2008 and March 2015 were recruited consecutively. Socio-demographic, clinical and consultation variables were recorded along with information about suicidal behaviours; migrants ( n = 379; 42.74% males, 57.26% females; age: 45.38 ± 16.95 years) were compared with native Italians ( n = 2942; 43.51% males, 56.49% females; age: 42.08 ± 15.89 years). Migrants were younger, more likely to be unemployed and less likely to be already under the care of a psychiatrist. Symptoms related to use of alcohol or substances were more frequent in migrants, especially female migrants. Migrants were less likely than native Italians to be referred for PC because of the presence of psychiatric symptoms, however they were more likely to be referred because of self-harming behaviour. Nonetheless, migrant status was not identified as a risk factor for suicidal behaviour in the multivariate analysis. The outcome of EDPC showed differences between migrants and natives. In absolute terms migrants were less likely to be admitted to a psychiatric ward after the EDPC than native Italians, while they were more likely to be monitored in the ED before being discharged or referred to outpatient care. In a high percentage of psychiatric examinations of migrants, no psychiatric symptoms were identified. Further studies are warranted to disentangle the meaning of these findings.

The latent structure of major depressive symptoms and its relationship with somatic disorder symptoms among Filipino female domestic workers in China

Emerging research have investigated the factor structure of major depressive disorder (MDD) symptoms based on DSM-5 nomenclature. However, to date, results have been inconsistent on what symptom-structure best represent MDD. This study examines the best fitting MDD among four competing models in a sample of overseas Filipino domestic helpers (N = 232). The results show that a two-factor model (Model 2b; Krause et al., 2010) provided the best fit. The model consist of two factors: somatic and non-somatic/affective symptoms. Somatic component includes sleep difficulties, fatigue, appetite changes, concentration difficulties, and psychomotor agitation/retardation while non-somatic/affective component covers anhedonia, depressed mood, feelings of worthlessness, and thoughts of death. Further, the results reveal a pattern where PHQ-15 somatic symptom-items have a higher significant relationship with MDD's somatic symptoms than with the MDD's non-somatic/affective symptoms. These findings suggest that the items of model 2b are appropriately embedded in their respective factors. Differentiating MDD factors have important clinical implications, particularly in the diagnosis and treatment of depression among overseas Filipino domestic helpers.

Psychological Burden in Female, Iraqi Refugees Who Suffered Extreme Violence by the "Islamic State": The Perspective of Care Providers

Introduction: A large number of refugees suffer from mental disorders such as post-traumatic stress disorder (PTSD). In the context of a special quota project, 1100 Yazidi women from Northern Iraq who had suffered extreme violence by the so-called Islamic State (IS) were brought to Germany to receive specialized treatment. This study aims to investigate the psychological burden and trauma-related symptoms of these female IS-victims from the perspectives of their care providers. Material and methods: Care providers with various professional backgrounds (N = 96) were asked to complete a self-developed questionnaire on a Likert-type scale ranging from 1 (very low) to 7 (very high) analyzing the psychological burden and trauma-related symptoms of the IS-traumatized women since their arrival in Germany. We controlled for potential confounders, namely the care providers' personal experiences of trauma and flight, by using chi-square tests. Results: The mean psychological burden for the whole period in Germany as perceived by care providers was M = 5.51 (SD = 0.94). As the main factors of distress the care providers reported: worries about family members in Iraq (M = 6.69; SD = 0.69), worries about relatives' possibilities to be granted asylum in Germany (M = 6.62; SD = 0.68), and uncertainties regarding their future (M = 5.89; SD = 1.02). The most prominent trauma-related psychological symptoms were nightmares (M = 6.43; SD = 0.54). The care providers reported that somatic complaints have been present among the refugees in the following manifestation: pain (M = 6.24; SD = 1.08), gastrointestinal complaints (M = 4.62; SD = 1.62), and dizziness (M = 4.40; SD = 1.59). The care providers' personal experiences of trauma and flight had no significant influence on their response behavior. Discussion: Care providers working with IS-traumatized female refugees evaluate the psychological burden and trauma-related somatic and psychological symptom loads of their clients as very high. The results of this study provide important information about the perceptions of care providers working in a refugee-services context and may provide insights for the progression of specialized treatment programs and interventions for highly traumatized refugees and culture-sensitive training programs for their care providers.

Culture and Psychopathology: New Perspectives on Research, Practice, and Clinical Training in a Globalized World

The present paper discusses the role of culture in understanding and treating psychopathology. It describes new perspectives on the conceptualization of psychopathology and on the definition of culture, and how these are intertwined. The impacts of culture, explicit and implicit discrimination, and minority stress on mental health are reviewed, especially in the current era. Culturally-sensitive assessment practices in psychopathology are emphasized, including addressing the multiple cultural identities of the patient, the explanatory models of the experienced distress, specific psychosocial stressors and strengths, and the cultural features of the practitioner-patient relationship in the clinical encounter. The particular case of psychotherapy in working with culturally diverse patients is explored. Finally, mainstreaming of culture in research and clinical training in psychopathology is highlighted, acknowledging that each clinical interaction is a cultural one.

