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REVIEW ARTICLE
Post-migration factors and mental health outcomes in asylum-seeking and
refugee populations: a systematic review
Christina Gleeson
a,b
, Rachel Frost
a,b
, Larissa Sherwood
b,c
, Mark Shevlin
a,b
, Philip Hyland
b,d
,
Rory Halpin
b,e
, Jamie Murphy
a,b
and Derrick Silove
f
a
School of Psychology, Ulster University, Coleraine, Northern Ireland;
b
Collaborative Network for Training and Excellence in
Psychotraumatology (CONTEXT), Trinity College, Dublin, Ireland;
c
Centre for Global Health, Trinity College, Dublin, Ireland;
d
Department
of Psychology, Maynooth University, Kildare, Ireland;
e
Department of Rehabilitation, Spiritan Asylum, Services Initiative, Dublin, Ireland;
f
School of Psychiatry, University of New South Wales, Sydney, Australia
ABSTRACT
The present systematic review examined post-migration variables impacting upon mental
health outcomes among asylum-seeking and refugee populations in Europe. It focuses on
the effects of post-settlement stressors (including length of asylum process and duration of
stay, residency status and social integration) and their impact upon post-traumatic stress
disorder, anxiety and depression. Twenty-two studies were reviewed in this study. Length of
asylum process and duration of stay was found to be the most frequently cited factor for
mental health difficulties in 9 out of 22 studies. Contrary to expectation, residency or legal
status was posited as a marker for other explanatory variables, including loneliness, dis-
crimination and communication or language problems, rather than being an explanatory
variable itself. However, in line with previous findings and as hypothesised in this review,
there were statistically significant correlations found between family life, family separation
and mental health outcomes.
Factores posteriores a la migración y resultados de salud mental en
poblaciones de refugiados y en búsqueda de asilo: una revisión
sistemática
La presente revisión sistemática examinó las variables posteriores a la migración que afectan los
resultados de salud mental entre las poblaciones de refugiados y en búsqueda de asilo en
Europa. Ésta se centra principalmente en los efectos de los factores estresantes posteriores al
asentamiento (incluyendo la duración del proceso de asilo y la duración de la estadía, el estado
de residencia y la integración social) y su impacto sobre el trastorno de estrés postraumático,
ansiedad y depresión. Veintidós estudios fueron revisados en este estudio. La duración del
proceso de asilo y la duración de la estadía fueron los factores más frecuentemente citados para
las dificultades de salud mental en 9 de 22 estudios. Siete estudios reportaron asociaciones
significativas entre los factores de riesgo y la salud mental, y éstos fueron moderados por el
estado de residencia. Más bien, el efecto del estatus legal estaba más estrechamente ligado
a otros factores posteriores a la migración; fue hallado actuando como un marcador de variables
adicionales posteriores a la migración, incluyendo la soledad, la discriminación y los problemas
de comunicación o idioma. También se encontró que las dificultades relacionadas a la familia
estaban asociadas con la duración de la estadía y el estado legal, concurrente con la noción de
que otras variables posteriores a la migración son más relevantes para los resultados de salud
mental que la residencia y la duración de la estadía.
寻求庇护者和难民人群的移民后因素和心理健康结果：—项系统综述
本系统综述考查了欧洲寻求庇护者和难民人群移民后变量对其心理健康的影响。它主要
关注移民后应激源的影响 (包括庇护过程的时长和停留时间, 居住状态和社会融合) 以及它
们对创伤后压力障碍, 焦虑和抑郁的影响。本研究综述了22个研究。在22项研究中的9项
中, 庇护过程的时长和停留时间被发现是最常被提及的心理健康困难因素。七项研究报告
了风险因素与心理健康之间的显著相关, 并且被居住状态调节。相反, 法律地位的影响与
其他移民后因素更加复杂地联系在一起。它被发现可以作为其他移民后变量的标志, 包括
孤独, 歧视, 沟通或语言问题。家庭相关困难还被发现与停留时间和法律地位有关, 同时还
认为其他移民后变量居住和停留时间对心理健康的影响更大。
ARTICLE HISTORY
Received 1 October 2019
Revised 24 February 2020
Accepted 22 June 2020
KEYWORDS
Post-migration; systematic
review; forced migration;
mental health
PALABRAS CLAVE
post-migración; revisión
sistemática; migración
forzada; salud mental
关键词
移民后; 系统综述; 被迫移
民; 心理健康
In 2018, 70.8 million people were forcibly displaced
worldwide (USA for United Nations High
Commissioner for Refugees, 2018), including
3.5 million asylum seekers and 25.9 million refugees.
The UNHCR reports that two-thirds of all displaced
people originate from Syria, Afghanistan, South Sudan,
CONTACT Christina Gleeson c.gleeson@ulster.ac.uk School of Psychology, Ulster University, Coleraine, BT52 1SA, Northern Ireland
EUROPEAN JOURNAL OF PSYCHOTRAUMATOLOGY
2020, VOL. 11, 1793567
https://doi.org/10.1080/20008198.2020.1793567
© 2020 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.
This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial License (http://creativecommons.org/licenses/by-nc/4.0/),
which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Myanmar, and Somalia. Studies show that asylum see-
kers and refugees are particularly vulnerable to traumatic
experiences which are threefold in nature: pre-migration,
peri-migration, and post-migration (Chen, Hall, Ling, &
Renzaho, 2017). Trauma exposure, in this sense, tends to
be cumulative. There is a higher prevalence rate of men-
tal health disorders among these groups compared with
the general population. This is especially notable in terms
of posttraumatic stress disorder (PTSD), anxiety, and
depression which are often comorbid in these popula-
tions (Fazel, Wheeler, & Danesh, 2005).
