Factors associated with mental disorders in long-settled war refugees: refugees from the former Yugoslavia in Germany, Italy and the UK

[Social Determinants of Mental Health among Refugees in Germany - The Influence of Postmigratory Social Isolation and Resources on Psychopathology and Utilization Behavior]

The mental health of refugees is influenced by a variety of pre-, peri- and postmigratory factors. It remains largely unclear how social determinants influence the utilization of psychiatric-psychotherapeutic treatment. We applied a questionnaire survey to 189 refugees from a clinical sample in a psychiatric hospital and from a control sample, which was not in treatment. The influence of social factors on psychopathology and utilization of care was analyzed by means of a CHAID algorithm. The total sample was highly stressed (54% PTSD and 41.4% depression symptoms). Patients were more severely affected in all psychometric scales as well as in traumatization and they were less able to draw on resources such as a social network or residence permit. The strongest predictor for psychotherapeutic-psychiatric treatment was social isolation in the living environment. For patients, the lack of a work permit was the strongest predictor of depression symptoms. The results point to the importance of postmigratory social determinants for the mental health of refugees. In particular, stable social relationships, together with formal factors such as work permit and residence title, should help to reduce mental distress and the need for psychiatric treatment.

Multiple trauma exposure and psychopathology in Syrian refugees living in Turkey: A latent class analysis

BACKGROUND

After the Syrian civil war, millions of Syrian refugees migrated to neighboring countries, with the majority settling in Turkey. The prevalence of mental disorders is notably higher among refugee populations. However, prior research on Syrian refugees have mostly used variable-centred approaches which have known limitations. Thus, the present study sought to examine the occurrence and co-occurrence of traumatic experiences among Syrian refugees living in Turkey using latent class analysis (LCA). Additionally, this study aimed to identify the associations between latent class membership and trauma-related psychopathology.

METHODS

Participants included 593 Syrian refugees living in Turkey. LCA was used to identify latent classes of trauma exposure. Demographic predictors of the latent classes were examined and associations with PTSD, CPTSD, depression and anxiety were also explored.

RESULTS

Three latent classes were identified based on trauma exposure; a "multiple traumas" class, "war and human suffering" class, and "low exposure, combat-exposed" class. Odds of PTSD, CPTSD, depression, or anxiety diagnosis did not differ significantly between classes, with the exception of the "multiple traumas" class who were more likely to meet the criteria for anxiety diagnosis compared to the "low exposure" class.

LIMITATIONS

Historic psychiatric symptoms or post-migration stressors could not be accounted for in this study, which may explain the lack of significant differences in most mental health outcomes by trauma exposure class.

DISCUSSION

The latent classes identified in this study correspond with previous research regarding trauma in Syrian refugees. However, this study largely failed to find significant differences in mental health diagnoses between classes. Future research should consider the effect of post-migration stressors in refugee populations, which may play a crucial role in mental health outcomes.

Trends and determinants of mental illness in humanitarian migrants resettled in Australia: Analysis of longitudinal data

Given the frequent exposure of humanitarian migrants to traumatic or stressful circumstances, there exists a potential predisposition to mental illness. Our objective was to pinpoint the trends and determinants of mental illness among humanitarian migrants resettled in Australia. This study considered five waves of longitudinal data involving humanitarian migrants resettled in Australia. Post-traumatic stress disorder (PTSD) and psychological distress were assessed using PTSD-8 and Kessler-6 screening tools. Through a Generalised Linear Mixed model (GLMM), variables displaying a 95% CI that excluded the value of 1.0 for the odds ratio were identified as associated factors for both PTSD and elevated psychological distress. The selection of multivariable covariates was guided by causal loop diagrams and least absolute shrinkage and selection operators methods. At baseline, there were 2399 humanitarian migrants with 1881 retained and at the fifth yearly wave; the response rate was 78.4%. PTSD prevalence decreased from 33.3% (95% CI: 31.4-35.3) at baseline to 28.3% (95% CI: 26.2-30.5) at year 5. Elevated psychological distress persisted across all waves: 17.1% (95% CI: 15.5-18.6) at baseline and 17.1% (95% CI: 15.3-18.9) at year 5. Across the five waves, 34.0% of humanitarian migrants met screening criteria for mental illness, either PTSD or elevated psychological distress. In the multivariate model, factors associated with PTSD were loneliness (AOR 1.5, 95% CI: 1.3-1.8), discrimination (AOR 1.6: 1.2-2.1), temporary housing contract (AOR 3.7: 2.1-6.7), financial hardship (AOR 2.2:1.4-3.6) and chronic health conditions (AOR 1.3: 1.1-1.5), whereas the associated factors for elevated psychological distress were loneliness (AOR 1.8: 1.5-2.2), discrimination (AOR 1.7: 1.3-2.2) and short-term lease housing (AOR 1.6: 1.0-1.7). The prevalence, persistence and consequential burden of mental illness within this demographic underscore the urgent need for targeted social and healthcare policies. These policies should aim to mitigate modifiable risk factors, thereby alleviating the significant impact of mental health challenges on this population.

'They tried to evil me': An explanatory model for Black Africans' mental health challenges

This paper explores the explanatory models of mental challenges among Black Africans in England. It argues that understanding these models is critical for providing culturally appropriate care to this population. The study employed qualitative methodology, and interpretative phenomenological analysis (IPA). Twelve mental health service users who are living in England and self-identified as first or second-generation Black Africans were purposively selected. The data were gathered using face-to-face semistructured interviews. Data were manually analysed in accordance with IPA concepts of searching for common, unique and idiosyncratic themes across transcripts. The findings revealed three themes Black Africans associated to their explanatory model of mental health challenges: complexities of migration, African-centred worldview and negative life experiences. To help alleviate the Eurocentric nature of mental health practice in England, it is hoped that this explanatory model will become an integral part of mental health practice in England and around the world.

Effect of food insecurity on depression, anxiety, and stress among resettled Syrian refugees in Ontario

Food insecurity has been linked to adverse health outcomes, particularly among vulnerable populations such as refugees. The aim of this study was to assess the prevalence of food insecurity and its association with depression, anxiety, and stress among resettled Syrian refugee parents in Ontario. This was a cross-sectional study with a total of 540 Syrian refugee parents who resided in Ontario for an average of four years and had at least one child less than 18 years who were interviewed. Information about food insecurity was collected based on the question "During the past year, did you ever eat less because there was not enough food or money for food?". Levels of depression, anxiety, and stress were assessed using the Depression Anxiety Stress Scales (DASS-21). Multiple linear regression analyses were performed to evaluate the relationship between food insecurity and depression, anxiety, and stress after adjusting for sociodemographic, migration-, and health-related factors. 44.6% of respondents reported experiencing food insecurity. Of participants, 7.6%, 8.9%, and 8.5% reported severe to extremely severe levels of depression, anxiety, and stress, respectively. Results of the multiple linear regression analysis showed that food insecurity was significantly associated with higher levels of depression (Adjβ = 2.00, p = 0.008), anxiety (Adjβ = 1.53, p = 0.013), and stress (Adjβ = 1.87, p = 0.019). Implementation of effective government interventions and frameworks are essential to reduce food insecurity among resettled Syrian refugees to ultimately improve their mental health outcomes and overall well-being.

Comparison of subjective quality of life domains in schizophrenia, mood, and anxiety disorders; an individual patient data meta-analysis

This study sought to compare satisfaction with different subjective quality of life domains across individuals with three different mental health disorders. Samples from four separate studies were combined to conduct a one-step individual patient data meta-analysis. 5329 individuals with either a schizophrenia (n = 1839), mood (n = 1650), or anxiety disorder (n = 1840) were included. Mean satisfaction ratings for each life domain were compared across disorders. Associations between satisfaction ratings and personal characteristics were investigated using multivariable mixed effect models. Results showed that individuals with an anxiety disorder had the widest range of scores and reported lower satisfaction in most domains compared to those with a schizophrenia or mood disorder. Individuals with a schizophrenia disorder rated domains to do with 'others', such as relationships with family and sex life, as lower than individuals with a mood or anxiety disorder. Satisfaction ratings were often more impacted by personal characteristics, such as employment status, than by diagnostic category. These results demonstrate that specific life areas are impacted differently in the three mental health disorders studied. However, further research needs to consider the impact of personal characteristics across disorders, and the subjective quality of life in individuals with anxiety disorders in particular warrants further investigation.