Upon Rejection: Psychiatric Emergencies of Failed Asylum Seekers

Background: The status of a refugee or asylum seeker is only recognised after legal processes. The uncertainty of these procedures or the rejection itself may severely impact mental well-being. Methods: We surveyed the patterns of psychiatric services used by patients whose applications for asylum had been rejected. In a retrospective investigation of admissions to the University Emergency Department in Bern, Switzerland between 1 March 2012 and 28 February 2017, we studied patients receiving a psychiatric consultation after their applications had been rejected. The primary endpoint was based on the comparison of these individuals with controls who were asylum seekers with pending asylum applications using the Mann-Whitney U test and the chi-square test (χ²) with a significance level of 0.05. Results: Thirty-eight cases were identified. There were more men than women and the mean age was 30.08 ± 9.62 years. Patients predominantly presented as walk-in patients (n = 16, 42.1%), most frequently due to suicidal ideation (n = 16, 42.1%). Stress-related disorders were the most common diagnosis (n = 29, 76.3%) and patients were mainly referred to inpatient treatment (n = 28, 73.7%). Patients with rejected applications were less likely to be living in reception centres than patients with a pending application (χ² = 17.98, p < 0.001). Conclusion: The profile of asylum seekers whose applications had been rejected reflects individuals with high-stress levels, potentially aggravated by the negative asylum decision.

Suicide Risk among Immigrants and Ethnic Minorities: A Literature Overview

Recent studies have demonstrated that immigrants and ethnic minorities may be at higher risk of suicidal behaviour as compared to the general population. We conducted a literature search to identify studies in English from 1980 to 2017 related to suicide risk among immigrants and ethnic minorities. Six hundred and seventy-eight reports were screened, and 43 articles were included in the qualitative synthesis of the review. Some studies reported lower rates of suicide attempts, while other findings suggested higher rates of suicidal behaviour and deaths among immigrants as compared to the native population. Also, a positive correlation was found between suicidal behaviour and specific countries of origin. Non-European immigrant women were at the highest risk for suicide attempts, a group which included young women of South Asian and black African origin. Risk factors among migrants and ethnic minorities were found to be: language barriers, worrying about family back home, and separation from family. The lack of information on health care system, loss of status, loss of social network, and acculturation were identified as possible triggers for suicidal behaviour. Overall, results suggest that specific migrant populations and ethnic minorities present a higher risk of suicidal behaviour than native populations, as well as a higher risk of death by suicide.

Psychiatric Emergencies of Asylum Seekers; Descriptive Analysis and Comparison with Immigrants of Warranted Residence

Background: The aim of our study was to assess utilization patterns of psychiatric services by asylum seekers. Methods: We included 119 adults who presented themselves at the University Emergency Department between 1 March 2012 and 1 January 2017 for psychiatric consultation. Descriptive data were compared with a control group of non-Swiss individuals with warranted residence permits using Mann-Whitney-U and chi square (χ²) tests. Results: Patients were mainly single, male, residing in reception centers, and presented themselves most frequently due to suicidal ideation. Almost 60% of the patients were assigned to inpatient treatments, with 28 involuntary cases. Compared to the control group, asylum seekers were younger and more often men (p < 0.001 for both). Further, they less often had family in Switzerland (χ² = 9.91, p = 0.007). The proportion of patients coming in as walk-ins was significantly higher in the control group than in asylum seekers (χ² = 37.0, p < 0.001). Asylum seekers were more frequently referred due to suicidal ideation and aggressive behavior than participants in the control group (χ² = 80.07, p < 0.001). Diagnoses for asylum seekers infrequently included mood, as they often reported stress-related disorders (χ² = 19.6, p = 0.021) and they were infrequently released home (χ² = 9.19, p = 0.027). Conclusion: Asylum seekers more frequently demonstrated severe symptoms such as suicidal ideation and aggressive behavior and they were mainly treated as inpatients, potentially due to minimal social resources.

Challenges of Combining Perspectives

Abstract.Background: Asylum seekers have increased risk of suicide and suicidal behavior, with differences related to origin, gender, and age. There are barriers to communication in clinical encounters between asylum seekers and clinicians. There is insufficient knowledge about how communication in the clinical encounter affects the suicide risk in female asylum seekers. Aims: To explore the documented communication between female asylum-seeking suicide attempters and clinicians and how it affects treatment. Method: The medical records of 18 asylum-seeking women who had attempted suicide were analyzed with content analysis. Results: Communication between patients and clinicians was affected by: the unbearable realities of the women; difficulties for clinicians in decoding languages of distress, and understanding trauma and subjective meanings of suicide; challenges of combining patients' and clinicians' perspectives; and a sense of shared powerlessness. Limitations: The medical records did not give direct access to the patient's experience, only to the patient as documented by the clinician. Conclusion: The results suggest that clinicians working with asylum seekers who have attempted suicide need to develop an understanding of social and cultural factors and of trauma issues. A question for further study is how an enhanced integration of context and subjectivity in psychiatric practice would equip clinicians for the specific challenges encountered.

Psychiatric screening and interventions for minor refugees in Europe: an overview of approaches and tools

Currently hundreds of thousands of minor refugees entered Europe. This group has been exposed to traumatic events pre-, during, and post-migration and is at increased risk of developing psychiatric disorders. In this article, we describe the results of our literature search on screening and interventions for post-traumatic stress disorder (PTSD) in minor refugees, in order to make recommendations for clinical practice. Results show that studies on diagnostic accuracy of assessment instruments and efficacy of mental healthcare interventions in this population are lacking. Traumatic experiences pre-flight, during the flight and at resettlement, superimposed by parental PTSD, and other contextual factors, might lead to more than 25% of minor refugees developing PTSD.

