Prevalence of and risk factors for mental disorders in refugees

Seminars in Cell & Developmental Biology 77 (2018) 144–152

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Seminars in Cell & Developmental Biology journal homepage: www.elsevier.com/locate/semcdb

Review

Prevalence of and risk factors for mental disorders in refugees Domenico Giacco ∗ , Neelam Laxhman, Stefan Priebe Unit for Social and Community Psychiatry (WHO Collaborating Centre for Mental Health Service Development), Queen Mary University of London, London, United Kingdom

a r t i c l e

i n f o

Article history: Received 16 May 2017 Received in revised form 3 November 2017 Accepted 21 November 2017 Available online 26 November 2017 Keywords: Refugees Prevalence Risk factors Mental disorders

a b s t r a c t Given the increasing numbers of refugees worldwide, the prevalence of their mental disorders is relevant for public health. Prevalence studies show that, in the first years of resettlement, only post-traumatic stress disorder (PTSD) rates are clearly higher in refugees than in host countries’ populations. Five years after resettlement rates of depressive and anxiety disorders are also increased. Exposure to traumatic events before or during migration may explain high rates of PTSD. Evidence suggests that poor social integration and difficulties in accessing care contribute to higher rates of mental disorders in the long-term. Policy and research implications are discussed. © 2017 Elsevier Ltd. All rights reserved.

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Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145 Prevalence rates of mental disorders in refugees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145 2.1. Psychotic disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145 2.2. Mood disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146 2.3. Anxiety disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146 2.4. Stress disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146 2.5. Somatisation disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146 2.6. Substance use disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147 2.7. Conclusions on prevalence rates and trans-diagnostic issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147 Risk factors for mental disorders in refugees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147 Traumatic events experienced before or during migration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147 4.1. Before migration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147 4.2. During migration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147 Poor social integration after resettlement in the host country . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147 5.1. Social isolation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147 5.2. Unemployment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148 5.3. Acculturation problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148 5.4. Detention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148 Difficulties in accessing mental health care in the host country . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148 6.1. Difficulties in navigating a new and unknown health care system . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148 6.2. Insufficient command of the host country language . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148 6.3. Beliefs about mental illness which are different from those commonly held in the host country . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148 6.4. Lack of trust in public organisations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148 Policy implications for the host countries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148

∗ Corresponding author at: Newham Centre for Mental Health, Glen Road, E13 8SP, London, United Kingdom. E-mail address: [email protected] (D. Giacco). https://doi.org/10.1016/j.semcdb.2017.11.030 1084-9521/© 2017 Elsevier Ltd. All rights reserved.

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7.1. Policy implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148 7.2. Helping social integration of refugees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149 7.3. Facilitating access to appropriate mental health care interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149 Research implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150 General conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150 Funding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150 Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150

1. Introduction According to the United Nations, a refugee is an individual who “owing to a well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion, is outside the country of his nationality, and is unable to, or owing to such fear, is unwilling to avail himself of the protection of that country” [1]. The number of forcibly displaced people in line with this definition is increasing in the last decades due to wars and political instability in different parts of the world. Figures reported by the United Nations High Commissioner for Refugees (UNHCR) in 2016 [2] show that there are 65.3 million forcibly displaced people around the world; 21.3 million have achieved refugee status. Over half of them are under 18 years old. Ten million forcibly displaced people are currently stateless and many others are in process of applying for asylum. The extent of the current problem may be illustrated by another figure: UNHCR has estimated that 34,000 people are forcibly displaced every day and seek asylum and refuge in other areas or countries. These people are usually referred to as refugees in the media and common parlance, as well as in research studies, although many of them may not have obtained a formal refugee status. Obtaining formal refugee status takes time and sometimes unwieldy procedures, whilst people live in precarious conditions such as residing in refugee camps and/or being unable to work or find independent housing [3–5]. The increase in the number of forcibly displaced people may pose a substantial pressure on mental health services in the countries where they are hosted. In the first instance, the arrival of such high numbers of people in a short period of time requires an appropriate response in terms of ensuring their right to basic health care is met. Moreover, they are exposed to risk factors for their mental health before, during and after migration and often encounter barriers to accessing appropriate care once they have re-settled [3–5]. For the purpose of this review, we have focused on studies which addressed refugees as this population is more represented in the scientific literature than other groups such as asylum seekers and undocumented migrants. For a number of practical and legal reasons, the prevalence of and risk factors for mental disorders have been more extensively studied and established for refugees than for those other groups [3]. However, there is some evidence that asylum seekers, irregular migrants and stateless people share many risk factors for mental disorders and barriers to access care, and may experience additional traumatic events such as uncertainty about the right to stay in a country and detention in immigration removal centres [3]. Information on prevalence rates of, and specific risk factors for, mental disorders in refugees is needed to help policy planning and inform the provision of appropriate care in the host countries. In this review, the evidence on prevalence rates for mental disorders in refugees is summarised, including psychotic disorders (F20-29) in the International Classification of Disease, [6], mood disorders (F30-39), anxiety, stress and somatisation disorders (F4049) and substance use disorders (F10-19).