Depression and anxiety in female refugees from East Africa and the Middle East displaced to Germany: cross-sectional results of the female refugee study, taking sociodemographic and migration-related factors into account

At the end of 2022, 108.4 million people around the world were forcibly displaced, the highest number ever recorded. Of these, 50% were women. Despite this situation, little is known about the mental health of female refugees. The first aim of this study was to examine the prevalence of depression and anxiety symptoms among female refugees in Germany. The second aim was to examine which sociodemographic and migration-related variables have an impact on refugees' mental health, and the third aim was to assess the potential predictors of their mental health. A sample of 92 female refugees from East Africa and the Middle East living in Germany were interviewed. Symptoms of depression and anxiety were assessed using the Hopkins Symptom Checklist (HSCL-25). The experience of potentially traumatic events (PTEs) was assessed using the Posttraumatic Diagnostic Scale (PDS) and the Harvard Trauma Questionnaire (HTQ). In our sample of female refugees, 65.2% reported symptoms of depression, and 60.9% reported symptoms of anxiety. Symptoms of depression or anxiety were associated with being from the Middle East, having a higher level of education, and reporting more PTEs. The multiple regression model for anxiety was able to explain 32.4% of the variance in anxiety symptoms. The findings highlight the high burden of mental health problems that female refugees bear. The identified predictors of depressive and anxiety symptoms should sensitize medical and refugee professionals to identify vulnerable individuals and groups, refer them to appropriate psychological treatment, and, where possible, modify the identified predictors.

Self-efficacy and locus of control as transdiagnostic factors in Middle Eastern refugees

Background: Many refugees report high levels of psychopathology. As a countermeasure, some psychological interventions aim at targeting mental health difficulties in refugees transdiagnostically. However, there is a lack of knowledge about relevant transdiagnostic factors in refugee populations.Objective: To inform intervention efforts empirically, we investigated whether self-efficacy and locus of control are transdiagnostically associated with symptoms of depression, anxiety, somatisation, psychological distress, and a higher-order psychopathology factor ('p') in Middle Eastern refugees residing in Germany.Method: In total, 200 Middle Eastern refugees took part in this cross-sectional study, comprising 160 male and 40 female refugees. Participants were, on average, 25.56 years old (SD = 9.19), and 182 (91%) originally came from Syria, while remaining refugees were from Iraq or Afghanistan. They completed measures of depression, anxiety, somatisation, self-efficacy, and locus of control.Results: In multiple regression models adjusting for demographic factors (gender and age), self-efficacy and external locus of control were transdiagnostically related to depression, anxiety, somatic symptoms, psychological distress, and a higher-order psychopathology factor. Internal locus of control had no detectable effect in these models.Conclusions: Self-efficacy and external locus of control appear critical in the mental health of refugees and may be important mechanisms in overcoming posttraumatic stress and resettlement stressors. Our findings support the need to target self-efficacy and external locus of control as transdiagnostic factors of general psychopathology in Middle Eastern refugees.

The burden of substance use and (mental) distress among asylum seekers: a cross sectional study

Background

Asylum seekers are a particularly vulnerable population due to a wide range of external stressors. Traumatic events and difficult social/economic prospects can lead to an elevated susceptibility for substance use disorders. The aim of the present study was to determine whether asylum seekers suffering from mental or physical distress present higher levels of substance use disorder (SUD) in a state reception center in Germany and whether there are identifiable risk or protective factors.

Methods

We performed a hierarchical logistic regression on data of N = 238 people who had applied for asylum in Germany to analyze the SUD variance explanation by (1) sociodemographic, (2) flight-specific, and (3) psychometric (ERQ, SOC-9 L, SCL-K9) variables. On level (4), we included the location of data collection (walk-in clinic or accommodation,) as an indicator of individual's need for a psychologist's or General practitioner's help in order to assess for the participant's (mental) distress.

Results

Low educational level, lower sense of coherence, and mental distress (location of data collection in the psychosocial or general medical outpatient clinic) were associated with SUD. Those suffering from SUD seemed to be less aware of external stressors as SUD was also associated with low levels of reported post-migratory stress.

Discussion

The association of SUD with psychological distress and lower education reaffirms the concept that some vulnerable groups are at a higher risk for substance-related difficulties. Strengthening the sense of coherence with targeted interventions might enable at-risk groups to cope better with forthcoming burdens and help with abstaining from current or future consumption.

Refugees' and asylum seekers' experiences of individual psychological therapy: A qualitative meta-synthesis

PURPOSE

The current review aimed to synthesise qualitative literature exploring adult refugees' and asylum seekers' experiences of individual psychological therapy.

METHODS

A comprehensive systematic search of the following databases led to the identification of eight studies for inclusion in this review: PsycINFO, PsycARTICLES, MEDLINE, EMBASE, CINAHL and Academic Search Ultimate. All selected studies used qualitative methodology to explore refugees' and asylum seekers' experiences of individual psychological therapy. Studies were appraised using an adapted version of the Critical Appraisal Skills Programme (CASP) Tool. The data from these selected studies were then synthesised using a meta-ethnographic approach.

RESULTS

The synthesis of selected studies resulted in the development of five themes; (i) the importance of recognition and validation within therapy, (ii) building a human connection within the therapeutic relationship and the importance of cultural competency, (iii) revisiting trauma, managing difficult emotions from therapy and regaining hope, (iv) the value of practical interventions, (v) 'one should not wake up the djinns (demons)'-cultural stigma and accessing therapy. These themes illustrated the complexities of working therapeutically with asylum seekers and refugees and the vital role of building trust and safety within the therapeutic relationship prior to engagement in therapeutic work. The results also highlighted varied responses to engaging in trauma work ranging from participants finding the experience transformative to others finding it unhelpful, some participants preferred more practical interventions. Participants' cultural backgrounds and pre-conceptions around therapy impacted on engagement and the therapist's cultural competency was a significant factor in therapeutic engagement.

CONCLUSIONS

Working therapeutically with asylum seekers and refugees involves a number of factors for consideration. Forced migrants' socio-political context was seen as central to their experiences of distress and recognition of these factors was imperative for positive therapeutic engagement. This review highlights a number of clinical implications to guide practitioners working therapeutically with this community.

Migrants' mental health recovery in Italian reception facilities

BACKGROUND

Forced migration leaves deep marks on the psychological well-being of migrants, with post-traumatic stress disorder (PTSD) and other psychological conditions being prevalent among them. While research has clarified the extent to which pre-migration trauma is a predictor of mental health outcomes, the role of post-migration stressors in the settlement environment are yet to be fully characterized.

METHODS

We monitored mental health of a cohort of 100 asylum-seekers during their 14-day COVID-19-related quarantine in reception facilities in Rome, Italy, through the administration of six questionnaires (a demographic survey, the WHO-5 well-being index, the Primary Care PTSD Screen for Diagnostic and Statistical Manual of Mental Disorders 5 (DSM-5), the Harvard Trauma Questionnaire, the Trauma and Loss Spectrum-Self Report, and the LiMEs-Italian version). Through the combination of statistical analysis and supervised learning, we studied the impact of the first contact with the reception system on asylum-seekers' mental health and sought for possible risk and shielding factors for PTSD.

RESULTS

We find that sheltering in refugee centers has a positive impact on migrants' mental health; asylum-seekers with PTSD reported more traumatic events and personality characteristics related to loss and trauma; life events are predictors of PTSD in asylum-seekers.

CONCLUSIONS

We identify past traumatic experiences as predictors of PTSD, and establish the positive role the immediate post-migration environment can play on migrants' psychological well-being. We recommend for host countries to implement reception models that provide effective protection and integration of asylum-seekers, similar to those in the Italian system.

Cognitive factors underlying the impact of postmigration stressors on subjective well-being: Well-being comparisons and self-efficacy

BACKGROUND

Migration and the resulting challenges in the host country can have a profound impact on the mental health of refugees and intensify preoccupation with one's own well-being. Yet, cognitive factors underlying the adverse impact of postmigration stressors are poorly understood.