CONCLUSION

To enhance the number of minor refugees recognized with PTSD, we recommend the use of a brief screening instrument. A public health approach, focusing on environmental supportive factors is the first step in treatment for this group, followed by short-term psychological group interventions focusing on psycho-education and stress reduction. Minor refugees with no improvement in PTSD symptoms by these interventions need referral to specialized mental health care services. Mental health providers should be culturally competent. What is Known: • Post-traumatic stress disorder, anxiety, sleeping problems, and depression are the most common psychiatric disorders in minor refugees. • Evidence based methods on screening and interventions in minor refugees with psychiatric disorders are lacking. What is New: • In the absence of validated screening tools a best practice reliable, quick and child-friendly tool is presented. • A layered system for mental health care and psychosocial support in minor refugees is explained.

Prevalence of emotional and behavioral problems and subthreshold psychiatric disorders in Austrian adolescents and the need for prevention

PURPOSE

Epidemiological data are crucial to plan adequate prevention strategies. Thus, this study aims at obtaining the prevalence of mental health problems (MHP) and subthreshold psychiatric disorders based on a representative sample of Austrian adolescents.

METHODS

Adolescents aged 10-18 were recruited from Austrian schools. Emotional and behavioral problems were determined using the Youth Self-Report (YSR); the point prevalence of subthreshold psychiatric disorders was assessed using structured diagnostic interviews. Sociodemographic variables including socioeconomic background, migration status, family structure, and place of residence were obtained. In addition, a non-school sample (unemployed adolescents, and child and adolescent psychiatry patients) was included to enhance representativeness and generalizability.

RESULTS

3446 students, 37 unemployed adolescents, and 125 child and adolescent psychiatric patients provided analyzable YSR data sets. In the school sample, 16.5% scored in the clinically relevant range, while internalizing problems were more prevalent (17.8%) than externalizing problems (7.4%). These prevalences increased by 0.7-2.0% when the non-school sample was taken into account. A low socioeconomic status (SES) and living in single parent families were associated with higher problem scores. Regarding the interviewed sample (377 students and 407 parents), subthreshold psychiatric disorders were observed in 12.7% of students. 92.5% of them have not yet received any kind of help.

CONCLUSIONS

A significant proportion of Austrian adolescents are at risk for MHP. A non-responder analysis indicates that the observed prevalence may be even underestimated. These findings emphasize the urgent need for targeted prevention, especially for reducing anxiety and depressive symptoms and for adolescents in disadvantaged families.

Migrant women’s negotiation of belonging through therapeutic relationships

Purpose

The purpose of this paper is to explore experiences and emotions of migrant women, who have been in psychotherapy in Sweden, their motives and experience of being treated in psychotherapy. The authors argue that not only traumas of the past but also social suffering in the post-migratory phase contribute to what brought them in contact with psychiatric care.

Design/methodology/approach

Narrative interviews with 12 migrant women, holding permanent residence permits, were conducted. The interviews were loosely structured around themes such as the experience of migration, of everyday living in Sweden, experiences of Swedish psychiatric care, and reflections and understandings of mental and physical health/ill health. Interview transcripts were analyzed thematically using abductive qualitative text analysis.

Findings

In the narratives an overarching motive for seeking out psychiatric help is the search for belonging and restoring a cohesive sense of self. Belonging is sought both in symbolic terms – formal access and right to health care – and in a deeper emotional sense as the therapist becomes a local adviser. The therapeutic encounter meets the human desire to be seen and confirmed as the person you are, and need to be, in the new host society. Meanwhile, psychotherapy as a way to negotiate belonging is also a risky endeavor, as the idealized view of the therapeutic relation may be disappointed.

Research limitations/implications

This study provides the interviewed migrant women’s perception of the psychotherapeutic relationship. Yet this relationship needs to be elaborated from different perspectives to improve understanding of psychotherapy in psychiatric care.

Originality/value

The paper fills a gap in research concerning the dominance of the psychiatric discourse over subjective understandings of health and illness, and how this relates to emotions of social suffering in the case of migrant women.

Counting the cost of Afrophobia: Post-migration adaptation and mental health challenges of African refugees in South Africa

There are few studies on the role of migration within sub-Saharan Africa and its relation to the development of mental illness. We investigated post-resettlement adaptation and mental health challenges of African refugees/migrants in Durban, South Africa. We interviewed 335 African help-seeking refugees/migrants for anxiety, depression (25-item Hopkins Symptom Checklist) and post-traumatic stress symptoms (30-item Harvard Trauma Questionnaire). Socio-demographic and migration history, focusing on post-migration circumstances and experiences of discrimination in the host country, were obtained. Association between migration and post-settlement factors and mental health outcomes were assessed using adjusted logistic regression models. Prevalence of mental distress was high: 49.4% anxiety, 54.6% depression and 24.9% post-traumatic stress symptoms. After adjustment for family separation since migration, recent arrival in South Africa was associated with increased risk for depression (aOR = 4.0, 95% CI:1.3-11.8) and post-traumatic stress (aOR = 5.2, 95% CI:1.7-15.9), while in unadjusted models, older age on arrival was associated with anxiety (aOR = 5.3, 95% CI:1.4-19.8) and depression (aOR = 6.2, 95% CI:1.6-24.3). History of family separation since migration was independently associated with depression and post-traumatic stress in all models. Discriminatory experiences since migration was also an independent risk factor for all three mental health outcomes. Finally, being divorced/widowed was associated with an increased risk for post-traumatic stress, while higher income earners were protected against post-traumatic symptoms, even after adjustment. Refugees/migrants in South Africa show a significant burden of mental distress that is linked to challenges of adjustment in an often hostile context. Services addressing these and other health-related, social-economic needs should be developed as a priority.

