Keywords

Introduction

Identifying mental illness in refugees poses multiple challenges to providers and organizations worldwide. These challenges range from technical aspects of language barriers and accessibility to phenomenological questions such as the definition of mental illness across cultures.

Nevertheless, most Western societies now consider refugees as a population with high prevalence of mental illness, and multiple efforts are ongoing toward standardizing screening methods and identifying risk factors early in the process of resettlement.

Screening for Mental Illness

Overseas Screening

As outlined in Chap. 3, the Secretary of Health and Human Services promulgates, under the authority of the Immigration and Nationality Act (INA) and the Public Health Service Act, regulations outlining the requirements for the medical examination of aliens seeking admission into the United States. The Division of Global Migration and Quarantine provides the Department of State (DOS) and the US Citizenship and Immigration Services (USCIS) physical and mental health screening guidelines for all examining physicians.

The purpose of the overseas mental health examination is to identify applicants with inadmissible health-related conditions that include any physical or mental disorder with associated harmful behavior and any drug abuse or dependence.

Following this evaluation, refugees with a mental disorder are classified as follows:

  • Class A refugees are diagnosed with a mental disorder with associated harmful behavior that may pose a threat to property or welfare of the alien or others. These refugees need an approved waiver for travel. An approved US healthcare provider is identified for the refugee. When the class A refugee arrives in the United States, he or she must report promptly to the identified US healthcare provider.

  • Class B refugees are diagnosed with a mental disorder with no current associated harm or behavior, or there is a history of harmful behavior judged not likely to recur. Refugees with a class B mental disorder do not require a waiver, but it is recommended that they are evaluated by a mental health specialist soon after arrival.

Domestic Screening

The domestic examination includes screening and a more comprehensive assessment, when indicated. The Centers for Disease Control and Prevention (CDC) recommends that mental health screening be performed at the first medical evaluation that refugees undergo in the United States. Other countries have also issued guidelines for mental health screening in refugees. Mental health screening and assessment are discussed in Chap. 14. Chapter 16 reviews best practices in assessing for sequelae of torture in refugees.

The range of psychiatric disorders seen in refugees is broad, and the severity of illness is variable. While posttraumatic stress disorder (PTSD) and depression are most prevalent among refugees, other conditions may be identified. The following sections discuss factors leading to higher risk of mental health conditions in refugees and review prevalence in different refugee populations.

Risk Factors for Psychiatric Problems in Refugees

Risk factors can be broadly considered under three phases of migration: premigration, post-migration, and during migration.

Premigration Factors

Age

Studies looking at age of refugees and prevalence of mental illness have produced variable results. Some studies showed that refugees of younger ages experience more depression [1], while other studies showed that adolescents do better than older adults, especially in the Ethiopian population [2]. And finally, other studies found that more severe PTSD symptoms and anxiety symptoms were associated with older age [3,4,5].

Gender

In most studies, women have a higher prevalence of PTSD and depression than men; and this finding has been consistent in refugees from the Middle East, Central Africa, Southern Asia, and Southeast Europe [6]. Other psychiatric conditions such as anxiety and pain disorder are also more common in women: tortured Bhutanese women reported higher prevalence of generalized anxiety disorder, pain disorder, and dissociative disorders than men [7]. Several studies, however, found depression more common in male refugees than in female refugees [1]; oftentimes, this is a reverse of the ratio seen in the country of origin. One study found an abnormal (80%) prevalence of psychosis in men in a Somali refugee clinic population [8].

Premigration Education

Overall, more educated refugees scored lower on the mental health indices [2], which is thought to be related to loss of status that these refugees experience during the resettlement. At the same time, patients with limited education have more difficulties with integration and are more likely to have depression [1]. In a review of North Korean refugees living in South Korea, the premigration level of education appeared to be a protective factor against developing mental health problems [9].