OBJECTIVE

We aimed at exploring the frequency and nature of well-being comparisons in the context of flight and migration using the Comparison Standards Scale for Well-being (CSS-W), which assesses well-being related social, temporal, counterfactual, criteria-based and dimensional aversive and appetitive comparisons. We further aimed at examining the mediating role of well-being comparisons and general self-efficacy in the relationship between postmigration stressors and psychological well-being.

METHODS

We conducted a survey with 1070 Arabic speaking forcibly displaced people in Germany assessing well-being comparisons, general self-efficacy, postmigration stressors, subjective well-being and social media engagement.

RESULTS

Factor analysis of the CSS-W yielded a theoretically grounded two-factor structure proposing an aversive (mostly upward) and an appetitive (mostly downward) comparison factor. Aversive and appetitive comparisons were reported by more than 99% of participants, with temporal comparisons being reported by 98.7% of participants. Postmigration stressors were significantly related to subjective well-being and aversive well-being comparisons and general self-efficacy partially mediated this relationship. Appetitive well-being comparisons, however, were not significantly related to neither postmigration stressors nor general self-efficacy.

CONCLUSION

Aversive well-being comparisons and general self-efficacy seem to play a significant role in the adverse effects of postmigration stressors on subjective well-being. Longitudinal research is needed to examine the directional dynamics between general self-efficacy, well-being comparisons and postmigration stressors.

Which life domains are people with major depression satisfied or dissatisfied with? An individual patient data meta-analysis

BACKGROUND

People with depression tend to score low on measures of subjective quality of life (SQoL) which has been suggested to reflect a general negative bias of perception. However, studies do not tend to investigate specific life domains. This study investigated satisfaction with life domains in people with major depression and explored influential factors.

METHODS

A one-step individual patient data meta-analysis combined data of 1710 people with major depression from four studies. In all studies, SQoL was measured on the Manchester Short Assessment of Quality of Life, which provides satisfaction ratings with 12 life domains. Associations between individual characteristics and satisfaction ratings were investigated using univariable and multivariable models.

RESULTS

Mean satisfaction ratings varied across life domains. Participants expressed dissatisfaction with several domains but expressed satisfaction with others, mainly for domains associated with close relationships. Some of the investigated characteristics were consistently associated with satisfaction ratings across the domains.

LIMITATIONS

The primary limitation of this study was in the analysis of individual characteristics, which were chosen based on identification in existing literature and availability in our datasets, and of which several were dichotomised to have sufficiently large numbers which may have resulted in lost nuance in the results.

CONCLUSIONS

People with major depression distinguish between their satisfaction with different life domains and are particularly satisfied with their close relationships. This challenges the notion of a general negative appraisal of life in this group, and highlights the need to evaluate satisfaction with different life domains separately.

Effectiveness of psychosocial interventions for post-traumatic stress disorder in refugees and asylum seekers resettled in low- and middle-income countries: A systematic review and meta-analysis

Refugees and asylum seekers are more prone to posttraumatic stress disorder (PTSD) than the general population. This systematic review aims to determine which psychosocial interventions effectively treat PTSD among refugees and asylum seekers in low- and middle-income countries (LMIC). Relevant papers were retrieved from the bibliographic databases. PTSD symptoms post-intervention was the primary outcome. Ten studies were selected with 1981 participants. In meta-analyses of Randomised control trials (RCTs), psychosocial interventions for PTSD (SMD -0.60, 95% CI -0.96 to -0.23; I2 = 91%; 95% CI 75-100; nine studies, 1789 participants) were shown to be clinically effective. Also, in case of depression (SMD -0.59, 95% CI -0.95 to -0.22; I2 = 84%; 95% CI 50-90; seven studies, 1248 participants). Eye Movement Desensitization and Reprocessing (EMDR) had the greatest effect size among psychosocial therapies for this demographic. However, the number of studies is small, and their methodological rigour is limited, thus future study should concentrate on performing more rigorous trials.

A Three-Year Longitudinal Study of Risk Factors for Suicidality in North Korean Defectors

BACKGROUND

This longitudinal study examined risk factors for future suicidality among North Korean defectors (NKDs) living in South Korea.

METHODS

The subjects were 300 NKDs registered with a regional adaptation center (the Hana Center) in South Korea. Face-to-face interviews were conducted using the North Korean version of the World Health Organization's Composite International Diagnostic Interview to diagnose mental disorders according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Subjects were also asked about sociodemographic and clinical factors at baseline. At follow-up after three years, the NKDs (n = 172 respondents) were asked to participate in an online survey, responding to self-questionnaires about suicidality. Logistic regression analyses were used to explore associations between baseline variables and future suicidality among NKDs.

RESULTS

Thirty (17.4%) of the 172 survey respondents reported suicidality at follow-up. The presence of health problems over the past year, any prior suicidality at baseline, a higher score on a trauma-related scale, and a lower score on a resilience scale at baseline were associated with greater odds of suicidality at follow-up after adjusting for age, sex, and educational level. Of all mental disorder categories, major depressive disorder, dysthymia, agoraphobia, and social phobia were also associated with significantly increased odds of suicidality at follow-up after adjusting for age, sex, educational level, and prior suicidality at baseline.

CONCLUSION

Resilience, a previous history of suicidality, and the presence of lifetime depressive disorder and anxiety disorder should be given consideration in mental health support and suicide prevention in NKDs.

Food Insecurity and Mental Health among Venezuelan Migrants and Refugees Living in Peru: Secondary Data Analysis of a Cross-Sectional Survey

The objective of this study was to analyze the association between food insecurity and mental health in Venezuelan migrants and refugees residing in Peru using data from the Survey Directed at the Venezuelan Population Residing in the Country (ENPOVE) conducted in 2022. The analysis included 7739 Venezuelan adults. The presence of mental health problems was self-reported, and household food insecurity was measured using the Food Insecurity Experience Scale. The study found that 4 out of 10 participants lived in households with moderate to severe food insecurity, and around 10% reported experiencing some mental health problem in the last month. The study identified a positive association between living in households with moderate to severe food insecurity and having some mental health problem compared to living in households without food insecurity. The findings suggest that food insecurity is a common problem among the Venezuelan migrant population residing in Peru, and measures are required to address this problem and mitigate its consequences on mental health and other health problems. The study highlights the need for international organizations to provide assistance and support to these populations and ensure adequate and sustainable follow-up of food insecurity at the national level. It is also necessary to implement early detection tests for mental health problems in the migrant population, especially in individuals exposed to food insecurity. This study provides relevant evidence for addressing public health in the Venezuelan migrant population residing in Peru.

Scaling-up problem management plus for refugees in Switzerland - a qualitative study

BACKGROUND

Refugees are at an increased risk of developing symptoms of mental disorders but face various structural and socio-cultural barriers to accessing mental health care. The SPIRIT project (Scaling-up Psychological Interventions in Refugees In SwiTzerland) seeks to promote the resilience of refugees and improve their access to mental health care. For this purpose, Problem Management Plus (PM+), an evidence-based low-intensity psychological intervention delivered by trained non-specialist "helpers", is being scaled-up in Switzerland.

OBJECTIVE

To identify factors influencing the process of the large-scale implementation of PM + for refugees in Switzerland and to develop recommendations to guide the implementation process.

METHODS

22 semi-structured interviews were conducted with key informants (Syrian refugees who previously participated in PM+, PM + helpers, health professionals working with refugees and decision-makers from the migration, integration, social, and health sectors). The data were analyzed using thematic analysis, combining an inductive and deductive approach.

RESULTS

The data revealed three major themes, which might have an impact for the longer-term implementation of PM + in Switzerland. First, preconditions for successful integration in the health system prior to scaling-up such as sustainable funding or the introduction of a stepped care approach. Second, the requirements for the PM + intervention supporting scale-up such as quality control during PM + delivery, PM + modality, time and setting when PM + is offered or the views on task sharing. Third, the perceived benefits of scaling-up PM + in Switzerland.

