Development and validation of a mental health screening tool for asylum-seekers and refugees: the STAR-MH

Age and environmental factors predict psychological symptoms in adolescent refugees during the initial post-resettlement phase

BACKGROUND

Adolescent refugees are at high risk of developing mental disorders but are often not recognised early. This pilot study aimed to identify early putative risk factors associated with psychological symptoms in newly resettled refugee youth at potential risk of subsequently developing mental disorders.

METHODS

Newly resettled adolescent refugees were recruited through English language schools in Melbourne, Australia. Participants were assessed with the MINI-Kid, Achenbach Youth Self-Report and Reaction of Adolescents to Traumatic Stress scale. Parents completed a mental health screening separately. Linear regression models were used to identify predictive factors associated with symptom ratings.

RESULTS

Seventy-eight, ostensibly well, refugee adolescents (mean age = 15.0 ± 1.6 years) resettled in Australia for 6.1 ± 4.2 months were assessed. Levels of anxiety, depression and post-traumatic stress symptoms were considerably lower than in mainstream population data. Prior displacement was a key determinant of symptomatology. Transitory displacement, irrespective of duration, was associated with elevated scores for depression (t (47) = -4.05, p < 0.0001), avoidance/numbing (U = 466, p < .05) and total trauma (U = 506, p < .05) symptoms. Older age was a unique predictor of depression (F (1,74) = 8.98, p < .01), internalising (F(1,74) = 6.28, p < .05) and total (F(1,74) = 4.10, p < .05) symptoms, whilst parental depression symptoms (t = 2.01, p < 0.05), displacement (t = 3.35, p < 0.01) and, expectedly, trauma exposure (t = 3.94, p < 0.001) were unique predictors of post-traumatic stress symptoms.

CONCLUSIONS

Displaced status, older age, and parental symptoms predicted psychological symptoms in adolescent refugees in an initial relatively asymptomatic post-resettlement phase. The early recognition of at-risk refugee youth may provide an opportunity for preventative mental health interventions.

Diagnostic test accuracy of screening tools for post-traumatic stress disorder among refugees and asylum seekers: A systematic review and meta-analysis

Background

Refugees and asylum seekers often experience traumatic events resulting in a high prevalence of post-traumatic stress disorder (PTSD). Undiagnosed PTSD can have detrimental effects on resettlement outcomes. Immigration medical exams provide an opportunity to screen for mental health conditions in refugee and asylum seeker populations and provide links to timely mental health care.

Objective

To assess the diagnostic accuracy of screening tools for PTSD in refugee and asylum seeker populations.

Methods

We systematically searched Medline, Embase, PsycINFO, CENTRAL and CINAHL up to 29 September 2022. We included cohort-selection or cross-sectional study designs that assessed PTSD screening tools in refugee or asylum seeker populations of all ages. All reference standards were eligible for inclusion, with a clinical interview considered the gold standard. We selected studies and extracted diagnostic test accuracy data in duplicate. Risk of bias and applicability concerns were addressed using QUADAS-2. We meta-analyzed findings using a bivariate random-effects model. We partnered with a patient representative and a clinical psychiatrist to inform review development and conduct.

Results

Our review includes 28 studies (4,373 participants) capturing 16 different screening tools. Nine of the 16 tools were developed specifically for refugee populations. Most studies assessed PTSD in adult populations, but three included studies focused on detecting PTSD in children. Nine studies looked at the Harvard Trauma Questionnaire (HTQ) with diagnostic cut-off points ranging from 1.17 to 2.5. Meta-analyses revealed a summary point sensitivity of 86.6% (95%CI 0.791; 0.917) and specificity of 78.9% (95%CI 0.639; 0.888) for these studies. After evaluation, we found it appropriate to pool other screening tools (Posttraumatic Stress Disorder Checklist, the Impact of Event Scale, and the Posttraumatic Diagnostic Scale) with the HTQ. The area under the curve for this model was 79.4%, with a pooled sensitivity of 86.2% (95%CI 0.759; 0.925) and a specificity of 72.2% (95%CI 0.616; 0.808).

