Mental Health and Refugees

Original Editor - Shaimaa Eldib Top Contributors - Shaimaa Eldib, Candace Goh, Naomi O'Reilly and Kim Jackson

Introduction

Mental health illness is considered as a leading cause for disability all over the world. It accounts for around 13 %of the global burden of disease and responsible for 33% of total years lived with disability[1][2]. It is estimated that people who suffer from severe mental illness, for example, severe depression, bipolar disorder and schizophrenia[3] are more likely to die prematurely than those who have not been affected. The problems of mental health are highly prevalent globally, affecting people across all regions of the world as it is expected to affect at least 1 of 3 people all over their life time[4][5]. Also, there are major economic consequences of this high prevalence. Around $16.3 trillion was estimated to be the cost of mental ill-health globally between 2011 and 2030 [6] and this has serious implications on standers of livings and socioeconomic development[7]. There are many barriers in treating mental illness, for example, stigma, discrimination [8][3] and governmental apathy[7] which exacerbating the current state of mental healthcare all over the world.

Refugees Crisis

The UN Refugee Agency (UNHCR)[9] defines a refugee as set out in the 1951 Convention[10][11]
Refugees.jpg
The 1951 Convention and its 1967 Protocol :

The primary and universal definition of a refugee that applies to States is contained in Article 1(A)(2) of the 1951 Convention, as amended by its 1967 Protocol, defines a refugee as someone who:

"owing to a well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion, is outside the country of his nationality and is unable or, owing to such fear, is unwilling to avail himself of the protection of that country; or who, not having a nationality and being outside the country of his former habitual residence, is unable or, owing to such fear, is unwilling to return to it[10].

According to the United Nations Refugee Agency (UNHCR), 65.6 million people have been forcibly displaced worldwide[12]. There were 20 people newly displaced every minute of 2016[13]. Europe Initially welcomed more than a million refugees and forced migrants between 2015 and 2016 [14]. Those who forced to leave their home countries lived in overcrowded reception facilities that have an effect, turned into long term detention centres with poor health and safety conditions[15] while waiting for resettlement or asylum decisions[14]. All these conditions created medical challenges and excessive need for the usage of health systems[16].

Refugees Mental Health

Currently, the responsibility of mental health support for the refugee is shared by a network of organizations like World Health Organization (WHO), the United Nations High Commissioner for Refugees (UNHCR), government and non‐profit organizations[17]. Most of the refugees suffer from post-traumatic stress disorder (PTSD) due to the circumstances that they faced which might affect the quality of their life[18][17].

Post-Traumatic Stress Disorder

"When something traumatic happens in your life it rocks you to the core. The world is no longer a safe place. It becomes somewhere that bad things can and do happen."[19]
PTSD can be defined as persisting, recurrent and disturbing memories or flashbacks of a witnessed or experienced trauma, along with other symptoms such as difficulty sleeping, feeling detached from people and current experiences, as well as exaggerated startle responses.[20] This disorder is considered the only major mental disorder that may have a known cause. Reactions like fear, horror, and helplessness may be portrayed as the person's physical integrity is being threatened.[21] Difficulties in emotional regulation, cognitive functioning, self-perception, relationships, somatisation and hopelessness may occur due to severe stress as a result of overwhelming circumstances and disturbing experiences [22]. The prevalence of traumatic experiences is common. It is found that more than two-thirds of persons in the general population may experience a significant traumatic event at some point in their lives.[23] Some studies on refugees in western countries showed that 9% suffered from PTSD and around 5% from depression. However, there were also studies that obtained results showing 30% among tested cases whom suffered from PTSD.[17] These findings suggest that most refugees are in a traumatized state and are in need of counselling[17].

Some studies explored the biological effect of this disorder, the findings showed :

  • Higher heart rate to sudden loud tones which suggests central sensitization.
  • Diminished the volumes of the hippocampus and anterior cingulate cortex which may explain conditions like: depression and substance abuse.[21]
  • Changes in brain and pre-existing vulnerability and neurotoxicity as origins of brain volume reductions in PTSD.
  • Amygdala and dorsal anterior cingulate cortex are hyper(re)active, whereas the ventral medial prefrontal cortex is hypo(re)active in PTSD and this may explain attentional bias towards the threat, impaired emotional regulation.[21]

The evidence showed that trauma-focused cognitive behavioural therapy or eye movement desensitisation and reprocessing should be considered in individuals with PTSD. Psychological treatments can reduce symptoms of PTSD[24]. Comprehensive programmes for mental health-care should be included in policy planning such as counselling and psychotherapy , pharmacotherapies, and psychosocial interventions.[17]

Gaps in Refugee Health

These videos describe the gaps in refugee health and their experiences.