While there is ample evidence of a significant asso-
ciation between pre-migration trauma and psycholo-
gical difficulties, for example the association between
torture and PTSD (Ibrahim & Hassan, 2017; Tufan,
Alkin, & Bosgelmez, 2013), less is known about the
relationship between post-migration factors and
mental health problems (Hynie, 2018). Certain psy-
chosocial variables that are specific to the post-
migration context (e.g., legal status) have been
shown to compound the psychological effects of pre-
migration trauma (Silove, Steel, McGorry, & Mohan,
1998). For example, uncertain immigration status has
been found to be as strong as predictor of PTSD as
pre-migration rape (Chu, Keller, & Rasmussen, 2013).
Therefore, resettlement into a ‘safe’ country is not
necessarily conducive to improved psychological
well-being.
There are several factors that come to prominence
following resettlement into a new country for refu-
gees and asylum seekers. These include legal status,
the asylum process, family issues, discrimination,
socio-religious factors, and unemployment.
Longitudinal research shows that limitation on
employment is a strong risk factor for depression,
particularly among men (Beiser, 2006). This challenge
to economic independence results in lower living
standards within host countries compared with
one’s country of origin (Silove, Sinnerbrink, Field,
Manicavasagar, & Steel, 1997).
This review examines the most frequently cited
post-migration stressors experienced by both asylum-
seeking and refugee populations within Europe and
their associations with mental health problems in the
context of resettlement into the host environment.
The review focuses on European nations as host
countries given the large proportion of asylum see-
kers it they intake each year. Of specific interest are
the implications of post-migration stressors on psy-
chological morbidity, with a view to understanding
the most effective mechanisms for improving psycho-
social well-being among these groups within the post-
migration context. Additionally, this paper looks at
salient pre-migration traumatic exposure which mod-
erates or predicts post-migration living difficulties in
the population. In order to facilitate a substantive
review, the Cochrane protocol for systematic reviews
was implemented throughout.
1. Method
1.1. Reviewers
In accordance with the Cochrane protocol, this study
involved three independent reviewers. Reviewers one
(CG) and two (RF) were responsible for screening
and selecting all studies, while reviewer three (MS)
was recruited as tie-breaker where agreement could
not be reached by CG and RF when reviewing
conflicts.
1.2. Review question
Which post-migration variables have the most signif-
icant effect on the mental health of asylum seekers
and refugees in Europe, according to the literature?
1.3. Scoping search
Throughout May 2018, reviewer one conducted pre-
liminary database enquiries using USearch. USearch
is a web-based resource available through Ulster
University’s online library services and provided by
EBSCOhost (Elton B. Stephens Co. host). This was
done to determine the approximate number of stu-
dies in relation to the review question and the most
appropriate databases to include in the main search.
Eight significant resources were identified through
the scoping search. These were CINAHL, Cochrane
Library, Embase, ERIC, Medline, PsycINFO,
PubMed, Scopus, and Web of Science. These data-
bases were chosen by identifying (1) the most popular
databases in relation to the number of applicable
studies they produced and (2) databases cited in
relevant systematic reviews (Bogic, Njoku, & Priebe,
2015). These were then used for the main search for
this review.
1.4. Search strategy
We conducted a systematic literature search of stu-
dies examining the relationship between post-
migration psychosocial factors and their impact on
mental health outcomes in asylum-seeking and refu-
gee populations in Europe. This search took place on
22 May 2018 using the 8 databases noted above
(CINAHL, Cochrane Library, Embase, ERIC,
Medline, PsycINFO, PubMed, Scopus, and Web of
Science). Initial limiters were set to English language
studies published between 2000 and 2018. Exclusion
criteria were applied later on in the process. This was
done to limit the possibility of selection bias and
2C. GLEESON ET AL.
erroneous omission of any relevant papers (Drucker,
Fleming, & Chan, 2016). The search terms and search
strategy were devised with the assistance of two sub-
ject librarians.
Thirty keywords were used to search each data-
base. Keywords were categorised according to three
concepts: population, predictors, outcomes. These
categories were searched using common synonyms
for each concept. Firstly, population was entered as
refugee*, ‘asylum seeker*’, immigrant*, migrant*,
‘displaced person*’, ‘displaced people*’. Secondly,
predictors were listed as accommodation, housing,
‘direct provision’, employ*, unemploy*, ‘health care’,
language*, ‘socio religio*’, communication*, religio*,
‘health care’, residen*, ‘legal status’, ‘social support*’,
family. Thirdly, outcomes included ‘psychosocial’,
‘psychosocial vulnerabilit*’, ‘post migration’, ‘post
settlement’, resettlement, ‘post flight’, postflight,
‘mental health’, ‘mental ill-health’, ‘mental ill*’.
Spelling variations were used in the search process
to ensure all relevant studies were included. Where
appropriate, truncation was employed to broaden
results. Keywords were combined in a search matrix
using Boolean operators. Synonyms for each indivi-
dual concept were firstly searched together using ‘or’.
Concepts were then combined using ‘and’. This
resulted in seven search permutations as illustrated
in Table 1.
1.5. Selection criteria and piloting
Criteria were firstly piloted on 22 May 2018. Twenty
studies (Table 2) were randomly and independently
selected through Covidence by both reviewers who
tested the selection criteria to evaluate their accuracy
for identifying appropriate texts. After this process,
changes were made in categories 1 and 5, study
population and publication type, respectively. In
terms of study population, initially ‘displaced
persons’ was entered as a single inclusion criterion.
This was subsequently changed to ‘externally dis-
placed’ only, also resulting in two additional exclu-
sion criteria. CG and RF determined these to be
‘internally displaced persons’ and ‘all displaced per-
sons owing to natural disaster’. Publication type was
updated to include only peer-reviewed studies.
Corresponding exclusion criteria were subsequently
redistributed as ‘book chapters’, ‘conference papers’,
‘theses’, ‘commentaries’, ‘letters’, and ‘replies’.
