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Change in visa status amongst Mandaean refugees: Relationship to psychological symptoms and living difficulties

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... Specifically, these studies have indicated that individuals with insecure visa status have higher levels of PTSD symptoms, depression symptoms, and suicidality compared to those with secure visas (Heeren et al., 2012;Hengst et al., 2018;Hocking et al., 2015;Ichikawa et al., 2006;Morgan et al., 2017;Premand et al., 2018;Silove et al., 1998;Steel et al., 2006a). Consistent with this, Nickerson, Steel, Bryant, Brooks, and Silove (2011) found that having one's visa status converted from temporary to permanent was associated with a significant decrease in psychological symptoms in a sample of Iraqi refugees living in Australia, with this decrease being mediated by a reduction in post-migration stressors. To date, however, studies have tended to focus specifically on psychopathological outcomes, which does not allow for the investigation of the broader societal impact of visa insecurity, including the extent to which individuals with insecure visa status are able to engage in the host community. ...
... Further, most studies investigating the mental health consequences of prolonged insecurity have either (a) been limited by small sample sizes, (b) focused on only one or two cultural groups, (c) not compared individuals with secure and insecure visa status, or (d) failed to control for important potential confounding factors (e.g. age, gender, trauma exposure) (Heeren et al., 2012;Hengst et al., 2018;Hocking et al., 2015;Ichikawa et al., 2006;Momartin et al., 2006;Morgan et al., 2017;Nickerson et al., 2011;Premand et al., 2018;Silove et al., 1998;Steel et al., 2006a). The latter may be especially important given that exposure to potentially traumatic events has been found to vary markedly between those with secure and insecure visa status (Steel et al., 2006a), potentially accounting for ultimate differences in psychological distress. ...
... Overall, these findings suggest that living with prolonged uncertainty regarding one's immigration status is associated with specific and deleterious mental health outcomes, and highlights the distinctive mental health needs of individuals with insecure residency. The possibility that immigration policy might play a contributing role in this respect is supported by other findings suggesting that transition to permanent visa status is accompanied by parallel improvements in mental health status (Nickerson et al., 2011). This finding has important policy implications, particularly at a time when international governments look to Australia's policies of temporary protection as a way to manage the influx of refugees and asylum-seekers to their shores (Ghezelbash, 2018;Jakubowicz, 2018;Miller, 2018). ...
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Background: The vast majority of the world’s refugees and people seeking asylum live in a state of sustained displacement. Little is known, however, about the mental health impact of prolonged insecurity. Objective: This study aimed to investigate the association between insecure visa status and mental health, suicidality, disability and social engagement in a sample of refugees and asylum-seekers living in Australia Method: Participants were 1,085 refugees with secure (i.e. permanent residency or Australian citizenship, n = 826, 76.1%) and insecure (i.e. asylum-seeker claim, bridging visa, temporary visa, n = 259, 23.9%) visa status who had arrived in Australia since January 2011, and were from Arabic, Farsi, Tamil or English-speaking backgrounds. Participants completed an online survey assessing pre- and post-migration experiences, mental health, disability and social engagement. Results: Results indicated that, after controlling for background factors, refugees with insecure visas had significantly greater PTSD symptoms, depression symptoms, thoughts of being better off dead and suicidal intent compared to those with secure visas. There were no group differences in disability. Refugees with insecure visas received support from significantly more groups in the Australian community than those with secure visas. Further, refugees with insecure visa status who had low group membership showed greater depression symptoms and suicidal intent than those with secure visa status who had low group membership. Conclusion: Findings highlight the negative mental health consequences of living in a state of protracted uncertainty for refugees and people seeking asylum, and the key role of social engagement in influencing mental health amongst insecure visa holders. Results also underscore the importance of designing and implementing policies and services that facilitate improved mental health for those with visa insecurity.
... Similarly, among refugees from Iran and Afghanistan, those with TPVs reported a worsening trajectory of depression and anxiety and maintenance of high PTSD scores over a twoyear follow-up, whereas those with permanent visas reported improvements in depression and anxiety and low levels of PTSD (Steel et al. 2011b). Correspondingly, conversion from a TPV to permanent residency was associated with significant improvements in depression and PTSD symptoms, mediated by reductions in living difficulties among Mandean refugees (Nickerson et al. 2011), suggesting that access to permanency status has potential for longer-term mental health benefits. However, research to date has been conducted with small sample sizes and with participants from a limited number of countries of origin, restricting our understanding of the effects of visa policy for diverse communities. ...
... Augmenting prior investigations of the effects of restrictive visa policies, the findings extend a growing body of evidence demonstrating the role of insecure visa status in health, social integration, and livelihood outcomes. Beyond the detrimental effects on psychological outcomes, temporary visas have been associated with difficulties in acquiring new language skills (Steel et al. 2011b), prolonged isolation (Johnston et al. 2009;Steel et al. 2011b), a lack of agency (Kenny et al. 2016), difficulties addressing resettlement stressors (Nickerson et al. 2011;Steel et al. 2011b), and a sense of uncertainty and anxiety for the future (Johnston et al. 2009;Procter et al. 2018). These difficulties have been measured longitudinally (Nickerson et al. 2011;Steel et al. 2011b) and demonstrate a widening gap in psychological outcomes between people with temporary and permanent protection. ...
... Beyond the detrimental effects on psychological outcomes, temporary visas have been associated with difficulties in acquiring new language skills (Steel et al. 2011b), prolonged isolation (Johnston et al. 2009;Steel et al. 2011b), a lack of agency (Kenny et al. 2016), difficulties addressing resettlement stressors (Nickerson et al. 2011;Steel et al. 2011b), and a sense of uncertainty and anxiety for the future (Johnston et al. 2009;Procter et al. 2018). These difficulties have been measured longitudinally (Nickerson et al. 2011;Steel et al. 2011b) and demonstrate a widening gap in psychological outcomes between people with temporary and permanent protection. In Switzerland, recent data indicate that delays in processing asylum claims reduce subsequent engagement in employment, an effect that is consistent across socio-demographic factors and countries of origin (Hainmueller et al. 2016). ...
Article
Objectives Current regional conflicts are creating a surge in forced migration, and heightened visa restrictions are increasingly being applied. The current study aimed to examine the relationship between visa insecurity and psychological outcomes within a large clinical sample of refugees and people seeking asylum in Australia. Methods The sample comprised 781 clients (53.9% male, 16–93 years) attending a clinic for trauma survivors. Country of birth was most frequently identified as Afghanistan (18.1%), Iraq (15.3%) and Iran (15.1%). The Hopkins Symptom Checklist was administered at admission. Results Latent class analyses identified four groups varying in severity of symptoms, namely very high (16.1%), high (38.1%), moderate (31.5%), and low (14.3%). People with insecure visa status were at least five times more likely to report high (OR = 5.86, p < 0.001) or very high (OR = 5.27, p < 0.01) depression and anxiety symptoms than those with permanent residency. Women were almost twice as likely to report high (OR = 1.96 p < 0.01) or very high (OR = 1.96, p < 0.05) symptoms. Conclusions The findings suggest that temporary visas play a significant role in psychological distress and that timely immigration processing has important implications for health outcomes.
... Furthermore, a change from insecure to secure immigration status among asylum seekers in the USA (Raghavan et al., 2013) and Ireland (Ryan et al., 2008), was found to be the strongest correlate of improvement in psychological distress. Additionally, among Mandaean refugees resettled in Australia, improved living conditions mediated the relationship between changes to a more secure visa status and reduced psychological distress (Nickerson et al., 2011). However, in the Mandean population, reduced living difficulties did not explain the link between obtaining a more secure visa status and improved mental health related quality of life (Nickerson et al., 2011). ...
... Additionally, among Mandaean refugees resettled in Australia, improved living conditions mediated the relationship between changes to a more secure visa status and reduced psychological distress (Nickerson et al., 2011). However, in the Mandean population, reduced living difficulties did not explain the link between obtaining a more secure visa status and improved mental health related quality of life (Nickerson et al., 2011). Therefore, it could be that post-migration factors other than those related to immigration status and living conditions plays a role in reducing psychological distress. ...
... Other factors associated with reductions in distress include change to a more secure immigration status. This finding supports existing literature linking secure immigration status with more positive wellbeing (Nickerson et al., 2011;Silove et al., 2007). Moreover, after accounting for change to a more secure immigration status and pre-migration trauma exposure, women were more likely than men to report improvements in both depression and PTSD symptoms. ...
Article
Mental health research among asylum seekers and refugees has largely focused on effects of pre-migration trauma on post-migration wellbeing. While emerging literature highlights the importance of post-migration factors, we do not yet understand how addressing these factors may influence change in psychological distress. This study uses archival clinical data to identify post-migration correlates of reductions in distress among torture survivors, after accounting for pre-migration trauma. Depression (Patient Health Questionnaire-9) and Post Traumatic Stress Disorder (PTSD; Harvard Trauma Questionnaire) were measured among torture survivors following 6 months of interdisciplinary treatment (N = 323). Relationships between pre-, post-migration factors, and changes in symptom levels from intake to six months follow-up, were evaluated using regression analyses. Average levels of depression and PTSD significantly reduced after six months of treatment. Higher exposure to pre-migration trauma, female gender, and change to a more secure visa status were associated with reduced distress. Accessing more social services and not reporting chronic pain were associated with reduced PTSD. Stable housing and employment significantly moderated the relationship between lower chronic pain and reduced PTSD. Although effect sizes were small, results emphasize the importance of post-migration factors on wellbeing among torture survivors and are a first step towards identifying key treatment targets.
... While the mental health of refugees and asylum seekers is clearly negatively affected by pre-migration trauma (Steel, Silove et al. 2002, in Australia policy concerning asylum seekers that has been elaborated by successive governments over more than 20 years is one of the major factors producing severe risk of mental disorder among asylum seekers . Among the elements of asylum seeker policy that are most toxic to mental health are long-term detention (Steel, Momartin et al. 2004, Silove, Austin et al. 2007, Coffey, Kaplan et al. 2010, temporary protection (Mansouri and Cauchi 2006, restriction of access to services (Nickerson, Steel et al. 2011), human rights violations (Momartin, Silove et al. 2003, Nickerson, Steel et al. 2011), exposure to threats of different kinds (Momartin, Silove et al. 2003) and fear for family remaining in the country of origin (Nickerson, Bryant et al. 2010). The impact is likely to be greatest and most long lasting in children (Newman and Steel 2008). ...
... While the mental health of refugees and asylum seekers is clearly negatively affected by pre-migration trauma (Steel, Silove et al. 2002, in Australia policy concerning asylum seekers that has been elaborated by successive governments over more than 20 years is one of the major factors producing severe risk of mental disorder among asylum seekers . Among the elements of asylum seeker policy that are most toxic to mental health are long-term detention (Steel, Momartin et al. 2004, Silove, Austin et al. 2007, Coffey, Kaplan et al. 2010, temporary protection (Mansouri and Cauchi 2006, restriction of access to services (Nickerson, Steel et al. 2011), human rights violations (Momartin, Silove et al. 2003, Nickerson, Steel et al. 2011), exposure to threats of different kinds (Momartin, Silove et al. 2003) and fear for family remaining in the country of origin (Nickerson, Bryant et al. 2010). The impact is likely to be greatest and most long lasting in children (Newman and Steel 2008). ...