We summarised evidence from available systematic reviews and reports [3,7,8] and conducted a systematic search on papers published after a meta-analysis conducted in 2005 [7] using similar search terms in order to identify the most updated evidence. The Embase, Medline and PsychInfo databases were searched. The search was finalised in January 2017. Most studies identified in the literature focused on prevalence rates of mental disorders in refugees who had arrived in a host country within the preceding five years (i.e. short-term resettled refugees). For each disorder, these studies are presented first, followed by those on refugees resettled for more than five years (long-term re-settled refugees). The latter show higher prevalence rates for some disorders, particularly depressive and anxiety disorders. This is followed by an overview of risk factors for mental disorders to which refugees are particularly exposed. Finally, policy and research implications for addressing mental health needs of refugees in the host countries are discussed. 2. Prevalence rates of mental disorders in refugees Studies on refugees have found wide variability in the rates of mental disorders across different refugee groups. This variability may occur because the groups have different backgrounds and characteristics [7–9], and live in more or less supportive contexts within the given host country [10]. However, the findings may also reflect that the type and quality of research methodologies varies substantially across studies. In particular, some findings suggest that the sampling method is a relevant factor influencing the identified prevalence rates of mental disorders. When an opportunistic or convenience sample (i.e. a sample in which people have not been randomly selected from a larger population) is adopted, prevalence rates tend to be higher than in more representative samples. Overall, studies of higher methodological quality tend to show lower prevalence rates of mental disorders than studies of poorer quality [3,7,8]. Another problem is whether the current diagnostic systems can be adapted to the way individuals interpret, react and emotionally expresses their psychological suffering in different cultures. This can lead to emotional suffering being either overlooked or excessive medicalised in refugee populations. The assessment of psychological symptoms in refugee or migrant populations can also be made more difficult by language barriers. Research shows that when using native speaker researchers, the rates of mental disorders in refugees tend to be lower than when using non-native speaker researchers [7]. 2.1. Psychotic disorders Only two studies assessed rates of psychotic disorders in shortterm resettled refugees [11,12]. These studies included Hmong people resettled in the United States [11] and Vietnamese people resettled in Norway [12]. About 2% of these refugees were diagnosed with a psychotic disorder. One study on long-term resettled refugees in Western European countries from the Balkan wars found a prevalence of psychotic

