Introduction
Around the world, the number of refugees displaced by war or violence reaches over 19 million. Among these populations, rates of mental disorders, such as anxiety disorders, post-traumatic stress disorder (PTSD), and depression, have been found to be higher in comparison to the general population. This observed increased vulnerability has been linked to experiences prior to migration, such as war exposure and trauma. Additionally, these anxiety disorders can manifest due to stressors post-migration, such as separation anxiety and the added load of resettlement in a new country. In general, increased rates of these disorders remain prevalent in refugee populations long after resettlement, however some studies have shown otherwise (1). In a particular refugee population, the Karenni refugees along the Burmese-Thai border, depression and anxiety rates (41% and 42%, respectively) are higher than the average rates of the US general population (7% and 10%, respectively). These rates have been linked again to traumatic events like violence, and also with harassment and a lack of basic needs. Furthermore, this population also showed a correlation of depression and anxiety disorders with post-resettlement hardships in regards to finding employment, and culturally and linguistically adapting to a new environment. Of another refugee population, Cambodian refugees residing in a refugee camp on the Thailand-Cambodia border, 82.6% of these individuals self-reported depression, of which 55% were confirmed by the Hopkins Symptoms Checklist to have experienced symptoms of major depression (2).
Symptoms of depression, according to the DSM-IV criteria, include changes in weight, sleep pattern, exhibiting a depressed mood for much of a day, a loss of interest in activities, lack of energy, feelings of worthlessness and guilt almost daily, lack of focus, and recurrent thoughts of death and suicide, which can include an attempting/creating plans for suicide. Symptoms of PTSD include intrusion, avoidance, and hyperarousal. PTSD typically manifests as a result of traumatic experiences. These traumatic events can include experiencing war, being held prisoner/hostage, torture, physical violence, death of a loved one, serious accidents/explosions, sexual harassment, and serious illness. Symptoms of generalized anxiety disorder include restlessness, irritability, fatigue, worrying, having trouble relaxing, sleeping, and focusing (3, 4).
Other factors that could be promoting the symptoms of PTSD, depression, and anxiety include acculturative stress. While research already shows that trauma related to war negatively impacts mental health, studies also show stress that accompanies the migration process can also have similar effects. One cause of these stresses is acculturation, the process of integrating into a new culture while also maintaining one’s origin culture and identity. This process is dependent on the attitudes of both the migrant and host groups. There are inconsistencies present in existing studies investigating the effects of acculturation on mental health, however acculturative stress in migration has been regularly identified as a mental health risk factor (5).
The current refugee demographic is a highly heterogeneous group, however there has been an increase of refugees from Arabic speaking countries in recent years; Europe in particular has seen a large increase of asylum applicants from Arabic speaking countries, with the two leading countries from where these applications come being Syria (35.9% of applications) and Iraq (6.9% of applications). Despite the growth of Arabic speaking refugees, few studies have investigated the mental health of these populations in recent years. The studies that have been done, however, display a large variation in results, showing the refugee population is a diverse group. Complications in studies that inhibit direct comparison between populations include the use of different psychometric instruments to measure mental health (4).
The purpose of this study is to investigate the relationship between refugee populations of various backgrounds and age groups and their increased vulnerability to post-traumatic stress disorder, depression, and other anxiety disorders. This study is to examine these relationships with factors before, during, and after the migration process, as well as any long-term presence of mental distress following migration.
Method
In the completion of this research, a number of articles was gathered from PubMed that examined the relationship between refugee populations and PTSD, depression, and other anxiety disorders. The articles chosen explored these relationships among various refugee populations from different areas of the world, and most refugee populations considered were affected by war and other organized violence. The studies included were exclusively human studies, and included case reports, case control studies, prospective studies, and clinical trials, all of which were communicated in English.
RESULTS
In a particular population, a group of Yazidi refugees, a study was done that determined the frequency of posttraumatic stress and depression in migrant Yazidi children and adolescents, and also examined the possible difference in experience and diagnosis between males and females. The study found that between children and adolescents, there were great differences in a resulting diagnosis. Children generally had less problems with mental illnesses than adolescents, who may have increased stress due to having more siblings (as adolescents were found to have more siblings, on average, than children). Other risk factors for depression in particular included having older parents, being female, and witnessing someone undergoing a violent or fatal situation. In terms of sex, females of both the children and adolescent groups were significantly more likely to have an established diagnosis, as males, in general, did not have one (6).