Chapter
Full-text available
Cultural and linguistic diversity is a core feature of the Australian population and a valued element of national identity. The proportion of the population that will be overseas-born is projected to be 32% by 2050. While a very active process of mental health system reform has been occurring for more than two decades - at national and state and territory levels - the challenges presented by cultural and linguistic diversity have not been effectively met. A review of Australian research on mental health of immigrant and refugee communities and their patterns of mental health service use reveals many gaps. Although lower rates of utilisation of specialist public mental health services by immigrants and refugees is repeatedly reported the lack of adequate population data prohibits conclusions about whether the observed patterns constitute under-utilisation. There are virtually no data on quality of service outcomes. A review of studies published in four key Australian journals reveals considerable neglect of cultural and linguistic diversity in Australia’s mental health research. The purpose of this chapter is to examine: what is known about the mental health of immigrant and refugee communities in Australia; whether Australian mental health research pays adequate attention to the fact of cultural and linguistic diversity in the Australian population; and whether national mental health data collections support evidence-informed mental health policy and practice and mental health reform in multicultural Australia. A set of strategic actions is suggested to improve knowledge about, and policy and service responses to, mental health problems in immigrant and refugee communities.
... One specific category of postmigration stress that may be particularly harmful to mental health is ongoing uncertainty regarding the resolution of the refugee determination process for asylum seekers or refugees on temporary visas. Insecure visa status has been significantly associated with increased levels of PTSD symptoms among refugees in Australia (Momartin et al., 2006;Nickerson, Steel, Bryant, Brooks, & Silove, 2011;Steel et al., 2011), the Netherlands (Knipscheer, Sleijpen, Mooren, ter Heide, & van der Aa, 2015), the United Kingdom (Morgan et al., 2017) and the United States (Chu, Keller, & Rasmussen, 2013). Visa insecurity may be particularly associated with elevated PTSD symptoms because it heightens realistic fears related to future trauma if repatriation is enforced, alongside a protracted loss of control and agency. ...
... Specifically, we found that insecure visa status predicted membership in the CPTSD and AD classes relative to both the low-symptom and PTSD classes. In Australia, visa insecurity is characterized by prolonged uncertainty regarding the future, a lack of control in the refugee determination process (e.g., unclear waiting times for decisions, sudden policy changes requiring new submissions), and elevated postmigration living difficulties (i.e., significant practical barriers, including restricted employment opportunities and access to services, family separation, fear for the future, and social problems including isolation and intercultural adjustment problems (Li et al., 2016;Momartin et al., 2006;Morgan et al., 2017;Nickerson et al., 2011;Steel et al., 2011). Notably, this group was not distinguished by higher trauma load or exposure to torture or sexual violence, but they did appear be younger than the PTSD class and were more likely to be female compared to the low-symptom class. ...
Article
Although it is well documented that exposure to severe, cumulative trauma and postdisplacement stress increases the risk for posttraumatic stress symptom disorder (PTSD), less is known about the representation and predictors of complex PTSD (CPTSD) symptoms in refugee populations. We examined PTSD and CPTSD symptom profiles (co-occurring PTSD and disturbances in self-organization [DSO] symptoms) and their premigration, postmigration, and demographic predictors, using latent class analysis (LCA), in a cohort of 112 refugees resettled in Australia. The LCA identified a four-factor model as the best fit to the data, comprising classes categorized as: (a) CPTSD, exhibiting high levels of PTSD and DSO symptoms (29.5%); (b) PTSD only (23.5%); (c) high affective dysregulation (AD) symptoms (31.9%); and (d) low PTSD and DSO symptoms (15.1%). Membership in the CPTSD and PTSD classes was specifically associated with cumulative traumatization, CPTSD OR = 1.56, 95% CI [1.15, 2.12], and PTSD OR = 1.64, 95% CI [1.15, 2.34]; and female gender, CPTSD OR = 14.18, 95% CI [1.66, 121.29], and PTSD OR = 16.84, 95% CI [1.78, 159.2], relative to the low-symptom class. Moreover, CPTSD and AD class membership was significantly predicted by insecure visa status, CPTSD OR = 7.53, 95% CI [1.26, 45.08], and AD OR = 7.19, 95% CI [1.23, 42.05]. These findings are consistent with the ICD-11 model of CPTSD and highlight the contributions of cumulative trauma to CPTSD and PTSD profiles as well as of contextual stress from visa uncertainty to DSO symptom profiles in refugee cohorts, particularly those characterized by AD. © 2019 International Society for Traumatic Stress Studies.
... In addition to the above, these families face increased exposure to violence, susceptibility to exploitation, heightened poverty, economic insecurity, and feelings of cultural and linguistic isolation (Laban, Gernaat, Komproe, van der Tweel, & De Jong, 2005;Nickerson, Steel, Bryant, Brooks, & Silove, 2011;Rousseau, Mekki-Berrada, & Moreau, 2001). The sense of displacement and related lack of trust in social institutions can further intensify dependence on the family unit and create a need for maintaining cultural continuity. ...
... Studies have found (Colic-Peisker & Tilbury, 2007;Nickerson et al., 2011) that issues of underemployment and the shame associated with the lack of social standing can be especially difficult for refugee men, as they often serve to undermine men's sense of identity and self-worth. Lack of employment, and the accompanying role reversal in the context of their wives employment status, can be particularly humiliating for the immigrant father and can be accompanied by feelings of social exclusion and dislocation. ...
Article
Full-text available
Studies have consistently found that fathers continue to be excluded from mainstream clinical social work practice when clinicians do not actively encourage their participation either because of lack of knowledge of how to engage fathers or biases against considering father involvement important. This holds especially true of immigrant and refugee fathers. With the majority of research studies focused on women and their children, a tremendous gap exists for male refugees and immigrants. Immigrant males and fathers in particular tend to be either forgotten or excluded from mainstream research. A significant gender bias exists in refugee research with less attention paid to boys, men, and fathers. This article provides an overview of the essential role of fathers in child development, the barriers that immigrant fathers face, their resilience through the immigration process, and how clinicians can establish a father-inclusive practice. A review will be presented on (1) the essential role of fathers in child development, (2) demographics of immigrant fathers, (3) the shifting of paternal roles and family structures, (4) social stressors and barriers for immigrant fathers, (5) the resilience of immigrant fathers, (6) barriers for fathers in clinical practice, (7) guidelines for father-inclusive practice, using a culturally informed socioecological family systems model.
... The mental health of refugees and asylum seekers is negatively affected by pre-migration trauma [82,83], longterm detention [82,[84][85][86], temporary protection [82,87,88], restriction of access to services [89], human rights violations [89,90], exposure to threats of different kinds [90] and fear for family remaining in the country of origin [91]. ...
... The mental health of refugees and asylum seekers is negatively affected by pre-migration trauma [82,83], longterm detention [82,[84][85][86], temporary protection [82,87,88], restriction of access to services [89], human rights violations [89,90], exposure to threats of different kinds [90] and fear for family remaining in the country of origin [91]. ...
... While the mental health of refugees and asylum seekers is clearly negatively affected by pre-migration trauma (Steel, Silove et al. 2002, in Australia policy concerning asylum seekers that has been elaborated by successive governments over more than 20 years is one of the major factors producing severe risk of mental disorder among asylum seekers . Among the elements of asylum seeker policy that are most toxic to mental health are long-term detention (Steel, Momartin et al. 2004, Silove, Austin et al. 2007, Coffey, Kaplan et al. 2010, temporary protection (Mansouri and Cauchi 2006, restriction of access to services (Nickerson, Steel et al. 2011), human rights violations (Momartin, Silove et al. 2003, Nickerson, Steel et al. 2011), exposure to threats of different kinds (Momartin, Silove et al. 2003) and fear for family remaining in the country of origin (Nickerson, Bryant et al. 2010). The impact is likely to be greatest and most long lasting in children (Newman and Steel 2008). ...
... While the mental health of refugees and asylum seekers is clearly negatively affected by pre-migration trauma (Steel, Silove et al. 2002, in Australia policy concerning asylum seekers that has been elaborated by successive governments over more than 20 years is one of the major factors producing severe risk of mental disorder among asylum seekers . Among the elements of asylum seeker policy that are most toxic to mental health are long-term detention (Steel, Momartin et al. 2004, Silove, Austin et al. 2007, Coffey, Kaplan et al. 2010, temporary protection (Mansouri and Cauchi 2006, restriction of access to services (Nickerson, Steel et al. 2011), human rights violations (Momartin, Silove et al. 2003, Nickerson, Steel et al. 2011), exposure to threats of different kinds (Momartin, Silove et al. 2003) and fear for family remaining in the country of origin (Nickerson, Bryant et al. 2010). The impact is likely to be greatest and most long lasting in children (Newman and Steel 2008). ...
Chapter
Full-text available
Cultural and linguistic diversity is a core feature of the Australian population and a valued element of national identity. The proportion of the population that will be overseas-born is projected to be 32% by 2050. While a very active process of mental health system reform has been occurring for more than two decades – at national state and territory levels – the challenges presented by cultural and linguistic diversity have not been effectively met. A review of Australian research on mental health of immigrant and refugee communities and their patterns of mental health service use reveals many gaps. Although lower rates of utilization of specialist public mental health services by immigrants and refugees are repeatedly reported, the lack of adequate population data prohibits conclusions about whether the observed patterns constitute underutilization. There are virtually no data on quality of service outcomes. A review of studies published in four key Australian journals reveals considerable neglect of cultural and linguistic diversity in Australia’s mental health research. The purpose of this chapter, which is an abbreviated and updated version of Minas et al. (Int J Mental Health Syst 7(1):23, 2013), is to examine what is known about the mental health of immigrant and refugee communities in Australia, whether Australian mental health research pays adequate attention to the fact of cultural and linguistic diversity in the Australian population, and whether national mental health data collections support evidence-informed mental health policy and practice and mental health reform in multicultural Australia. A set of strategic actions is suggested to improve knowledge about, and policy and service responses to, mental health problems in immigrant and refugee communities.
... Furthermore, it is also possible that visa status may moderate the relationships investigated in this study. Findings have shown that individuals with insecure visa status (i.e., temporary protection, asylum seeker status) report more psychological symptoms and poor adjustment to resettlement, than individuals with secure visa status (Heeran et al., 2014;Nickerson et al., 2011). The current study did not have adequate sample sizes for each group to examine potential differences, and future studies investigating the influence of visa status on the relationships between perceived torture controllability and current psychological symptoms is indicated. ...
Article
Torture is associated with greater psychopathology, however, the specific mechanisms underlying the effects of torture remain unclear. Research suggests that the perceived uncontrollable nature of, rather than the exposure to, torture, influences the development of psychological disorders. Perceived distress during torture has also been shown to influence psychological outcomes. This cross-sectional study explored the relationship between perceived torture controllability, emotions (i.e., anger and fear) during torture, and current posttraumatic stress (PTS), depression and anger symptoms, controlling for the effects of post-migration living difficulties. Data were collected from 108 refugees and asylum seekers in treatment at two psychiatric clinics in Zurich, Switzerland. Path analyses revealed negative correlations between PTS, depression and anger symptoms, and perceived torture controllability, and positive correlations with anger and fear during torture. Furthermore, the effects of perceived torture controllability on PTS and depression symptoms were mediated by fear during torture, and on anger symptoms via anger during torture. This was over and above the effects of post-migration living difficulties on psychological symptoms. The study provides preliminary evidence that perceived uncontrollability and distress during torture might be significant risk factors for current mental health of torture survivors. These findings may have implications for informing interventions for torture survivors.
... Migration is a process accompanied by significant socio-psychological pressures that affect migrants' mental state. Compared to local populations, migrants, including asylum seekers and work migrants, are at increased risk of physical and mental illnesses (Kirmayer et al., 2011;Lindencrona, Ekblad, & Hauff, 2008;Magalhaes, Carrasco, & Gastaldo, 2010), including post-traumatic stress disorder (PTSD), anxiety, somatization, depression and psychotic disorders (Cantor-Graae & Selten, 2005;Lerner, Kertes & Zilber, 2005;Mirsky, 2009;Nickerson, Steel, Bryant, Brooks, & Silove, 2011;Steel et al., 2009). The increased risk for legal migrants seems to occur even when conditions of immigration are relatively favorable, as they are in Israel (Arieli, 1992;Levav, Kohn, Flaherty, Lerner, & Aisenberg, 1990;Mirsky, Kohn, Levav, Grinshpoon, & Ponizovsky, 2008;Zilber & Lerner, 1996). ...