After piloting, studies were selected for inclusion
based on eight categories of criteria. These studies
were required to meet criteria in all categories: (1)
either asylum seekers, refugees, or displaced persons
(not owing to natural disasters) who were male or
female, 18 years and over, had a history of psycholo-
gical trauma or torture and underwent mental health
assessment; (2) post-migration psychosocial factors,
either legal, accommodation, education, social, finan-
cial, employment, health, informal supports (e.g.
family, religious), formal supports (e.g. therapeutic,
NGO); (3) publication timeframe 2000–2018; (4)
English language; (5) peer-reviewed publications; (6)
primary data; (7) outcomes related to post-migration
psychosocial stressors and mental health or the dose–
response relationship linking pre-migration trauma
to post-migration psychosocial vulnerability; (8) qua-
litative and quantitative.
Category 1 exclusions included studies which
focused on the general population or did not specifi-
cally address asylum seekers, refugees, or displaced
persons who were male or female, 18 years and over,
had a history of psychological trauma or torture and
underwent mental health assessment. Category 2
excluded psychosocial factors related to pre-
migration and peri-migration contexts. Category 3
eliminated all studies that were published prior to
2000. The decision to impose this limit was based
on a preliminary review of the literature which
Table 1. Search terms for systematic review.
Search 1 Concept 1 refugee* OR ‘asylum seeker*’ OR immigrant* OR migrant* OR ‘displaced person*’ OR ‘displaced people*’
Search 2 Concept 2 Accommodation OR housing OR ‘direct provision’ OR employ* OR unemploy* OR ‘health care’ OR
language* OR ‘socio religio*’ OR communication* OR religio* OR ‘health care’ OR residen* OR ‘legal
status’ OR ‘social support*’ OR family
Search 3 Concept 3 ‘psychosocial’ OR ‘psychosocial vulnerabilit*’ OR ‘post migration’ OR ‘post settlement’ OR resettlement OR
‘post flight’ OR postflight
Search 4 Concept 1 + 2 refugee* OR ‘asylum seeker*’ OR immigrant* OR migrant* OR ‘displaced person*’ OR ‘displaced people*’
AND Accommodation OR housing OR ‘direct provision’ OR employ* OR unemploy* OR ‘health care’ OR
language* OR ‘socio religio*’ OR communication* OR religio* OR ‘health care’ OR residen* OR ‘legal
status’ OR ‘social support*’ OR family
Search 5 Concept 1 + 3 refugee* OR ‘asylum seeker*’ OR immigrant* OR migrant* OR ‘displaced person*’ OR ‘displaced people*’
AND ‘psychosocial’ OR ‘psychosocial vulnerabilit*’ OR ‘post migration’ OR ‘post settlement’ OR
resettlement OR ‘post flight’ OR postflight
Search 6 Concept 2 + 3 Accommodation OR housing OR ‘direct provision’ OR employ* OR unemploy* OR ‘health care’ OR
language* OR ‘socio religio*’ OR communication* OR religio* OR ‘health care’ OR residen* OR ‘legal
status’ OR ‘social support*’ OR family AND ‘psychosocial’ OR ‘psychosocial vulnerabilit*’ OR ‘post
migration’ OR ‘post settlement’ OR resettlement OR ‘post flight’ OR postflight
Search 7 Concept 1 + 2 + 3 refugee* OR ‘asylum seeker*’ OR immigrant* OR migrant* OR ‘displaced person*’ OR ‘displaced
people*’AND Accommodation OR housing OR ‘direct provision’ OR employ* OR unemploy* OR ‘health
care’ OR language* OR ‘socio religio*’ OR communication* OR religio* OR ‘health care’ OR residen* OR
‘legal status’ OR ‘social support*’ OR family AND ‘psychosocial’ OR ‘psychosocial vulnerabilit*’ OR ‘post
migration’ OR ‘post settlement’ OR resettlement OR ‘post flight’ OR postflight
Each concept was searched individually and then combined.
EUROPEAN JOURNAL OF PSYCHOTRAUMATOLOGY 3
Table 2. Studies included in the literature synthesis.
Study (first author and
publication year) Countries Population Study design Post-migration stress measure Mental health measure Methodology
Study
quality (%)
Bogic (2012) Germany, Italy
and the UK
Refugees Cross-sectional Amended version of the 24-item Life Stressor
Checklist Revised
Mini International Neuropsychiatric Interview (MINI) Mixed 100
Bruhn (2018) Denmark Longitudinal Interview Harvard Trauma Questionnaire (HTQ) Mixed 90
Carswell (2011) The UK Refugees &
asylum seekers
Cross-sectional Demographic and Post-Migration Living
Difficulty Questionnaire;
Short Form Social Support Questionnaire
(SSQ6);
Duke-UNC Functional Social Support
Questionnaire (Duke-UNC FSSQ)
Harvard Trauma Questionnaire (HTQ);
Hopkins Symptom Checklist-25 (HSCL-25)
Mixed 85
Droždek (2013) The Netherlands Refugees &
asylum seekers
Cross-sectional Interview Harvard Trauma Questionnaire (HTQ)
Hopkins Symptom Checklist-25 (HSCL-25)
Quantitative 80
Gerritsen (2006) The Netherlands Refugees &
asylum seekers
Cross-sectional Self-report questionnaire developed for study Harvard Trauma Questionnaire (HTQ);
Hopkins Symptoms Checklist-25
(HSCL-25);
Quantitative 95
Heeren (2014) Switzerland Refugees &
asylum seekers
Cross-sectional Index calculated specifically for study; items
were based on
Heckmann and Schnapper’s integration
concept;
Marlowe-Crowne Social Desirability Scale
Short Form X1
Harvard Trauma Questionnaire (HTQ);
Posttraumatic Diagnostic Scale (PDS);
Hopkins Symptom Checklist-25 (HSCL-25)
Quantitative 95
Heeren (2012) Switzerland Asylum seekers Cross-sectional Self-report questionnaire developed for study Harvard Trauma Questionnaire (HTQ);
Posttraumatic Diagnostic Scale;
Mini International Neuropsychiatric Interview (MINI)
Post-traumatic stress diagnosis scale;
Hopkins Symptom Checklist-25 (HSCL)
Mixed 85
