Chronic pain and mental health problems among Syrian refugees: associations, predictors and use of medication over time: a prospective cohort study

Pain as a Symptom of Mental Health Conditions Among Undocumented Migrants in France: Results From a Cross-Sectional Study

Objectives

This study aimed to explore the associations between mental health status and experienced pain among undocumented migrants (UMs) in France.

Methods

We used data from the multicentric cross-sectional "Premier Pas" study conducted in the Parisian and Bordeaux regions from February to April 2019. Participants over 18 years of age were recruited from sixty-three sites. Pain was assessed through two variables: overall pain and musculoskeletal pain. Mental health conditions, including anxiety, sleep disorders, depression, and posttraumatic stress disorder (PTSD) were evaluated. Logistic regression models were used to explore associations, controlling for social determinants of health (SDHs).

Results

Our findings revealed significant associations between mental health status and pain among the 1,188 included participants. Sleep disorder was associated to higher odds of musculoskeletal pain (aOR = 2.53, 95% CI [1.20-5.33], p = 0.014). Stratified results indicated that among women, depression was associated to higher odds of pain (aOR = 4.85, 95% CI [1.53-13.36], p = 0.007).

Conclusion

This large study confirms the connection between mental health status and pain among UMs, providing valuable evidence for clinicians to address mental health issues in this population.

The role of mind-body interventions in traumatised refugees' primary care: A qualitative exploration of professionals' experiences in a dedicated programme in Geneva

Post-traumatic physical and psychological symptoms are pervasive among refugees. Primary care staff face numerous challenges and often seek innovative ways of addressing their refugee patients' physical and mental health needs. A nascent body of literature suggests that mind-body interventions (MBIs1) have a positive effect on post-traumatic symptoms in this population. But the quality of evidence is still poor, and little is known about the role MBI could play in the primary care of refugees. Following the implementation of two different kinds of MBI in a dedicated primary care unit, this study aimed to explore staff members' perceptions and prescribing habits for MBI. Given the paucity of information about this topic, we used a qualitative design combining ethnography and discourse analysis providing in-depth insight into professionals' experiences of MBI. Data collected over five-months of non-participative observation and the transcription of twelve interviews were analysed following the Interpretative Phenomenological Analysis method (IPA) yielding four main results: (1) Generally poor initial understanding of MBI; (2) A variety of conditions and situations where MBIs appeared acceptable and helpful; (3) A persistent lack of experience and knowledge about the indications for MBI, hindering prescription; (4) The importance of articulating MBIs with mental health services. These results, in the light of the existing literature, suggest that stronger evidence for MBI efficacy for refugees is required, a key to improving professionals' understanding of MBI, providing them with explicit prescription criteria, and encouraging stakeholders to implement these innovative interventions.

Including highly educated migrants in academia to improve their health-protocol for a pilot intervention

Introduction

Norway's healthcare system needs a diversified work force to meet societal demands for improved cultural competence. However, many migrants in Norway who were educated as health professions in their home countries are not practicing these professions. This may negatively affect their physical and mental health and hinder their personal social integration. Though good health is often seen as a precondition for work, relevant working activities can also improve health. However, including health professionals with foreign education in academic institutions prior to receiving necessary accreditation is a complex task. This study will pilot an intervention aiming to improve health through meaningful integration of these professionals in academic environments.

Materials and methods

This paper is a protocol for a non-randomized pilot intervention study targeting migrants who are waiting for their health education accreditation in Norway. To test the benefits of meaningful activity on health and explore possibilities for implementing such activity, we have designed a six-month long intervention consisting of including nurses, doctors, and other highly educated migrants with healthcare backgrounds between 20 and 67 years of age, into health-related working tasks, at two higher education institutions in Bergen, Norway. The intervention will be tailored according to the participant's expertise. This hybrid type 2 pilot protocol paper will present how feasibility, fidelity, dose received (satisfaction), and dose of exposure (participation), will be assessed and whether the intervention is experienced as beneficial for the participants' health as primary outcome utilizing both quantitative and qualitative methods.

Conclusion

We present a complex, personalized intervention that has the potential for large scale implementation in the future. By thoroughly presenting our designed intervention and assessment methods, this protocol will add to the study's transparency and facilitate replicability and comparison with future studies. This study will be of benefit to the migrants themselves, policy makers, government agencies and academia at large as it can point to a unique and sustainable way of speeding up the integration of highly educated migrants in their respective fields in a new host country.