The use of psychiatric services by young adults who came to Sweden as teenage refugees: a national cohort study

AIMS

To investigate the patterns of use of different forms of psychiatric care in refugees who settled in Sweden as teenagers.

METHOD

Cox proportional hazards models were used to estimate the use of different forms of psychiatric care from 2009 to 2012 in a population of 35 457 refugees, aged from 20 to 36, who had settled in Sweden as teenagers between 1989 and 2004. These findings were compared with 1.26 million peers from the same birth cohorts in the general Swedish population.

RESULTS

Unaccompanied and accompanied refugees were more likely to experience compulsory admission to a psychiatric hospital compared with the native Swedish population, with hazard ratios (HRs) of 2.76 (1.86-4.10) and 1.89 (1.53-2.34), respectively, as well as psychiatric inpatient care, with HRs of 1.62 (1.34-1.94) and 1.37 (1.25-1.50). Outpatient care visits by the young refugees were similar to the native Swedish population. The longer the refugees had residency in Sweden, the more they used outpatient psychiatric care. Refugees born in the Horn of Africa and Iran were most likely to undergo compulsory admission, with HRs of 3.98 (2.12-7.46) and 3.07 (1.52-6.19), respectively. They were also the groups who were most likely to receive inpatient care, with HRs of 1.55 (1.17-2.06) and 1.84 (1.37-2.47), respectively. Our results also indicated that the use of psychiatric care services increased with the level of education in the refugee population, while the opposite was true for the native Swedish population. In fact, the risks of compulsory admissions were particularly higher among refugees who had received a secondary education, compared with native Swedish residents, with HRs of 4.72 (3.06-7.29) for unaccompanied refugees and 2.04 (1.51-2.73) for accompanied refugees.

CONCLUSIONS

Young refugees received more psychiatric inpatient care than the native Swedish population, with the highest rates seen in refugees who were not accompanied by their parents. The discrepancy between the use of inpatient and outpatient care by young refugees suggests that there are barriers to outpatient care, but we did note that living in Sweden longer increased the use of outpatient services. Further research is needed to clarify the role that education levels among Sweden's refugee populations have on their mental health and health-seeking behaviour.

The emotional distress of asylum seekers in Israel and the characteristics of those seeking psychiatric versus medical help

Israel has become a destination for asylum seekers. Asylum seekers often experience emotional distress, but have limited access to health services and rarely use psychiatric services. This study sought to understand and characterize the use of psychiatric versus medical services by asylum seekers in Israel. We compared the emotional distress, stressful life events and previous treatment consultations of 21 psychiatric service users (PSU) and 55 medical service users (MSU) at the Open Clinic of Physicians for Human Rights in Tel-Aviv. Participants completed a socio-demographic questionnaire, the General Health Questionnaire (GHQ-12), the Stressful Life Events Scale and the Health Care Utilization Questionnaire. PSU and MSU did not have significantly different levels of emotional distress. PSU reported significantly more stressful life events during the past year than MSU ( M = 5.81, SD 3.47 vs. M = 3.8, SD 2.35, p < 0.01). In comparison to MSU, PSU utilized more medical ( M = 4.33, SD 2.28) and non-medical ( M = 2.38, SD 1.92) services ( p < 0.001) than MSU. Asylum seekers who consulted multiple treatment agencies in the last year were 1.55 times more likely to seek psychiatric treatment than those who had consulted only a few treatment agencies. Emotional distress in asylum seekers appears to be under-diagnosed in the Open Clinic and under-treated by mental health professionals. To better detect this distress, a thorough screening is recommended at assessment. Collaboration with mental health professionals and community and religious leaders consulted in the past is important and can contribute to good health care outcomes in this population.

Migration, violence, and the role of psychiatry in Italy

Immigration to Italy has been increasing exponentially in the last decades due to the international political changes and conflicts in the Middle East. The relationship between immigration and crimes is a debated issue, and violent radicalization of second or third generations of migrants is under increased scrutiny. Consequently, many politicians and political parties use nationalist and xenophobic language. Inevitably, this will have an impact on reactions of the larger population, as well as that of migrants. Psychiatry can have a major role in dealing with immigrants' health needs, and also assessing risk and preventing violent behaviours due to mental disorders. It is possible to prevent some radicalization by employing strategies of education, leading to better integration of immigrants in the community (based on education, housing, work, etc.). However, often specialist services for migrants are lacking, and mental healthcare professionals may remain poorly trained. Italy is one of the major countries in Southern Europe with a large number of illegal and legal migrants; thereby, creating a major pressure on the resources. It is important to understand the links between globalization, migration, and violence in Italy, in order to prevent future radicalization. It is also useful for psychiatrists to act as advocates for migrants to help reduce xenophobia and discrimination supported by some national cultural and political movements. Ethno-psychiatric facilities should be promoted, as well as policies of support, integration, and prevention should be employed to promote legal migration through the European countries.