Kivling-Bodén (2002) Sweden Refugees Cross-sectional Life-in-Exile Questionnaire Harvard Trauma Questionnaire (HTQ) Quantitative 75
Laban (2007) The Netherlands Asylum seekers Cross-sectional World Health Organization Quality of Life-Bref
scale (WHOQOL-Bref);
Post-Migration Living Problems Checklist
(PMLP)
World Health Organization Composite International Diagnostic
Interview (CIDI), version 2.1
Mixed 75
Laban (2005a) The Netherlands Asylum seekers Cross-sectional Interview World Health Organization Composite International Diagnostic
Interview (CIDI), version 2.1;
Mixed 80
Laban (2005b) The Netherlands Asylum seekers Cross-sectional Interview World Health Organization Composite International Diagnostic
Interview (CIDI), version 2.1
Mixed 75
Laban (2008) The Netherlands Asylum seekers Cross-sectional Post-Migration Living Problems Checklist
(PMLP);
World Health Organization Quality of Life-Bref
scale (WHOQOL-Bref)
Harvard Trauma Questionnaire (HTQ);
World Health Organisation Composite International Diagnostic
Interview
(CIDI), version 2.1
Mixed 75
Lamkaddem (2015) The Netherlands Refugees &
asylum seekers
Longitudinal Checklist created for study Hopkins Symptom Checklist-25 (HSCL)
Harvard Trauma Questionnaire (HTQ)
Quantitative 100
Lecerof (2016) Sweden Asylum seekers Cross-sectional Questionnaire created for study General Health Questionnaire (GHQ-12); Quantitative 75
Mölsä (2014) Finland Refugees Cross-sectional Interview;
EuroQoL EQ-5D
Beck’s Depression Inventory (BDI);
General Health Questionnaire (GHQ-12)
Mixed 80
Nosè (2018) Italy Refugees &
asylum seekers
Cross-sectional Unclear Life Events Checklist (LEC);
General Health Questionnaire (GHQ-12);
Mini International Neuropsychiatric Interview (MINI)
Hamilton Rating Scale for Depression (HRSD)
Mixed 85
(Continued )
4C. GLEESON ET AL.
Table 2. (Continued).
Study (first author and
publication year) Countries Population Study design Post-migration stress measure Mental health measure Methodology
Study
quality (%)
Schick (2016) Switzerland Refugees Cross-sectional Post-Migration Living Difficulties Checklist
(PMLD)
Harvard Trauma Questionnaire (HTQ);
Posttraumatic Diagnostic Scale (PDS);
Hopkins Symptom Checklist-25 (HSCL)
Quantitative 100
Steel (2017) Sweden Refugees &
asylum seekers
Cross-sectional Post-Migration Living Difficulties (PMLD);
Cultural Lifestyle Questionnaire
Harvard Trauma Questionnaire (HTQ); Mixed 100
Teodorescu (2012a) Norway Refugees Cross-sectional Questionnaire developed for study Structured Clinical Interview for DSM-IV-TR PTSD Module (SCID
PTSD);
MINI International Neuropsychiatric Interview 5.0.0 (MINI);
Structured Interview for Disorders of Extreme Stress (SIDES);
Hopkins Symptom Checklist (HSCL-25);
Impact of Event Scale Revised (IES-R);
Life Events Checklist (LEC)
Mixed 95
Teodorescu (2012b) Norway Refugees Cross-sectional World Health Organization Quality of Life-Bref
scale (WHOQOL-Bref);
Questionnaire developed for study
Life Events Checklist (LEC);
Structural Clinical Interview for DSM-IV- TR
PTSD Module (SCID-PTSD);
MINI International Neuropsychiatric Interview
5.0.0 (MINI);
Impact of Event Scale-Revised (IES-R);
Posttraumatic Growth Inventory Short Form (PTGI-SF);
Hopkins Symptom Checklist (HSCL-25)
Mixed 90
Tinghög (2017) Sweden Refugees Cross-sectional Seven single-item questionnaire developed
for study
To identify respondents that had been exposed to
refugee-related PTEs before arriving to Sweden, two
(identical) checklists were developed to cover the premigration and
perimigration periods separately;
Hopkins Symptom Checklist (HSCL-25);
Harvard Trauma Questionnaire (HTQ);
WHO-5 Well-being Index (WHO-5)
Quantitative 95
Toar (2009) Ireland Refugees &
asylum seekers
Cross-sectional 18-item checklist developed for study Harvard Trauma Questionnaire (HTQ);
Hopkins Symptom Checklist (HSCL-25);
Quantitative 90
EUROPEAN JOURNAL OF PSYCHOTRAUMATOLOGY 5
indicated that relevant studies were published from
2000 onwards. Category 4 exclusions specified studies
that were not published in English. Non-English lan-
guage texts were omitted because time limitations did
not allow for translation. Category 5 was limited to
peer-reviewed studies. Book chapters, conference
papers, theses, commentaries, letters, and replies
were all excluded. Category 6 excluded all data
other than primary data. The review team agreed
that this would avoid overuse of the same data in
multiple reviews. Category 7 excluded any outcomes
that did not focus on either post-migration psycho-
social factors in relation to refugee and asylum seeker
mental health or the dose–response link between pre-
existing trauma and post-migration psychosocial vul-
nerability. Category 8 exclusions included systematic
reviews, narrative reviews, meta-analyses and meta-
syntheses. This was done to avoid reviewing the same
data on multiple occasions. All 9,940 studies identi-
fied in search seven, the final search strategy (Table 1)
were exported to Covidence, online programme for
systematic reviews, launched in 2013 (Veritas Health
Innovation Ltd).
1.6. Title and abstract screening
After duplicates were removed, a total of 6179 studies
remained for title and abstract screening. Reviewers
one and two were required to allocate one vote each
per study using the Covidence platform. This was
either ‘yes’, ‘no’, or ‘maybe’ depending on its match
with the selection criteria. Once this stage was com-
pleted, 6,099 studies were deemed irrelevant based on
the inclusion and exclusion criteria, leaving a total of
80 papers proceeding to the full-text review.