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disorders of 1.3% [10], which is similar to that found in short-term resettled refugees [11,12]. Based on the current evidence, the prevalence rates for psychotic disorders in refugees appear similar to those in the host countries’ populations. However, the first years of resettlement may be a critical period for the development of psychosis in refugees. A study carried out in Sweden found a higher incidence rate of psychosis (adjusted hazard ratio: 2.9) in refugees whilst residing in the host country compared to Swedish born nationals [13]. 2.2. Mood disorders Various studies have focused on rates of depressive disorders in refugees, whilst other mood disorders have received less attention [3]. A meta-analysis conducted in 2005 identified fourteen papers assessing rates of depressive disorders, providing data for a total of 3616 adult refugees [7,14–25] These studies were carried out in six countries and the refugees were from three main regions: Southeast Asia, former Yugoslavia, Haiti and Cuba. In the studies with at least 200 participants, about 5% (4–6%) were diagnosed with major depression. Some study characteristics were associated with prevalence rates. Those studies in which interviewers were from a different ethnic group, those with small sample sizes, those that lacked random sampling methods and those that implemented unstructured assessments of depression yielded higher prevalence rates than studies that were more methodologically rigorous [7]. In the last twelve years, two community studies (i.e. in general populations of refugees recruited in the community and not in clinical settings) were conducted. Only one of them was a random sampling based community study. This study reported a very low prevalence of people with a diagnosis of depression (1%) [26]. However, a much higher percentage of refugees (20%) reported clinically significant symptoms of depression [26] as assessed on the Hopkins Symptoms Checklist [27]. The other community study [28], which used snowball sampling (i.e. recruiting based on referrals from participants, community organisations and informal networks), found similar self-reported rates of significant symptom levels of depression (20%) using the same checklist [27]. Hence, despite the general rates of diagnosed depression appearing similar or lower than those in the general population, many refugees may experience symptoms of clinical depression in the first years of resettlement in the host country, and subsequently encounter barriers to accessing care. In long-term resettled refugees the prevalence of diagnosed depressive disorders is clearly higher than in the host country populations [8–10]. Similar to studies on short-term resettled refugees, studies of higher methodological quality generally reported lower prevalence rates. However, these prevalence rates are still higher than in host countries’ populations, being in the range of 20% and above. Prevalence rates were also related to both the country that the refugees came from and the country that they resettled in. Refugees from former Yugoslavia and Cambodia tended to report the highest rates of mental disorders, as well as refugees resettling in the USA [8]. 2.3. Anxiety disorders The review by Fazel and colleagues [7] found five studies on generalised anxiety disorder [11,12,17,19,24] showing an overall prevalence rate of 4% of refugees diagnosed with this disorder. This rate is not significantly different to usual rates of this disorder in general populations [3]. A more recent study found that 1.8% of refugees had been diagnosed with any anxiety disorder [26], whilst 19% [26] to 20.3% [28] of refugees reported significant symptoms of anxiety on the Hopkins Symptoms Checklist [27].

Similar to the rates of depressive disorders, the rates of anxiety disorders are increased in long-term resettled refugees. Rates of anxiety disorders ranged from 20.3% to 88% across studies [8].

2.4. Stress disorders The literature has addressed mainly PTSD. Other stress and adjustment disorders have been less studied and their prevalence rates have not been systematically assessed [3,7,8]. The prevalence of PTSD in refugees (9%) [7] is consistently higher than estimates in host country populations (1–3%) [3,29]. The rates of PTSD are even higher in refugee children, being overall 11% and ranging from 7% to 17% in different studies [7]. The comorbidity of PTSD and depression is frequent: Fazel et al’s meta-analysis [7] reported that 40% of refugees with PTSD also have depression whilst 70% of refugees with depression have PTSD. The comorbidity between PTSD and depression was found to be even higher in refugees exposed to torture and treated in Trauma Clinics (80–90%) [30,31]. People with comorbidity between PTSD and depression show higher risk of suicide and lower quality of life than those with PTSD or depression alone [32]. In long-term resettled refugees, rates of PTSD are still higher than in host country populations, being between 4.4% and 86% in different studies [8]. Some studies on refugees diagnosed with PTSD focused on potential biological factors which make groups of refugees, or individuals within them, more or less likely to develop PTSD. This is based on the theory of “memory reconsolidation” [33]. Each time the reconsolidation process happens, the individual may reinforce negative beliefs associated with the traumatic memory, such as guilt [33]. Variation in these processes may be related to genetic factors, which may influence susceptibility to develop PTSD. However, studies looking at family clustering of PTSD provide inconsistent data. Some studies have found no difference between mental health and quality of life in children of parents diagnosed with PTSD and in those whose parents have not been diagnosed [34] whilst other studies have found a higher prevalence of PTSD in children of parents with PTSD [35].