Conclusions

Our review identified several screening tools that perform well among refugees and asylum seekers, but no single tool was identified as being superior. The Refugee Health Screener holds promise as a practical instrument for use in immigration medical examinations because it supports the identification of PTSD, depression, and anxiety across diverse populations. Future research should consider tool characteristics beyond sensitivity and specificity to facilitate implementation in immigration medical exams.

Registration

Open Science Framework: 10.17605/OSF.IO/PHNJV.

Epidemiology of depression among displaced people: A systematic review and meta-analysis

INTRODUCTION

Displaced people are prone to develop mental health problems due to resettlement in new environments, traumatic events and forced migration. Depression is a mental health problem repeatedly observed among displaced people such as refugees, migrants, asylum seekers and internally displaced persons (IDPs). Therefore, estimating the global pooled prevalence of depression as well as pinpointing its determinants may support policymakers and health care workers to mitigate the disease burden and improve the psychological well-being of displaced people.

METHODS

PubMed, EMBASE, CINAHIL, Psych-INFO, and SCOPUS databases were searched for English written relevant observational studies conducted between 1984 and 2020. The methodological quality of studies was assessed using the Newcastle Ottawa Scale (NOS). Heterogeneity across studies was checked using the Q- and I² test. Publication bias was checked by observing Funnel plot symmetry and using Egger's regression test. STATA 16 was used to combine studies using a random effect model.

RESULTS

Of the 4102 studies identified, 81 studies with an overall sample size of 53,458 were included in the current systematic review and meta-analysis. The pooled prevalence estimate of depression among displaced people was 26.4% (95% CI; 22.2-31.1). Also, three in five IDPs, one in three refugees and asylum seekers and one in four migrants suffer from depression globally. Being female migrant [AOR: 2.46 95% CI: 1.79-3.13, I²=34.5%), non-partnered marital status [AOR: 2.29, 95% CI: 1.29-3.30, I²= 0.00%], and perceived low social support [AOR: 1.76, 95% CI: 1.00-2.52, I²=34.6%] were significant determinants of depression among displaced people.

CONCLUSION

Overall, around 1 in 4 displaced people suffer from depression and exceed the prevalence of depression reported by community samples in different nations and demonstrate a need for culturally fitting and targeted responses from migrant/refugee host nations and their serving clinicians.

Mental Health Screening Approaches for Resettling Refugees and Asylum Seekers: A Scoping Review

Refugees and asylum seekers often face delayed mental health diagnoses, treatment, and care. COVID-19 has exacerbated these issues. Delays in diagnosis and care can reduce the impact of resettlement services and may lead to poor long-term outcomes. This scoping review aims to characterize studies that report on mental health screening for resettling refugees and asylum seekers pre-departure and post-arrival to a resettlement state. We systematically searched six bibliographic databases for articles published between 1995 and 2020 and conducted a grey literature search. We included publications that evaluated early mental health screening approaches for refugees of all ages. Our search identified 25,862 citations and 70 met the full eligibility criteria. We included 45 publications that described mental health screening programs, 25 screening tool validation studies, and we characterized 85 mental health screening tools. Two grey literature reports described pre-departure mental health screening. Among the included publications, three reported on two programs for women, 11 reported on programs for children and adolescents, and four reported on approaches for survivors of torture. Programs most frequently screened for overall mental health, PTSD, and depression. Important considerations that emerged from the literature include cultural and psychological safety to prevent re-traumatization and digital tools to offer more private and accessible self-assessments.

Prevalence of mental disorders in refugees and asylum seekers: a systematic review and meta-analysis

BACKGROUND

Studies have identified high rates of mental disorders in refugees, but most used self-report measures of psychiatric symptoms. In this study, we examined the percentages of adult refugees and asylum seekers meeting diagnostic criteria for major depressive disorder (MDD), post-traumatic stress disorder, bipolar disorder (BPD), and psychosis.

METHODS

A systematic literature search in three databases was conducted. We included studies examining the prevalence of MDD, post-traumatic stress disorder, BPD, and psychosis in adult refugees according to a clinical diagnosis. To estimate the pooled prevalence rates, we performed a meta-analysis using the Meta-prop package in Stata (PROSPERO: CRD42018111778).