These were ‘no mental health component’, ‘insuffi-
cient statistical analysis’, ‘does not explicitly refer to
study population’, ‘insufficiently specific’, ‘text unavail-
able from author’, ‘not available in English’, ‘qualitative
study’, ‘book chapter’, ‘non-academic study’, ‘seminar
paper’, ‘editorial’, ‘outside Europe’, and ‘population
under 18’.
1.7. Full-text screening and extraction
Reviewers 1 and 2 allocated one vote per study, either
‘include’ or ‘exclude’. There were 13 options for
excluding studies after full-text screening (Figure 1).
There were two stages involved in data extraction:
pilot extraction and final extraction. Firstly, a pilot
extraction was conducted by Reviewers 1 and 2. Both
independently extracted data from only 10 studies
which were randomly chosen from Covidence. For
the final extraction phase, each reviewer then inde-
pendently assessed 50% of the remaining papers, with
the option to ‘include’ or ‘exclude’ each text.
1.8. Quality assessment
(Shea et al., 2007; Well & Littell, 2016) Study quality was
assessed twice during the extraction stage. Firstly, using
subjective criteria for inclusion, based on the review pro-
tocol. Secondly, using a 19-question assessment schedule,
to review the overall quality of each text. Both CG and RF
were responsible for the preliminary assessment. CG
conducted the final quality review after each of the papers
was extracted. Each question was assessed using either
‘yes’, ‘no’, ‘somewhat’ or ‘not appropriate’ options. To
pass the quality assessment, at least 14 of 19 questions
(74%) had to be endorsed with a ‘yes’ vote. All studies
passed this assessment.
2. Results
Twenty-two studies were used for the final review
and synthesis (Table 2). The total sample for these
studies was N = 5,572, with individual studies ran-
ging from n = 26 to n = 1,215. In line with the
inclusion criteria, studies were limited to European
nations that acted as host countries for refugees and
asylum seekers from across the globe. Four studies
were conducted in Sweden which included the lar-
gest proportion of the overall sample at n = 2,516
(Kivling-Bodén & Sundbom, 2002; Lecerof,
Stafström, Westerling, & Östergren, 2016; Tinghög
et al., 2017). The Netherlands accounted for
n = 1,444 participants across eight studies
(Droždek, Kamperman, Tol, Knipscheer, & Kleber,
2013; Gerritsen et al., 2006; Laban, Gernaat,
Komproe, & Jong, 2007; Laban et al., 2005a, 2005b;
Laban, Komproe, Gernaat, & Jong, 2008;
Lamkaddem, Essink-Bot, Devillé, Gerritsen, &
Stronks, 2015; Steel, Dunlavy, Harding, & Theorell,
2017). Two studies were conducted in Italy with
a sample of n = 406 (Bogic et al., 2012; Nosè et al.,
2018). Two further studies in Norway accounted for
70 participants (Teodorescu et al, 2012a, 2012b).
Switzerland was home to 392 participants across
three studies (Heeren et al., 2012, 2014; Schick
et al., 2016) and the UK included 349 participants
from the overall sample size drawn from two studies
(Bogic et al., 2012; Carswell, Blackburn, & Barker,
2011). Additional studies drew participants from
Ireland (n = 88) (Toar, O’Brien, & Fahey, 2009),
Finland (n = 128) (Mölsä et al., 2014), Germany
(n = 255) (Bogic et al., 2012), and Denmark
(n = 34) (Bruhn et al., 2017).
A total of 11 predictors were hypothesised and
these were investigated across the twenty-two stu-
dies. The following predictors were included inso-
far as data were reported and explicitly related to
mental health outcomes across the studies’
populations.
6C. GLEESON ET AL.
2.1. Length of asylum process and duration of
stay
Nine studies investigated the length of asylum procedure
and duration of stay (Heeren et al., 2012, 2014; Laban
et al., 2007, 2005a, 2005b, 2008; Mölsä et al., 2014; Nosè
et al., 2018; Teodorescu et al., 2012a). A protracted asy-
lum process was one of the most frequently cited stres-
sors to occur during the post-migration period. Using
data comparing two pre-stratified groups, those resident
for less than 6 months and those resident for greater than
2 years, Laban et al. (2007) reported the length of the
asylum procedure to be an important risk factor for
psychiatric morbidity (OR = 2.16, CI = 1.15–4.08).
Those who were long-stayers (greater than two years)
suffered higher rates of psychiatric disorders than those
who had been resident for shorter periods of less than
6 months (62% compared to 42%). It was also the stron-
gest predictor for lower overall quality of life, increased
disability, and somatic complaints (Laban et al., 2008).
Despite an increase in psychiatric disorders asso-
ciated with length of stay, an increase in mental health
service use was not observed (Laban et al., 2007).
Teodorescu et al. (2012a) report four significant inverse
correlations between length of stay and current PTSD
diagnosis (r = −0.26), depression symptoms (r = −0.27),
anxiety symptoms (r = −0.39), general psychological
distress (r = −0.35). While Nosè et al. (2018) found
length of stay to be a protective factor, where the
mean duration was 13 months (Nosè et al., 2018).
Contrary to popular research, one study (Heeren et al.,
2012) found no correlations between length of stay and
mental health outcomes. This finding was duplicated in
another later study by Heeren et al. (2014) who reported
a significant increased level of anxiety associated with
length of stay for refugees only (r = 0.40). Similarly,
Mölsä et al. (2014) reported only a marginal positive
association between duration of stay and depressive
symptoms.
2.2. Residency status
Three studies reported residency status in relation to
mental health outcomes with sufficient detail (Heeren
et al., 2014; Lamkaddem et al., 2015; Toar et al.,
2009). Strong associations were reported between sta-
tus and mental health risks, but only in instances
Figure 1. PRISMA (preferred reporting items for systematic reviews and meta-analyses) flow-diagram illustrating review process.
EUROPEAN JOURNAL OF PSYCHOTRAUMATOLOGY 7
where other post-migration stressors were present.