Region of Origin

In general, refugees from rural areas had poorer outcomes [2]. Refugees from Europe had relatively worse mental health outcomes than those from Asia or the Middle East when the comparator groups were non-refugee residents in those respective regions [2]. In addition, Southeastern European subjects had more somatic complaints than Central African refugees [10].

History of Trauma

By definition, a refugee is exposed to traumatic events; and there is no doubt that this exposure increases the risk of mental health problems, as shown in numerous studies. Not all trauma is equal however, and many studies have tried to link specific psychiatric conditions to specific types of trauma. In most studies, trauma is defined according to the Diagnostic and Statistical Manual of Mental Disorders (DSM) V as “exposure to actual or threatened death, serious injury or sexual violence” [11]. Multiple studies have looked at what aspect of the trauma influences the risk for subsequent mental health problems. For instance, some authors have divided traumatic experiences in four groups: life threat, war exposure, torture, and sexual violence [12]. Among these, exposure to life threat trauma was a significant predictor of PTSD and depressive symptom severity [12]. Exposure to war had a less severe impact on young adults’ sense of self and other psychological problems compared to older adults [13]. There are multiple studies showing that a history of torture increases the risk of mental health problems [14] and that in victims of torture, mental health problems may persist long after the resettlement [15, 16]. Details on impact of torture will be discussed in Chap. 16.

The concept of “cumulative trauma” summarizes the fact that more episodes of trauma were related with more intensive symptoms of PTSD in refugees (with the exception of the symptom of avoidance, which did not correlate with the number of traumatic events/experiences) [17]. Cumulative trauma also predicted a higher incidence of anxiety and depression [3].

“Trauma centrality” is another significant concept in understanding the role of trauma in developing psychopathology and defines how close a subject is to the event; directly witnessing murder, kidnapping, or disappearance of family members is associated with emotional suppression, which increases the risk for PTSD [13].

Death of a Relative

Having lost a relative or a close friend in the home country or during the resettlement has been associated with increased likelihood of psychiatric problems [18,19,20].

Migration Factors

The following factors characterizing the migration process have been associated with poorer mental health status: being detained after leaving the country [21], immigration detention [22], forced repatriation [23], incidence of torture [14], time spent in the refugee camp, waiting to be granted refugee status/asylum status, and not being satisfied in the camp [24]. Stopping somewhere else before resettlement to the current location was linked with a higher risk of developing major depressive disorder [25]. For minors, being unaccompanied at the time of migration predicted poorer mental health outcomes [26, 27].

Being granted the refugee status had a positive impact on mental health [28]; in addition, having the right to return to the country of origin was also associated with less depression [29].

Post-migration Factors

Although emphasis is often placed on the refugees’ experience of trauma in their country of origin, there is a growing body of evidence that factors related to their post-settlement period can contribute more to mental health problems than experiences prior to fleeing their country [30, 31].

Communication Problems

Lack of knowledge of the language of the adoptive country can affect the prevalence of mental health problems in two ways: On the one hand, it can seriously impact the quality of adjustment to the new environment and therefore increase the prevalence of depression or anxiety [32,33,34]. On the other, communication barriers can cause underdiagnosis and poor access to care leading to underreporting of psychiatric problems. Interestingly, however, Somali refugee men with higher English proficiency seemed to have worse mental health in one study [35].

Housing Accommodations

Permanent private accommodations were related to better mental health than institutional or temporary accommodations [2, 33, 36]. In addition, residential mobility (frequent changes in residence) was seen as stressful and worsened mental health [37]. Living in unsafe neighborhoods and being concerned for one’s physical safety can also contribute to psychiatric problems [18].

Restricted Economic Opportunity

Lack of employment or loss of economic status has been associated with worse mental health [2, 31, 33, 38]. Stable housing and employment significantly moderated treatment response of patients with PTSD and chronic pain [39].

Access to Care

Time spent before presenting for services significantly predicted anxiety, PTSD, and depression in torture survivors in the United States [3].