Article
Israel has become a destination for asylum seekers. Asylum seekers often experience emotional distress, but have limited access to health services and rarely use psychiatric services. This study sought to understand and characterize the use of psychiatric versus medical services by asylum seekers in Israel. We compared the emotional distress, stressful life events and previous treatment consultations of 21 psychiatric service users (PSU) and 55 medical service users (MSU) at the Open Clinic of Physicians for Human Rights in Tel-Aviv. Participants completed a socio-demographic questionnaire, the General Health Questionnaire (GHQ-12), the Stressful Life Events Scale and the Health Care Utilization Questionnaire. PSU and MSU did not have significantly different levels of emotional distress. PSU reported significantly more stressful life events during the past year than MSU (M = 5.81, SD 3.47 vs. M = 3.8, SD 2.35, p < 0.01). In comparison to MSU, PSU utilized more medical (M = 4.33, SD 2.28) and non-medical (M = 2.38, SD 1.92) services (p < 0.001) than MSU. Asylum seekers who consulted multiple treatment agencies in the last year were 1.55 times more likely to seek psychiatric treatment than those who had consulted only a few treatment agencies. Emotional distress in asylum seekers appears to be under-diagnosed in the Open Clinic and under-treated by mental health professionals. To better detect this distress, a thorough screening is recommended at assessment. Collaboration with mental health professionals and community and religious leaders consulted in the past is important and can contribute to good health care outcomes in this population.
... 4 Moreover, the bureaucratic process of the asylum seekers' application in the host country is long and impeded by uncertainty, insecurity, and often takes place under unfavorable living conditions, factors that are aggravating health care problems. 10,11 All of these influences together lead to a distinctively different health care profile in asylum seekers. Thus, physicians need to be aware of the special medical needs and conditions of asylum seekers if they are to provide this patient population adequate medical treatment. ...
Article
According to the United Nations Refugee Agency (UNHCR), 65.6 million people have been forcibly displaced worldwide. Several factors have a major influence on asylum seekers' health; so, their health profile is markedly different from that of the population in the country of asylum. The aim of this study is to review the major issues physicians need to be aware of when treating asylum seekers, with a special focus on the neurological problems of asylum seekers and refugees. The major impact factors on refugees' health are linked to experiences and exposure (1) in the country of origin, (2) in refugee camps and en route to Europe, and (3) in the process of immigration into the host country and living in European asylum centers. Refugees' health is also affected by psychological problems and by infectious diseases. Additionally, chronic diseases resulting in polymorbidity, cancer, and neurological diseases are easy to overlook and demand special attention. Neurological injuries/diseases may be traumatic (e.g., spinal cord injuries), posttraumatic (e.g., chronic pain syndromes), the result of cerebral infections, or the consequences of starvation (e.g., epilepsy, ataxia, and paraesthesia). The main challenges for physicians are lack of awareness of the asylum seekers' specific health care problems, language and intercultural communication problems, as well as access and integration of asylum seekers into the health care system. The health issues of asylum seekers are manifold and challenging to physicians. Awareness of these conditions is mandatory to ensure good clinical practice for this patient population, which has a huge burden in chronic, infectious, mental, and neurological diseases.
... [28,29] In addition to the stress of uncertainty, the reduced access to services and institutions that comes with less secure statuses might underlie this association. [30] Importantly, we find that men who received a protection status more recently exhibit greater distress than those who reported protection in 2016, in the first survey wave. This might be due to longer exposure to uncertainty, but perhaps also to stressors associated with the transition into a more permanent residence in the host country. ...
Article
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Background: Responding to the mental health needs of refugees remains a pressing challenge worldwide. We estimated the prevalence of psychological distress in a large refugee population in Germany and assessed its association with host country factors amenable to policy intervention and integration indicators. Method: We analysed the second wave of the IAB-BAMF-SOEP, a representative Germany-wide survey of 2,639 adult refugees who arrived between 2013 and 2016, which included the Refugee Health Screener. Results: Almost half of the population surveyed (41.3%[95%-CI:37.9%-44.6%]) was affected by psychological distress. 10.9%(8.3%-13.4%) of the population screened positive for severe distress. Risk of distress was particularly high for women (53%[47.1%-58.9%]), older refugees (aged ≥55:70.4% [58.5%-82.2%]), Afghan nationals (61.2%[53.2%-69.2%]), individuals under threat of Deportation (RR:1.54[1.13-2.1]), single males (1.41[1.09-1.82]), and those in collective housing (1.2[1.02-1.42]). Distressed males had a lower likelihood of employment (0.66[0.51-0.84]) and reduced participation in integration courses (0.9[0.81-1.01]). Affected females were less often in education (0.43[0.18-1.04]). Conclusions: The finding that a large minority of refugees in Germany exhibits distress calls for an expansion of mental health services for this population. Service providers and policy-makers should consider the increased risk among female, older and Afghan refugees, as well as among single men, residents in collective housing and those under threat of deportation. The associations between mental health and integration processes like labour market, educational program and integration course participation also warrant consideration.
... After discharge from our acute program, more than half of our patients were still waiting for an asylum decision or for family reunification, and most of the patients were still living in refugee accommodation. These factors may have substantially contributed to an increased symptom severity (Nickerson, Steel, Bryant, Brooks, & Silove, 2011;Schock et al., 2016). The long-term course of the wellbeing of traumatized refugees not only depends on successful therapeutic and psychosocial interventions but to a large part on the safety, living-conditions and social openness of the country of exile. ...
Article
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Background: A short-term multimodal acute treatment program of approximately six months' duration for newly arrived refugees at Center ÜBERLEBEN (Berlin Center for Torture Victims) was developed. The purpose of this study was to evaluate this program by examining changes in PTSD, anxiety and depression symptom severity after treatment, and to reflect on practical experiences in carrying out the program. Methods: At the beginning (T1) and following completion of the short-term treatment program (T2) patients in a single-group design were assessed with the Posttraumatic Stress Disorder Checklist for PTSD and the Hopkins-Symptom Checklist for depression and anxiety (per-protocol analysis). Results: Of the 92 patients who completed T1, 44 completed T2 assessments. Medium to large effect sizes were found for reductions in overall PTSD (d = 0.88), depression (d = 0.83), and anxiety symptoms (d = 0.67). While at the beginning of treatment (T1) 97.7% (n = 43) fulfilled diagnostic criteria for both PTSD and depression, and 95.5% (n=42) for anxiety, at T2, 70.5% (n = 31) fulfilled the criteria for clinically relevant PTSD, 79.5% (n = 35) for depression and 70.5% (n = 31) for anxiety. Discussion: Despite the high symptom load at the beginning of treatment, uncertainties regarding residence status, and the unstable living conditions, patients seem to benefit from the multidisciplinary short- term treatment. This study adds preliminary evidence to the efficacy of multimodal treatment and suggests that improvements in symptom severity can be achieved within the often extremely stressful period after arrival.
... Items scored at least 2 ("moderately serious problem") were considered positive responses, yielding a total count of living difficulties. The PMLD scale has consistently been identified as a predictor of mental health among displaced populations (12,31,35). ...
Article
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Background: Refugee mental health is affected by traumatic stressors as well as post-migration living difficulties (PMLD). However, their interaction and causal pathways are unclear, and so far, no distinct treatment recommendations regarding exile-related stressors exist. Methods: In a 3-year follow-up study, PMLD and symptoms of post-traumatic stress (PTS), depression and anxiety were examined in a clinical sample of severely traumatized refugees and asylum seekers (N = 71). Results: In regression analysis, reduction in PMLD predicted changes over time in depression/anxiety, but not in PTS. The opposite models with PMLD changes as outcome variable proved not significant for PTS, and significant, though less predictive, for depression/anxiety. Conclusions: In addition to well-established trauma-focused interventions for the treatment of PTS, psychosocial interventions focusing on PMLD might contribute to a favorable treatment response in traumatized refugees, particularly with regard to depression and anxiety.
... Daily stressors have been found to mediate the impact of war trauma on psychological well-being among resettled adults (Nickerson, Steel, Bryant, Brooks & Silove, 2010) and waraffected youth (Newnham, Pearson, Stein & Betancourt, 2015). Both war trauma and post-migration stressors influence mental health, and the post-migration environment may either foster or impend recovery from losses and traumatic experiences of war (Miller & Rasmussen, 2016). ...
Article
Unaccompanied refugee minors (UMs) are at significant risk to experience severe mental health symptoms (Derluyn, Broekaert & Schuyten). Trauma‐focused treatments have been found to be effective for traumatized refugees (Slobodin & de Jong). However, trauma‐focused mental health services are seldom available, and treatment fails when UMs lack trust in service providers (Majumder, O'Reilly, Karim & Vostanis). In order to address this gap, a 10‐session group based mental health intervention for UMs was developed and then pilot tested in 3 accommodation units for UMs in Finland. The implementation and effectiveness of the intervention was studied by qualitative and quantitative methods. The process was completed by 18 UMs. Symptom measures showed no statistically significant changes on the mental health variables studied. However, staff members and UMs reported increased trust and communication, and participating staff members felt empowered to facilitate groups independently. The group model promoted social interaction and built trust in the accommodation units. Further studies are required to UMs.
... Given the very limited resettlement assistance furnished in the United States, many refugees resettle in areas with lowercost housing and high community violence (American Psychological Association, 2010). Daily hardships experienced by youth and adults affected by conflict (Newnham, Pearson, Stein, & Betancourt, 2015) and resettled in high-income nations (Fazel et al., 2012;Nickerson, Steel, Bryant, Brooks, & Silove, 2011) can play a larger role in later mental health outcomes than early traumas. Consideration of current stressors and hardships are an important addition to clinical case assessments. ...
Article
Most mental health services for trauma-exposed children and adolescents were not originally developed for refugees. Information is needed to help clinicians design services to address the consequences of trauma in refugee populations. We compared trauma exposure, psychological distress, and mental health service utilization among children and adolescents of refugee-origin, immigrant-origin, and U.S.-origin referred for assessment and treatment by U.S. providers in the National Child Traumatic Stress Network (NCTSN). We used propensity score matching to compare trauma profiles, mental health needs, and service use across three groups. Our sample comprised refugee-origin youth (n = 60, 48.3% female, mean age = 13.07 years) and propensity-matched samples of immigrant-origin youth (n = 143, 60.8% female, mean age = 13.26 years), and U.S.-origin youth (n = 140, 56.1% female, mean age = 12.11 years). On average, there were significantly more types of trauma exposure among refugee youth than either U.S.-origin youth (p < .001) or immigrant youth (p ≤ .001). Compared with U.S.-origin youth, refugee youth had higher rates of community violence exposure, dissociative symptoms, traumatic grief, somatization, and phobic disorder. In contrast, the refugee group had comparably lower rates of substance abuse and oppositional defiant disorder (ps ranging from .030 to < .001).This clinic-referred sample of refugee-origin youth presented with distinct patterns of trauma exposure, distress symptoms, and service needs that merit consideration in services planning.