2.5. Somatisation disorders Some reports suggest that somatic equivalents of psychological distress are frequent in refugee groups [3,32]. A relationship between trauma and somatisation has been reported, where the number of unexplained physical symptoms are overall higher in refugees, than in the general population [36]. Tortured patients often display pain in areas that they have been tortured, even after physical signs of torture are not present [36]. It has been suggested that if there is psychological distress resulting from the trauma, pain is more likely to become chronic [36] Studies specifically focusing symptoms related to pain, have found that refugees are more likely to ask for medical help for somatic pain, rather than for mental distress due to fear of appearing ‘mad’ [37]. Another factor for an increased presence of unexplained physical symptoms in refugees is fear of stigma. However, no studies assessing the exact prevalence of somatisation disorders in these groups are available [3]. Only one study (which was carried out in long-term resettled refugees) included a formal assessment of rates of somatisation disorders according to diagnostic criteria [10]. This study found a 1.2% prevalence rate of somatisation disorders. This rate is not significantly different from usual rates in host country populations.

D. Giacco et al. / Seminars in Cell & Developmental Biology 77 (2018) 144–152 Table 1 Prevalence rates of mental disorders compared to the host population.

Psychotic disorders Mood disorders Anxiety disorders Stress-related disorders (PTSD) Somatisation disorders Substance use disorders

Short-term resettlement

Long-term resettlement

Same rates Same rates Same rates Increased No clear data Lower or same rates

Same rates Increased Increased Increased Same rates Same rates

2.6. Substance use disorders A systematic review carried out in 2016 [38] found 44 quantitative studies assessing substance use disorders among refugees, although only ten of them were rated as having high methodological quality. In studies using validated measures, the prevalence of hazardous or harmful alcohol use ranges from 4% to 36%, alcohol dependence ranges from less than 1% to 42% and drug dependence ranges from 1% to 20%. Some studies comparing substance use disorders to host country populations found lower rates whilst other found similar rates. The heterogeneity in findings is likely to reflect differences in the patterns of substance use between the refugees’ countries of origin and the host country, which affect both the availability of substances and the social norms for using them [39,40]. Refugees show higher rates of hazardous or harmful alcohol use in camp settings compared to when they live in regular communities (17%–36% in camp settings and 4%–7% in community settings). Some authors have spoken of a “refugee paradox” referring to the often lower prevalence of substance use disorders in short-term resettled refugees compared to host populations [41]. However, studies in long-term resettled refugee populations found that rates of substance use disorders in refugees tend to become more similar to host populations over time [10,42]. Substantial differences were observed in the rates of substance use disorders among similar refugees in different countries, which may further suggest that substance use patterns can be influenced by social norms in the host country [3,10,40]. The comparison between prevalence rates of mental disorders in refugees and in host countries is summarised in Table 1. 2.7. Conclusions on prevalence rates and trans-diagnostic issues PTSD appears to be most frequent in refugees than in general population in the host country, probably because of a higher exposure to significant traumatic events of refugees. However, it is worth noting that, similarly to host country populations, depressive and anxiety disorders are the most frequent mental disorders among refugees and they tend to become more frequent over time after resettlement [7]. The burden of mental illness and coping with traumatic experiences may lead to high rates of self-harm and suicide in refugees. A recent review found that the prevalence risk of suicide amongst refugees ranged from 3% to 34% [43]. Difficulties in adjusting in their host country, integrating in a new culture and leaving their family behind seem to be the most important predictive factor of self −harm and suicide [26]. The extent to which refugees were exposed to trauma and particularly torture [44] may also influence suicidal ideation.