Other post-migration factors associated with worse mental health outcomes are worry about family not in the host country [40, 41], initiating conflict not resolved [2], uncertainty of their status [42], experiencing discrimination [43], and facing repatriation to a country they had previously fled [2]. In general, social disconnection in the host country was associated with poorer mental health even three decades after settlement [44]. The impact of acculturation may vary with gender—in Somali girls, for instance, greater Somali acculturation was associated with better mental health, while for Somali boys, greater American acculturation was associated with better mental health [45].

Prevalence of Common Mental Illnesses

Determining the prevalence of various psychiatric disorders in the refugee populations presents multiple levels of challenges. Most of the prevalence studies were performed in clinical populations, typically refugees who were seen either in mental health clinics or in general health programs, which already introduces a selection bias. Epidemiologic studies attempt to overcome this bias, but face communication difficulties, fear of stigma, and local beliefs about mental illness and how it is integrated in everyday life. These factors lead to low rates of participation and minimization of symptoms on questionnaires. In addition, the measures used to identify mental health problems have to meet the demands of being, at the same time, culture specific, standardized, and practical for the provider. A study looking at how refugee trauma and health status were measured in English-language publications identified over 125 different screening or diagnostic instruments used [46]. This illustrates the complexity of studying the prevalence of mental illness in the refugee population.

Communication Challenges

Communication can be particularly difficult when working with refugees due to multiple factors: language and cultural differences, the effect of culture on symptoms and illness behavior, differences in family structure, acculturation, and intergenerational conflict. These difficulties can be addressed through specific inquiry, use of trained interpreters, culture brokers, meetings with families, and community organizations [47].

Use of Interpreters

The first step in working with an interpreter is selecting the language in which the interview will be conducted. Refugees, like many migrants, oftentimes speak more than one language. Although it may be convenient to conduct the interview in a language that is known to both patient and clinician, effort must be made in order to identify the language in which the patient can be most accurate. This will help avoid abbreviated statements and allow the expression of emotional content. In certain situations, it may be possible to dispense with interpreter services: patients speak some English and insist on conducting the interview in English or later in treatment when patients’ mastery of English improves. Interpreters or translators should be familiar with the psychiatric assessment, and they need to be able to translate (to find the corresponding words from one language to another while retaining the same meaning) and also to interpret which implies the transmission of denotative meaning, in addition to the connotative meaning [48]. It is important to train the interpreter to translate in such a way that the clinician can assess the important parts of the mental status exam such as the process, association, and affect.

Use of Bilingual Providers

A frequent model uses the bilingual psychiatric worker, which is sometimes employed in places where there are communities of refugees from the same country or cultures. In this case, attention must be given to boundaries and countertransference. Patients tend to try to recreate the doctor-patient relationship from their country, which often may be different from the accepted model in the United States. Some examples include total trust and obedience in the provider (which can translate into a passive attitude or lack of participation), a desire to compensate the provider with gifts, or asking the provider for a letter of reference for a job application. A sensitive but firm delineation of boundaries will help the refugee in learning and adjusting to the US healthcare system and will promote a healthy societal integration in general. For all clinicians evaluating or treating refugees, but especially for those clinicians who are themselves prior refugees, special attention must be given to countertransference, and additional peer supervision should be sought if necessary.

Treatment Beliefs

Another factor that can affect the attendance of mental health programs and the evaluation of the prevalence of psychiatric disorders in refugees and immigrants is the use of alternative or complementary medicine. Traditionally it was believed that the use of alternative medicine is associated with avoidance of Western medicine in immigrants. A study of Cambodian refugees showed that 34% of them relied on alternative medicine in the past year; however, only 5% used the alternative medicine exclusively. Surprisingly, using alternative medicine was positively associated with seeking Western sources for mental health care [49].