... Unsurprisingly, these individuals have often faced significant trauma which has been accompanied by high rates of psychological disorders (Hansson, Tuck, McKenzie, & Lurie, 2012;Murphy, 2014). While particularly acute before they migrate (Rasmussen, Crager, Baser, Chu, & Gany, 2012), the trauma often continues after they both (a) begin seeking protection (Nickerson, Steel, Bryant, Brooks, & Silove, 2011;Steel, Liddell, Bateman-Steel, & Ziwi, 2011;Steel, Momartin, Silove, Ceollo, & Aroche, 2011) and (b) are resettled (Chu, Keller, & Rasmussen, 2013). Often, these individuals also go unassisted and untreated (Shaw, 2016). ...
Thesis
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Culture has been identified as an important factor in mediating how individuals experience and process trauma. This thesis investigated the import of various cultural dimensions on traumatic symptomatology by scrutinizing key elements of the ‘Threat to Conceptual Self’ Model (TCSM). The model explicates the role of culture in arousing heightened traumatic responses associated with Posttraumatic Stress Disorder. Four studies are discussed involving participants from conflict-affected Colombia who were still living in Colombia or now living in Ecuador as refugees and asylum seekers. Participants contributed data via surveys and solicited cognitive representations in the form of autobiographical memories of everyday memories, traumatic events, self-defining memories, and future imaginings. Study One investigated the extent to which participants from Colombia around the Ecuadorian border share a specific culture, as well as the extent to which this cultural disposition is stable over time. Evidence suggests that the Colombians appear to share a cultural milieu, though cultural constructs vary longitudinally on an individual level. Study Two investigated the extent to which the cultural milieu of the Colombians in Ecuador comports with their traumatic experiences. Findings indicated that traumatic experiences prime cultural dispositions addressing independence, individualism, security, stability, and autonomy. Study Three examined the import of cultural elements vis-à-vis extreme traumatic symptomatology, finding that significant trauma comports with significant incongruity with many cultural constructs. Finally, Study Four confirmed that the cognitive representations examined in this thesis are consistent with previous reports of the impact of trauma on autobiographical memories and future imaginings. The evidence is unclear, however, regarding the degree to which culture mediates the effects of trauma on thoughts addressing one’s conceptual sense of oneself, which the TCSM suggests is a significant perpetuating and maintaining factor of traumatic symptomatology. The thesis concludes in discussing the theoretical implications of the TCSM; reviewing the evidence of cultural elements and traumatic symptomatology among various cognitive representations; and proposing key areas of further research into the import of culture into the ways in which trauma is experienced and maintained.
... • post-migration resettlementrelated stressors were the most important correlates of mental health (Finklestein and Solomon (2009);Chen, Hall, Ling, & Renzaho (2017); Carswell, Blackburn, & Barker (2011); Gorst-Unsworth & Goldenberg (1998)) • permanent residency: reduction of posttraumatic symptoms + strain of post-migration stressors (Keller et al., 2006;Nickerson, Steel, Bryant, Brooks & Silove, 2011) • Focused on quanatitative outcome + western biomedical model ...
Presentation
Full-text available
As female refugees often were confronted with gender-based violence in their past according to previous studies there is a high risk of re-victimization in the host country. Social workers as well as the refugee girls in the youth welfare system are walking a tightrope between care givers/receivers, power gaps and intersectional processes.
... Prolonged social isolation, unemployment, and persistent bad living conditions might have increased feelings of helplessness and lack of perspective and thus depressive symptoms among individuals holding residence permits. Nevertheless, the results are in line with findings on the negative impact of prolonged asylum processes (Laban et al., 2004(Laban et al., , 2008, rejected asylum claims (Silove et al., 2007), and temporary visas (Nickerson, Steel, Bryant, Brooks, & Silove, 2011) on various mental health outcomes, despite differences in specific psychological domains depending on the residence status (Heeren et al., 2014). In addition, residence permit status was associated with lower PGD symptom levels, even after controlling for traumatic and loss experiences. ...
Article
Full-text available
Background: Besides the high exposure to traumatic events, many refugees to Europe experienced tremendous interpersonal losses. Objective: The aim of this study was to investigate the rate and potential risk factors of prolonged grief disorder (PGD) in recently fled asylum seekers who lived in collective accommodations in Germany. Method: Three groups of asylum seekers from different countries (N = 99) completed the Traumatic Grief Inventory Self-Report Version (TGI-SR), Posttraumatic Stress Disorder Checklist-5 (PCL-5), and Patient Health Questionnaire depression module (PHQ-9). Individuals in Group 1 were waiting for asylum decisions (n = 29), Group 2 members were in appeal against rejected asylum claims (n = 32), and Group 3 members had been permitted temporary residence status (n = 38). Results: The loss of a loved person was reported by 92% of participants. The criteria for provisional PGD diagnosis according to Prigerson criteria were met by 20% of participants, 16% fulfilled the criteria for DSM-5 persistent complex bereavement disorder. Probable posttraumatic stress disorder (45%) and depression (42%) rates were high. The total number of lost nuclear family members and PTSD symptoms were associated with higher and temporary residence status was predicted lower PGD symptom levels. Conclusions: These results show that a substantial proportion of asylum seekers suffer from PGD. This points to the need to screen for problematic grief in the current refugee population in Europe.
... The association of somatic complaints (i.e., somatization symptoms and pain) with postmigration living difficulties has attracted little research attention to date. While PMLDs have repeatedly been identified to be related to mental health problems in refugees over and above trauma exposure [32,46,[54][55][56], this is one of the first studies to our knowledge to show an association with regard to physical health complaints. The association of PMLD with the PTSD Criterion E and the "arousal" factor and pain suggests a shared basis in terms of an elevated stress level, in analogy to the above-cited neurobiological and cognitive models. ...
Article
Objective.: Post-traumatic stress disorder (PTSD) and somatic symptoms, such as pain, are frequently seen in refugees. Their relationship is poorly understood, and the treatment of these comorbid conditions can be very challenging. The current cross-sectional study examined pain and other somatic symptoms and their relationship with trauma history, PTSD symptom clusters, and current living difficulties among treatment-seeking refugees. Methods.: One hundred thirty-four treatment-seeking traumatized refugees (78% male, mean age = 42 years) were assessed regarding lifetime traumatic experiences, symptoms of post-traumatic stress, overall pain and somatic symptoms, and postmigration living difficulties. Results.: An exploratory factor analysis of the 12 somatic symptoms revealed two distinct factors: somatic symptoms related to bodily dysfunction ("weakness") and somatic symptoms related to increased sympathetic activity ("arousal"). DSM-5 PTSD Criteria D "alterations in cognitions and mood" and E "alterations in arousal and reactivity" were primarily related to "weakness," while PTSD Criterion E "alterations in arousal and reactivity" and postmigration living difficulties were associated with "arousal." Overall pain was associated primarily with living difficulties and PTSD Criterion D and Criterion E. Conclusions.: Results indicate that somatic symptoms are of considerable concern among traumatized refugees and that different patterns of somatic symptoms are associated with different clusters of PTSD symptoms. The findings contribute to the better understanding of the symptom presentation of traumatized people who are experiencing somatization and potentially inform treatment directions and highlight the importance of screening for PTSD in refugees presenting with pain and somatic symptoms.
... The association of somatic complaints (i.e., somatization symptoms and pain) with postmigration living difficulties has attracted little research attention to date. While PMLDs have repeatedly been identified to be related to mental health problems in refugees over and above trauma exposure [32,46,[54][55][56], this is one of the first studies to our knowledge to show an association with regard to physical health complaints. The association of PMLD with the PTSD Criterion E and the "arousal" factor and pain suggests a shared basis in terms of an elevated stress level, in analogy to the above-cited neurobiological and cognitive models. ...
... Restriction of rights and access to services related to visa status negatively affect the mental health of asylum seekers (Laban, Gernaat, Komproe, Schreuders, & De Jong, 2004;Nickerson, Steel, Bryant, Brooks, & Silove, 2011). Miller and Rasmussen Rasmussen et al., 2010) further suggested that stressful social and material conditions (daily stressors) that are exacerbated by the restrictive policies in growing hostile political situations in many industrial countries partially mediate the relationship between exposure to traumatic events and mental ill-health. ...
Article
We investigated the combined effect of the severity of exposure to traumatic events and perceived social support on posttraumatic stress disorder (PTSD) symptoms among male asylum seekers in Israel. A convenience sample of 90 men who sought asylum from Eritrea and Sudan and presented at the Open-Clinic in Tel-Aviv, Israel, participated in the study. Participants completed measures assessing exposure to traumatic events, perceived social support and PTSD symptoms in their native language. The majority of participants had been exposed to traumatic events. Lack of shelter, ill health without access to medical care, imprisonment and torture were most prevalent. Perceived social support was associated with lower PTSD symptoms only among those who reported low exposure to traumatic events. Among asylees who reported high exposure to traumatic events, social support did not affect the association between exposure to traumatic events and PTSD symptoms. Our findings show that perceived social support serves as a significant moderator in the relationship between exposure to traumatic events and PTSD symptoms among asylum seekers, depending on the severity of exposure to traumatic events. The complex relationship between protective factors such as perceived social support, exposure to trauma and mental health should inform mental health services for forced migrants.
... Specifically, we had 3 aims: (1) to examine the prevalence of sleep disturbance symptoms within this sample; (2) to examine the relationships between sleep disturbance and mental health symptoms, psychosocial concerns, and demographic profiles; and (3) to explore whether specific subsets of individuals could be identified through clusters of symptoms. Given the well-established association between migration status and psychological symptoms and resettlement difficulty, 22 for the second and third aims, we investigated the associations separately for the refugee and asylum seeker groups. Additionally, we assessed these relationships separately for children and adults. ...
Article
Background: Worldwide, 68.5 million individuals are refugees, asylum seekers, or internally displaced. Although many studies have examined mental health concerns in this population, few studies have assessed sleep or examined the relationship between sleep and mental health or psychosocial functioning. Objectives: The objectives were to (1) examine the prevalence of sleep disturbance within refugees and asylum seekers from diverse backgrounds, (2) examine mental health and psychosocial factors associated with sleep disturbance, and (3) explore whether symptoms cluster together in unique subsets of individuals. Methods: Clinician-administered interview data (N = 2703) were obtained from a large mental health service in greater Melbourne, Australia. Data included patient demographics, sleep disturbance, mental health (anxiety, depression, traumatic stress symptoms), and psychosocial concerns (family dysfunctions, interpersonal difficulties, social isolation). Results: A total of 75.5% of the sample reported moderate or severe sleep disturbance. Severity of sleep disturbance was positively correlated with severity of mental health symptoms, psychosocial concerns, age, and migration status. This was true in both refugee and asylum seeker populations and in both adults and children. Cluster analyses revealed 3 subsets of individuals: those with "severe sleep and anxiety symptoms," "mild to moderate symptoms," and "mild symptoms." Using "mild symptoms" as the comparator, being a refugee and increasing age were associated with a 1.57- and 1.02-fold increase, respectively, in the likelihood of classification as "severe sleep and anxiety problems" and 1.70- and 1.02-fold increase, respectively, in the likelihood of classification as "mild to moderate symptoms." Conclusion: These findings suggest that systematic screening of sleep disturbance among refugees and asylum seekers during health-related visits is needed.
... Post-migration experiences have increasingly been investigated. Everyday life after conflict exposure and migration is often plagued with demands that undermine health as much or more than a trauma exposure itself (Chen et al., 2017;Fazel, 2018;Hou et al., 2018;Hynie, 2018;Morina et al., 2011;Nickerson et al., 2015Nickerson et al., , 2011Steel et al., 2006). Factors including discrimination, restrictions in living arrangements, settlement in refugee camp, among others, were associated with higher depressive and PTSD symptoms among refugee children ( Bronstein and Montgomery, 2011;Fazel et al., 2012;Porter and Haslam, 2005;Tol et al., 2013). ...