CONCLUSIONS

Our results have shown that PM + must be scaled-up within a stepped care approach, including a functioning triage system and sustainable funding. Rather than selecting one modality or setting, it seemed preferable to offer a variety of formats and settings to achieve maximum reach and benefits. A successful scale-up of PM + in Switzerland might have various benefits. Communicating them to policy-makers and health providers, might enhance their acceptability of the intervention and their willingness to adopt PM + in regulatory structure and promote it.

The refugee and asylum seeker mental health treatment screener (RAS-MT-screener): Feasibility and psychometric properties of a questionnaire detecting refugees' and asylum seekers' need and urgency for mental health treatment

OBJECTIVE

Refugees and asylum seekers are highly vulnerable to the development of mental health problems, yet oftentimes their need is underestimated. We aimed to develop a culturally sensitive screening tool for primary care settings assessing the urgency and need for mental health treatment to close this gap.

METHOD

Items for the screening tool were selected out of an item pool generated by a group of clinical experts based on the data obtained from n = 307 asylum seekers in a refugee state registration and reception center in Germany. Out of these, n = 111 attended a psychosocial walk-in clinic, and clinicians' ratings of urgency and need for mental health treatment were added.

RESULTS

The resulting questionnaire comprised 8 items assessing urgency and 13 items assessing need for mental health treatment. Sensitivity was =0.74 and specificity =0.70. Participants of clinical and non-clinical samples differ highly significantly (p < .001). Cross-cultural validity was shown by comparing measurement invariance for different countries of origin.

CONCLUSION

The RAS-MT-Screener is a clinically and cross-culturally valid screening tool in primary care settings for the urgency and need for mental health treatment with acceptable psychometric properties. Future research on its external and construct validity is warranted.

The prevalence and risk factors for anxiety and depression symptoms among migrants in Morocco

Humanitarian migration can result in mental health issues among migrants. The objective of our study is to determine the prevalence of anxiety and depression symptoms among migrants and their risk factors. A total of 445 humanitarian migrants in the Orientale region were interviewed. A structured questionnaire was used in face-to-face interviews to collect socio-demographic, migratory, behavioral, clinical, and paraclinical data. The Hospital Anxiety and Depression Scale was used to assess anxiety and depression symptoms. Risk factors for anxiety and depression symptoms were identified using multivariable logistic regression. The prevalence of anxiety symptoms was 39.1%, and the prevalence of depression symptoms was 40.0%. Diabetes, refugee status, overcrowding in the home, stress, age between 18 and 20 years, and low monthly income were associated with anxiety symptom. The associated risk factors for depression symptoms were a lack of social support and a low monthly income. Humanitarian migrants have a high prevalence of anxiety and depression symptoms. Public policies should address socio-ecological determinants by providing migrants with social support and adequate living conditions.

Associations among migration risk factors, cultural identity conflict, and psychological symptoms among Syrian emerging adults with refugee backgrounds in the Netherlands

OBJECTIVES

In the present study, we examined relations between premigration, perimigration, and postmigration risk factors (i.e., potentially traumatic events [PTEs], postmigration living problems [PMLPs], stressful life events) and psychological symptoms (i.e., anxiety/depression, posttraumatic stress) in Syrian emerging adults with refugee backgrounds; we also tested cultural identity conflict as a possible mediator of these relations. We expected that greater exposure to migration risk factors was associated with more psychological symptoms and that higher cultural identity conflict would contribute to these associations.

METHODS

We used data from the first wave of Karakter, a longitudinal study of 158 Syrians with refugee backgrounds (69.0% men, age range 18-35). Participants completed a questionnaire assessing PTEs, PMLPs, stressful life events, cultural identity conflict, and symptoms of anxiety/depression and posttraumatic stress.

RESULTS

Correlational analyses indicated that more PTEs and stressful life events were related to higher levels of cultural identity conflict and more psychological symptoms. Furthermore, greater cultural identity conflict was associated with more psychological symptoms. We did not observe indirect effects of cultural identity conflict in the mediation analyses.

CONCLUSIONS

Results suggest that postmigration stressors and cultural identity conflict are associated with psychological symptoms among Syrian emerging adults who have resettled in the Netherlands.

Effects of Posttraumatic Stress Disorder and Mental Disorders on the Labor Market Integration of Young Syrian Refugees

Civil war experience in the Syrian home country, insecurity and critical life events during migration, or adverse events in the receiving country might affect refugees' mental health. This paper addresses the effects of psychological distress and mental disorders on refugees' labor market integration in Germany between 2016 and 2021. We employ survey data from about 2700 young Syrians, delivering information on individuals' experience of migration and arrival in Germany in 2016. The survey data were successfully merged with register data, delivering detailed information regarding individuals' process of labor market integration and employment status from 2016 to 2021. Overall, the labor market integration of young refugees improved remarkably over time. In 2021, about 69% of the study population was integrated in a wider sense, and 30% was employed in fulltime contracts in 2021. However, the results indicate long-lasting effects of PTSD and mental disorders on individuals' labor market integration, whilst individuals' characteristics related to migration and arrival lose relevance over time and hardly affect labor market integration around five years after arrival. High PTSD scores in 2016 indicate a significantly reduced full-time employment probability in 2021. Anxiety and depression show significant negative effects on individuals' labor market integration, but with a less severe impact compared to a PTSD diagnosis.

Substance (mis)use among refugees as a matter of social ecology: insights into a multi-site rapid assessment in Germany

BACKGROUND

Previous research concluded that substance (mis)use is increasing among forcibly displaced populations. Nevertheless, little research has been conducted within a social ecological framework aimed at identifying and understanding the factors affecting substance (mis)use embedded in the post-migration context in high-income countries. The present study aims to develop an understanding of the links and underlying mechanisms between refugees' social ecological determinants and substance (mis)using behavior.

METHODS

Rapid assessments (RAs), including 108 semi-structured interviews and 10 focus group discussions with key persons from various professional, and personal backgrounds, were carried out in German urban and rural areas. The RA approach of interviewing key persons and not solely refugees that (mis)use substances allowed us to gather multi-perspective knowledge on this sensitive topic. Qualitative content analysis was applied, aiming at identifying determinants of substance (mis)use embedded in the post-migration context of refugees and understanding the underlying mechanisms.

RESULTS

One main result of the data suggests that the link between refugees' countries of origin and their post-migration substance (mis)use is not as direct as often assumed. It is observed that refugees' prospects and opportunities in receiving countries (e.g., work permits) undermine this commonly reproduced link. Further determinants are related to living conditions in German refugee shelters and social relations with peers and families. The influence of refugees' living conditions can be summarized as potentially increasing substance availability and distress, whereas family separation produces a loss of control and responsibility, increasing the risk for substance (mis)use. Peers' influence on substance (mis)use was reported to reflect a search for a sense of belonging.

CONCLUSIONS

Given that refugees who (mis)use substances have limited to no control over the factors identified in our study to be associated with substance (mis)use, common treatment and prevention approaches are challenged. Furthermore, we recommend aiming for a holistic comprehension of refugees' substance (mis)use by expanding the focus beyond individuals to the social ecological context in any attempt, including prevention, treatment, research, and policy.

An online tiered screening procedure to identify mental health problems among refugees

BACKGROUND

Many refugees suffer from mental health problems due to stressful and traumatic events before, during, and after migration. However, refugees are facing a wide variety of barriers, limiting their access to mental health care. Internet-based tools, available in several languages, could be one way to increase the availability of mental health services for refugees. The present study aimed to develop and test a screening tool to screen for clinically relevant symptoms of psychiatric disorders common among refugees (i.e. Depression, Anxiety, Post-traumatic stress disorder, and Insomnia). We, designed, translated, and adapted an internet-based tiered screening procedure suitable for use with the largest refugee populations residing in Sweden. The tool aims to accurately identify symptoms of mental distress (Tier 1), differentiate between symptoms of specific psychiatric disorders (Tier 2), and assess symptom severity (Tier 3). We tested the overall efficiency of using a tiered screening procedure.