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of resettlement and of depression, anxiety disorders and PTSD in longer-term resettled refugees. They may also be responsible for high rates of heterogeneity across different refugee populations and in different studies [3]. 4. Traumatic events experienced before or during migration Severe traumatic events before or during migration may make refugees vulnerable to develop mental disorders [3]. 4.1. Before migration Traumatic events experienced before migration may be related to exposure to war, persecution or economic hardship and reflect exactly the reasons why the refugees had decided to leave their home. Refugees can be exposed to war directly or indirectly, witnessing destruction and death or have had traumatic experiences including torture and personal combat involvement [45–49]. Persecution for political, ethnic, religious or other reasons may involve torture, imprisonment, violations of human rights of the person or death of family members [50–53]. Being exposed to torture, in particular, seems to be a particularly influential factor in increasing the likelihood of developing a mental disorder. The psychological consequences of torture are even more likely if people who are tortured experience fear for their life or if torture is enduring for a long time [54]. Refugees may also have experienced extreme levels of poverty and economic hardship, including a lack of food, water, shelter, and other basic needs and resources [53]. 4.2. During migration The process of migration can expose refugees to additional traumatic events [55]. Many refugees have travelled in unsafe boats or in enclosed trains or trucks, and may have walked on dangerous land routes. During their journey refugees have frequently experienced physical harm, sexual violence, infectious diseases, extortion and human trafficking. Finally, displacement in itself is a risk factor for mental health, as found in people displaced following a natural catastrophe and in refugees displaced for political reasons [56]. Displacement can be a recurring experience as refugees are likely to be hosted in a number of countries and camps during their journey. Psychological symptoms are particularly frequent in displaced migrants who had directly witnessed loss of loved ones, near death experiences and being wounded [57]. 5. Poor social integration after resettlement in the host country Poor social integration has been found to be associated with higher rates of depressive and anxiety disorders and PTSD [8,10]. Studies have linked different aspects of a poor integration into the society of the host country to higher rates of mental disorders. These aspects include social isolation, unemployment and acculturation problems.

3. Risk factors for mental disorders in refugees 5.1. Social isolation 1.1.6 Risk factors for mental disorders in refugees relate to traumatic events experienced before or during migration and lack of social integration after resettlement in the host country. These risk factors may explain the higher prevalence of PTSD in the first years

Refugees can struggle to establish new social connections in the host country and end up being socially isolated [8,58]. In some cases, forced separation from family members and support net-

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6. Difficulties in accessing mental health care in the host country Refugees frequently encounter difficulties in accessing health care. This can result in delayed diagnostic assessments and treatments of mental disorders which can then lead to a deterioration or chronicisation of the condition. These difficulties include problems in navigating a new and unknown health care system, an insufficient command of the language of the host country, different views than those held in host countries about mental disorders and their treatment, and a lack of trust in public organisations due to premigration experiences of persecution and/or fear of being reported to authorities. 6.1. Difficulties in navigating a new and unknown health care system Refugees are often unaware of their legal entitlements for accessing care and do not know which services are available to them. Clinicians can be similarly unaware of the entitlements of the refugees, which can prevent or delay appropriate referrals to mental health care [63–65]. 6.2. Insufficient command of the host country language

Fig. 1. Risk factors for mental health before, during and after migration.

works occurs during migration or after resettlement, which further reduces social support for some refugees. This is a particular concern for children and adolescents [59].

5.2. Unemployment Not having a job is not only in itself a risk factor for mental disorders; it can also hinder full integration into the new environment [3,58]. Particularly in some refugee groups, not being able to provide resources for one’s own family is associated with a higher likelihood of experiencing clinically significant symptoms of depression [26].

5.3. Acculturation problems Acculturation is defined as the process of cultural and psychological change that results from moving from one culture to another [59]. This process may be particularly challenging for refugees who have not chosen to migrate from their country or could not select the country they would migrate to [60]. Inappropriate acculturation can cause significant difficulties to form social connections in the host country and lead to psychological distress and mental disorders [59–61].

5.4. Detention Some refugees, before their refugee status is confirmed, may also experience being detained in immigration removal centres. Higher rates of PTSD and depression have been found amongst refugees with longer detention experiences in Australia, suggesting that the conditions experienced in immigration centres have a long term negative effect on the mental health of refugees [62] Fig. 1.

In mental health care in particular, verbal communication between patients and clinicians is central for diagnosis and treatment [65–67]. A lack of clear communication between patients and clinicians can hinder the accurate detection of mental health symptoms and prevent appropriate treatment, especially psychotherapy [67]. 6.3. Beliefs about mental illness which are different from those commonly held in the host country Supernatural or physical explanations for mental disorders or unusual beliefs that may be misinterpreted as psychotic symptoms can be found in some groups. This can make the clinical assessment challenging and, consequently lead to lack of treatment or inappropriate interventions [66]. 6.4. Lack of trust in public organisations Experiences of persecution before migration and fear of being reported to authorities in the host country may lead refugees − particularly asylum seekers and irregular migrants − to avoid accessing care or mistrust services and clinicians. These concerns make it difficult for these groups to engage with an unfamiliar health care system and share sensitive information on their history, current living situation and mental health difficulties [67–69]. 7. Policy implications for the host countries Awareness of the identified risk factors for mental disorders among refugees has several implications for policy strategies to optimise the prevention and treatment of mental disorders in these groups. Various policies have already been tried at regional and local levels, and there are a range of experiences to inform recommendations [65,67]. 7.1. Policy implications Refugees have often been exposed to different traumatic events before and during migration. The history of patients with different potentially traumatic experiences should be assessed and considered both in primary care and specialised mental health services.