Article
Full-text available
Background: There are a growing number of forced migrants worldwide. Early detection of poor adjustment and interventions to facilitate positive adaptation within these communities is a critical global public health priority. A growing literature points to challenges within the post-migration context as key determents of poor mental health. Aims: The current meta-analysis evaluated the association between daily stressors and poor mental health among these populations. Method: A systematic search in PsycINFO, PubMed, and Web of Science identified relevant studies from inception until the end of 2018. Effect sizes (correlation coefficients) were pooled using Fisher’s Z transformation and reported with 95% confidence intervals. Moderator and mediator analyses were conducted. The protocol is available in PROSPERO [CRD42018081207]. Results: Analysis of 59 eligible studies (n=17,763) revealed that daily stressors were associated with higher psychiatric symptoms (Zr=0.126-0.199, 95% CI=0.084-0.168, 0.151-0.247, p<0.001) and general distress (Zr=0.542, 95% CI=0.332-0.752, p<0.001). Stronger effect sizes were observed for mixed daily stressors relative to subjective, interpersonal, and material daily stressors, and for general distress relative to post-traumatic stress symptoms and general well-being. Effect sizes were also stronger for children and adolescents relative to adults. Daily stressors fully mediated the associations of prior trauma with post-migration anxiety, depressive, and post-traumatic stress disorder symptoms. Conclusions: This meta-analysis provides a synthesis of existing research on the role of unfavorable everyday life experiences and their associations with poor mental health among conflict-affected forced migrants. Routine assessment and intervention to reduce daily stressors can prevent and reduce psychiatric morbidity in these populations.
... They are likely to live in overcrowded situations without supportive social networks (Schweitzer et al., 2011). Living with legal uncertainties and having to cope with discrimination can further increase adjustment problems (Nickerson, Steel, Bryant, Brooks, & Silove, 2011;Slonim-Nevo & Dorchin-Regev, 2016). Indeed, in a study among asylum seekers from Darfur in Israel, participants reported many difficulties in almost all areas: worries about family members at home, access to medical care, fears of deportation, work conditions, and discrimination (Slonim-Nevo et al., 2015). ...
Article
This paper describes a single-session Social Art intervention with a group of Eritrean migrant detainees in Israel during which they described their journey and created messages to the hegemonic Israeli society. The paper describes the protocol of the puzzle art intervention. It then presents the central themes within the asylum seekers’ art that include remembering home, the traumatic journey, arriving in Israel, and pleas to have empathy and to enable them to be free rather than imprison them. The aim of this case study is theoretical, using the case study to describe the characteristics and mechanisms of Social Arts (SA) as manifested in this activity. It shows how a SA orientation integrates the dual areas of psychological and also social agency. This is discussed as a complex theoretical challenge as well as an advantage. This paper hopes to illuminate the complexity of elements of SA as a specific and under-researched direction within art therapy. The descriptive arts activity also provides a protocol for using arts in similar shared reality group and community contexts.
... 57,58 Symptoms of depression, anxiety and PTSD have been associated with post-migration factors, such as holding a temporary visa, insecurity about visa status, no access to health services and being separated from society. 13,[59][60][61] Refugees and migrants who are integrated into society or hosted in a supportive environment experience fewer symptoms of depression, distress and PTSD than refugees and migrants separated from society. 27,61,62 Hence, as expected, prevalence rates of depression and PTSD are higher among non-detained refugees and migrants than among nonrefugee or migrant populations. ...
Article
Full-text available
Background The number of forced migrants is increasing worldwide. Some governments detain refugees and migrants in immigration detention centres, which is associated with adverse mental health outcomes. Aims To estimate prevalence rates of depression, anxiety and post-traumatic stress disorder (PTSD) in child and adult refugees and migrants in immigration detention. Method Pre-registered systematic review with meta-analysis (Prospero ID: CRD42020196078). Results Systematic searches in Medline, Embase and Web of Science (final search date 1 October 2020) yielded nine eligible studies on the mental health of detained refugees and migrants (total n = 630 refugees and migrants, 522 of them in detention, among which 26 were children). For adults, prevalence rates for depression were 68% (95% CI 0.53–0.83%), for anxiety 54% (95% CI 0.36–0.72%) and for PTSD 42% (95% CI 0.22–0.63%). Theoretical comparisons with data from other meta-analyses revealed that prevalence rates and symptom severity were higher in detained, relative to non-detained samples. Conclusions Our data show a huge burden of mental health problems in detained refugees and migrants of all ages, also relative to non-detained samples. This suggests that immigration detention independently and adversely affects the mental health of refugees and migrants. This insight should encourage countries to minimise the use of immigration detention and implement alternative measures instead.
... 46 47 In addition to the stress of uncertainty, the reduced access to services and institutions that less secure statuses often entail might underlie this association. 48 Our results furthermore indicate that males who received a protection status more recently may experience greater distress than those who have been protected for longer. This might be due to more prolonged exposure to uncertainty, but perhaps also to stressors associated with the transition into a more permanent residence in the host country. ...
Article
Full-text available
Objectives Responding to the mental health needs of refugees remains a pressing challenge worldwide. We estimated the prevalence of psychological distress in a large refugee population in Germany and assessed its association with host country factors amenable to policy intervention and integration indicators. Design A cross-sectional and population-based secondary analysis of the 2017 wave of the IAB-BAMF-SOEP refugee survey. Setting Germany. Participants 2639 adult refugees who arrived in Germany between 2013 and 2016. Main outcome measures Psychological distress involving symptoms of depression, anxiety and post-traumatic stress disorder was measured using the Refugee Health Screener-13. Results Almost half of the population surveyed (41.2% (95% CI: 37.9% to 44.6%)) was affected by mild, moderate or severe levels of psychological distress. 10.9% (8.4% to 13.5%) of the population screened positive for severe distress indicative of an urgent need for care. Prevalence of distress was particularly high for females (53.0% (47.2% to 58.8%)), older refugees (aged ≥55, 70.4% (58.5% to 82.2%)) and Afghans (61.5% (53.5% to 69.5%)). Individuals under threat of deportation were at a greater risk of distress than protection status holder (risk ratio: 1.55 (95% CI: 1.14 to 2.10)), single males at a greater risk than males with nuclear families living in Germany (1.34 (1.04 to 1.74)) and those in refugee housing facilities at a greater risk than those in private housing (1.21 (1.02 to 1.43)). Distressed males had a lower likelihood of employment (0.67 (0.52 to 0.86)) and reduced participation in integration courses (0.90 (0.81 to 0.99)). A trend of reduced participation in educational programmes was observed in affected females (0.42 (0.17 to 1.01)). Conclusion The finding that a substantial minority of refugees in Germany exhibits symptoms of distress calls for an expansion of mental health services for this population. Service providers and policy-makers should consider the increased prevalence among female, older and Afghan refugees, as well as among single males, residents in housing facilities and those under threat of deportation. The associations between mental health and integration processes such as labour market, educational programme and integration course participation also warrant consideration.
... To date, no study has reported about differences in mental health status and related factors among undocumented migrants at different stage of their integration process in Europe. While better integration into the host society through the reception of a residency permit has been associated with better mental health status in refugees in Western countries and in youth in the United States, no study has so far explored this topic in undocumented adults Europe [19,20]. The burden of mental health conditions and the factors associated may differ at different stage of the integration process and thus require distinct social and health policies. ...
Article
Full-text available
Background Undocumented migrants live and work in precarious conditions. Few studies have explored the mental health consequences of such environment. The objective of this study is to describe the mental health of migrants at different stages of a regularization program. Methods This cross-sectional study included migrants undocumented or in the process of regularization. We screened for symptoms of anxiety, depression and sleep disturbance using validated tools. We created a composite outcome of altered mental health including these components plus self-report of a recent diagnosis of mental health condition by a health professional. Results We enrolled 456 participants of whom 246 (53.9%) were undocumented. They were predominantly women (71.9%) with a median age of 43.3 (interquartile range: 15.5) years, from Latin America (63.6%) or Asia (20.2%) who had lived in Switzerland for 12 (IQR: 7) years. Overall, 57.2% presented symptoms of altered mental health. Prevalence of symptoms of anxiety, depression and sleep disturbance were 36% (95% confidence interval: 31.6–40.6%), 45.4% (95% CI: 40.8–50.1%) and 23% (95% CI: 19.2–27.2), respectively. Younger age (adjusted odd ratio: 0.7; 95% CI: 0.5–0.9 for each additional decade), social isolation (aOR: 2.4; 95% CI: 1.4–4.2), exposure to abuse (aOR: 1.9; 95% CI: 1.1–3.5), financial instability (aOR: 2.2; 95% CI: 1.4–3.7) and multi-morbidity (aOR: 3.2; 95% CI: 1.7–6.5) were associated with increased risk of having altered mental health while being in the early stages of the process of regularization had no effect (aOR: 1.3: 95% CI: 0.8–2.2). Conclusions This study highlights the need for multi-pronged social and health interventions addressing the various domains of undocumented migrants living difficulties as complement to legal status regularization policies. Protection against unfair working conditions and abuse, access to adequate housing, promoting social integration and preventive interventions to tackle the early occurrence of chronic diseases may all contribute to reduce the burden of altered mental health in this group. More research is needed to assess the long-term impact of legal status regularization on mental health.
... Mathilde ROZE Bien que le statut administratif n'était pas associé à la dépression ou à l'ESPT dans nos études, une étude a montré que le fait de passer d'un visa temporaire au statut de résident permanent était associée à une amélioration significative des symptômes de stress post-traumatique et de dépression, et à une amélioration de la qualité de vie liée à la santé mentale [324]. Dès la fin du XIXe siècle, la psychiatrie prend donc une autre dimension, nombre de théories pour décrire la maladie mentale sont formulées, sur la paranoïa, la démence, la dégénérescence, la névrose, l'hystérie, la schizophrénie... En effet, c'est l'époque du développement de la psychanalyse. ...
Thesis
Dans le contexte actuel de l’augmentation du nombre de familles sans logement en Île-de-France et compte tenu de leur vulnérabilité, il est nécessaire de mieux connaitre leurs caractéristiques, notamment en santé mentale. L’objectif de cette thèse est d’étudier les facteurs associés à la santé mentale des mères et des enfants sans logement en Ile de France, afin d’apporter des données françaises à la littérature scientifique sur le sujet afin de contribuer à enrichir la réflexion sur les modes d’action pouvant améliorer la santé mentale des familles les plus démunies. Cette thèse a été réalisée à partir de l’enquête ENFAMS (ENfants et FAMilles Sans logement), menée par l’Observatoire du Samu social de Paris auprès de 801 familles sans logement en Île-de-France, par des binômes enquêteur-psychologue bilingues pendant l’hiver 2012-2013. A partir de ces données, nous avons montré que les mères de familles sans logement présentaient de fortes prévalences de dépression caractérisée (28,8%) et d’Etat de Stress Post Traumatique (ESPT) (18,9%), que leurs enfants présentaient de haut niveau de difficultés émotionnelles et comportementales (20,8%) et que la santé mentale des mères était associée aux difficultés émotionnelles et comportementales de leur enfant. Les facteurs associés à la dépression des mères étaient le fait de savoir parler français, le risque suicidaire, l’ESPT et le renoncement à des soins médicaux. Le risque d’ESPT des mères était associé au départ du pays d’origine pour une cause violente, la dépression au cours des 12 derniers mois, et l’instabilité résidentielle. Les difficultés émotionnelles et comportementales des enfants étaient associées à la région de naissance des parents, la mobilité résidentielle, la santé des enfants et le surpoids, les habitudes de sommeil des enfants, le risque suicidaire des mères, le fait que les enfants n’aiment pas l’hébergement de leur famille et qu’ils soient victimes de moqueries à l’école. Cette thèse permet de mieux appréhender les facteurs associés à la santé mentale des mères et des enfants de familles sans logement. Ainsi, le système de santé de droit commun et les professionnels en soins primaires doivent profiter de l’opportunité qu’offre chaque contact avec ces familles pour dépister les troubles de la santé mentale tant chez les mères que chez leurs enfants, et les aiguiller vers les structures existantes pour faciliter leur accès à aux soins.