Asylum seekers were reported to be at greater risk
of PTSD (OR = 2.50), depression/anxiety (OR = 3.00)
symptoms when compared to refugees (Toar et al.,
2009). However, after controlling for other pre- and
post-migration stressors and other ongoing condi-
tions, residency was no longer associated with
PTSD, depression or anxiety.
Residency status was reported, thus, as a marker
for other explanatory variables. Furthermore, Heeren
et al. (2014) report unchanged levels of PTSD
between those granted status and asylum seekers.
PTSD was, thus, purportedly unassociated with resi-
dency. In other studies, obtaining residency, or refu-
gee status, was found to improve the overall health of
this population (Lamkaddem et al., 2015). But, again,
further (mediation) analysis showed that improve-
ments were related to an increase in opportunities,
resources and supports available as a consequence of
gaining refugee status. That is, factors associated with
living outside of the asylum system.
2.3. Family
Four studies related family status to post-migration
psychosocial difficulties among these populations
(Bruhn et al., 2017; Tinghög et al., 2017;
Lamkaddem et al., 2015). With an increase in
family/social supports related to status, Lamkaddem
et al. (2015) report that family/social support as one
of the three main mechanisms through which status
operates to improve PTSD, anxiety and depression
symptomology. Laban et al. (2006) reported that
family-related issues, including missing one’s family,
worries about family back home, an inability to go
home and loneliness, had one of the highest odds
ratios for at least one psychiatric disorder.
Participants who had been resident ≥2 years scored
significantly higher than newly arrived – less than
6 months. Regarding psychiatric treatment adminis-
tered in an outpatient setting, family issues were
reported as one of the most significant post-
migration stressors to interfere with treatment
(Bruhn et al., 2017). Additionally, Tinghög et al.
(2017) found that stressors related to family life and
separation were significantly correlated with mental
ill-health. ‘Distressing conflicts in family (family con-
flicts)’ was reported to be significantly associated with
anxiety, depression, low subjective well-being and
PTSD. While the same was predominantly true of
‘feeling sad because not reunited with family mem-
bers (home country and family concerns)’, although
this was not significantly associated with anxiety.
However, upon conducting a sensitivity analysis,
this variable was no longer significantly associated
with any mental health outcomes (Tinghög et al.,
2017).
2.4. Social integration and weak social network
Three studies looked at the concept of social integra-
tion and weak social network in relation to mental
health outcomes (Schick et al., 2016; Teodorescu
et al., 2012a, 2012b). In one study, bivariate correla-
tion analysis showed that post-traumatic growth has
a strong negative associated with poor social integra-
tion and weak social network (Teodorescu et al.,
2012b). Social network in this instance was measured
by the number of good friends that participants had
within the host country. In this sample of psychiatric
outpatients, the average number of friends reported
was 3.0 (range = 0 to 11). Over 25% of the sample
had no friends in their reception country. In another
study, Teodorescu et al (2012a) also reported weak
social integration into the wider host society to be
associated only with psychiatric morbidity and higher
levels of psychiatric symptomatology. However, weak
social integration into one’s ethnic community was
associated with current PTSD diagnosis.
Regardless of the duration of stay, one study
(Schick et al., 2016), reported that social integration
for refugees was notably lacking and did not improve
considerably for long-stayers despite participants
being resident for over 10 years. This was measured
using a version of the Post-Migration Living
Difficulties Checklist (PMLDC; Silove et al., 1997;
Steel, Silove, Bird, McGorry, & Mohan, 1999)
M = 20.7 (SD = 6.1, scale range 0–28). Social integra-
tion problems were significantly associated with
health-related quality of life and functional impair-
ment (r = −0.47), depressive symptom severity
(r = 0.44), PTSD (r = 0.43), and anxiety (r = 0.29).
Moreover, in regression analysis, depression and
anxiety symptoms were shown to predict difficulties
with social integration. Interestingly, integration dif-
ficulties were more strongly associated with symp-
toms of depression and PTSD than frequency of
traumatic events.
2.5. Finance
Only two studies offered any significant insight into
post-migration financial difficulties in the context of
mental health outcomes (Bruhn et al., 2017; Lecerof
et al., 2016). Conducting a bivariate analysis, Lecerof
et al. (2016) reported financial difficulties to increase
the risk of mental health decline (OR = 2.35, 95% CI
1.64–3.38). An analysis of effect modification also
showed a positive association between mental health
outcomes and low social participation co-occurring
with financial difficulties. In a study on post-
migration stressors and their impact on mental health
treatment, Bruhn et al (2017) found that financial
difficulties related to work were the most frequent
factor interfering with treatment.
8C. GLEESON ET AL.
2.6. Employment
Four studies explored employment as a significant
post-migratory factor correlated with mental health
outcomes (Bogic et al., 2012; Steel et al., 2017;
Teodorescu et al., 2012a, 2012b). In a sample of
multi-traumatised psychiatric outpatients from
a refugee background, unemployment was shown to
explain only 1.5% (F (5,45) = 12.62, p <.001) of the
variance for psychological health (Teodorescu et al.,
2012b). Rendering this variable an insignificant con-
tributor to overall mental health outcomes.
Conversely, in a similar sample of multi-traumatised
refugees, unemployment was reported to have the
most significant correlations with psychiatric illness
and symptom severity (Teodorescu et al., 2012a).
This was shown to be particularly true in terms of
increase in the level of depressive symptoms. In
another study, conducted by Bogic et al. (2012),
these findings were further endorsed by showing
mood disorders (major depression, dysthymia, hypo-
mania, and mania) to be associated with unemploy-
ment. Furthermore, Steel et al. (2017) found
employment status to be significantly correlated
with assimilation into the host environment.
2.7. Housing and accommodation
Along with financial difficulties and discrimination,
housing problems were shown to increase the risk of
mental ill-health in one study (Lecerof et al., 2016).