METHODS

Seven hundred fifty-seven refugees residing in Sweden, speaking any of the languages Arabic, Dari, Farsi, English, or Swedish, completed an online questionnaire following a three-tiered procedure with screening instruments for each tier. In this study, the Tier 3 scales were used as reference standards for clinically relevant symptoms, to evaluate screening efficiency in terms of accuracy and reduction of item burden in previous tiers.

RESULTS

The results show that the tiered procedure could reduce the item burden while maintaining high accuracy, with up to 86% correctly assessed symptoms and few false negatives with moderate symptoms and above (at most 9%), and very few with severe symptoms (at most 1.3%).

DISCUSSION

This study generated an accurate screening tool that efficiently identifies clinically relevant symptoms of common psychiatric disorders among refugees. Using an adapted online tiered procedure to screen for multiple mental health issues among refugees has the potential to facilitate screening and increase access to mental health services for refugees. We discuss the utility of the screening tool and the necessity of further evaluation.

Refugee and Asylum Seeker Communities and Access to Mental Health Support: A Local Case Study

The complex mental health needs of refugee and asylum seeker (RAS) communities, often resulting from past trauma, are not met by overburdened and inadequate service provision. Pre-displacement, in-transit, and post-settlement traumas create a specific set of mental health needs which underfunded mental health services often cannot meet, despite the illusion of access to a range of services. This paper aims to explore how a range of stakeholders responded to inadequate provision at the local level. Interviews and focus groups with regional stakeholders, charities and RAS community groups, which were conducted as part of wider mixed-methods project on international migration in Northern England, revealed several gaps in provision. Findings indicate that charities and community groups are often left to fill the gap and provide signposting and liaison with local authorities. However, these groups are often ill-equipped to provide sufficient support but the absence of commissioned services leaves limited options. We conclude by suggesting that further research is necessary on trauma, RAS communities, and the pathways to mental health support.

The mental health of forcibly displaced couples

Most current research investigating traumatic stress is focused on its effects at the individual level, utilizing the implicit assumption that trauma-related disorders are mutually independent within families and communities. However, there is reason to assume that trauma-related symptoms within couples are influenced by each partner's risk factors and symptoms. Using the actor-partner interdependence model, this study aimed to test whether symptoms of posttraumatic stress disorder (PTSD) and depression were predicted by participants' partner's exposure to traumatic events over and above the influence of the participant's own experiences. For this purpose, we interviewed 687 heterosexual, married Iraqi and Syrian couples in Iraq's Kurdistan region who had been forcefully displaced. We assessed symptoms of PTSD and depression using locally validated scales. Nearly all participants (98.8%) reported exposure to at least one traumatic event, with husbands reporting exposure to a higher number of traumatic events than wives, d = 0.48, p < .001. More than half of the participants met the criteria for a probable PTSD (61.1%) or major depressive disorder diagnosis (60.4%). Within couples, significant actor effects of experienced trauma exposure on personal PTSD and depressive symptoms were observed for both husbands and wives. Further, there were significant partner effects of wives' traumatic experiences on husbands' PTSD and depressive symptoms as well as of husbands' traumatic experiences on wives' PTSD and depressive symptoms. The findings argue for the interdependence of trauma-related symptoms within dyads in a dual-trauma context, suggesting the presence of intracouple transmission of trauma-related symptoms.

The impact of experiencing severe physical abuse in childhood on adolescent refugees' emotional distress and integration during the COVID-19 pandemic

Background

Accumulating evidence highlights the importance of pre- and post- migration stressors on refugees' mental health and integration. In addition to migration-associated stressors, experiences earlier in life such as physical abuse in childhood as well as current life stress as produced by the COVID-19-pandemic may impair mental health and successful integration - yet evidence on these further risks is still limited. The present study explicitly focused on the impact of severe physical abuse in childhood during the COVID-19 pandemic and evaluated the impact of these additional stressors on emotional distress and integration of refugees in Germany.

Methods

The sample included 80 refugees, 88.8% male, mean age 19.7 years. In a semi-structured interview, trained psychologists screened for emotional distress, using the Refugee Health Screener, and integration status, using the Integration Index. The experience of severe physical abuse in childhood was quantified as a yes/no response to the question: "Have you been hit so badly before the age of 15 that you had to go to hospital or needed medical attention?" Multiple hierarchical regression analyses further included gender, age, residence status, months since the start of the COVID-19 pandemic and length of stay in Germany to predict emotional distress and integration.

Results

Two regression analyses determined significant predictors of (1) emotional distress (adjusted R ² = 0.23): duration of being in the pandemic (ß = 0.38, p < 0.001) and severe physical abuse in childhood (ß = 0.31, p = 0.005), and significant predictors of (2) integration (adjusted R ² = 0.53): length of stay in Germany (ß = 0.62, p < 0.001), severe physical abuse in childhood (ß = 0.21, p = 0.019) and emotional distress (ß = -0.28, p = 0.002).

Conclusion

In addition to migration-associated stressors, severe physical abuse in childhood constitutes a pre-migration risk, which crucially affects the well-being, emotional distress and integration of refugees in Germany.

Assessing Mental Illness Risk Among North Korean Refugees and Immigrants Resettled in South Korea

IMPORTANCE

The global increase in the numbers of refugees and immigrants has made mental health a major public concern. Although they are divided, North and South Korea share a common ethnic heritage.

OBJECTIVE

To investigate mental illness risk among North Korean immigrants living in South Korea and compare it with that of the general South Korean population.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective, population-based cohort study was based on National Health Insurance claims data from 2007 to 2019, and North Korean immigrants and refugees (NKIRs) and age-matched and sex-matched members of the general population (GP) were included with a 1:3 ratio. Data were analyzed from March 2022 to August 2022.

EXPOSURE

Emigration from North Korea to South Korea.

MAIN OUTCOMES AND MEASURES

Mental illness incidence and risk through a Cox proportional risk model adjusted for sex, age, disability, region, Charlson Comorbidity Index score, and insurance premium percentile.

RESULTS

A total of 37 209 NKIRs and 111 627 members of the GP were enrolled. The final analysis examined 112 851 individuals (73 238 [64.9%] female, median [IQR] age 34 [19-47] years), with 90 235 (80.0%) in the GP and 22 616 (20.0%) in the NKIR group. The propensity score-matching population numbered 24 532 in total, with 12 266 each in the NKIR and GP groups. NKIR patients had a higher mental illness risk than the GP (hazard ratio [HR], 2.12; 95% CI, 2.04-2.21). The multivariable adjusted HRs (95% CI) for developing mental disorders were 4.91 (3.59-6.71) for posttraumatic stress disorder, 3.10 (2.90-3.30) for major depressive disorder, 2.27 (2.11-2.44) for anxiety and panic disorder, 2.03 (1.58-2.60) for bipolar affective disorder, 1.85 (1.53-2.24) for alcohol use disorder, and 1.89 (1.46-2.45) for schizophrenia.

CONCLUSIONS AND RELEVANCE

In this study, NKIR individuals showed a significantly higher risk of developing most mental disorders. Interventional strategies can prevent psychiatric morbidity and ensure adequate care for this population.

Refugee-related trauma patterns and mental health symptoms across three generations of Hmong Americans

Hmong adults who are Vietnam War refugees have been exposed to refugee-related trauma, but little is known about associations between patterns of trauma exposure and mental health outcomes in Hmong adults. We examined patterns of trauma exposure and mental health symptoms (i.e., somatization, depression, anxiety, and probable posttraumatic stress disorder [PTSD]) in three generations of Hmong adults (N = 219). Trauma exposure and probable PTSD were measured using the Harvard Trauma Questionnaire-Hmong Version. Somatization, depression, and anxiety symptoms were measured using the Brief Symptom Inventory. Latent class analysis (LCA) and auxiliary analysis of sociodemographic characteristics and mental health symptoms were performed. The best-fitting LCA model described three distinct classes: complex and pervasive trauma (60.3%), combat situation and deprivation trauma (26.0%), and low exposure to refugee-related trauma (13.7%). Participants in the complex and pervasive trauma class were the oldest, had the shortest U.S. residency, were the least proficient in English, and reported the most severe mental health symptoms; those in the combat situation and deprivation trauma class were the youngest, moderately proficient in English, and reported moderate mental health symptoms; and those in the low exposure to refugee-related trauma class were the most proficient in English, had the longest U.S. residency, and reported the least severe mental health symptoms. Our findings call for surveillance and a trauma-informed approach for Hmong elders with limited English proficiency, who have a high risk of experiencing accumulative effects of refugee-related trauma and are susceptible to poor mental health outcomes.