... related to these challenges, waiting for an asylum decision is associated with limited access to the national welfare system. Nickerson, Steel, Bryant, Brooks, and Silove (2011) studied the relationship between changes in visa statuses, psychological symptoms, and living difficulties amongst mandean refugees in australia. they found that limited rights and limited access to services related to residency issues have a negative impact on mental health. ...
Research
Full-text available
Editors: Jessica Blöcher, luisa eyselein, Justin Shrum, Anja Wells Academic reviewer/ co-editor: Simon Kolbe Academic team: Irene Ciambezi, Erika Mosebach-Kornelsen, Caroline Sander, Giorgia Stefani, Heike Menzel-Kötz Graphic Design: Nino Bach "The European Commission states that human trafficking[1] has a “detrimental effect on individuals, society, and the economy” and is a “gross violation of fundamental rights, and is explicitly prohibited under the Charter of Fundamental Rights of the European Union”.[2] This study emerged from the INTAP project, Intersectional approach to the process of integration in Europe for survivors of human trafficking, funded by the European Commission. It was carried out to investigate the integration process of Nigerian survivors and to answer the central question of how to strengthen opportunities and overcome hindrances to the process of integration in Europe for Nigerian survivors of human trafficking for sexual exploitation? The qualitative study was conducted on 35 Nigerian Survivors, 18 experts and 2 focus groups. The data was collected by a semi-structured qualitative interview with questions on different aspects of integration and was transcribed and analysed using the MAXQDA software. Key findings of this study are the role of a Person of Trust as the biggest opportunity and the role of fear as biggest hindrance for survivors’ integration. Further implications are the need for more state funding for gender-specific and mother-child friendly safe housing and SoT-specialised social workers and NGOs. Asylum policies need to be adjusted in order to refrain from deporting SoTs. Along with this, the EU Member States should release more funds for anti-racism and other Social Impact Projects in order to counteract refugee hostility in society. A brief guide to the contents of the report: Chapter 2 provides the context of the study and presents the state of research. Readers interested in the methodological approach can go to Chapter 3. Readers who are most interested in specific topics within integration (e.g. health care system, housing, etc.) can go to Chapter 4 with the specific code summaries. Practitioners (e.g. social workers, volunteers, etc.) whose focus is on practical implications can go directly to Chapter 5.2 and 5.3. [1] Human trafficking is defined here according to the UN-Protocol to Prevent, Suppress and Punish Trafficking in Persons (A/RES/55/25) (also known as the “Palermo Protocol”). This definition was also the basis for the EU Directive on preventing and combating trafficking in human beings and protecting its victims (2011/36/EU). [2] European Commission. 2016. “Report from the Commission to the European Parliament and the Council - Report on the Progress Made in the Fight against Trafficking in Human Beings (2016).” COM(2016) 267 Final. Brussles. " source: www.intap-europe.eu
... 7,14,76 ) Notwithstanding the health risks of pre-migration experiences of trauma and social dislocation associated with fleeing persecution, 42,44-46 for refugees, these employment-related difficulties compounded other resettlement stressors, such as navigating the refugee determination process, long periods of uncertainty, and cuts to income support. 51,[77][78][79] Refugee participants had been in Australia for an average of 5.5 years (in contrast to 2.5 years for the non-refugee participants). There are cumulative and compounding health impacts associated with experiencing multiple stressors resulting from this manufactured precarity. ...
Article
Full-text available
Employment and work-related exploitation and discrimination are important social determinants of health. However, little is known about the experiences of people on temporary visas in Australia, particularly those on refugee visas. This article reports on a study of people living on temporary visas in South Australia and their experiences of workforce exploitation and discrimination and impacts on health. Interviews were conducted with 30 people: 11 on non-refugee temporary visas and 19 on refugee temporary visas. Data was analyzed thematically. Analysis identified experiences of exploitation and discrimination in the Australian labor market that included difficulties securing work, underpayment, overwork, and hazardous workplaces. These experiences had negative health effects, particularly on mental health. None had made a formal complaint about their treatment, citing the precarity of their visas, difficulties finding an alternative job, and lack of knowledge about what to do. The impacts were especially evident for refugees who were also grappling with pre-settlement trauma and ongoing uncertainties about their future protection. Overall, these findings of discrimination and exploitation in the workplace and subsequent ill health highlight the pervasive impact of neoliberal agendas and stress the need for industrial, immigration, and welfare reform to protect workers on temporary visas.
Article
Background: Decentralized health systems in Low and Middle-Income Countries (LMICs) impacted by humanitarian crises lack resources and a qualified workforce to attend to the overwhelming demand for mental health care in emergencies. Innovative approaches that are safe, cost-effective, and scalable are needed to address the burden of traumatic stress brought by emergencies. High mobile phone ownership rates combined with the precision of neural, cognitive, and biometric measures of trauma and its feasible integration with Artificial Intelligence (AI) makes digital application (app) interventions a promising pathway to promote precision diagnosis and high-impact care. Objective: The aims of this study are to advance methods for the objective diagnosis and treatment of trauma in emergencies across LMICs by examining (i) neural, cognitive, and biometric markers and (ii) the efficacy of the eResilience App, a neuroscience-informed mobile health mental health app intervention, via changes in clinical symptomatology, cognitive performance, and brain activity. Methods: Trauma-exposed African refugees residing in Australia were selected for this study. A research software version of the eResilience App with advanced monitoring capabilities was designed for the trial. Participants completed the eResilience App at home during a seven-day period. Clinical, cognitive, and electrophysiological data were collected during baseline and post-test to examine biomarkers of trauma and the efficacy of the proposed digital intervention for the treatment of trauma and its potential outcomes including depression, anxiety, physical symptoms, self-harm, substance misuse, and cognitive impairment. In addition, biofeedback, wellbeing, and subjective stress data points were collected via the app during the treatment week, followed by clinical interviews at 1, 3, 6 and 12-months post-intervention. Results: Data collection was conducted between 2018 and 2020. A total n=100 participants exposed to war were screened, n= 75 were enrolled and assigned to a trauma-exposed control (n=38) or Posttraumatic Stress Disorder (PTSD) condition (n=37), and n= 70 completed all baseline, treatment, and post-test assessments. A total n=62 of the n=70 who completed the intervention opted to enrol in the 3, 6 and 12-month follow-ups. Data collection is complete, and results are being prepared for publication. If proven efficacious, this proof-of-concept clinical trial will inform fully powered randomized clinical trials in LMICs to further develop AI-powered, app-based diagnostic and prognostic features, and determine the app's cross-cultural efficacy for the treatment of trauma in emergency settings. Conclusions: This protocol provides researchers with a comprehensive background of the study rationale, a detailed guideline for replication studies interested in examining the feasibility and the efficacy of the eResilience App across varied demographics, and a robust framework for investigations of low-cost objective diagnostic markers in mental health interventions. Methodological limitations and suggestions are also provided. Clinicaltrial: Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12616001205426. Universal Trial Number (UTN): U1111-1180-0347.
Chapter
Despite international efforts to uphold human rights, organized state persecution and systematic torture are on the rise worldwide, as are severe traumas to the civilian population in (civil) wars. The majority of people who leave their countries of origin due to persecution and war are internally displaced persons or flee to neighbouring countries. Only a minority of these people reach Europe, North America or Australia as refugees fleeing to exile countries. The treatment of traumatised refugees and torture victims brings along special requirements: working mostly in a transcultural setting, involving interpreters, as well as the treatment of extremely traumatised people, most of whom suffer from complex disorders. At the same time, the patients are in a process of coping and adaptation determined by many factors due to cultural uprooting and stress in exile. This chapter describes how psychotherapy with traumatised refugees and survivors of torture can be implemented.
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Questo manuale è stato sviluppato nell’ambito del progetto INTersectional APproach to the process of integration in Europe for survivors of human trafficking (INTAP). INTAP mirava a trovare soluzioni più durature per l’integrazione delle SoT nigeriane, rendendo più efficaci gli attuali sistemi di integrazione per le SoT nigeriane attraverso l’incorporazione di un approccio intersettoriale culturalmente sensibile, incentrato sulle vittime, in linea con la Direttiva sulla tratta di esseri umani dell’UE37. Piuttosto che creare nuovi programmi di integrazione, INTAP ha voluto mostrare le migliori prassi. Queste migliori prassi per le misure di integrazione delle SoT nigeriane sono presentate in questo manuale.
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Numerous studies have linked the high rates of traumatic events experienced by refugees to the elevated rate of mental health problems in these populations. A growing body of evidence has also highlighted the importance of considering postmigratory stressors when making sense of displaced person distress. This study explored the relationship between mental health and postmigratory stress for asylum seekers and refused asylum seekers in Britain. The study further examined if those refused asylum experienced elevated distress and postmigratory stress compared to those awaiting the outcome of asylum applications. Results indicated that participants (N = 97) had endured a range of pre- and postmigratory stressors and had high scores on measures of anxiety, depression, and PTSD. A postmigratory factor comprising items associated with isolation, restrictive policies, and stressors associated with having an insecure immigration status, was significantly associated with PTSD scores. This relationship remained when controlling for the variance accounted for by premigratory trauma predictors. Being refused asylum was the strongest predictor of depression and anxiety. Those refused asylum scored higher on a factor associated with barriers to accessing services. Social materialist theories of distress are drawn upon to contextualise the heightened vulnerability of those refused asylum. The paper concludes by emphasising the problems associated with taking an exclusively trauma-focussed approach when working with asylum seekers and argues for community orientated interventions to support displaced people to cope with the various stressors endured in exile.
Chapter
Worldwide there are over 80 million refugees and forcibly displaced people, who are at risk of exposure to repeated potentially traumatic events and ongoing stressors during their resettlement. This article reviews the current knowledge about the prevalence, risk factors, and nature of mental health conditions in refugees. It also addresses the evidence regarding treatment of mental health problems in refugees as well as the major challenges for delivering better mental health care to this population. The article also highlights issues that clinicians need to be sensitive to when assessing and treating refugees with mental health conditions.
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Background: Since the onset of the 2015 European refugee crisis, ~4. 46 million people have sought asylum in the European Union, with Germany logging the largest share of all asylum applications. In addition to the severe adversities before and during flight, the process of settling into a new environment involves stressors that affect psychological well-being and mental health. The aim of this systematic review was to examine contextual factors during post-migration that influence the mental health and well-being of asylum seekers and refugees (ASRs) in Germany. Methods: Following PRISMA guidelines, a systematic review was conducted across multiple databases for English and German studies published between 2015 and 2020 with index keywords. Results: From a total of 303 articles, 156 duplicates were removed and, after title review, another 87 were excluded for not meeting the inclusion criteria. After assessing the abstracts of the remaining 60 articles, 39 were excluded. Full texts of 21 articles were assessed for eligibility and after excluding 8 articles, 13 articles were included in the review. The results demonstrate high rates of psychological distress among ASRs in Germany and the significant influence of contextual factors on their mental health and psychological well-being. The risk factors for poor mental health include an uncertain asylum status, living in shared asylum accommodations, separation from the nuclear family, lack of German language skills, integration issues and discrimination, while employment is a protective factor. Conclusion: Asylum seekers and refugees have high prevalence rates of psychological distress directly influenced by contextual factors in Germany. Based on these findings, policy makers are strongly recommended to apply preventive strategies to reduce mental health problems of ASRs in Germany.