The synergy of the refugee crisis and the financial crisis in Greece: Impact on mental health

BACKGROUND

The current global financial crisis that started in 2008 resulted in a significant decline in global trade, slowing/reversing economic growth worldwide, and a dramatic increase in public sector debt. At the same time, the global migrant/refugee crisis has reached extreme rates, with millions of people being forced to abandon their homes and communities because of war, political violence or related threats. There is a broad consensus about the deleterious consequences of these crises on psychological well-being, depression, anxiety disorders, insomnia, alcohol abuse and suicidal behavior. Although the separate consequences of economic recession and immigration are extensively discussed in previous research, we know very little about the processes through which the intersection of economic crisis and migrant crisis contributes to the vulnerabilities of natives and migrants during these crises. Of particular concern is the status of children, adolescents and their families, who constitute one of the most vulnerable groups in society.

AIM

To discuss the contexts that economic and migrant crises shape and suggest possible effects of this intersection on mental health risks, especially among children, adolescents and their families, through reflecting on the recent experience in Greece.

METHOD

Review of the literature and critical analysis of the effects of the confluent crises.

CONCLUSION

The interactive effects of these two crises need further exploration. Novel and diverse models of psychological understanding need to be developed in order to manage the effects of the confluent crises. The role of mental health professionals is crucial in this respect, offering culturally flexible, accommodating and empathetic approaches, allowing healing and acceptance in the face of adversity.

Mental health problems of second generation children and adolescents with migration background

OBJECTIVE

Despite the growing number of young second-generation immigrant (SGI) children and adolescents, studies about their mental health are rare. The objective of this study was to investigate the mental health problems of SGI children and adolescents in Istanbul, Turkey.

METHODS

In a clinical sample the mental health of 54 SGIs and 50 native children and adolescents were examined using the Schedule for Affective Disorders and Schizophrenia for School Aged Children-Present and Lifetime Version (K-SADS-PL) and Children's Global Assessment Scale. The assessments were carried out by a blinded rater.

RESULTS

SGI children had higher rates of psychiatric disorders such as depression (p = 0.001), post-traumatic stress disorder (PTSD) (p = 0.011) and anxiety disorders (p = 0.013), more comorbid disorders and lower functionality scores compared to their native counterparts (p = 0.001).

CONCLUSIONS

SGI children seem to have higher rates of psychiatric disorders most probably due to migration-induced burdens. The professionals treating SGI children should have more awareness for these problems to be able to approach them in a culture and language sensitive way.

[Mental treatment of refugees in Germany : Model for a stepped approach]

The recent influx of refugees and asylum seekers into Germany poses a challenge for the national healthcare system. In compliance with the present Asylum Seekers Benefits Act, the national healthcare system can be expected to have 1.5 million new members by early 2017. Providing adequate care particularly for people with mental illnesses or disorders will represent an immense challenge for all actors in the system. The circumstances of the flight combined with the foreign linguistic and socio-cultural background increase the severity of the cases and the difficulties of treatment. No procedures or guidelines for treatment have yet been established to ensure a standardized, cost-efficient and therapeutically effective treatment of patients with this background. This article describes the components of a stepped treatment procedure and proposes a stepped and collaborative care model (SCCM) that could be evaluated in nationwide studies. This approach is based on national and international treatment guidelines and aims to provide target-group specific, culturally sensitive methods of diagnosis and treatment. The various steps of the model build on each other, with the first steps relying on technological aids (e.g. online or smartphone options) and support from lay helpers and the more expensive specialist psychiatric and psychotherapeutic therapy only being initiated in cases of more severe mental disorders.

Mental health and trauma in asylum seekers landing in Sicily in 2015: a descriptive study of neglected invisible wounds

BACKGROUND

In 2015, Italy was the second most common point of entry for asylum seekers into Europe after Greece. The vast majority embarked from war-torn Libya; 80,000 people claimed asylum that year. Their medical conditions were assessed on arrival but their mental health needs were not addressed in any way, despite the likelihood of serious trauma before and during migration. Médecins sans Frontières (MSF), in agreement with the Italian Ministry of Health, provided mental health (MH) assessment and care for recently-landed asylum seekers in Sicily. This study documents mental health conditions, potentially traumatic events and post-migratory living difficulties experienced by asylum seekers in the MSF programme in 2014-15.

METHODS

All asylum seekers transiting the 15 MSF-supported centres were invited to a psycho-educational session. A team of psychologists and cultural mediators then provided assessment and care for those identified with MH conditions. Potentially traumatic events experienced before and during the journey, as well as post-migratory living difficulties, were recorded. All those diagnosed with MH conditions from October 2014 to December 2015 were included in the study.

RESULTS

Among 385 individuals who presented themselves for a MH screening during the study period, 193 (50%) were identified and diagnosed with MH conditions. Most were young, West African males who had left their home-countries more than a year prior to arrival. The most common MH conditions were post traumatic stress disorder (31%) and depression (20%). Potentially traumatic events were experienced frequently in the home country (60%) and during migration (89%). Being in a combat situation or at risk of death, having witnessed violence or death and having been in detention were the main traumas. Lack of activities, worries about home, loneliness and fear of being sent home were the main difficulties at the AS centres.

CONCLUSION

MH conditions, potentially traumatic events and post-migratory living difficulties are commonly experienced by recently-arrived ASs, this study suggests that mental health and psychosocial support and improved living circumstances should be integrated into European medical and social services provided by authorities in order to fulfil their humanitarian responsibility and reduce the burden of assimilation on receiving countries.

Hospital Admission and Criminality Associated with Substance Misuse in Young Refugees - A Swedish National Cohort Study

Background

High rates of mental health problems have been described in young refugees, but few studies have been conducted on substance misuse. This study aimed to investigate the patterns of hospital care and criminality associated with substance misuse in refugees who settled in Sweden as teenagers.