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Of course, the history of patients cannot be changed anymore, but policies and clinical practice can help refugees to cope with their memories and distress. The link between poor social integration and a higher likelihood of developing mental disorders suggests that pro-active interventions to facilitate social integration and access to care should reduce mental disorders. 7.2. Helping social integration of refugees Many refugees encounter conditions of extreme deprivation in the host country, when they − for example − live at least temporarily without shelter or in unsafe refugee camps, or have no access to sufficient water and food. Children often have no or delayed access to school education or are in overcrowded classes. Opportunities for regular employment are often restricted for refugees [2,3]. Even after obtaining the legal status of a refugee, they can face social exclusion and disadvantages in the host country. As social isolation, unemployment and acculturation problems have been shown to be associated with higher rates of mental disorders and reduced access to mental health care, policies should aim at reducing these risk factors [70–73]. Programs focusing on education may include support for acquiring the language of the host country, acknowledgement of qualifications obtained in the country of origin, and school models that support the integration and link of refugees with students of the host country. Initiatives in education can include training teachers in cultural awareness and competency [70–72]. Social isolation may be reduced though housing programmes that promote the integration of refugees into community neighbourhoods, and through community forums and targeted events to support the social connectedness of refugees in the new context [70–73]. To facilitate employment, specific vocational programmes can help refugees to acquire skills and qualifications for regular employment in the host country, particularly for younger adults [73]. To support acculturation, peers from similar ethnic groups may act as ‘sponsors’ and help newly arrived refugees to familiarise themselves with the new context and integrate in the host country [72]. 7.3. Facilitating access to appropriate mental health care interventions There are various ways to reduce or eliminate barriers to accessing mental health care: targeted outreach services for refugees; a good coordination of physical and mental health services; tailored provision of information about health care entitlements; widespread availability of interpretation services, and cultural competence training for clinicians. Such strategies can help to facilitate easier access to health services. Outreach services can engage with refugees, provide information and support, identify people with mental disorders, and help them to access services. These outreach services make themselves easily available, and are often familiar with the specific background of the group they support. In order to be effective, outreach services should be closely linked with mainstream services [65,67,73–75]. Good coordination of mental and physical health care services is needed once patients have reached mainstream health services. Simple referral processes and administrative procedures can help to deliver appropriate treatment to refugees, who often have complex health needs and are more inclined to access mental health care through general health services rather than specialised mental health services. Access to general health services can be easier e.g. through emergency departments of hospitals which are avail-

