Refugee mental health - the psychiatric challenge of the century

Sweden has accepted more refugees per head of population than any other European country. And it has pioneered research into the mental health consequences among those who have been forced to abandon their homes.

According to a recent paper, refugees are 66% more likely to experience schizophrenia or other non-affective psychotic disorder than migrants from the same region who are not refugees, and 3.6 times more likely to experience these outcomes than the offspring of native-born Swedish parents.¹  

The increased risk of psychosis was especially clear in men, and was found in refugees from all areas except sub-Saharan Africa. It is consistent with being caused by pre-emigration exposure to war, violence and persecution. Data were based on a national register including more than 1.3 million people born in 1984 and later, and cover 8.9 million years of follow up. Incidence was adjusted for age, sex, income, and population density.

Mental health in crisis situations

More broadly, according to the European Psychiatric Association (EPA) position paper on psychiatric care,² refugees:

• Are at greater risk of many mental health problems. These include major mood and anxiety disorders, post-traumatic stress disorder and psychosis. Among children, the prevalence of PTSD has been put at one in five.
• May present with symptoms that are culture-specific. Along with language difficulties, this is likely to lead to a high rate of misdiagnosis
• May not know how to access public provision of health care
• Are more likely than others to discontinue treatment
• Have specific needs that health care providers may find difficult to meet.

Among refugee children, the prevalence of PTSD may be 20%.

As well as financial support, this crisis requires innovative thinking, research into the most effective means of meeting the need, and reinforcement of intercultural skills, says the EPA paper.

High rates of depression, anxiety and PTSD

Germany has been generous in its response to the mounting crisis, and the number of refugees received is the equivalent of a large city, with all its accompanying psychiatric needs. The Saxon city of Halle is relatively small, but illustrates the extent of the problem.  A recent study of 214 asylum seekers (all but 24 were men) found that 55% were suffering from depression, 40% from anxiety disorder and 18% PTSD.³  Suicidal thoughts were mentioned by 6%.

The authors of the study emphasized the need for questions about psychological health to be included in initial medical screening and for this to take into account the culturally and linguistically diverse nature of the refugee population.

The number of refugees reaching Germany is the equivalent of a large city, with all its psychiatric needs

The EPA, which – through its national organisations -- represents almost eighty thousand European psychiatrists, has advocated the need for a religion and culture-specific approach to the mental healthcare of refugees, and a mix of local initiatives and expert co-ordinating centres.

One idea is that problems of language and cultural difference might be managed at least in part, not by the psychiatrists in European countries receiving refugees, since they are unlikely to have all the skills required, but by linking patients with doctors at a distance. This may mean e-consultation with psychiatrists of similar cultural background in other countries, and perhaps even in patients’ countries of origin.

Psychiatric care bordering conflict zones

The provision of psychiatric care in countries bordering those from which refugees come has been highlighted by a World Health Organisation-funded study of eight thousand displaced Syrians now living in Jordan.⁴ Almost 19% felt they could not undertake activities of daily living because of feelings of fear, anger, fatigue or hopelessness. Social isolation, aggression, and issues of child protection were among the consequences.

Among children aged two to twelve years, nocturnal enuresis was a particular problem.

Although unprecedented in its scale in post-World War II Europe, mass migration is not an isolated event. According to the WHO, almost sixty million people across the globe are being forced to flee their homes. The sad fact is that what we learn from the psychiatric care of refugees coming to Europe and in countries bordering conflict zones in the Middle East will have many applications elsewhere.