RESULTS

We identified 7048 records and 40 studies (11 053 participants) were included. The estimated pooled prevalence rates were 32% (95% CI 26-39%; I ² = 99%) for MDD, 31% (95% CI 25-38%; I ² = 99.5%) for post-traumatic stress disorder, 5% (95% CI 2-9%; I ² = 97.7%) for BPD, and 1% (95% CI 1-2%; I ² = 0.00%) for psychosis. Subgroup analyses showed significantly higher prevalence rates of MDD in studies conducted in low-middle income countries (47%; 95% CI 38-57%, p = 0.001) than high-income countries studies (28%; 95% CI 22-33%), and in studies which used the Mini-International Neuropsychiatric Interview (37%; 95% CI 28-46% p = 0.05) compared to other diagnostic interviews (26%; 95% CI 20-33%). Studies among convenience samples reported significant (p = 0.001) higher prevalence rates of MDD (35%; 95% CI 23-46%) and PTSD (34%; 95% CI 22-47%) than studies among probability-based samples (MDD: 30%; 95% CI 21-39%; PTSD: 28%; 95% 19-37%).

CONCLUSIONS

This meta-analysis has shown a markedly high prevalence of mental disorders among refugees. Our results underline the devastating effects of war and violence, and the necessity to provide mental health intervention to address mental disorders among refugees. The results should be cautiously interpreted due to the high heterogeneity.

Professional mental health support seeking in Women of Refugee Background resettled in Australia: An exploratory study of facilitators and barriers

The present study is the first to investigate factors influencing professional mental health support seeking in Women of Refugee Background (WoRB) in Australia. WoRB are a vulnerable population with a range of complex mental health needs. Despite this, research has indicated that WoRB are an underrepresented population in the utilisation of mental health support services. This is a particular concern in Australia, due to an increasing number of WoRB being resettled. A multivariate logistical regression was conducted on a sample of 450 WoRB resettled in Australia from the Building a New Life in Australia (BNLA) data set to investigate factors associated with seeking professional mental health support. Several factors were identified as being significantly associated with professional mental health support seeking in WoRB resettled in Australia, including age, resettlement location, marital status, prearrival trauma involving violence against women, language barriers and health-related variables, including mental distress and long-term disability. The current study provides a unique insight into professional mental health support seeking from a gendered perspective in WoRB resettled in Australia. Insights into factors that influence seeking professional mental health support in this highly vulnerable population must inform mental health practice, service delivery and policies.

An embodied distress: African asylum seekers' experiences of mental health difficulties while awaiting an asylum outcome in Ireland

The mental health of asylum seekers has attracted significant interest and examination. Quantitative studies have consistently indicated that asylum seekers experience mental distress at a higher rate than both host populations and their refugee counterparts. Qualitative insight into asylum seekers' embodied experience of mental distress is limited. This qualitative narrative study aimed to explore African asylum seekers' everyday embodied experiences of mental distress. Sixteen semi-structured one-to-one interviews were conducted with African asylum seekers who had experienced mental distress and were receiving mental health care services in Ireland. Narrative data were analysed using a holistic analysis framework of narrative form and content. Participants described their everyday endurance of relentless rumination, shame, self-loathing, anger, and mistrust, and of becoming demoralised and hopeless. Study findings indicate that asylum seekers' mental distress interweaves the physical, psychological, emotional, and social realms, thus impacting on the whole of their being. Consequences for asylum seekers include feeling anaesthetised, having a severely diminished capacity to connect and interact with their external surroundings and other people, and, for some, efforts to end their life.Examinations of, and responses to, asylum seekers' mental distress must delve beyond the confines of diagnostic categorisations and codifications of symptomology. To achieve heightened understanding and efficacious interventions, we must empathetically listen and engage with asylum seekers' narratives of distress and the socio-cultural and socio-political context they inhabit.

The prevalence of mental illness in refugees and asylum seekers: A systematic review and meta-analysis

BACKGROUND

Globally, the number of refugees and asylum seekers has reached record highs. Past research in refugee mental health has reported wide variation in mental illness prevalence data, partially attributable to methodological limitations. This systematic review aims to summarise the current body of evidence for the prevalence of mental illness in global refugee populations and overcome methodological limitations of individual studies.