Methods

Gender stratified Cox regression models were used to estimate the risks of criminal convictions and hospital care associated with substance misuse from national Swedish data for 2005–2012. We focused on 22,992 accompanied and 5,686 unaccompanied refugees who were aged 13–19 years when they settled in Sweden and compared them with 1 million native Swedish youths from the same birth cohort.

Results

The risks of criminal conviction associated with substance misuse increased with the length of residency in male refugees, after adjustment for age and domicile. The hazard ratios (HRs) were 5.21 (4.39–6.19) for unaccompanied and 3.85 (3.42–4.18) for accompanied refugees after more than 10 years of residency, compared with the native population. The risks were slightly lower for hospital care, at 2.88 (2.18–3.79) and 2.52(2.01–3.01) respectively. Risks were particularly pronounced for male refugees from the Horn of Africa and Iran. The risks for all male refugees decreased substantially when income was adjusted for. Young female refugees had similar risks to the general population.

Conclusion

The risks of criminality and hospital care associated with substance misuse in young male refugees increased with time of residency in Sweden and were associated with a low level of income compared with the native Swedish population. Risks were similar in accompanied and unaccompanied refugees.

Psychiatric symptoms and disorders among Yazidi children and adolescents immediately after forced migration following ISIS attacks

BACKGROUND

The aim of the present study was to evaluate psychiatric problems and disorders among Yazidi Kurd refugee children and adolescents, who were assessed immediately after their forced migration following life-threatening attacks by ISIS terrorists.

METHODS

We retrospectively analyzed the psychiatric assessments of 38 Yazidi children and adolescents (age 2-18, mean 12 years, m:f = 16:22), which were performed upon their arrival at the refugee camp.

RESULTS

All children and adolescents exhibited psychiatric problems and disorders, 50 % had one, and 50 % had more than one. The most relevant problems were disturbed sleeping (71 % of children), followed by depression (36.8 %), conversion disorders (28.9 %), adjustment (21.8 %), acute (18.4 %) and posttraumatic stress (PTSD, 10.5 %) disorders, and non-organic enuresis (18.4 %).

CONCLUSION

Our study confirms the results of previous studies, asserting that refugee children and adolescents do not just suffer from PTSD but from various other problems that are already present in the first days of resettlement. Children and adolescents living in refugee camps urgently need psychosocial support.

Does migration affect the outcome of inpatient psychotherapy? Results from a retrospective cohort study

OBJECTIVE

Reliable data to determine whether migrant patients benefit sufficiently from evidence-based mental health interventions are scarce. Our aim was to examine the effect of migration on the outcome of inpatient psychotherapy.

METHODS

We conducted a retrospective cohort study and predicted the course of the global severity index of the Symptom Checklist 90 during therapy based on data from our routine clinical practice (N=542). We used mixed models for our analysis and included relevant clinical characteristics.

RESULTS

One hundred and twenty-one patients of our sample had a history of migration which was consistently associated with more symptoms at baseline assessment. Patients with direct experiences of migration had the highest level of symptoms before therapy but also showed the largest decrease of symptoms during therapy (B=-0.09, SD=0.04, p=0.030). This interaction effect could be accounted for by our clinical variables. Patients with indirect experiences of migration did not differ from other patients in their level of improvement (B=-0.05, SD=0.04, p=0.149).

CONCLUSION

According to our preliminary data, migration does not seem to negatively affect the outcome of inpatient psychotherapy. Limitations of these promising findings are discussed together with the strong need for more advanced studies in this area of research.

Discrimination, poor mental health, and mental illness

Discrimination is a major public health issue. Discrimination is known and well recognized to be associated with poor physical and mental health, as well as creating social divisions and fear that undermines the success of society and economic progress. Policies to eradicate discrimination and prejudice in the public sphere, and in public life, need thoughtful and careful planning and engagement by all public institutions and in the way they conduct their business. This forms the basis of social justice. Employers, politicians, and public servants, as well as other stakeholders, irrespective of their professional status, all have ethical responsibilities to uphold such actions and policies, values, and supporting behaviours, as a core principle of successful societies.

Factors associated with psychological distress or common mental disorders in migrant populations across the world

We systematically review factors associated with the presence of psychological distress or common mental disorders in migrant populations. Articles published between January 2000 and December 2014 were reviewed and 85 applying multivariate statistical analysis were selected. Common mental disorders were significantly associated with socio-demographic and psychological characteristics, as observed in large epidemiological studies on general populations. The probability of common mental disorders occurrence differs significantly among migrant groups according to their region of origin. Moreover, traumatic events prior to migration, forced, unplanned, poorly planned or illegal migration, low level of acculturation, living alone or separated from family in the host country, lack of social support, perceived discrimination, and the length of migrants' residence in the host country all increase the likelihood of CMD. In contrast, language proficiency, family reunification, and perceived social support reduce such probability. Factors related with the risk of psychiatric morbidity among migrants should be taken into account to design preventive strategies.

The impact of forced migration on the mental health of the elderly: a scoping review

BACKGROUND

The worldwide elderly population fraction is increasing, with the greatest rise in developing countries. Older adults affected by conflict and forced migration mainly taking place in developing countries may be particularly vulnerable to poor mental health due to other age-specific risk factors. This review aims to explore global evidence on the effect of conflict-induced forced migration on the mental health of older adults.

METHODS

Seven bibliographic databases were searched. The title and abstract of 797 results were reviewed for qualitative and quantitative studies meeting inclusion and exclusion criteria.