To further examine the mental health of Yazidi children and adolescents, another study was done to investigate the presence of psychiatric symptoms and disorders immediately following forced migration. The study found that various disorders, not just PTSD, had already manifested in the refugee population within early days of resettlement. Children who have experienced forced migration have been shown to be more vulnerable to behavioral and emotional problems than children who have not experienced such trauma. These children, following the forced migration, were observed to be very shy after their arrival to the camp, and avoided contact with the other children. Additionally, they still communicated fears of being captured and generally did not yet feel safe in their new environment. Most of the children also had great difficulty sleeping. Of the assessed children, the most prevalent diagnosis was depressive disorder, with which over one third of the children were diagnosed (7).
Factors that could be possibly associated with psychiatric symptoms and disorders are torture and other traumatic events. Civilians in war-zones typically experience at least one traumatic event due to war, and war refugees are often subjected to torture as well. Among Syrian Kurdish refugees, there were positive correlations between PTSD symptoms and traumatic events such as being forced to flee one’s country, witnessing violence, and confinement due to violence. Moreover, while males are more likely to experience trauma, females have been seen to be more likely to have symptoms of PTSD. However, one study examining Syrian Kurdish refugees in the Kurdistan region of Iraq, the prevalence of PTSD in males and females displayed no significant difference, which may be a result of cultural differences (8).
Refugee populations who have already experienced traumatic events are often vulnerable to increased symptoms if they experience another stressful event. Thus, it has been investigated whether or not new traumatic or stressful events affect mental health of an already PTSD diagnosed individual. In a study involving refugees from mainly Iran, the Balkan region, and Turkey, in which all participants were diagnosed with PTSD, groups that did experience a new significant life event displayed increased avoidance behavior. This is believed to be a mechanism for these individuals so as to not activate a defensive reaction to the new trauma. Additionally, it was found that stressful life events affected symptoms more than traumatic life events. Overall, it was found that new significant life events result in a significant increase in PTSD symptoms, especially avoidance (9).
Furthermore, refugees diagnosed with PTSD often are consequently diagnosed with secondary psychotic features as well. These secondary psychotic features can include hallucinations and delusions, and the impact of these features can make PTSD with Secondary Psychotic features (PTSD-SP) an incredibly burdening disorder. Refugees are uniquely vulnerable to developing secondary psychotic features with PTSD, as they are usually subjected to more long-term trauma than other PTSD patients. Moreover, refugee populations often lack familiar support systems as they seek asylum abroad so as to escape their threatening situations, exacerbating the problem. In a particular study, 74 of 181 refugees diagnosed with PTSD were identified to also have secondary psychotic features (10).
Prior to the migration process, there are environmental factors that can be associated with the development of mental disorders. in a particular group of Ethiopian immigrants and refugees, the prevalence of depression was significantly higher among those who experienced pre-migration trauma and internment in a refugee camp. Other factors, like witnessing death in a family, lacking resources such as water, shelter, and food, have shown to be highly associated with depression. Individuals who experienced more traumatic events were found to be more vulnerable to depression, as trauma can lead to hopelessness and a loss of interest in activities (11). In North Korea, war and organized violence is not the primary reason for individuals to seek asylum, rather they are often trying to escape political oppression. Nevertheless, the traumatic experiences, such as torture, violence, imprisonment, and witnessing death, are shared (12).
In this group of North Korean refugees, insomnia, which is often associated with depressive and post-traumatic stress symptoms, was found to be higher in those individuals who had experienced traumatic events prior to migration. These findings suggest that refugee insomnia may develop because of these traumatic experiences (12). Another study of Syrian refugees in Turkey found that other factors could contribute to the development of PTSD, like being diagnosed with a psychiatric disorder in the past or having a family history of psychiatric disorder, along with experiencing trauma. It is also important to note that refugees, along with trauma and prior diagnoses, face major obstacles to meet health care needs while still in war zones or areas affected by natural disasters (13).
During migration, there are other stressors that can be associated with depression and anxiety. This stress can be from an uncertainty in the future, as is typical of asylum seekers. In two Danish asylum centers, the mental health of rejected asylum seekers was evaluated. In this group of Iraqi asylum seekers, the prevalence of anxiety symptoms was 94%, and depression symptoms had a prevalence of 100%. The length of stay in the asylum centers, as well as the number of traumatic events, were taken to be risk factors associated with psychological distress (14).
Among those in refugee camps, there are daily stressors that can exacerbate mental problems, such as lacking basic necessities, restricted movement, and continued concern for safety, as refugee camps are only short-term solutions (15). Some studies have also found that keeping some kind of consistency in the life of refugees can ease mental distress. For example, in a group of Syrian child refugees, the prevalence of PTSD was lower than expected; the researchers claim this could be because these children travelled with at least one parent, transferring a crucial part of the child’s psychosocial environment. Therefore, having a parent accompany children during travel in the migration process can be a factor that can reduce post-traumatic stress in children. Additionally, the refugees had a successful flight during migration, creating feelings of hope for the future (16).