METHODS AND FINDINGS

A comprehensive search of electronic databases was undertaken from 1 January 2003 to 4 February 2020 (MEDLINE, MEDLINE In-Process, EBM Reviews, Embase, PsycINFO, CINAHL, PILOTS, Web of Science). Quantitative studies were included if diagnosis of mental illness involved a clinical interview and use of a validated assessment measure and reported at least 50 participants. Study quality was assessed using a descriptive approach based on a template according to study design (modified Newcastle-Ottawa Scale). Random-effects models, based on inverse variance weights, were conducted. Subgroup analyses were performed for sex, sample size, displacement duration, visa status, country of origin, current residence, type of interview (interpreter-assisted or native language), and diagnostic measure. The systematic review was registered with PROSPERO (CRD) 42016046349. The search yielded a result of 21,842 records. Twenty-six studies, which included one randomised controlled trial and 25 observational studies, provided results for 5,143 adult refugees and asylum seekers. Studies were undertaken across 15 countries: Australia (652 refugees), Austria (150), China (65), Germany (1,104), Italy (297), Lebanon (646), Nepal (574), Norway (64), South Korea (200), Sweden (86), Switzerland (164), Turkey (238), Uganda (77), United Kingdom (420), and the United States of America (406). The prevalence of posttraumatic stress disorder (PTSD) was 31.46% (95% CI 24.43-38.5), the prevalence of depression was 31.5% (95% CI 22.64-40.38), the prevalence of anxiety disorders was 11% (95% CI 6.75-15.43), and the prevalence of psychosis was 1.51% (95% CI 0.63-2.40). A limitation of the study is that substantial heterogeneity was present in the prevalence estimates of PTSD, depression, and anxiety, and limited covariates were reported in the included studies.

CONCLUSIONS

This comprehensive review generates current prevalence estimates for not only PTSD but also depression, anxiety, and psychosis. Refugees and asylum seekers have high and persistent rates of PTSD and depression, and the results of this review highlight the need for ongoing, long-term mental health care beyond the initial period of resettlement.

Prolonged Grief Disorder Among Refugees in Psychological Treatment-Association With Self-Efficacy and Emotion Regulation

BACKGROUND

While Prolonged Grief Disorder (PGD) among refugees has recently started to attract scientific attention, knowledge regarding associated psychological factors remains limited. Given the multifactorial context of persecution, trauma, displacement, and exile-related difficulties, obtaining a better understanding of PGD in refugees is crucial because PGD may affect psychological well-being, level of functioning, and social integration.

METHODS

In a sample of refugees receiving psychological treatment in Switzerland (N = 88), we examined the relationship between severity of PGD and potentially associated factors such as emotion regulation, perceived self-efficacy, as well as potentially traumatic events and post-migration living difficulties.

RESULTS

In a regression analysis, difficulties in emotion regulation and lower perceived self-efficacy were associated with greater severity of PGD, while post-migration living difficulties and potentially traumatic events did not emerge as significant factors.

CONCLUSION

These findings suggest that emotion regulation and perceived self-efficacy are associated with PGD in refugees in psychological treatment and are thus potential targets for treatment interventions.

Appropriateness of the Asylum Seeker Resource Centre-adapted Refugee Health Assessment Tool

People seeking asylum (PSA) are recommended to undertake a comprehensive risk-based health assessment within 1 month of arrival in Australia. The Asylum Seeker Resource Centre (ASRC) offers health services to PSA in Victoria, through the ASRC nurse-led clinic. A healthcare assessment is conducted by nurses using a Refugee Health Assessment (RHA) tool. A process evaluation was conducted to assess if the adapted 2016 version of the RHA tool was able to appropriately identify, describe and prioritise the needs of PSA. Twelve ASRC nurses who conducted assessments were interviewed. All interviews were audio recorded, transcribed and analysed. The adapted RHA tool was considered as appropriate for identifying, describing and prioritising the needs of PSA. Three key interconnected themes emerged influencing the appropriateness of the tool: the tool; users' experiences; and the individual characteristics of the PSA undergoing the assessment. Key tool limitations included: the structure not being user-friendly; variability in users' sensitivity to using the tool; and the limited feedback from PSA on the adapted RHA tool. Given the high number of people seeking asylum in Australia and the complexity of their healthcare needs, this research provides preliminary guidance on ways to improve the appropriateness of the ASRC-adapted RHA tool.