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able for 24 h and are not associated with the potential stigma of having a mental disorder [65–67]. Information on the health care entitlements of refugees and on available services may be provided in a variety of ways [3,65,67]. Websites have been created to disseminate information on programmes specifically catering for the needs of refugee populations [3]. Yet, written communication is not always appropriate, when refugees are not fully literate or are more used to communicating orally. In these cases, information can be provided via different media with verbal messages such as videos [3]. When more traditional classroom-based approaches are feasible, they can be used to provide information and help to reduce social isolation [76]. Psychoeducation may also help refugees as having more accessible information for both mental and physical disorders may increase the likelihood of refugees seeking help from the right services. Psycho-education groups have been offered to refugee groups with the purpose to increase awareness of self-help strategies and help learn skills to identify self- concerns and knowing when to seek help [77]. High quality interpretation services are essential to help the clinician to explore the thoughts, beliefs, experiences and psychological symptoms of refugee patients. Using interpreters who are trained and qualified fosters a better patient experience [65,67] whilst clinicians also require skills in using and working with interpreters [78]. Interpretation can also be used in psychological treatments and positive outcomes of interpreter mediated psychotherapeutic interventions have been reported in the literature [95]. Telephone interpretation services are available as an alternative to vis-à-vis interpretation [3,65,67,75]. Technology-based tools, such as video-conferencing, can facilitate consultations with clinicians who speak the same language, without costs for travel of patients and clinicians (“tele-psychiatry”) [79]. Different cultural beliefs and symptom presentations (e.g. physical symptoms as signs of depression or anxiety) of refugees can make it difficult for clinicians to diagnose mental disorders and agree with patients on a treatment plan. Therefore, it has been suggested that mental health clinicians should be trained in cultural awareness, so that they are competent and confident in managing a diverse range of patients from different cultures, reaching an accurate diagnosis, and engaging them in effective treatment [65,67,80,81]. For example, clinicians can be made aware that some patients may have physical or supernatural explanations for their mental disorder, whilst others may be reluctant to disclose personal details for fear of discrimination and a lack of trust due to previous difficult relations with authorities and organisations [65–67]. Most interventions that can help refugees in general do not differ from those offered to other groups, including pharmacological interventions as well as individualised and group therapies [82]. However, some psychotherapeutic interventions, such as Narrative exposure therapy (NET) and Culturally adapted CBT have been used and tested almost exclusively in these populations and policies may consider their inclusion in mental health care provision. NET helps the patients to create a personal narrative integrating of traumatic memories and experiences in their personal experiences [83,84] and has been shown to be effective in reducing PTSD symptoms making this more favourable than treatment as usual [85]. NET is a short-term therapy and requires less intensive and long training than other therapies [83]. This makes it practical for use in populations which struggle to engage in long term treatments and to respond to humanitarian emergencies in which there is little time to obtain trained therapists. Culturally adapted-CBT (CA- CBT) has been developed to specifically address cultural barriers in treatment [86], targets somatic sensations and incorporates treatment of comorbid anxiety disorders. CA-CBT includes the use of yoga and meditation as well as a focus on emotion exposure [86]. CA-CBT has been found to be

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clinically effective in refugee groups from different backgrounds [86,87]. 8. Research implications Most refugees in the world are displaced internally within their own country or to the nearest countries which are most often low and middle income countries [2]. However, research has so far focused on high-income Western countries either in Europe, Australia or North America [3,7,8]. In these countries, there are usually resources and infrastructures for conducting research studies, which do not exist in low and middle income countries. Further systematic studies in low and middle income countries are required for a more global understanding of the mental disorders of refugees and the risk factors for the onset and chronicisation of such disorders in the host country. Another problematic aspect of research on mental disorders in refugees is that it tends to pool refugees from different contexts and cultures, although their backgrounds, experiences and ability to adapt in the host country are usually very diverse. Depending on what refugees have gone through, and currently experience, mental disorders can be difficult to distinguish from appropriate reactions. For refugees who have been exposed to significant levels of potentially traumatic events and on-going extreme stress, e.g. through torture, sexual abuse, and threats to be killed, the question arises as to whether subsequent mental distress reflects an appropriate physiological reaction or should indeed be seen as a mental disorder. The same problem occurs when refugees live in highly stressful and uncertain conditions in the host country, potentially with the threat to have to leave the host country again [3,7,8]. Moreover, different ways of expressing mental disorders based on different cultures may challenge the validity of the prevalence rates collected through assessment methods which are rooted in the understanding of mental disorders commonly held in the Western world [7,8]. More research on explanatory models of mental distress in different cultures and in refugee groups who are in the transition between cultures is required to address these conceptual and methodological problems. Such research has to consider refugees from very different groups and situations, and it can be difficult to move from findings for specific groups in a defined historical and societal context to a more widely applicable understanding of relevant processes in the host countries [88]. Even when evaluating prevalence rates consistently assessed through standard diagnostic criteria for classification of mental disorders, there is a huge variation in rates among different studies [3,7,8]. This variation can be explained either in light of inconsistent methodologies or of true variations between groups. It is likely that both factors contribute to this variation. Ideally all studies assessing prevalence rates should be assessed through community studies based on random sampling. However, these methodologies suffer from low response rates in people who are approached at random [10]. They also require an investment of time and resources which is either unavailable or inappropriate when there is a need to provide a prompt response to the mental health needs of refugees, particularly in less well-resourced countries. In addition to this, it needs to be considered that if true differences are present based on the specific groups and countries of resettlement, the generalisability of any specific study is still questionable, no matter how methodologically rigorous the investigation might be. Finally, prevalence rates are established in cross-sectional studies and almost all studies reported in this review used a crosssectional design. Yet, longitudinal studies − although for a number of reasons difficult to conduct − are required for refugees, in order to understand rates of remission and chronicisation of mental disorders [89]. Data on long-term outcomes in groups should reflect