Chronic pain and use of painkillers, healthcare services and long-term impairment among Syrian refugees: a cross-sectional study

BACKGROUND

The global increase in forcibly displaced populations highlights the importance of understanding their health needs. Chronic pain is prevalent among refugees, poses significant personal and public health challenges, and complicates their integration into new home countries. Understanding refugees' pain post-migration and how it is being managed is crucial for ensuring adequate and timely interventions and fostering health equity. This paper explores the associations between pain levels and the use of painkillers, healthcare services, and long-term impairment among Syrian refugees with chronic pain, one year after their resettlement in Norway.

METHODS

This cross-sectional study is based on survey data collected from 353 quota refugees in 2018-19, one year after resettlement in Norway. The primary outcomes were the use of painkillers, the use of healthcare services, and long-term impairment, according to reported chronic pain levels. Associations between these outcomes and chronic pain levels were studied using Poisson regression, adjusted by sociodemographic variables and trauma experience.

RESULTS

Of the 353 adults included, 52% were women, and the median age was 36 years. A total of 5% reported very mild/mild, 10% moderate, and 12% strong/very strong chronic pain over the last four weeks. Significant associations were found between all chronic pain levels and use of non-prescription painkillers (adjusted relative risks (aRR) (95% CI)); mild (3.1 (2.0-4.7)), moderate (1.8 (1.1-2.8)), strong (1.7 (1.1-2.6)), and prescription painkillers; mild (4.6 (2.2-9.5)), moderate (5.6 (3.2-10.0)), strong (6.7 (3.9-11.3)), compared to those without chronic pain. Use of emergency rooms, specialist care, and hospitalization were significantly associated with strong chronic pain, with aRR (95% CI) of 2.0 (1.2-3.5), 3.9 (2.1-7.0) and 2.4 (1.3-4.4), respectively. Long-term impairment was strongly associated with chronic pain across all pain levels; mild (8.6 (5.6-13.49)), moderate (6.7 (4.3-10.5)) and strong (6.6 (4.3-10.4)).

CONCLUSION

Despite their young age, more than a quarter of the Syrian refugees in our study reported chronic pain one year after resettlement in Norway. High levels of pain were related to the use of medication, healthcare services, and long-term impairment. Understanding the dynamics of pain among refugees is crucial to ensure adequate and timely management.

Assessing the health status of migrants upon arrival in Europe: a systematic review of the adverse impact of migration journeys

BACKGROUND

Numerous studies have explored the impact of pre- and post-migration factors on the overall health of migrant populations. The objective of this study is to enhance our understanding of additional determinants affecting migrants' health by examining the impact of the migration phase and related journeys in the European context.

METHODS

We conducted a systematic review of studies published in the MEDLINE, Embase, and Scopus databases from 2003 up to January 5, 2024. We included observational studies reporting information on the health status of migrant populations recorded upon arrival in a country situated in Europe, and on the transit phase, including specific risk factors experienced during the journey or its characteristics. Title and abstract screening were performed using active learning techniques provided by ASReview software. The results of the included studies were presented qualitatively, with a focus on publications that formally assessed the association between the journey and the investigated health outcomes. The systematic review was registered on PROSPERO, CRD42024513421.

RESULTS

Out of 11,370 records screened, we ultimately included 25 studies, all conducted since 2017. Most adopted a cross-sectional design and a quantitative approach, with relatively small sample sizes. The majority of the studies were conducted in Serbia and Italy. Only 14 of them formally assessed the association between different exposures in the transit phase and health outcomes, including mental health, well-being and quality of life, infectious and non-communicable diseases.

CONCLUSION

Epidemiological research focusing on the transit phase in Europe remains limited, with few available studies facing challenges related to data collection, study design and analysis, thereby limiting the interpretability and generalisability of their results. These findings underscore the need for action, prompting the development of adequate and feasible strategies to conduct additional studies focusing on migrant populations during migration journeys.