Lecerof et al. (2016) report an odds ratio of 2.79 (95%
CI 1.84–4.22) for poor mental health where partici-
pants endured housing issues while age, sex, educa-
tional level, social participation and trust in others
were controlled for. Together, housing difficulties
and low social participation was reported to be the
most significant risk factor for poor mental health
(Lecerof et al., 2016). Trust in others, conversely,
appeared to be a protective factor against declining
mental health related to housing difficulties (Lecerof
et al., 2016).
2.8. Language proficiency
Across the twenty-two studies, five studies assessed
associations between language acquisition/profi-
ciency, social integration and mental health outcomes
(Toar et al., 2009; Schick et al., 2016; Mölsä et al.,
2014; Tedorescu et al., 2012a; Laban et al., 2006). It
was noted that language difficulties appear among the
most salient post-migration stressors experienced by
asylum seekers (Toar et al., 2009). Interestingly,
Laban et al. (2006) also found that regardless of
time spent in the host country for asylum seekers,
language proficiency did not differ considerably
between two pre-stratified groups based on the
duration of stay. The mean scores for language pro-
blems for those living in the recipient country less
than 6 months and greater than 2 years were 55.9 and
51.7, respectively.
Refugees appear to report higher rates of profi-
ciency in terms of ability to communicate in the
language native to their host countries. In a sample
of traumatised refugees attending outpatient treat-
ment, self-reported medium-high language (host
country) proficiency was recorded at 83%. 8.9%
scored below this threshold (Teodorescu et al.,
2012a). However, this finding was challenged by
Schick et al. (2016) who reported less than 20% of
refugee participants had sufficient proficiency to
answer questionnaires relating to their migration
experiences. Indeed, Heeren et al. (2014) found lan-
guage proficiency to be marginally negatively asso-
ciated with symptoms of depression (β = −0.20)
among older refugees (50–80 years).
2.9. Education
Three studies looked at education as a predictor of
mental health outcomes among asylum seekers and
refugees (Bogic et al., 2012; Tinghög et al., 2017; Toar
et al., 2009). Tinghög et al. (2017) reported similar
prevalence rates of PTSD among participants regard-
less of educational attainment. Years in education ran-
ged from 0 to 9, more than 9 years without a university
degree, and more than 12 years with a university
degree. However, subjective well-being was reportedly
lower among those with a lengthier educational back-
ground. Overall mental health remained largely unaf-
fected by educational attainment in this sample.
However, Bogic et al. (2012) found education to be
independently associated with increased instances of
mood and anxiety disorders. Asylum seekers were
also found to have had a lower level of education
when compared to refugees (Toar et al., 2009).
2.10. Gender
Three studies discussed gender as a predictor of post-
migration variables and mental health outcomes
(Bogic et al., 2012; Kivling-Bodén & Sundbom,
2002; Mölsä et al., 2014). In a comparative, cross-
sectional study (Mölsä et al., 2014) of Somali refugees
and their Finnish counterparts, female refugees
reported poorer current health and quality of life
than male refugees. Kivling-Bodén and Sundbom
(2002) reported a greater diagnosis for PTSD at base-
line (T1) for males (73.3%) than females (54.5%).
However, there was a non-significant difference
between males (60%) and females (63.6%) at T2.
A partial least squares regression analysis was carried
out to ascertain if there were differences in the rela-
tionships between post-traumatic symptom severity
EUROPEAN JOURNAL OF PSYCHOTRAUMATOLOGY 9
at T1, age, and the life-situation at T2 and post-
traumatic symptom severity at follow-up. For
females, they found a significant association where
41.7% of the variance between post-traumatic symp-
tom level at T1, age, and life-situation variables at T2
predicted 94.8% of the variance in the posttraumatic
symptom level at T2. Whereas for males, the same
analysis indicated that 17.7% of the variance in post-
traumatic symptom level at T1 explained 66.9% of the
variance in the posttraumatic symptom level at T2.
Post-migration variables most strongly associated
with decreased levels of post-traumatic symptoms
purportedly differed according to genders. Kivling-
Bodén and Sundbom (2002) report that social con-
tact, particularly with their own ethnic group,
improved symptoms. For males, however, this senti-
ment did not hold true. In a study by Bogic et al.
(2012), increased instances of mood disorders,
including major depression, dysthymia, hypomania
and mania, were found to be associated with being
female.
2.11. Pre-migration trauma as a predictor of
post-migration living difficulties
Three studies described in detail the types and fre-
quency of pre-migration trauma in relation to post-
migration mental health outcomes (Steel et al., 2017;
Teodorescu et al., 2012b; Tinghög et al., 2017). The
types of pre-migration traumatic experiences
reported were similar across most studies. However,
the rank and degree at which these were experienced
across the samples differed. Tinghög et al. (2017)
reported war (85%) and exposure to potentially life-
threatening situations (79%) as the most common
pre-migration trauma for their sample. Forced
separation from friends and/or family (67.9%) and
loss of significant other (64%) also ranked highly.
They found 63% of the sample had been witnesses
to violence or assault, 33% had been victims of vio-
lence or assault, 31% experienced torture, while 7%
were survivors of sexual assault. In a study of multi-
traumatised psychiatric outpatients with a refugee
background, Teodorescu et al (2012b) found severe
human suffering was the highest pre-migration
trauma for 89.1% of the sample. Additionally, physi-
cal assault occurred in 87.3% of cases and 78.2% were
subjected to assault with a weapon. However, expo-
sure to war stood at 76.4%. Captivity was the least
endorsed, by 56.4% of participants.
Steel et al. (2017) reported the mean number of
pre-migration traumatic experiences for their sample
to be 9. Frequency of traumatic experiences differed
according to gender. Males were found to have
experienced more traumatic events (M = 11.00;
SD = 8.00). Women, conversely, reported fewer
(M = 7.00; SD = 7.00). Material deprivation was
ranked highest at 68% of the sample. Sixty-five
per cent experienced the death or disappearance of
family and 60% experienced confinement. While 54%
reported being exposed to situations of war, 38%
incurred bodily injury and 21% were forced to inflict
harm upon others.