RESULTS

Six studies were selected for the in-depth review. Five papers assessed mental health in older adult populations displaced as refugees. One paper assessed mental health of older adults with varying immigration status.

CONCLUSIONS

This review highlights the dearth of evidence about the impact of forced migration on the mental health of older adults. Further research is needed to explore the risk factors and processes that contribute to adverse mental health outcomes among older adult populations. This is essential to the development of interventions for this vulnerable and at-risk population, particularly in resource-poor settings.

Exploring the infant feeding practices of immigrant women in the North West of England: a case study of asylum seekers and refugees in Liverpool and Manchester

Little is known about the infant feeding experiences of refugees residing in the UK. To enable successful health promotion for this population, such experiences must be understood. The study aimed to gain an understanding of infant feeding practices among a group of UK-based refugee mothers. Objectives were to explore mothers' perceptions and influences of infant feeding practices, to explore challenges faced by mothers in feeding their infants and to identify concerns and experiences of health care professionals with regard to caring for them. Fifteen semi-structured interviews and two focus group discussions with refugee mothers and five semi-structured interviews with health care providers were conducted in 2012. A framework approach was used to identify main themes. Overall mothers were dissatisfied with their infant feeding outcomes. A preference to exclusively breastfeed was often not achieved. Most resorted to using formula feed, perceiving that this was primarily due to a lack of support. Mothers who were positive to human immunodeficiency virus followed the UK guidelines of exclusively formula feeding for 6 months, but struggled with guilt of not being able to breastfeed. All mothers unable to exclusively breastfeed experienced a sense of loss. Lack of wider support services coupled with complex lifestyles appeared to create challenges in providing infant feeding support. The results highlight a need for an intensified response to facilitate these mothers to maintain their preferred infant feeding choices, or when required, to support them in the adoption of a new method. Using experienced refugee mothers to guide newer mothers, and integrating health and social care, would be positive starting points.

Management of breast cancer in an Asian man with post-traumatic stress disorder: a case report

Background

Migration to the UK has increased considerably, which is reflected in the diverse multicultural population which includes asylum seekers and economic migrants. Differences in ethnic and cultural values between the host and newcomer populations could impact on effective health care provision, especially in gender-biased conditions such as breast cancer. Breast cancer is rare in men and the diagnosis is often met with disbelief. This case report describes an unusual case of breast cancer in an Afghan man who is an asylum seeker of Asian ethnic origin.

Case presentation

A focused ethnographic case study and in-depth interview was used to gain qualitative data and insight into the personal experiences of a male Afghan asylum seeker, age unknown (estimated to be in his 30s), with post-traumatic stress disorder who was electively admitted into hospital for the investigation of a suspicious lump in his left breast, which was subsequently found to be breast cancer. He was extremely reluctant to accept a breast cancer diagnosis and initially would not consent to any treatment, preferring to seek further opinion. During consultation with various members of the breast team he continually declined to accept the diagnosis and felt there was an error in the investigative protocol. Through the involvement of a Muslim nurse, fluent in Urdu and knowledgeable of the Afghan culture and religious background, we learned about his experiences and feelings; he opened up to her about his experiences in Afghanistan, detailing his experiences of trauma as a result of war, and disclosing that he had been diagnosed as having post-traumatic stress disorder by his physician. He saw breast cancer as a “woman’s disease” which deeply affected his feelings of masculinity and left him feeling vulnerable.

Conclusions

While sensitivity is undoubtedly required when diagnosing gender-biased conditions such as breast cancer in men, our experience showed this is exacerbated in ethnic minority groups where language barriers often exist and awareness of cultural differences is required. Awareness of the possibility of post-traumatic stress disorder in migrant populations from conflict-torn areas is also recommended during consultation.

Exploring domestic violence and social distress in Australian-Indian migrants through community theater

In many parts of the world, young adult women have higher levels of common mental disorders than men. The exacerbation of domestic violence (DV) by migration is a salient social determinant of poor mental health. Ecological models describe factors contributing to DV as operating at individual, family, cultural, and societal levels. We explored the interplay among these factors in an Indian community living in Melbourne, Australia, in a qualitative participatory action research study using a modified Forum Theater approach. We here present findings on connections between migration, societal factors, and social/family/cultural factors in DV. The study captured the voices of women living in the community as they describe how DV contributes to their emotional difficulties. Improved understanding of the sociocultural dynamics of DV and the associated social distress in this migrant Indian community can be used to guide the development of culturally sensitive prevention and response programs to assist migrant women from the Indian subcontinent who present with psychopathology and suicidal behaviors associated with DV.

The Role of Cultural Psychiatry in Improving the Policy Response to Central America's Unaccompanied Minors at the American Border: Local and Global Implications

Since 2014, children from El Salvador, Guatemala, and Honduras unaccompanied by their parents have fled in large numbers to the United States to escape violent crime and social disadvantage. Current mental health policies in the U.S. government's response can be improved based on guidelines from professional psychiatric and psychological organizations. These guidelines emphasize the importance of immigration and culture, raising questions into how the field of cultural psychiatry can offer conceptual frameworks and methods to research unaccompanied minor migration as a humanitarian problem. This paper conducts a policy analysis by reviewing shortcomings in the U.S. response and explores the potential contributions of cultural psychiatrists in optimizing services to address the needs of these children in the U.S. and their countries of origin.