Impact of War and Resettlement on Vietnamese Families Facing Dementia: A Qualitative Study

OBJECTIVES

Most Vietnamese immigrants in the U.S. today arrived as political refugees due to the Vietnam War in the late 20th century. Refugees are disproportionally affected by health and mental health disparities as a result of experiencing distress and potentially traumatic experiences before, during, and after their migration processes. This study involved Vietnamese families facing dementia and used a qualitative approach to investigate participants' experiences before, during, and right after their resettlement in the U.S.

METHODS

In-person interviews were conducted with 11 Vietnamese adults who cared for their family member with dementia. A descriptive analysis approach was used.

RESULTS

Five major themes emerged from the interviews:1) immigrating separately from family members, 2) difficult and unsafe journeys, 3) experiences of loss, 4) lack of support systems in the U.S., and 5) feelings of unhappiness, sadness, or signs of depression.

CONCLUSIONS

This study provides a close examination of Vietnamese refugees' unique backgrounds and how individuals with dementia and their caregivers from this population may be disproportionally impacted by stress.

CLINICAL IMPLICATIONS

To reduce health disparities, we recommend that providers and policymakers allocate more resources for culturally appropriate routine assessment, treatment, and referrals of those with dementia and their caregivers.

Association between time of residence and self-perception of distress, interpersonal relationships, and social role in Venezuelan immigrants in Lima, Peru 2018-19: mixed-methods study

BACKGROUND

Immigrants arriving in a new country face changes that affect their social, employment, and migratory status. We carried out a mixed-methods study in the rapidly growing Venezuelan immigrant population in Lima, Peru. The objective was to determine whether there was an association between time in Peru and self-perception of symptom distress (SD), interpersonal relationships (IR), and social role (SR).

METHODS

The quantitative central component consisted of a cross-sectional study, surveying 152 participants using the Outcome Questionnaire 45.2 (OQ-45.2). The qualitative component, based on phenomenology, explored experiences and challenges during the migration process. Semi-structured in-depth interviews were conducted in 16 informants.

RESULTS

An association that was observed was the increase in the risk of clinically significant SR score with additional years of age. All informants mentioned having witnessed or experienced xenophobia in Peru. Every informant stated that significant labor differences existed between the countries. The most reported somatic symptoms were symptoms of anxiety and alterations of sleep. Additionally, no informant expressed a desire to remain in Peru long term.

CONCLUSIONS

A minority of participants registered a clinically significant total score and in each of the three domains of SD, IR, and SR. No association between months in Lima and the self-perception of distress was found. However, this could be due to the short amount of time spent in Peru and any change in self-perception might only be perceived after years or decades spent in Peru. This study is one of the first to use mixed-methods to explore the mental health of the immigrant Venezuelan population.

The relationship between employment and health for people from refugee and asylum-seeking backgrounds: A systematic review of quantitative studies

Background

For the general population, the positive effects of paid employment on health and wellbeing are well established. However, less is known for people from refugee and asylum-seeking backgrounds. This review aims to systematically summarise the quantitative literature on the relationship between employment and health and wellbeing for refugees and asylum seekers.

Method

A search strategy was conducted in online databases, including MEDLINE, PsychINFO, EMCARE, SCOPUS, CINHAL, ProQuest and Web of Science. Articles were screened against inclusion and exclusion criteria. Studies published in English between 2000 to October 2021 were included if they used quantitative methods to consider the relationship between employment and health for refugees and asylum seekers in resettlement countries. Study quality was assessed using The Joanna Briggs Institute's Critical Appraisal Tools. Findings were synthesised using a narrative approach.

Results

Seventy-two papers were identified. The majority of papers (N = 58, 81%) examined the association between employment and mental health outcomes. Overall, while there were inconsistencies in the findings, employment had a positive effect on mental health particularly in reducing levels of psychological distress and depression. Though more limited in number, the papers examining physical health suggest that people who are employed tend to have better physical health than unemployed persons. There was some evidence to support the bi-directional relationship between employment and health. Poor mental and physical health negatively impacted the odds of employment and occupational status of refugees.

Conclusion

Good quality employment is an essential component of refugee resettlement and this review found that in general employment is also beneficial for refugee health, particularly aspects of mental health. More research regarding the effects of employment on physical health is required. The effects of refugee-specific factors such as gender roles, torture, and trauma on the relationship between employment and health also require further investigation.

‘We are inferior, we have no rights’: Statelessness and mental health among ethnic minorities in Northern Thailand

Research has shown that asylum seekers, refugees, and internally displaced persons, including stateless persons, are at increased risk of poor mental health. Yet, only a few studies explicitly focus on stateless persons. This article examines the association between legal status and mental health among Akha, Lahu and Tai-Yai people in Northern Thailand. A convergent parallel mixed-methods design was adopted and primary data were collected in June 2020 by face-to-face, semi-structured interviews with persons who do not hold a nationality (n = 108). A distinction was made between registered (nationalityless) and unregistered (stateless) persons since only the former have a legal status in Thailand. The correlates of mental health were analyzed using descriptive statistics and logistic regression. Qualitative thematic analysis was employed to gain deeper insights into the relationship between legal status, ethnicity and mental health. The quantitative results weakly suggest that stateless persons are more likely to have poorer mental health than nationalityless persons, who are recognized as habitually resident in Thailand and are recorded in the country's civil registry. The qualitative results, however, show that the legal status afforded to nationalityless persons is considered important as it gives rise to hope and increases livelihood opportunities. Yet, respondents also pointed out that it is not comparable to citizenship. The odds of having poorer mental health are significantly higher for Lahu and Tai-Yai respondents. The importance of ethnicity is confirmed by the qualitative results. These further indicate that citizenship problems and ethnicity are deeply interrelated. Stigma, discrimination, and lack of social support are key risk factors identified by respondents. Disaggregating data to better understand the heterogeneity of persons without nationality could play a key role in accelerating efforts to resolve protracted citizenship problems and close ethnic gaps.

•

Legal recognition and ethnicity affect the mental health of persons without nationality.

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Stigma, discrimination, and lack of social support are key risk factors.

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Disaggregated data are essential for identifying and addressing existing gaps.

Global prevalence of anxiety and PTSD in immigrants: a systematic review and meta-analysis

BACKGROUND

A systematic and meta-analysis of the prevalence of anxiety and posttraumatic stress disorder (PTSD) in immigrants was conducted.

METHODS

Based on the keywords, scientific databases were systematically searched to identify articles. The search included the three databases PubMed, Google Scholar and Research Gate until June 2020. The analysis was performed to assess the prevalence of anxiety and PTSD; subgroups were examined based on anxiety disorders.

RESULTS

The prevalence of agoraphobia, PTSD, generalized anxiety disorder (GAD), panic disorder, obsessive-compulsive disorder (OCD), social phobia and specific phobia were 4, 25, 9, 4, 3, 5 and 8%, respectively.

CONCLUSIONS

Considering the findings of the present study regarding the significant prevalence of anxiety and PTSD in the immigrant population, it is necessary to pay special attention to the mental health of this population.

The longitudinal course of posttraumatic stress disorder symptoms in war survivors: Insights from cross-lagged panel network analyses

Many war survivors suffer from chronic posttraumatic stress disorder (PTSD). Unraveling the complexities of PTSD symptoms over time is crucial for understanding this condition. Going beyond a common pathogenic pathway perspective, we applied the network approach to psychopathology to analyze longitudinal data from war survivors with PTSD in five Balkan countries approximately 8 years after war in the region and a follow-up assessment 1 year later (N = 698). PTSD diagnosis was established using the Mini-International Neuropsychiatric Interview, and PTSD symptoms were assessed using the Impact of Events Scale-Revised. Undirected cross-sectional networks for baseline and follow-up revealed no differences in the overall connectivity between these two networks. The intrusion symptom "I had waves of strong feelings about it" had the strongest expected influence centrality. Directed cross-lagged panel network models indicated that hyperarousal symptoms predicted other PTSD symptoms from baseline to follow-up, whereas several avoidance symptoms were predicted by other PTSD symptoms. The findings underscore the importance of emotional reactions and further suggest that hyperarousal symptoms may influence other PTSD symptoms. Future research should investigate causality and associations between between-person and within-person networks.