3. Discussion
The aim of this review was to examine and synthesise
evidence of post-migration factors affecting mental
health outcomes for asylum-seeking and refugee
populations across Europe. Twenty-two studies were
included in this review.
Length of asylum process and duration of stay was
found to be the most frequently cited factor for
mental health difficulties in 9 out of 22 studies. This
was in line with the review’s hypothesis based on the
relevant literature which cites lengthy waiting times
for processing applications across Europe. Three stu-
dies reported statistically significant associations
between residency status and mental health.
However, residency status was not independently
associated with mental health. Instead, residency
was found to be a marker for other explanatory vari-
ables and this appears consistent in other studies
(Silove et al., 1998). In a study of Tamil asylum
seekers, refugees and other immigrants residing in
Australia, Silove et al. (1998) reported higher levels
of stress among asylum seekers compared with refu-
gees and other migrants.
Family difficulties were also shown to be related to
residency and duration of stay (Laban et al., 2006;
Lamkaddem et al., 2015). This appears to buttress the
claim that other post-migration variables are more
relevant to mental health outcomes than residency
and duration of stay (Tinghög et al., 2017; Coffeya,
Kaplana, Sampson, & Montagna Tucci, 2010; Silove
et al., 1997) Silove et al. (1997) found that family
separation, and in particular separation from one’s
spouse, was significantly associated with anxiety and
depression for asylum seekers. Family separation is
shown to result in feelings of guilt and powerlessness
particularly relating to one’s inability to protect their
families from difficulties back home (Tinghög et al.,
2017).
Talking to friends and developing a broad social
network was reported as a very useful support where
family were unavailable (Whittaker, Hardy, Lewis, &
Buchan, 2005). With such importance placed on
one’s social network, it is unsurprising that post-
traumatic stress and depressive symptomology were
significantly and positively associated with poor
social integration and weak social network or support
(Teodorescu et al., 2012b; Gorst-Unsworth &
Goldenberg, 1998; Schweitzer, Melville, Steel, &
Lacherez, 2006). However, for some, mistrust in
10 C. GLEESON ET AL.
others leads to increasing isolation. A lack of trust in
others may partially explain why social integration,
particularly outside of one’s own ethnic group, was
not shown to improve with duration of stay (Schick
et al., 2016). Additionally, mistrust of others was
shown as a risk factor for declining mental health
when related to housing and accommodation issues
(Lecerof et al., 2016). Poor social integration and
weak social network were also associated with decline
of mental health; housing difficulties and low social
participation were reported to be the most significant
risk factor for poor mental health (Lecerof et al.,
2016). Thus, it appears that a lack of social support
was a significant predictor of other post-migration
difficulties.
Additionally, employment, or the ability to finan-
cially support oneself and one’s family, was closely
related to personal identity and self-worth, and it was
expected that unemployment would have a negative
effect on overall health and quality of life (Teodorescu
et al., 2012b). Male asylum seekers were reported to
endure more financial-related stress than females. This
was unsurprising given that males were more likely than
females to be unemployed. For males, in particular,
employment was seen as a significant marker of
achievement.
4. Limitations
Since the search parameters were limited to European
host countries alone, there was little discussion by way
of non-European practice regarding asylum seekers and
refugees. From this point of view, it was difficult to
contextualise European law regarding seeking asylum
within a global setting. It was especially difficult to
accurately account for the role of age on this and
other factors considering there was no substantial com-
parison between older and younger age groups. There
appears to be some evidence pointing towards increased
acculturative difficulties among older groups, but this
finding must be read with caution.
Additionally, the frequent misuse of synonyms
purportedly referring to ‘asylum seekers’ and ‘refu-
gees’ such as ‘immigrants’ and ‘migrants’ made it
difficult to ascertain in some studies which popula-
tions precisely were being referred to. Some studies
were excluded on the basis that it was not immedi-
ately clear whether terms such as ‘immigrants’ or
‘migrants’ denoted forced or non-forced migrant
populations. An overall assessment regarding the
quality of the review was made based on the authors’
inability to sufficiently differentiate their subject
populations. Given that these are two entirely distinct
populations and inclusion of the latter would skew
the validity of this review, the reviewers elected to
omit these studies. It cannot, therefore, be guaranteed
that relevant papers were not overlooked.
5. Conclusions and recommendations
This review examined several post-migration vari-
ables impacting upon mental health outcomes
among asylum-seeker and refugee populations. It
counters existing findings which suggest that mental
health decline among these populations is most sig-
nificantly associated with residency status and length
of asylum procedure/duration of stay. Overall, status
is thus shown to be an important marker for other
explanatory variables. There is mixed evidence about
the length of asylum process and duration of stay.
Current evidence points towards a significant nega-
tive association between these two variables.
However, there are conflicting indications claiming
that no significant relationship exists. There is suffi-
cient ambiguity in this regard for this association or
lack of to be investigated further. Additionally, we
know that social integration, weak social network and
trust in others appear insidiously problematic across
many post-migration variables. This is shown to be
especially prevalent among older groups who report
increased difficulties with acculturation. There is
empirical evidence to suggest that these factors are
perhaps more strongly associated with mental health
outcomes than any other post-migration variable.
Such a finding is useful for devising psychosocial
intake risk assessment measures, particularly those
focusing on mental health outcomes including
PTSD, depression and anxiety.
Disclosure statement
The authors declare that they have no conflicts of interest.
Funding
This project was conducted as part of the Collaborative
Network for Training and Excellence in Psychotraumatology
(CONTEXT). CONTEXT has received funding from the
European Commission under the Marie Skłodowska-Curie
grant agreement [No. 722523].
ORCID
Christina Gleeson http://orcid.org/0000-0002-2895-8240
Rachel Frost http://orcid.org/0000-0002-5078-171X
Larissa Sherwood http://orcid.org/0000-0002-3559-8116
Mark Shevlin http://orcid.org/0000-0001-6262-5223
Philip Hyland http://orcid.org/0000-0002-9574-7128
Jamie Murphy http://orcid.org/0000-0003-1821-0025
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