Phenomenology

In addition to the above challenges, given that the phenomenology of mental illness can be very different across cultures, Western diagnoses are not universally accepted as valid for these populations. However, most studies of prevalence utilize Western psychiatric diagnoses as outlined in the Diagnostic and Statistical Manual of Mental Disorders (DSM) and may overestimate or underestimate true psychological distress in refugee populations. Even the best standardized instruments have to be complemented with a comprehensive assessment within the appropriate cultural framework, and symptoms and impairment have to be observed over time. See Chap. 14 for a discussion of validated assessment scales and mental health assessment in refugee populations.

With all these caveats, studies across refugee populations have consistently shown PTSD and depression to be the most commonly encountered diagnoses. A review of studies of refugees resettled in Western countries showed a PTSD prevalence of 9% and major depression prevalence of 5% [50]. A review of studies that included traumatized refugees in post-conflict regions showed a higher rate of 30% for both PTSD and depression [51]. In general, larger and more methodologically rigorous studies showed lower prevalence of these disorders.

Other Psychiatric Disorders

Anxiety disorders are found to be co-morbid with PTSD and depression in many individual refugee studies. Enduring personality changes as a manifestation of chronic vulnerability and loss is also reported in refugees.

In addition, other psychiatric disorders have been described in refugee populations:

  • Traumatic brain injury is frequently present in the medical history of the refugees, and it can present with a wide range of psychiatric problems [52, 53]. One clinical sample of refugees with moderate to severe mental disorder found that 51% of refugees had a history of head injury [54]; the CDC recommends screening all refugees for history of head trauma.

  • Postnatal or postpartum depression tends to have a higher prevalence in refugee women compared to the general population. One review found the prevalence of postpartum depression as high as 42% in migrant women (including immigrants, asylum seekers, and refugees) as opposed to 10–15% in native-born women [55]. One study from Jordan reported that half (49.6%; n = 181) of the Syrian refugee women scored >12 on the Edinburgh Postnatal Depression Scale (EPDS) [56]. Migrant women at greatest risk to develop depressive symptoms were those who experienced abuse, had pain post-birth, worried about family members left behind, had food insecurity, and had reduced access to healthcare (limited insurance and/or no regular care provider) [56, 57]. A particular risk factor for depression in women is domestic violence, considered to be underreported by refugees due to cultural factors, fear of stigma, and also fear of losing children to the child protection agencies if abuse is reported.

  • Suicide rates were four to five times higher in Ethiopian immigrants than in the national population in one study [58]. More recently, higher suicide rates were observed in Bhutanese refugees resettled in the United States compared to other refugee groups [59].

  • Pathological gambling was initially thought to be very common in Cambodian refugees (70% prevalence [60]); however, a later study, considered to be more representative of Cambodian refugee communities in the United States, showed a prevalence of only 13.9% [61].

  • Substance abuse has been reported as well: 45% of Indo-Chinese refugees had problems with alcohol or tobacco, while 13.9% of the same had problems with drugs [62].

  • Psychoses: A study of Somali refugees in Minnesota showed an 80% prevalence of psychosis in young Somali men compared to non-Somali clinic samples [8, 94].

Table 13.1 presents a summary of the most illustrative studies regarding prevalence of psychiatric disorders in refugees.

Table 13.1 Prevalence of psychiatric problems in refugees
Full size table

Psychiatric Comorbidity

It is important to keep in mind that refugees often experience more than one psychiatric condition and that once a mental health problem is present, the risk of co-morbid problems is increased. In a clinical sample of 61 refugee outpatients from psychiatric clinics in Norway, 80% of those who had PTSD had three or more additional psychiatric diagnoses [10]. Hocking found that 99% of mental health problems in refugees were associated with PTSD or depression [93]. In a different study, 40.9% of refugees with PTSD had secondary psychotic symptoms [94]. Women refugees with PTSD had three times higher incidence of positive screening for eating disorders [63].