Effects of blast exposure on anxiety and symptoms of post-traumatic stress disorder (PTSD) among displaced Ukrainian populations

Generalized anxiety and symptoms of post-traumatic stress disorder (PTSD) are common among individuals forcibly displaced during war and conflict. Blast exposure may be one important contributor of such symptoms. The aims of this study were to provide data on blast-related experiences of internally displaced persons (IDPs) and refugees following Russia's invasion of Ukraine, and to assess the influence of blast exposure on generalized anxiety, and PTSD flashbacks and nightmares. An online health needs survey was distributed to Ukrainian IDPs and refugees between April and July 2022 using Facebook Ads Manager. Participants reported whether they experienced blast exposure since the beginning of the invasion, and whether they took medication for a mental health condition before the war started. Finally, they completed measures of generalized anxiety (GAD-2), and PTSD flashbacks and nightmares. Analyses included 3253 IDPs and 5073 refugees (N = 8326). Results revealed that 67.6% of total participants- 79.9% of IDPs and 61.7% of refugees-reported blast exposure since Russia's invasion. Further, 69.1% (95% CI: 68.05, 70.15) of total participants met the cut-off for generalized anxiety in which further diagnostic evaluation was warranted. Compared to refugees, IDPs reported higher generalized anxiety and greater frequency of PTSD symptoms, specifically flashbacks and nightmares. Further analyses revealed that the impact of blast exposure on flashback frequency was stronger among IDPs compared to refugees (β = 0.51; t(8322) = 11.88, p < .0001, 95% CI: 0.43, 0.60) and among participants with pre-existing mental health conditions compared to those without (β = 0.18; t(8157) = 2.50, p = .013, 95% CI: 0.04, 0.33). Mental health and psychosocial support must be prioritised within humanitarian relief for both IDPs and refugees and especially among people with underlying mental health conditions.

Neurological Care of Refugees and Other Forcibly Displaced Persons

There are more than 100 million forcibly displaced persons (FDPs) in the world today, including a high number of people who experience neurologic symptoms and presentations. This review summarizes the conceptual frameworks for understanding neurological health risks and conditions across the migration journey (premigration, migration journey, and postmigration) and life span, including special attention to pediatric FDPs. The interaction with psychiatric illness is discussed, as well as the available published data on neurologic presentations in FDPs in the medical literature. A social determinant of health lens is used to provide ways in which forcible displacement can influence brain health and neurological outcomes. Priorities and future needs for the neurological care of refugees and other FDPs are suggested.

Psychotic and Somatic Symptoms Are Frequent in Refugees With Posttraumatic Stress Disorder: A Narrative Review

OBJECTIVE

In 2021, 89.3 million refugees were vulnerable to posttraumatic stress disorder (PTSD) after exposure to multiple and repeated traumatic experiences. The recent war in Ukraine provoked 7 million refugees to flee their homes. Specific clinical presentations of PTSD in refugee populations may not be familiar to most physicians. The goal of this review is to describe the diagnosis and specific clinical features of PTSD in refugees.

METHODS

This narrative review of 263 articles explores 3 PTSD diagnoses that are frequently described in refugee populations and that have been observed in our clinical practices: complex PTSD, PTSD with psychotic symptoms, and PTSD with somatic symptoms.

RESULTS

While complex PTSD does not seem to be related to individuals' culture and origin, the other 2 diagnoses have been specifically described in refugee populations. PTSD with somatic manifestations appears to be the most frequently described and commonly acknowledged form in refugee populations, whereas PTSD with psychotic symptoms remains more controversial due to its clinical variability and association with comorbid disorders.

CONCLUSIONS

The difficulty of identifying PTSD with psychotic symptoms and PTSD with somatic symptoms in refugee populations may lead to misdiagnosis and explain the moderate effectiveness of care delivered to these populations. Appropriate diagnosis is essential to provide optimal psychiatric care to refugee populations.

Factors affecting adherence to psychotropics in trauma-affected refugees: data from a randomized controlled trial

Non-adherence to psychotropic drugs may reduce treatment effectiveness and may cause exacerbation of illness. Among migrant populations, studies have identified low adherence to psychotropic drugs. This study aimed to identify factors that were associated with the three basic components of adherence: non-initiation, non-implementation (blood sample), and discontinuation in a clinical sample of trauma-affected refugees diagnosed with posttraumatic stress disorder. The data for this study is derived from a randomized controlled trial (n = 108). Based on existing literature, individual sociodemographic and clinical candidate predictor variables that may affect the initiation, continuation, and implementation to psychotropics were selected as exposure variables. Logistic regression was used to assess the risk relation between non-initiation, non-implementation, discontinuation, and the individual sociodemographic and clinical factors. Three factors - level of education, turn-up rate for medical doctor sessions, and discomfort in relation to the psychotropics - were associated with non-initiation, non-implementation, or discontinuation. The relatively small sample size poses a limitation. Furthermore, factors not examined in the current study may have affected non-initiation, non-implementation, and discontinuation. The study identified level of education, turn-up rate for medical doctor sessions, and discomfort in relation to medicine as important factors in relation to treatment with psychotropics in trauma-affected refugees. Factors contributing to a low turn-up rate, and factors that are consequences of a low turn-up rate, as well as communication and trust in the patient-provider interaction need further research attention. Furthermore, there is a need for research on interventions addressing adherence for refugees with mental illness.