Physiotherapists, Healthcare Professionals, and Refugees

Healthcare professionals should be aware that there are several factors that have a major influence on asylum seekers health:

A study on mental health and service needs among a group of refugees in Malaysia showed that refugees emphasized concerns about accessing opportunities for permanent resettlement and worries about economic survival[31]. Close to all the participants in the study reported that they would be interested in taking part in supportive group services. Therefore, as service providers, high attention to mental well-being and coping strategies must be incorporated while evaluating basic needs, even in temporary settings.

References

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  2. Funk M. Global burden of mental disorders and the need for a comprehensive, coordinated response from health and social sectors at the country level. Retrieved on. 2016 Oct;30.
  3. 3.0 3.1 Thornicroft G, Brohan E, Rose D, Sartorius N, Leese M, INDIGO Study Group. Global pattern of experienced and anticipated discrimination against people with schizophrenia: a cross-sectional survey. The Lancet. 2009 Jan 31;373(9661):408-15.
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  8. Lasalvia A, Zoppei S, Van Bortel T, Bonetto C, Cristofalo D, Wahlbeck K, Bacle SV, Van Audenhove C, Van Weeghel J, Reneses B, Germanavicius A. Global pattern of experienced and anticipated discrimination reported by people with major depressive disorder: a cross-sectional survey. The Lancet. 2013 Jan 5;381(9860):55-62.
  9. https://emergency.unhcr.org/entry/55772/refugee-definition
  10. 10.0 10.1 Fitzpatrick J. Revitalizing the 1951 refugee convention. Harv. Hum. Rts. J.. 1996;9:229.
  11. Zimmermann A, Dörschner J, Machts F, editors. The 1951 Convention relating to the status of refugees and its 1967 protocol: A commentary. Oxford University Press; 2011 Jan 27.
  12. 12.0 12.1 Müller M, Khamis D, Srivastava D, Exadaktylos AK, Pfortmueller CA. Understanding refugees' health. InSeminars in neurology 2018 Apr (Vol. 38, No. 02, pp. 152-162). Thieme Medical Publishers.
  13. 13.0 13.1 Ellis BH, Winer JP, Murray K, Barrett C. Understanding the mental health of refugees: Trauma, stress, and the cultural context. InThe Massachusetts General Hospital textbook on diversity and cultural sensitivity in mental health 2019 (pp. 253-273). Humana, Cham.
  14. 14.0 14.1 Fotaki M. A crisis of humanitarianism: refugees at the gates of Europe. International journal of health policy and management. 2019 Jun;8(6):321.
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  16. Kotsiou OS, Kotsios P, Srivastava DS, Kotsios V, Gourgoulianis KI, Exadaktylos AK. Impact of the refugee crisis on the Greek healthcare system: A long road to Ithaca. International journal of environmental research and public health. 2018 Aug;15(8):1790.
  17. 17.0 17.1 17.2 17.3 17.4 Silove D, Ventevogel P, Rees S. The contemporary refugee crisis: an overview of mental health challenges. World Psychiatry. 2017 Jun;16(2):130-9.
  18. Wilker S, Catani C, Wittmann J, Preusse M, Schmidt T, May T, Ertl V, Doering B, Rosner R, Zindler A, Neuner F. The efficacy of Narrative Exposure Therapy for Children (KIDNET) as a treatment for traumatized young refugees versus treatment as usual: study protocol for a multi-center randomized controlled trial (YOURTREAT). Trials. 2020 Dec;21(1):1-6.
  19. Post-traumatic stress disorder (PTSD). Available from: https://www.mind.org.uk/information-support/types-of-mental-health-problems/post-traumatic-stress-disorder-ptsd/about-ptsd/ (Accessed 18 May 2020).
  20. Ringold S, Burke A, Glass RM. Refugee mental health. JAMA. 2005 Aug 3;294(5):646
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  25. TED Ex Talks. Bridging the Refugee Health Gap | Claire Jones | TEDxUQ. Available from: http://www.youtube.com/watch?v=3iogISgezbQ[last accessed 28/07/2020]
  26. Tanishq Suryavanshi. What is the Refugee Mental Health Crisis and How Can We Address it?. Available from: http://www.youtube.com/watch?v=eRfyQl_mSGs[last accessed 28/07/2020]
  27. TED. How we can bring mental health support to refugees | Essam Daod. Available from: http://www.youtube.com/watch?v=0g0S34XE2b8[last accessed 28/07/2020]
  28. Wångdahl J, Lytsy P, Mårtensson L, Westerling R. Health literacy among refugees in Sweden–a cross-sectional study. BMC public health. 2014 Dec 1;14(1):1030.
  29. Uba L. Cultural barriers to health care for southeast Asian refugees. Public health reports. 1992 Sep;107(5):544.
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