Reciprocal relationships between employment status and psychological symptoms: findings from the Building a New Life in Australia study

BACKGROUND

Finding work is an important priority for many refugees in the initial years following settlement in a host country. Difficulties in finding work could conceivably both contribute to and be a consequence of symptoms of posttraumatic stress disorder (PTSD) and psychological distress commonly reported by refugees.

PURPOSE

We sought to determine the direction of these relationships and the possibility of a reciprocal association between employment status on one hand, and symptoms of PTSD and psychological distress on the other, in a large refugee sample.

METHODS

A secondary analysis of three face-to-face interview assessments conducted across 5 years with 894 adult refugee participants (M = 39.9 years, SD = 12.8) from the Building a New Life in Australia study was conducted. Symptoms of psychological distress, posttraumatic stress, and employment status were assessed on each occasion. Preliminary analysis identified the cross-sectional relationships between psychological distress, PTSD symptoms, and employment status, while cross-lagged models were used to identify the longitudinal relationships between these respective symptoms.

RESULTS

Symptoms of psychological distress and not being in paid work were significantly correlated with each other at each time point (ranging 0.09-0.25) and they reciprocally influenced each other over time. Likewise, PTSD symptoms and not being in paid work were correlated with each other after 3 years and 5 years (r = 0.21 and 0.23 respectively), and a reciprocal relationship between these was found over time.

CONCLUSION

The current findings indicate that interventions which target either mental health or work opportunities could have multiple downstream benefits for refugees.

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.

The impact of an insecure asylum status on mental health of adult refugees in Germany

Background

Forcibly displaced people have a higher chance of developing post-traumatic stress disorder (PTSD) compared to people who have not experienced displacement. In addition to potentially traumatic events due to war, persecution, and flight, post-migration living stressors are an important influencing factor. Among these, an insecure asylum status is one of the main stressors with which forcibly displaced people must cope. The aim of this study was to investigate the additive effect of an insecure asylum status on PTSD symptomatology in refugees, over and above the influence of other pre- and peri-migration factors, in particular potentially traumatic event types reported and duration of stay in Germany.

Method

Two overlapping convenience samples of 177 and 65 adult refugees that were assessed at different timepoints were interviewed by means of face-to-face interviews. Interviews were conducted in either Arabic, Farsi, Kurmancî, English, or German with the assistance of interpreters where necessary. Besides residence status and potentially traumatic events experienced, mental distress was assessed via the Refugee Health Screener-15 (RHS-15; Study A) and the PTSD Checklist for DSM-5 (PCL-5; Study B).

Results

In both samples, an insecure asylum status explained a significant additional amount of variance of PTSD symptomatology, on top of traumatic events experienced and time since arrival in Germany.

Conclusion

Results suggest that refugees with an insecure asylum status are at higher risk for experiencing increased PTSD symptomatology. Policy changes of asylum procedure in receiving countries could have a positive impact on refugees’ mental health.

Transient refugees' social support, mental health, and physiological markers: Evidence from Serbian asylum centers

OBJECTIVES

Refugees seeking safety across international borders are often exposed to a wide breadth of psychosocially stressful experiences that may fracture existing sources of social support and impair the generation of new social relationships, with implications for their long-term health and resilience. Using data from recently settled refugees in two asylum centers in Serbia, we examined the associations between social support, mental health, and physiological markers.

METHODS

In this mixed-method study of refugees (age 18-50 years, n = 76), we collected key socio-demographic information and conducted semi-structured interviews about refugees' journey and stay in Serbia, trauma/loss, and their sources of social support. We also collected self-reported measures of mental well-being as well as physiological markers relevant to repeated exposure to chronic psychosocial stress (fingernail cortisol and dried blood spots for analysis of Epstein-Barr virus [EBV] antibody titers).

RESULTS

We found that refugees with longer journeys reported lower social support than those with shorter journeys. Refugees with lower social support reported poorer mental well-being, greater PTSD-related symptoms, and higher recent perceived stress than those with higher social support. We also observed that refugees with lower social support and higher recent stress, respectively, tended to exhibit higher fingernail cortisol levels. However, we did not observe comparable patterns linking EBV antibodies with psychosocial functioning.

CONCLUSION

Our cross-sectional findings are consistent with the notion that social support is likely to be a critical component in effective interventions aimed at mitigating the adverse health effects of relocation-related illnesses and poor social functioning as they await resettlement.

Protocol of a feasibility trial for an online group parenting intervention with an integrated mental health component for parent refugees and asylum-seekers in the United Kingdom: (LTP + EMDR G-TEP)

OBJECTIVES

Conflicts expose families to a range of factors that could have a negative impact upon parental mental health which in turn leads to poor growth and development of children. Early support can improve parental mental health and parenting behaviours but currently, there is a lack of evidence on parenting interventions for forcibly displaced populations. This study aims to deliver an online parenting intervention with a mental health component for refugee and asylum-seeker parents to evaluate its feasibility and acceptability.

METHODS

This is a single-arm trial without a control group. The trial aims to recruit 14 refugee and asylum-seeker parents into an Online Learning Through Play and Eye Movement Desensitization and Reprocessing Group Traumatic Episode Protocol (LTP + EMDR G-TEP). The intervention will be delivered by trained research team members using online platforms.

RESULTS

The participants' sense of parenting competence, symptoms of traumatic stress, anxiety and depression will be measured at baseline and post-intervention. Semi-structured interviews at post-intervention will also be conducted.

DISCUSSION

This study will assess the feasibility and inform the design of a future randomized controlled trial which aims to evaluate the effectiveness of LTP + EMDR G-TEP intervention for parent refugees and asylum-seekers with young children.

Psychologists' Perspectives on the Psychological Suffering of Refugee Patients in Brazil

Worldwide there are 79.5 million displaced people, many of which face war, violence, tragic flights and struggles in host countries. Research shows augmented prevalence rates of mental disorders among refugees internationally, but little is known about refugee mental health in Latin American countries. Furthermore, only a few studies have taken into consideration the knowledge of clinical psychologists who treat refugee patients. The present study examines the experiences of 32 psychologists in Brazil regarding their refugee patients' psychological suffering and mental disorders. Semi-structured interviews were conducted in various locations in Brazil and analysed following a consensual qualitative research approach. Four clusters of refugee patients' suffering were synthesised: post-migration stressors, traumatic experiences, flight as life rupture, and the current situation in the country of origin. The most frequently described conditions in patients were anxiety and depression. However, the results also show that the use of manuals for the classification of mental disorders is contested among psychologists in Brazil. Most psychologists stressed patients' socio-political suffering and saw patients' symptoms as normal reactions to their experiences. There is a need to acknowledge the socio-political suffering of refugees in Brazil and foster their mental health by tackling current post-migration stressors such as discrimination.

The impact of morally injurious events in a refugee sample: A quantitative and qualitative study

BACKGROUND

Posttraumatic Stress Disorder (PTSD) is often reported by refugees that faced violence and persecution. Some stressful events may also entail moral conflicts or dilemmas, described as "potentially morally injurious events" (PMIE). Very few studies have yet investigated the nature of these PMIEs in traumatized refugees, using both quantitative and qualitative data.

METHOD

For this retrospective study, secondary data analysis was used to examine the traumatic events of 183 patients. Based on established definitions of a PMIE, participants were allocated to a Moral Injury (MI) group if they reported lasting distress after exposure to an event of which they indicated that it transgressed their moral beliefs. The remaining participants were allocated to the No-MI group. The type of PMIEs was categorized using qualitative analysis. The groups were compared in terms of PTSD severity, feelings of guilt, and general mental health symptoms.