Associations between postmigration living situation and symptoms of common mental disorders in adult refugees in Europe: updating systematic review from 2015 onwards

BACKGROUND

Refugees and asylum seekers have a high prevalence of psychiatric disorders such as post-traumatic stress disorder (PTSD), anxiety, and depression. The postmigration context inheres different risk and protective factors for mental health of refugees and asylum seekers in host countries. We conducted a systematic review to update knowledge on the association between characteristics of the postmigration living situation (PMLS) and mental health outcomes in Europe since 2015.

METHODS

We searched in five databases according to the PRISMA statement. From a total of 5,579 relevant studies published in 2015-22, 3,839 were included for title and abstract screening, and 70 full texts screened for eligibility. Out of these, 19 studies on refugees and asylum seekers conducted in European countries after 2014 were included in this systematic review. The quality of studies was assessed by using the Mixed Methods Appraisal Tool (MMAT) - version 2018. We performed a narrative synthesis using the four layers of the social determinants of health framework.

RESULTS

A wide range of risk and protective factors for mental health in the PMLS were identified as exposure measures, which included individual factors (e.g., language skills), social and community networks (e.g., family concerns, loneliness and social support, discrimination), living and working conditions (e.g., legal status, duration of residence, unemployment and financial hardship, housing) as well as general socio-economic, cultural and environmental factors (e.g., social status, acculturation). We found postmigration stressors are positively associated with symptoms of depression, anxiety, and PTSD, albeit not consistently so. Especially, the general socio-economic, cultural and environmental factors showed weak associations with mental health.

CONCLUSIONS

Heterogenous study characteristics likely explain the inconsistent associations between characteristics of the PMLS and mental health outcomes. However, broken down in its component layers, most risk and protective factors of the PMLS were significantly associated with symptoms of mental disorders showing the same direction of association across the included studies, while the association between some stressors or resources of the PMLS and mental health turns out to be less homogeneous than expected. Characteristics of the PMLS contribute to the high prevalence of mental diseases of refugees and asylum seekers. Disadvantages in general socio-economic conditions, living and working conditions, in access to social and community networks need to be redressed, in addition to better access to health care.

[Aspects of psychosomatics and psychotraumatology in refugees : Challenges for internal medicine]

Many people seek protection from war and violence in Germany. Flight and displacement often have an impact on mental health. The situation in the country of arrival, separation, grief and loss, and worries about the future can be additional burdens. The barriers to adequate healthcare are high, a visit to the doctor for somatoform complaints is sometimes less alien than talking about fears and hopelessness. The medical internistic encounter thus plays an important key role in recognizing and adequately assessing psychological symptoms without pathologizing. A brief overview of innovations in the International Classification of Diseases and Related Health Problems 11th edition (ICD-11) on stress-related disorders aims to facilitate the assignment. Information on screening, trauma-informed interviewing and interpreter-assisted communication complement the recommendations of the current guidelines.

Effect of a self-help group intervention using Teaching Recovery Techniques to improve mental health among Syrian refugees in Norway: a randomized controlled trial

Background

Mental health symptoms among refugees are common, often related to chronic pain disorders, and their management is usually challenging. Studies evaluating the effect of group therapies among adult refugees to improve mental health symptoms are scarce.

Aims

To assess the effect of Teaching Recovery Techniques (TRT) on mental health and to reduce pain disorder among adult Syrian refugees.

Method

A randomized controlled trial was designed to study the effect of a self-help group intervention using TRT. The outcomes, mental health symptoms measured by Impact of Event Scale-Revised (IES-R) and General Health Questionnaire (GHQ-12) and chronic pain measured by Brief Pain Inventory (BPI), were reported as regression coefficients (B) with 95% confidence intervals.