Cut-off Scores and Clinical Change Indices for the Dutch Outcome Questionnaire (OQ-45) in a Large Sample of Normal and Several Psychotherapeutic Populations

The Outcome Questionnaire-45 (OQ-45; Lambert et al., ) has been designed for frequent assessment of a patient's functioning during the course of psychotherapy and has become one of the most frequently used outcome measures in the Netherlands. The OQ-45 was originally normed on outpatients in secondary care only, but is applied in a wide variety of patient populations. As such, it has become increasingly important to provide cut-off scores with the normal population, as well as between different patient populations. The present large-scale Dutch study aims to provide cut-off scores between several populations. Data were collected from the normal population (n = 1810) and patients in five different treatment settings: outpatient primary care (n = 1581), outpatient secondary care (n = 9433), private practice (n = 457), day patient (n = 481) and inpatient therapies (n = 485), a total of more than 14.000 administrations. Reliable change indices and cut-off scores were calculated using the method of Jacobson and Truax (). The reliable change index for the patient population was calculated as 18 and the cut-off between the normal and patient population as 56. Sensitivity, specificity and area under the curves of cut-off scores between the normal population and the treatment settings were satisfactory and generally higher than 0.80. Between the patient populations, these measures were generally too low for strict use. The OQ-45 total score can satisfactorily discriminate between the normal and patient populations. For assignment to specific treatment types, the OQ-45 may help, but its use is somewhat limited in practice. Copyright © 2015 John Wiley & Sons, Ltd.

KEY PRACTITIONER MESSAGE

The Dutch OQ-45 has satisfactory levels of reliability, sensitivity, specificity and area under the curve. The new overall cut-off score for normal function for the Dutch OQ-45 is 56 and the new reliable change index is 18. Cut-off scores for several therapeutic treatments are provided.

Clinical Encounters with Immigrants: What Matters for U.S. Psychiatrists

About 3.2 percent of the population across the globe are migrants. Today, unprecedented numbers of people are relocating in the U.S. and more than ever, psychiatrists find themselves caring for immigrant patients. International migration is a multilayered issue that often has implications for the mental health of migrants. Thus, there is an increasing interest in understanding how the different factors associated with migration processes affect the mental health outcomes of immigrants. We group these factors into three categories: immigrant process, clinical encounter, and mental health services. When possible, we incorporate a gendered and life span perspective and suggest avenues for including what we know into the care of children, adults, and elderly psychiatric patients with immigrant backgrounds. We pay special attention to the immigrant paradox literature, which explains why some immigrants are healthier when they start their journey, and why their mental health deteriorates as they live longer in the host societies. We aim at providing psychiatrists an understanding of what to ask, assess, and consider when caring for patients who are international migrants.

Disparities in mental health care provision to immigrants with severe mental illness in Italy

AIM

To determine whether disparities exist in mental health care provision to immigrants and Italian citizens with severe mental illness in Bologna, Italy.

METHODS

Records of prevalent cases on 31/12/2010 with severe mental illness and ≥1 contact with Community Mental Health Centers in 2011 were extracted from the mental health information system. Logistic and Poisson regressions were carried out to estimate the probability of receiving rehabilitation, residential or inpatient care, the intensity of outpatient treatments and the duration of hospitalisations and residential care for immigrant patients compared to Italians, adjusting for demographic and clinical covariates.

RESULTS

The study population included 8602 Italian and 388 immigrant patients. Immigrants were significantly younger, more likely to be married and living with people other than their original family and had a shorter duration of contact with mental health services. The percentages of patients receiving psychosocial rehabilitation, admitted to hospital wards or to residential facilities were similar between Italians and immigrants. The number of interventions was higher for Italians. Admissions to acute wards or residential facilities were significantly longer for Italians. Moreover, immigrants received significantly more group rehabilitation interventions, while more social support individual interventions were provided to Italians.

CONCLUSIONS

The probability of receiving any mental health intervention is similar between immigrants and Italians, but the number of interventions and the duration of admissions are lower for immigrants. Data from mental health information system should be integrated with qualitative data on unmet needs from the immigrants' perspective to inform mental health care programmes and policies.

EMDR for Syrian refugees with posttraumatic stress disorder symptoms: results of a pilot randomized controlled trial

BACKGROUND

The most common mental health problems among refugees are depression and posttraumatic stress disorder (PTSD). Eye movement desensitization and reprocessing (EMDR) is an effective treatment for PTSD. However, no previous randomized controlled trial (RCT) has been published on treating PTSD symptoms in a refugee camp population.

OBJECTIVE

Examining the effect of EMDR to reduce the PTSD and depression symptoms compared to a wait-list condition among Syrian refugees.

METHOD

Twenty-nine adult participants with PTSD symptoms were randomly allocated to either EMDR sessions (n=15) or wait-list control (n=14). The main outcome measures were Impact of Event Scale-Revised (IES-R) and Beck Depression Inventory (BDI-II) at posttreatment and 4-week follow-up.

RESULTS

Analysis of covariance showed that the EMDR group had significantly lower trauma scores at posttreatment as compared with the wait-list group (d=1.78, 95% CI: 0.92-2.64). The EMDR group also had a lower depression score after treatment as compared with the wait-list group (d=1.14, 95% CI: 0.35-1.92).

CONCLUSION

The pilot RCT indicated that EMDR may be effective in reducing PTSD and depression symptoms among Syrian refugees located in a camp. Larger RCTs to verify the (cost-) effectiveness of EMDR in similar populations are needed.