the ever-changing composition of refugee groups. Not all refugees stay in the host country and every new wave of refugees can have very different characteristics from the previous one. Longitudinal studies in individuals can also show how risk factors influence mental disorders over time and which aspects of social integration and targeted interventions are most helpful to prevent or overcome mental disorders in the long-term. 9. General conclusions Social risk factors related to refugee backgrounds before migration, the experience of migration and their integration (of lack there of) in the host country are related to the prevalence of mental disorders in refugee groups. These disorders are particularly more frequent when refugees are not socially integrated and feel excluded from the society of the host country. Strategies to minimise the problem of mental disorders in refugee groups [3,68] should prioritise the social integration of refugee groups and, when needed, facilitate the access to health services and evidence based interventions through removal of identified barriers. In order to deal with refugees with mental disorders effectively services require: a) sufficient resources, e.g. for arranging interpreting services and treating a high number of people which may migrate to the host country in a limited timeframe; b) appropriate organisation, e.g. for co-ordinating physical and mental health care, and c) culturally competent clinicians, e.g. for understanding and engaging with explanatory models of mental illness patients from different cultural backgrounds [68]. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Acknowledgements None. References [1] UNHCR, UNHCR− Convention and Protocol Relating to the Status of Refugees, Conventi and protocol Relating to the status of Refugees, 56, UNHCR, 1956, http://dx.doi.org/10.1093/iclqaj/6.3.533. [2] Figures-At-a-Glance @ Www.Unhcr.Org, (n.d.). http://www.unhcr.org/ figures-at-a-glance.html. [3] S. Priebe, D. Giacco, R. El-Nagib, Public Health Aspects of Migrant Health: a Review of the Evidence on Health Status for Labour Migrants in the European Region, WHO Eur., 2015. [4] H. Bradby, R. Humphris, D. Newall, J. Phillimore, WHO. | Public Health Aspects of Migrant Health: A Review of the Evidence on Health Status for Refugees and Asylum Seekers Ind the European Region, WHO Reginal Off. Eur., 2015 http://www.euro.who.int/ data/assets/pdf file/0004/289246/WHO-HENReport-A5-2-Refugees FINAL.pdf. [5] E. De Vito, C. de Waure, M.L. Specchia, W. Ricciardi, Public health aspects of migrant health: a review of the evidence on health status for undocumented migrants in the european region, world heal, Organ. Heal. Evid. Netw. Synth. Rep. 42 (2015) 1–36 http://www.ncbi.nlm.nih.gov/pubmed/27536764. [6] WHO, International Statistical Classification of Diseases and Related Health Problems (International Classification of Diseases)(ICD) 10th Revision − Version:2010, WHO, 2010 http://apps.who.int/classifications/icd10/browse/ 2010/en. [7] M. Fazel, M. Wheeler, J. Danesh, Prevalence of serious mental disorder in 7000 refugees resettled in western countries: a systematic review, Lancet 366 (2005) 1605, http://dx.doi.org/10.1016/S0140-6736(05)61027-6. [8] M. Bogic, A. Njoku, S. Priebe, Long-term mental health of war-refugees: a systematic literature review, BMC Int. Health Hum. Rights. 15 (2015) 29, http://dx.doi.org/10.1186/s12914-015-0064-9. [9] M. Porter, N. Haslam, Predisplacement and postdisplacement factors associated with mental health of refugees and internally displaced persons, JAMA 294 (2005) 602–612, http://dx.doi.org/10.1001/jama.294.5.602. [10] M. Bogic, D. Ajdukovic, S. Bremner, T. Franciskovic, G.M. Galeazzi, A. Kucukalic, D. Lecic-Tosevski, N. Morina, M. Popovski, M. Schützwohl, D. Wang, S. Priebe, Factors associated with mental disorders in long-settled war refugees:

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