Often, depression in refugees has long-term effects; a study of Guatemalan refugees in Mexico found a 38.8% lifetime prevalence of depression. Another found Karenina refugees settled on the Thai-Burma border to have a lifetime depression prevalence of 41.8% (11). Post-migration stress can be related to feelings of insecurity; in a group of North Korean refugees settled in South Korea, the refugees still felt unsafe due to a fear of being arrested and deported back to North Korea (12). Post-migration mental distress has also been associated with acculturative stress; in a study of 7,000 refugees resettled in western countries, refugees were found to be about ten times more likely to have PTSD than an age-matched group from the host country’s general population (17).
Acculturation, as previously stated, is the process of integrating oneself into a new culture while also maintaining one’s origin culture and identity. This process can create a considerable amount of stress for new refugees trying to restart lives in new countries, often resulting in anxiety and depression, as well as the exacerbation of post-traumatic stress. Acculturative stress is based on the Demands of Immigration experienced, relating to general experiences that cause stress in immigrants and refugees. These include unfamiliarity with daily tasks, difficulties in finding employment, learning the host country’s language, discrimination, and a feeling of not belonging in one’s new environment. As an example of overcoming language barriers and its effect on mental health, Bosnian refugees living in Australia reported significantly more stress in terms of accommodating to the host language than Bosnian refugees living in Austria. It has also been found that acculturative stress affects mental health based on the social atmosphere a refugee experiences in a host country, indicated by immigration policies and the general attitude of the host society towards refugees and different cultures (5).
CONCLUSION & DISCUSSION
Refugee populations have an increased vulnerability to post-traumatic stress disorder, depression, and anxiety due to their exposure to traumatic experiences prior to migration and additional stress experienced during and after the migration process. Prior to the migration process, refugees often experience trauma from organized violence and political oppression, which can include the death of a loved one, torture, imprisonment, witnessing public executions, lacking basic necessities, etc. (11, 12). Other risk factors prior to migration include previous diagnoses of psychiatric disorders in oneself and/or family members (13).
The development of such disorders can happen regardless of age, however some age groups may experience more intense symptoms than others. Children in particular can develop behavioral and emotional problems as a result of certain traumatic experiences they may face, like forced migration (7). However, adolescents have been found to be more likely to have PTSD, which could possibly be related to risk factors such as having more siblings or older parents, among others (6).
Studies varied in regards to showing differences in the manifestation of mental distress between males and females. Some studies, however, showed being female as a risk factor for depression, and made it more likely than males to have an established diagnosis (6). In relation to PTSD, studies have often shown women to be more likely to exhibit PTSD symptoms, however this has not been entirely consistent when the prevalence of PTSD was investigated among some Syrian Kurdish refugees, possibly due to culture differences (8). Neverthless, being female was generally associated with increased mental distress.
During the migration period, there are several factors that can contribute to mental distress, such as lingering feelings of unsafety and uncertainty in the future. Findings of depression and anxiety in refugee populations denied asylum were incredibly high, at 100% and 94%, respectively (14, 15). Factors that have been shown to help this process with children include maintaining some aspects of a refugee’s previous environment in the migration process, such as ensuring the child travels with at least one patient (16).
Post-migration can also include many difficulties that can cause mental distress to be worsened and/or have a long-term presence. A common factor associated with mental distress post-migration is acculturative stress, often experienced by refugees and immigrants. Experiences that result in acculturative stress include unfamiliarity with daily tasks, overcoming language barriers, facing discrimination, etc. Acculturative stress is often unique to one’s environment because of the attitudes of the host country and whether certain changes in environment, such as language, are great (5). Not only are refugee populations incredibly vulnerable to PTSD, but they also often face secondary features with their PTSD, increasing the burden of the mental disorder. These features can include hallucinations and disorders. Refugees are uniquely vulnerable to these secondary features because of their more long-term trauma, and because they are thrust into unfamiliar environments and therefore lack familiar support systems. Consequently, refugees with PTSD are very likely to also be experiences secondary symptoms (10).
Possible weaknesses in this study include the limited number of studies available, possibly due to a lack of funding. Moreover, of the existing studies, some have mentioned potential errors in reporting and data due to the effectiveness of translated diagnosis checklists for some refugee populations, as well as the ability of the refugees to accurately report their symptoms under mental distress. More studies are needed examining the increased vulnerability of refugee populations to post-traumatic stress, depressive, and anxiety disorder in order to better integrate them into a new host society.