Results

Seventy-six adults participated: 38 in the intervention and 38 in the control groups. Intention-to-treat analyses showed a significant effect on general mental health as measured by GHQ-12 with B (95% CI) of -3.8 (-7.2, -0.4). There was no effect of TRT on mental health when assessed by IES-R (-1.3 (-8.7, 6.2)) or on pain levels assessed by BPI (-0.04 (-4.0, 3.9)).

Conclusions

This self-help group intervention significantly improved general mental health symptoms among adult refugees but had no effect on trauma symptoms or chronic pain. Higher participation rates might be necessary to achieve the full potential of TRT.

Trial registration: The trial was registered with Clinical Trials.gov at https://clinicaltrials.gov/ct2/show/NCT03951909. To include user participation in the design of the interventions, the study was retrospectively registered on 19 February 2019.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13033-022-00557-4.

Chronic pain, mental health and functional impairment in adult refugees from Syria resettled in Norway: a cross-sectional study

BACKGROUND

Limited research exists on pain and especially the co-occurrence of pain and mental ill health in general refugee populations. The present study aimed to approximate the prevalence of chronic pain (CP) among adult refugees from Syria resettled in Norway; investigate the association between CP and mental ill health; and explore how CP and mental ill health associate with both perceived general health and functional impairment. Gender as potential effect modifier in these associations was also examined.

METHODS

Cross-sectional, postal survey questionnaire.

INCLUSION CRITERIA

≥ 18 years old; refugee from Syria; and arrived in Norway between 2015 and 2017. Study sample was randomly drawn from full population registries, and n = 902 participated (participation rate ≈10%). CP was measured with 10 items on pain lasting for ≥ 3 consecutive months last year. Symptoms of anxiety, depression and PTSD were measured with the HSCL and HTQ scales, respectively. Ordered and binomial logistic regressions were used in analyses. Gender was tested as effect modifier with Wald test for interaction.

RESULTS

In the sample overall, the proportion of participants who reported severe CP was 43.1%. There was strong evidence that anxiety, depression and PTSD were associated with higher levels of CP. In fully adjusted regression models, including both CP and mental health variables, CP was strongly associated with poor perceived general health whereas mental health showed much weaker associations. The association between mental health (anxiety and PTSD) and functional impairment was highly gender specific, with strong associations in men but not in women. CP was strongly associated with functional impairment with no difference across gender.

CONCLUSION

The study shows a high burden of CP in a general population of adult refugees from Syria with likely substantial adverse consequences for daily functioning. The strong association between CP and mental ill health suggests personnel working with refugees' health should be attuned to their co-occurrence as both problems may need to be addressed for either to be effectively mitigated. A clear mismatch exists between the burden on health caused by pain in general refugee populations and the amount of available evidence to guide mitigating strategies.

TRIAL REGISTRATION

NCT03742128.

Self-rated health and quality of life among Syrian refugees in Ireland - data from a cross-sectional study

INTRODUCTION

As a response to the humanitarian crisis in Syria, the Irish government agreed to accept up to 4000 refugees for resettlement in Ireland in 2016. Prior to their arrival in Ireland, health screening was carried out by the International Organisation for Migration. However, no population-level measurement of the health status or needs takes place in Ireland to inform policy or health services requirements.

METHODS

Cross-sectional data from a self-completed questionnaire among 194 Syrian Refugees aged 16 years and older resident in reception centres in Ireland in 2017/2018 is reported upon. The questionnaire measured self-reported health including quality of life and all study material were available in English and Arabic. The data was examined applying descriptive statistics and regression analysis.

RESULTS

Syrian Refugees in Ireland consist of a relatively young cohort; in this study the majority of participants were younger than 35 years (69.5%). Two-thirds of the respondents reported their overall health status to be good or very good. The most common health condition was found to be headache and the most common medications used were painkillers. Chronic pain was experienced by one quarter of respondents; 27.5% were considered as suffering from anxiety and 10.0% had symptoms compatible with post-traumatic stress disorder (PTSD). A significant relationship was observed between chronic pain and self-rated health, as well as between chronic pain and anxiety. Quality of life (QoL) scores were lowest for the QoL environment domain.

CONCLUSIONS

Chronic pain is relatively widespread among these young and otherwise healthy refugees. Psychological distress and trauma are important factors in respondents' quality of life scores. Chronic pain is associated with one's mental health. Our findings and the literature suggests that the diagnosis and treatment of pain and providing care in a culturally sensitive manner should be a priority and included in the preparation and training of the relevant care providers. Additionally, the impact of living conditions on quality of life should not be underestimated.