RESULTS

Of the total sample, 55 participants reported one or more acts of transgression (MI group) and 128 reported no acts of transgression (No-MI group). Analyses of PMIEs revealed six themes 1) failing to prevent harm to others, 2) not giving aid to people in need, 3) leaving family members behind that consequently lead to injury or death of others, 4) making indirect and direct moral decisions leading to injury or death of others, 5) betrayal, and 6) engaging in the harm of others. No differences were found between groups on the clinical outcomes, except for feelings of guilt.

CONCLUSION

A considerable number of traumatized refugees reported confrontation with PMIEs. Experiencing PMIEs appeared unrelated to elevated posttraumatic mental health issues.

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.

Fear of COVID-19 and Depression, Anxiety, Stress, and PTSD among Syrian Refugee Parents in Canada

Introduction

The high frequency of COVID-19 has had an impact on the psychological health of all countries and socioeconomic groups around the world, with refugees suffering the brunt of the burden. The aim was to assess the relationship between fear of COVID-19 and depression, anxiety, stress, and PTSD among Syrian refugee parents residing in the Greater Toronto Area.

Methods

A convenience sample of 274 Syrian refugee parents residing in Ontario was recruited. Fear of COVID-19 was measured using the Fear of COVID-19 Scale (FCV-19S). Levels of depression, anxiety, stress and PTSD were assessed using the Depression Anxiety Stress Scales (DASS-21), and Primary Care PTSD screen (PC-PTSD). Multiple Linear Regression analyses were performed to assess the relationship between FCV-19S and the DASS-21 subscales and PC-PTSD.

Results

Severe levels of depression, anxiety, and stress were reported by 12.2%, 26.8%, and 9.7% of participants respectively, and 24.1% screened positive for PTSD. FCV-19S was associated with higher levels of stress (β = 0.27, p = 0.006), anxiety (β = 0.40, p <0.001), depression (β = 0.32, p = 0.001) and PTSD (β = 0.04, p = 0.015).

Discussion

Government initiatives should consider tackling fear concerning pandemics among Syrian refugee parents to help enhance their mental well-being.

Waiting for family reunification and the risk of mental disorders among refugee fathers: a 24-year longitudinal cohort study from Denmark

PURPOSE

To examine whether family separation caused by prolonged waiting for family reunification is associated with the risk of mental disorders among refugee fathers.

METHOD

Based on full-population Danish registry data covering 1995-2015, we mapped arrival patterns among nuclear refugee family members resettled in Denmark (n = 76,776) and established a cohort of refugee fathers (n = 6176) who all arrived alone and later obtained family reunification with their wife and children. The fathers were followed for up to 24 years, from the day their residence permit was issued until their first psychiatric diagnosis, emigration, death, or study end, whichever came first. Using Cox proportional hazard regression, we estimated hazard ratios (HRs) of being diagnosed with a mental disorder (i) for the period while the fathers were still separated from their family and (ii) across varying lengths of family separation.

RESULTS

The HR of any mental disorder was 2.10 (95% confidence interval (CI): 1.57-2.81) for fathers still separated from their family compared with those who had obtained family reunification. The HR increased with longer family separation. Compared with fathers separated for < 9 months, the HR of any mental disorder was 1.43 (95% CI 1.08-1.89) for 9-11 months' separation, increasing to 2.02 (95% CI 1.52-2.68) for 18-23 months' separation. Results were driven by post-traumatic stress disorder.

CONCLUSION

Fathers waiting for their wives and children face an increased risk of mental disorders. Countries receiving refugees should be aware that delaying family reunification can lead to adverse mental health effects.

Psychological distress in refugees: The role of traumatic events, resilience, social support, and support by religious faith

Many refugees have been exposed to potentially traumatic events and report elevated levels of psychological distress. However, refugees vary greatly in the severity of mental health problems. Intra- and interpersonal factors help some refugees to cope effectively. To shed light on these factors, we scrutinized how potentially traumatic events, resilience, social support, and support by religious faith are associated with psychological distress in refugees in Germany and German residents. We assessed data from 205 German residents and 205 refugees (total N = 410). Questionnaires assessing psychological distress, potentially traumatic events, resilience, social support, and perceived support by religious faith were disseminated online in Arabic and German. Refugees reported higher levels of psychological distress, more exposure to potentially traumatic events, less social support, less resilience, and more perceived support from their faith than German residents. Using a pathway model, lower social support and resilience partially accounted for group differences of higher psychological distress in refugees. This study points to the importance of social support and individual resilience in explaining mental health discrepancies between refugees and residents. This, in turn, may inform future intervention studies to reduce elevated levels of psychological distress experienced by refugees.

Predicting and preventing dropout in research, assessment and treatment with refugees

Refugees and asylum seekers are exposed to multiple burdensome experiences and suffer from ongoing post-migration stressors that are known to affect the physical and mental health. In psychological treatment offered to refugees and asylum seekers, dropout is an important challenge. The current practice-oriented review aims to provide for the first time knowledge on the prevalence, prediction and prevention of dropout in psychological treatment for refugees and asylum seekers. Due to the limited empirical evidence for this specific population, we synthesized refugee-specific research but also reviewed the existing evidence on dropout from treatment in general and specifically discuss how the findings can be adapted to refugee populations. The review integrates literature from online databases, grey literature, hand search and expert contacts. Prevalence rates of dropout from psychological treatment in Western samples are reported at about 20%. For refugees and asylum seekers, evidence from single efficacy trials showed considerable variability in dropout rates (0%-64.7%). Further, for refugees and asylum seekers, specific sociodemographic variables, high initial impairment, deviating expectations and perceptions of mental health and psychological treatment, as well as external barriers seem to be important predictors for dropout. To prevent dropout, it is important to develop and promote cultural competencies, adapt the treatment to refugee-specific needs and focus on role induction, preparation for treatment, fostering the therapeutic alliance and strengthening hope. Future specific research on dropout in treatment offered to refugees and asylum seekers is needed.

Forecasting the Suitability of Online Mental Health Information for Effective Self-Care Developing Machine Learning Classifiers Using Natural Language Features

Background: Online mental health information represents important resources for people living with mental health issues. Suitability of mental health information for effective self-care remains understudied, despite the increasing needs for more actionable mental health resources, especially among young people. Objective: We aimed to develop Bayesian machine learning classifiers as data-based decision aids for the assessment of the actionability of credible mental health information for people with mental health issues and diseases. Methods: We collected and classified creditable online health information on mental health issues into generic mental health (GEN) information and patient-specific (PAS) mental health information. GEN and PAS were both patient-oriented health resources developed by health authorities of mental health and public health promotion. GENs were non-classified online health information without indication of targeted readerships; PASs were developed purposefully for specific populations (young, elderly people, pregnant women, and men) as indicated by their website labels. To ensure the generalisability of our model, we chose to develop a sparse Bayesian machine learning classifier using Relevance Vector Machine (RVM). Results: Using optimisation and normalisation techniques, we developed a best-performing classifier through joint optimisation of natural language features and min-max normalisation of feature frequencies. The AUC (0.957), sensitivity (0.900), and specificity (0.953) of the best model were statistically higher (p < 0.05) than other models using parallel optimisation of structural and semantic features with or without feature normalisation. We subsequently evaluated the diagnostic utility of our model in the clinic by comparing its positive (LR+) and negative likelihood ratios (LR−) and 95% confidence intervals (95% C.I.) as we adjusted the probability thresholds with the range of 0.1 and 0.9. We found that the best pair of LR+ (18.031, 95% C.I.: 10.992, 29.577) and LR− (0.100, 95% C.I.: 0.068, 0.148) was found when the probability threshold was set to 0.45 associated with a sensitivity of 0.905 (95%: 0.867, 0.942) and specificity of 0.950 (95% C.I.: 0.925, 0.975). These statistical properties of our model suggested its applicability in the clinic. Conclusion: Our study found that PAS had significant advantage over GEN mental health information regarding information actionability, engagement, and suitability for specific populations with distinct mental health issues. GEN is more suitable for general mental health information acquisition, whereas PAS can effectively engage patients and provide more effective and needed self-care support. The Bayesian machine learning classifier developed provided automatic tools to support decision making in the clinic to identify more actionable resources, effective to support self-care among different populations.