Medical Comorbidity with Psychiatric Illness

Refugees with mental health problems often present with physical symptoms as their chief complaint, and multiple studies have shown pain to be comorbid with PTSD and depression. Specific PTSD symptoms (Criterion D = negative alterations in cognitions and mood and Criterion E = alterations in arousal and reactivity according to DSM V) have been associated with higher level of reported physical pain [95]. Somatization, a term typically used when patients present with physical complaints without a clear medical or surgical diagnosis, has been long considered rather common in refugees of non-Western origins [96]. It has been postulated that the stigma of mental illness is high in these populations, and having a physical illness is somewhat “more acceptable”; therefore, patients would express their psychological distress through physical complaints. Before attributing physical complaints to history of trauma, it is important however to remember that migrants diagnosed with PTSD and depression have significantly higher rates of chronic disease compared with migrants without diagnosed psychiatric disorders—especially infectious disease, neurological disease, and pulmonary disease [97]. Treatment of the psychological symptoms improves physical symptoms, and conversely, addressing chronic pain facilitates treatment response of PTSD symptoms [39].

Resilience and Posttraumatic Growth

Although the prevalence of psychiatric problems is relatively high compared to the general population, many of the refugees succeed in integrating in the receiving society and achieving a good quality of life. Long-term outcome studies show that while psychological distress remains high in some resettled refugees, trauma-related symptoms overall decline over time and many refugees have no mental illness at ten-plus years after resettlement [98]. The concept of posttraumatic growth, which summarizes the positive personal changes one makes in reaction to traumatic events, has received recent attention from researchers. Posttraumatic growth is related to a higher quality of life in general; in addition, it explained more of the variance in quality of life than did posttraumatic stress symptoms, depressive symptoms, or unemployment [99]. Religious beliefs are often associated with resilience [32] and less mental health problems [100]. Bridging social networks were also associated with better mental health, particularly in women [101].

Culture-Specific Syndromes

Each culture has specific syndromes that in the Westerner’s eye are classified as psychiatric diseases or specific presentations of more common psychiatric diseases. Various populations can present with specific syndromes, but at the same time, the same syndrome can be seen in different cultures located in different geographic regions. For instance, women who jump into wells in suicide attempts have been described in Pakistan, Punjab, Bangladesh, and Sri Lanka [102]. Koro (the penis shrinking syndrome) is a classic example of a culture-bound syndrome seen in different ethnic and geographic groups [103]. Survivors of the Rwanda genocide divided mental health symptoms into a mental trauma syndrome (a PTSD-like presentation plus some depression symptoms plus “local” symptoms) and a grief syndrome (other depression symptoms plus “local” symptoms) [104]. Multiple culture-specific syndromes have been described in the Cambodian population; among them are Khya ˆ l attacks (a variant of panic attack, characterized by physical symptoms and fear of heart arrest) and khmaoch sangot (“the spirit pushes you down”—a form of sleep paralysis) [105].

Cultural factors may also become specific risk factors for mental health problems; for example, in Lao refugees, violating clan and kingship rules is associated with higher risk of suicide [106].

Transcultural psychiatry, which, in part, focuses on the study of these syndromes, is a rapidly growing discipline. While only a subset of refugees manifest clearly defined cultural syndromes, there are many subtle cultural variations in illness manifestations. In working with refugees, one must not only become familiar with the specific culture to which the patients belong but also consider local and individual specifics and avoid premature labeling. Many areas of conflict are extremely multicultural or multireligious. As in any clinical setting, maintaining an attitude of inquiry and curiosity will facilitate breaking transcultural barriers.

Summary

Many factors in the premigration, migration, and post-migration phases of displacement predispose refugees to psychological distress and mental illness. While prior trauma is a major risk factor, many other social and acculturation factors in the resettlement period also contribute significantly to mental distress. Prevalence of mental illness in refugees is difficult to measure due to methodological and cultural reasons, but PTSD and major depression are consistently shown to be high compared to host populations in resettled countries. However, refugees also exhibit resilience, and the majority successfully integrate into their host countries and function well over time.