Article
STUDY OBJECTIVES:Sleep disturbance is common in those who experience trauma. In a sample of non-treatment seeking refugees, we examined the associations between trauma exposure, post-migration stress, sleep symptoms and post-traumatic psychological symptoms. METHODS:Syrian and Iraqi refugees (N = 86; 51% female; M age=45 years) residing in Australia were recruited from the local community. Cross-sectional descriptive design, multinominal regression analyses, and mediation analyses were used. Participants completed Arabic measures assessing pre-migration trauma exposure, post-migration stress, sleep symptoms, and mental health. They also completed 7-days of sleep diaries and actigraphy. RESULTS:34.9% of the participants were identified as normal sleepers, 32.6% as probably having insomnia, and 32.6% as likely having insomnia. Variables associated with greater sleep disturbance (McFadden’s R2=0.57) included: greater trauma exposure, increased time of resettlement, greater post-migration stress, and greater pre-sleep arousal. The association of pre-migration trauma exposure to current posttraumatic symptoms was mediated sequentially by post-migration stress and sleep symptoms. CONCLUSIONS:Our findings highlight the extent of sleep disturbance in refugees. We found evidence for an indirect pathway between trauma exposure and posttraumatic symptoms, through pre-migration stress and sleep (particularly pre-sleep arousal). In the current global refugee crisis, improving the existing system of care in countries experiencing increased migration is critical. As sleep disturbance is a modifiable condition associated with mental health, targeting sleep could be an important component of psychological interventions for refugees.
Article
This paper explores how middle aged and older asylum applicants in the UK speak about health in relation to migratory experiences. It proposes biocredibility as a novel theoretical concept, through which the narratives of those migrating to the UK to seek asylum can be analysed. The UK government's hostile environments policies, which aim to make life uncomfortable for irregular migrants in the UK in order to drive down migration, have been criticised on legal, material and moral grounds. This paper adds to this critique. Narrative analysis of semi-structured interviews shows that the majority of the asylum applicants interviewed felt their health was poor and told of the difficulties of life in the UK. Stories of homelessness, poverty and exclusion dominated, underpinned by the erosion of their perceived trustworthiness and credibility through encounters with the Home Office. Particular personal experiences of social, political and economic strife in exile were narrated closely against stories of illness. The concept of biocredibility refers to, and provides a way of understanding, participants' propensity for creating narrative enclaves for pathographies as a discursive mechanism to add credibility to narratives of lived experience. In this way, visceral descriptions of biological suffering can function as a narrative resource. It does this firstly by providing material and social context for adverse health, thus allowing participants to attribute a socio-political cause for their illness. Secondly it interjects experiences of illness into life narratives, thus effectively communicating the significance of such experiences. Finally, it provides narrative evidence of individuals’ autobiographical testimony. For discredited and marginalised asylum applicants, biocredibility can be understood to represent a strategy used to re-negotiate credibility and urges a critical consideration of the hostile and austere socio-political context in which it is observed.
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After briefly describing the aim of this handbook in this subchapter and some facts on Nigerian human trafficking in Chapter 2, Chapter 3 explains the importance of a Person of Trust in the integration process of Nigerian SoT. Chapter 4 showcases what competencies are needed for a Person of Trust to support the integration of Nigerian SoT successfully. Chapter 5 describes the main intersections that are relevant for integrating Nigerian SoT in EU host societies. This chapter contains several theme pages, in which the main results of the research paper are discussed as well as best practices and proposals for action for the given intersections are outlined. Chapter 6 summarises the main recommendations concluded from the findings of the INTAP project. This handbook gives Nigerian SoT as well as experts a voice, as they raised recommendations based on their experience, giving ideas on how to offer tailored assistance to the specific needs of each individual SoT. Although this handbook focuses on the case study of Nigerian SoT, the best practices can be used in conjunction with already existing integration programmes. This handbook showcases tools of how to offer a culturally-sensitive (including spirituallysensitive) and gender-specific intersectional approach for the integration of Nigerian SoT in a victim-centred manner. The purpose of this handbook is, therefore, threefold: 1. As a practical guide to improve practitioners’ (in particular social workers’) skills in supporting the integration of Nigerian SOT. 2. As a resource for governmental, non- as well as inter-governmental organisations to adapt and support existing or conceptualise new, more effective psycho-social integration programmes. 3. As a tool for other readers interested in the project findings – such as people working as volunteers, from academia or the general public – to foster their knowledge on the topic of human trafficking and a gender-specific, culturally- sensitive and victim-centred intersectional approach to integration.
Chapter
The refugee experience is characterised by exposure to multiple traumatic events both in one’s country of origin and during displacement. Researchers have found that severity of traumatic events and cumulative trauma are associated with an increased prevalence of mental health problems. Refugees typically also experience numerous post-migratory stressors following arrival in the resettlement country. Accordingly, several studies have found an association between pre-migratory traumatic events, post-migratory stressors and mental health outcomes in refugees. In this chapter, common trauma-related mental health problems among refugees will be presented. The influence of traumatic events and post-migratory stressors on refugee mental health will be discussed. The information provided in the chapter is based on available research as well as the authors’ clinical experience at the Competence Centre for Transcultural Psychiatry (CTP) in Denmark.
Chapter
An unprecedented number of children and adolescents are migrating to escape war and persecution, often unaccompanied by family (UNHCR: Global trends forced displacement in 2015. The UN Refugee Agency, Geneva, 2016). These children face security and health risks in their country of origin, on the journey to safety, and sometimes in their place of resettlement. The trauma and hardships that accompany these experiences have potential to create significant mental health difficulties. This chapter aims to review the risk factors associated with mental health disorders among refugee children and adolescents exposed to war, violence and displacement, and to critically review the effectiveness of psychological interventions recently used with this population. Precipitating and maintaining factors that influence the expression of mental health difficulties and resilience among children and adolescents affected by war are discussed according to a social ecological framework. While the effectiveness of individual, group- and school-based interventions is compelling, more evidence is needed to determine optimal models of intervention delivery for this population.
Chapter
The refugee experience is a complex phenomenon and subject to a multitude of influencing factors including reminiscences of the traumatic past, and distress related to post-migration and ecological factors. While posttraumatic stress disorder (PTSD) is highly prevalent among refugees, psychiatric comorbidity is rather the rule than the exception. Though the literature provides evidence for the effectiveness of trauma-focused treatment in reducing symptoms of PTSD among refugees, PTSD may neither be the only nor the most important aspect, and the exclusive therapeutic focus on PTSD often does not result in satisfactory treatment responses. This chapter seeks to put the refugee experience into a broader context integrating clinically relevant aspects of pre- and post-migration. Practical recommendations are given in order to overcome obstacles and pitfalls and to achieve more favorable outcomes in the treatment of this vulnerable population. Clinical considerations are illustrated by two case reports.
Chapter
Multiple stressors and adverse events can influence the development and well-being of refugee children and adolescents resettled in high-income country. This chapter proposes to use an eco-systemic approach to develop culturally sensitive interventions adapted to the youth level of development. A phased intervention, which distinguishes the arrival period, the early resettlement, and the more long-term needs, is proposed. The chapter also emphasizes the importance of taking into account the host country context, and in particular the present upsurge in anti-refugee attitudes, in planning training and prevention and intervention programs.
Technical Report
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Responses to women who have experienced complex trauma need to be sensitive, coordinated and consistent between services and agencies to ensure women’s wellbeing and safety from violence. However, the development of shared frameworks of practice for addressing complex trauma has been forestalled by a lack of professional consensus and understanding. There is a need for holistic research into “best practice” responses to address complex trauma that place the needs and understandings of diverse women at the centre. This project sought to develop a comprehensive picture of how complex trauma is being constructed in public policy and practice and by women with experiences of complex trauma.
Chapter
Trotz internationaler Bemühungen um die Einhaltung der Menschenrechte nehmen organisierte staatliche Verfolgung und systematische Folterungen weltweit zu, ebenso schwere Traumatisierungen der Zivilbevölkerung in (Bürger-)Kriegen. Der Großteil der Menschen, die ihre Herkunftsländer aufgrund von Verfolgung und Krieg verlassen, sind Binnenflüchtlinge oder fliehen in die jeweiligen Nachbarländer. Nur ein Bruchteil dieser Menschen erreichen als Geflüchtete die Exilländer Europas, Nordamerikas oder Australien. Die Behandlung traumatisierter Geflüchteter und Folteropfer bringt besondere Anforderungen mit sich: Arbeiten zumeist im interkulturellen Setting, unter Einbeziehung von Sprachmittelnden sowie die Behandlung extrem traumatisierter, meist an komplexen Störungen leidender Menschen. Gleichzeitig befinden sich die Patienten durch Entwurzelung und Belastungen im Exil in einem von vielen Faktoren determinierten Bewältigungs- und Anpassungsprozess.
Article
Aims Refugees and asylum seekers are at high risk of mental health problems such as post‐traumatic stress disorder (PTSD) and depression. Elucidating the occurrence and correlates of these problems in specific resettled refugee populations may be helpful in informing tailored prevention and health promotion programs. We sought to elucidate the occurrence and correlates of depressive symptoms among Afghan refugees resettled in Launceston, a regional town of Australia. Methods We conducted a cross‐sectional survey of 66 resettled Afghan refugees residing in Launceston in April 2019. We used the Hopkins symptoms checklist (HSCL‐25) and the post migration living difficulties scale (PMLD) to measure depression symptoms and post‐migration variables, respectively. Demographic characteristics and levels of physical activity were also assessed. Multivariate analysis was used to examine factors associated with depressive symptoms. Results High levels of depressive symptoms were reported by 21.2% of participants (95% CI: 12.1%‐33.0%) and were more common among female participants (41.2%, 95% CI: 18.4%‐67.1%) than male participants (14.3%, 95% CI: 5.9%‐27.2%). Isolation (loneliness, being or feeling alone) (OR = 19.5, 95% CI: 1.9‐203.5) and physical inactivity (OR = 9.2, 95% CI: 1.8‐45.8) were the only variables independently associated with depressive symptoms. Conclusions Depressive symptoms were common among Afghan refugees living in Launceston, particularly women, and were associated with isolation and physical inactivity. Hence these factors might usefully be targeted in local health promotion and prevention programs.
Chapter
Although the vast majority of research into posttraumatic mental health, including posttraumatic stress disorder (PTSD), emerges from western nations, most of the world’s population exposed to trauma and adversity live in non-western countries. People living in low- and middle-income countries (LMICs) are more likely to be exposed to a range of difficult live events and not surprisingly experience higher rates of mental disorders. This chapter reviews the current knowledge about mental health, and particularly posttraumatic mental health, in LMICs. It commences with a review of the prevalence of disorders in LMICs, outlines some of the major risk factors for disorders, and discusses current evidence pertaining to treatment initiatives. The chapter also focuses on the major challenges facing the field of mental health in balancing the need to address mental health problems in LMICs with the ongoing reality that LMICs have limited resources to allocate to mental health programs. The chapter outlines the role of scalable, task-shifting approaches that have implemented mental health non-specialists to deliver programs in settings where there is a large gap between mental health needs and treatment delivery.
Article
Objective: Forcibly displaced persons may be at elevated risk for poor mental health outcomes because of the COVID-19 pandemic. This study sought to examine associations between COVID-19-related socioeconomic insecurity and mental health outcomes among asylum seekers. Methods: The authors evaluated the association between the degree of food, housing, and income insecurity related to the pandemic and mental health outcomes among East African asylum seekers in a high-risk, postdisplacement setting in the Middle East (i.e., Israel). Results: Anxiety symptom severity (p=0.03) as well as the rate of suicidal ideation among women (odds ratio [OR]=2.81, p=0.016) were significantly elevated in a community sample of asylum seekers during the COVID-19 pandemic (N=66) relative to a similar sample (N=158) from the same community and context assessed before the pandemic. No differences between the two groups were observed for severity or rate of probable depression or posttraumatic stress disorders. In addition, among the sample assessed during the pandemic, socioeconomic insecurity due to the pandemic was strongly associated with elevated symptom severity and probable anxiety, depression, and posttraumatic stress disorders as well as suicidal ideation (R2 range=0.19-0.35; OR range=4.54-5.46). Conclusions: Findings are consistent with growing evidence of a mental health crisis among asylum seekers that is linked to COVID-19 control policies and residential status policies. The results highlight the risk for suicidal ideation linked to intersectional marginalization among female asylum seekers. These findings may inform postdisplacement policy making, social justice advocacy, humanitarian aid, and clinical science and practice to mitigate poor mental health outcomes associated with COVID-19 among forcibly displaced persons.
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In this article, we attempt to distinguish between the properties of moderator and mediator variables at a number of levels. First, we seek to make theorists and researchers aware of the importance of not using the terms moderator and mediator interchangeably by carefully elaborating, both conceptually and strategically, the many ways in which moderators and mediators differ. We then go beyond this largely pedagogical function and delineate the conceptual and strategic implications of making use of such distinctions with regard to a wide range of phenomena, including control and stress, attitudes, and personality traits. We also provide a specific compendium of analytic procedures appropriate for making the most effective use of the moderator and mediator distinction, both separately and in terms of a broader causal system that includes both moderators and mediators. (46 ref) (PsycINFO Database Record (c) 2012 APA, all rights reserved)
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In recent years, Immigration Detention Centres (IDC) have become sites of increasing concern in Australia, due to their notoriously negative impact on the mental health of detained asylum seekers. In this paper, I question whether it is possible and beneficial to promote mental health in what might be thought of as an inherently 'unhealthy' setting. Drawing upon health promotion theory and a Foucauldian approach to power, I critique the effectiveness of two major forms of health promoting work carried out in the immigration detention setting: internally-organised services and externally-organised support and advocacy. Given the problematic nature of the detention setting, I argue that the 'effectiveness' of these efforts is bound up in their capacity for subverting or positively reforming the IDC system itself as a barrier to mental health.
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Uncertainties continue about the roles that methodological factors and key risk factors, particularly torture and other potentially traumatic events (PTEs), play in the variation of reported prevalence rates of posttraumatic stress disorder (PTSD) and depression across epidemiologic surveys among postconflict populations worldwide. To undertake a systematic review and meta-regression of the prevalence rates of PTSD and depression in the refugee and postconflict mental health field. An initial pool of 5904 articles, identified through MEDLINE, PsycINFO and PILOTS, of surveys involving refugee, conflict-affected populations, or both, published in English-language journals between 1980 and May 2009. Surveys were limited to those of adult populations (n > or = 50) reporting PTSD prevalence, depression prevalence, or both. Excluded surveys comprised patients, war veterans, and civilian populations (nonrefugees/asylum seekers) from high-income countries exposed to terrorist attacks or involved in distal conflicts (> or = 25 years). Methodological factors (response rate, sample size and design, diagnostic method) and substantive factors (sociodemographics, place of survey, torture and other PTEs, Political Terror Scale score, residency status, time since conflict). A total of 161 articles reporting results of 181 surveys comprising 81,866 refugees and other conflict-affected persons from 40 countries were identified. Rates of reported PTSD and depression showed large intersurvey variability (0%-99% and 3%-85.5%, respectively). The unadjusted weighted prevalence rate reported across all surveys for PTSD was 30.6% (95% CI, 26.3%-35.2%) and for depression was 30.8% (95% CI, 26.3%-35.6%). Methodological factors accounted for 12.9% and 27.7% PTSD and depression, respectively. Nonrandom sampling, small sample sizes, and self-report questionnaires were associated with higher rates of mental disorder. Adjusting for methodological factors, reported torture (Delta total R(2) between base methodological model and base model + substantive factor [DeltaR(2)] = 23.6%; OR, 2.01; 95% CI, 1.52-2.65) emerged as the strongest factor associated with PTSD, followed by cumulative exposure to PTEs (DeltaR(2) = 10.8%; OR, 1.52; 95% CI, 1.21-1.91), time since conflict (DeltaR(2) = 10%; OR, 0.77; 95% CI, 0.66-0.91), and assessed level of political terror (DeltaR(2) = 3.5%; OR, 1.60; 95% CI, 1.03-2.50). For depression, significant factors were number of PTEs (DeltaR(2) = 22.0%; OR, 1.64; 95% CI, 1.39-1.93), time since conflict (DeltaR(2) = 21.9%; OR, 0.80; 95% CI, 0.69-0.93), reported torture (DeltaR(2) = 11.4%; OR, 1.48; 95% CI, 1.07-2.04), and residency status (DeltaR(2) = 5.0%; OR, 1.30; 95% CI, 1.07-1.57). Methodological factors and substantive population risk factors, such as exposure to torture and other PTEs, after adjusting for methodological factors account for higher rates of reported prevalence of PTSD and depression.
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The number of asylum seekers, refugees and internally displaced people worldwide is rising. Western countries are using increasingly restrictive policies, including the detention of asylum seekers, and there is concern that this is harmful. To investigate mental health outcomes among adult, child and adolescent immigration detainees. A systematic review was conducted of studies investigating the impact of immigration detention on the mental health of children, adolescents and adults, identified by a systematic search of databases and a supplementary manual search of references. Ten studies were identified. All reported high levels of mental health problems in detainees. Anxiety, depression and post-traumatic stress disorder were commonly reported, as were self-harm and suicidal ideation. Time in detention was positively associated with severity of distress. There is evidence for an initial improvement in mental health occurring subsequent to release, although longitudinal results have shown that the negative impact of detention persists. This area of research is in its infancy and studies are limited by methodological constraints. Findings consistently report high levels of mental health problems among detainees. There is some evidence to suggest an independent adverse effect of detention on mental health.
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The United States is accepting the largest number of displaced persons since World War II. Over 70% are Southeast Asians; many have suffered serious war trauma and torture. Cultural differences in health-seeking behavior and lack of specialized mental health services make the recognition of psychiatric distress in Southeast Asia refugees difficult for American health care providers. The authors describe the development and validation of Cambodian, Laotian, and Vietnamese versions of the Hopkins Symptom Checklist-25. This brief, simple, and reliable instrument is well received by refugee patients, offers an effective screening method for the psychiatric symptoms of anxiety and depression, and is especially helpful for evaluating trauma victims.
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In this article, we attempt to distinguish between the properties of moderator and mediator variables at a number of levels. First, we seek to make theorists and researchers aware of the importance of not using the terms moderator and mediator interchangeably by carefully elaborating, both conceptually and strategically, the many ways in which moderators and mediators differ. We then go beyond this largely pedagogical function and delineate the conceptual and strategic implications of making use of such distinctions with regard to a wide range of phenomena, including control and stress, attitudes, and personality traits. We also provide a specific compendium of analytic procedures appropriate for making the most effective use of the moderator and mediator distinction, both separately and in terms of a broader causal system that includes both moderators and mediators.
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Data from general population surveys (n = 1483 to 9151) in nine European countries (Denmark, France, Germany, Italy, the Netherlands, Norway, Spain, Sweden, and the United Kingdom) were analyzed to cross-validate the selection of questionnaire items for the SF-12 Health Survey and scoring algorithms for 12-item physical and mental component summary measures. In each country, multiple regression methods were used to select 12 SF-36 items that best reproduced the physical and mental health summary scores for the SF-36 Health Survey. Summary scores then were estimated with 12 items in three ways: using standard (U.S.-derived) SF-12 items and scoring algorithms; standard items and country-specific scoring; and country-specific sets of 12 items and scoring. Replication of the 36-item summary measures by the 12-item summary measures was then evaluated through comparison of mean scores and the strength of product-moment correlations. Product-moment correlations between SF-36 summary measures and SF-12 summary measures (standard and country-specific) were very high, ranging from 0.94-0.96 and 0.94-0.97 for the physical and mental summary measures, respectively. Mean 36-item summary measures and comparable 12-item summary measures were within 0.0 to 1.5 points (median = 0.5 points) in each country and were comparable across age groups. Because of the high degree of correspondence between summary physical and mental health measures estimated using the SF-12 and SF-36, it appears that the SF-12 will prove to be a practical alternative to the SF-36 in these countries, for purposes of large group comparisons in which the focus is on overall physical and mental health outcomes.
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Evidence is emerging that psychiatric disorders are common in populations affected by mass violence. Previously, we found associations among depression, posttraumatic stress disorder (PTSD), and disability in a Bosnian refugee cohort. To investigate whether previously observed associations continue over time and are associated with mortality emigration to another region. Three-year follow-up study conducted in 1999 among 534 adult Bosnian refugees originally living in a refugee camp in Croatia. At follow-up, 376 (70.4%) remained living in the region, 39 (7.3%) were deceased, 114 (21.3%) had emigrated, and 5 (1%) were lost to follow-up. Those still living in the region and the families of the deceased were reinterviewed (77.7% of the original participants). Depression and PTSD diagnoses, based on Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria and measured by the Hopkins Symptom Checklist-25 and the Harvard Trauma Questionnaire, respectively; disability, measured by the Medical Outcomes Study Short-Form 20; and cause of death, determined by family interviews with review of death certificates, if available. In 1999, 45% of the original respondents who met the DSM-IV criteria for depression, PTSD, or both continued to have these disorders and 16% of respondents who were asymptomatic in 1996 developed 1 or both disorders. Forty-six percent of those who initially met disability criteria remained disabled. Log-linear analysis revealed that disability and psychiatric disorder were related at both times. Male sex, isolation from family, and older age were associated with increased mortality after adjusting for demographic characteristics, trauma history, and health status (for male sex, adjusted odds ratio [OR], 2.63; 95% confidence interval [CI], 1.17-5.92; living alone, OR, 2.40; 95% CI, 1.07-5.38; and each 10-year increase in age, OR, 1.91; 95% CI, 1.34-2.71). Depression was associated with higher mortality in unadjusted analysis but was not after statistical adjustment (unadjusted OR, 3.12; 95% CI, 1.55-6.26; adjusted OR, 1.85; 95% CI, 0.82-4.16). Posttraumatic stress disorder was not associated with mortality or emigration. Spending less than 12 months in the refugee camp (OR, 11.30; 95% CI, 6.55-19.50), experiencing 6 or more trauma events (OR, 3.34; 95% CI, 1.89-5.91), having higher education (OR, 1.90; 95% CI, 1.10-3.29), and not having an observed handicap (OR, 0.11; 95% CI, 0.02-0.52) were associated with higher likelihood of emigration. Depression was not associated with emigration status. Former Bosnian refugees who remained living in the region continued to exhibit psychiatric disorder and disability 3 years after initial assessment. Social isolation, male sex, and older age were associated with mortality. Healthier, better educated refugees were more likely to emigrate. Further research is necessary to understand the associations among depression, emigration status, and mortality over time.
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Multilevel models are increasingly used to estimate models for hierarchical and repeated measures data. The authors discuss a model in which there is mediation at the lower level and the mediational links vary randomly across upper level units. One repeated measures example is a case in which a person's daily stressors affect his or her coping efforts, which affect his or her mood, and both links vary randomly across persons. Where there is mediation at the lower level and the mediational links vary randomly across upper level units, the formulas for the indirect effect and its standard error must be modified to include the covariance between the random effects. Because no standard method can estimate such a model, the authors developed an ad hoc method that is illustrated with real and simulated data. Limitations of this method and characteristics of an ideal method are discussed.
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