U. Altunöz1, W. Machleidt2, I. T. Graef-Calliess3

1 Dr, Wahrendorff Clinic, Department of Transcultural Psychiatry & Psychotherapy, Hannover, Germany. 2 Prof Dr, Hannover Medical School, Hannover, Germany.

3 Prof Dr, Wahrendorff Clinic, Department of Transcultural Psychiatry & Psychotherapy, Hannover; Research group Social & Transcultural Psychiatry & Psychotherapy, Hannover Medical School,

Department of Psychiatry, Germany.

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Mental Health of Traumatized Refugees and Asylum Seekers in Germany

First International Conferenceon Transcultural Psychiatry inCentral European Countries24. 4. – 26. 4. 2015Gdynia / Poland

Presentation Plan

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Asylum & refugee policy in Germany

Asylum seekers & refugees and medical & mental care

Mental health of asylum seekers and refugees in Germany

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Asylum & refugee policy in Germany

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Germany has always been a host country. Since 1953 4.1 million person applied for asylum in

Germany, 77.4% of them since 1990. The highest application rate was in 1992 (438.191).

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In 2014 202.834 persons applied for Asylum. There was an increase of 59.7% when compared with 2013. Countries of origin of those applicants were Syria, Serbia, Eritrea, Albania, Afganistan, Kosovo, Bosnia-Herzegovina, Macedonia, Somalia, Iraq.

Federal Office for Migration & Refugees is responsible for the process.

+ The Dublin Procedure +Toleration (Duldung): 94.500 people tolerated and 35.000 of them >6, 29.000 of them >8 years live in Germany!!!!

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Asylum seekers & refugees and medical & mental care

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Asylum seekers and refugees receive only basic health care (§ 4

AsylbLG).

Acute Diseases Pregnancy Childbirth

Other services can be introduced in individual special cases if they are essential to safeguard the health (§ 6 AsylbLG).

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Social Welfare Office often denies

reimbursement

Chronic

Diseases ?

Trauma ?

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They can go directly to the emergency services.

For any other urgent (!) health problems they should personally take a document (Krankenschein) from Social Welfare Office and in special cases f. e. specialist consultation, referral of a physician is required.

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Due to These Administrationsasylum seekers and refugees may not see a physician until

their health has deteriorated sharply, so that they constitute an emergency.

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This problem is long known and has been addressed by civil society organizations and health professionals

through initiatives on different societal levels, ranging from political campaigns to the provision of solidarity

health-care services.

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Mental health of asylum seekers and refugees in Germany

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Information about health status and provision of the health care to asylum seekers is not captured by German routine health information system.

There is yet no systematic overview on the health status of and health-care provision to asylum seekers in Germany.

A pertinent example can be found in the literature on mental health of asylum seekers.

The international systematic reviews on the prevalence of mental health disorders among asylum seekers, none list any studies

conducted in Germany.

Lack of studies?

Inclusion criteria of the reviews?

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Although, over the last 20 years, an increasing number of investigations into the mental health of individual migrant groups have been published in Germany, there are still only limited data on the health status of asylum seekers and refugees.

Most authors have assumed that in comparison to other migrant groups, asylum seekers and refugees have a more impaired general state of health, both physical and mental (e.g., Fazel, Wheeler, & Danesh, 2005; Gerritsen et al., 2006; Maier, Schmidt, & Mueller, 2010).

The results of international research indicate that asylum seekers and those whose asylum applications have been rejected show higher rates of pre-migratory traumatic experience and, accordingly, often have mental disorders associated with trauma (Robjant, Hassan, & Katona, 2009).

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Along with depressive disorders, somatoform pain disorders (Maier et al., 2010) and anxiety disorders, posttraumatic stress disorders contribute most strongly to the increased mental morbidity observed in asylum seekers and refugees (Fazel et al., 2005).

A meta-analysis showed that the prevalence rate for depression was almost twice as high for refugees and asylum seekers as for so-called “migrant workers” (Lindert et al., 2009).

Another meta-analysis showed that post-migration factors play a more important role in mental health of immigrants than pre-migration and migration factors (Bourque et al, 2011) .

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German studies on the subject are very few, most of them written in German and have small samples.

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Gabel et al (2006) searched PTSD among asylum seekers during the asylum interview process and found that 40 of the 76 asylum seekers had PTSD (40%) (2006).

Sieberer et al (2011) investigated expert reports of 62 asylum seekers and found that 82.3% of the asylum seekers reported on traumatization. PTSD war the most common diagnosis (74.1%), followed with depressive disorders (ICD-10: F32.x in 33.9 % and ICD-10: F33.x in 25.9 %). Suicidal tendency was found in 56.5 % of the asylum seekers.

Von Beutel et al (2007) studied long term effects of being a refugee in a representative community sample and found that former refugees reported reduced quality of life, they suffered more often from panic attacks, were compromised in their health and well-being.

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Gavranidou et al (2008) investigated psychological symptoms of the refugee children and adolescents (11-17 years) in Munich. Those refugees report high numbers of emotional and behavioral symptoms and significant correlations were found between exile-related family stressors and current psychological symptoms.

Muhtz et al (2011) searched long-term consequences of flight and expulsion during childhood in 502 participants from the former German eastern territories who were displaced as children at the end of World War II (at the age of 5-12 years). 31.5% participants diagnosed with full PTSD, and 33.7% fulfilled the criteria of a current partial PTSD. Participants with PTSD reported a significantly reduced quality of life. That study is very important because it demonstrates the long-term consequences of flight and expulsion during childhood in aging former refugee children more than 60 years later.

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Nika et al (2000) reported a case of 18 year old Croat refugee with a first episode schizophrenia and discussed the German laws for foreigners as a possible factor for the maintenance of the disease. Short residence permits, the release of the professional discretion to the authorities, deficient information about the laws and the unclear situation in the native country of the patients can lead to a worst course and prognosis of the disease.

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There are many civil society organisations, clinics, associations and networks which are dealing with the issue of the health/mental health of the asylum seekers and refugees in Germany.

Not all the practical work (especially the optimistic ones) can be reflected to the scientific studies.

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Here is a lucky one

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And a new good news

1st March 2015: Change in the law for asylum seekers and refugees.

After 15 months (previously was 4 years) asylum seekers and refugees have the opportunity to have a health insurance card.

By this means the bureaucratic procedures will be shorter although the scope of the health care provision stays the same.

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What are we doing?

We offer in our transcultural psychiatry outpatient clinic special office hours for traumatized refugees in Hannover/Germany.

Culture sensitive assessment Psychiatric emergency care If necessary referral to our day clinic, our inpatient ward or

other psychiatric services Support by social workers

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Besides the individual psychotherapeutic support and psychopharmacological approaches, we have just began to the trauma oriented group therapies in cooperation with Asklepios Clinic-Göttingen.

non-verbal group therapy for trauma stabilization.

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‘In Germany, it may take a long time before migrants become full members of society with equal opportunity for achievement and with equal access to the healthcare system, not least in the area of mental health, with the same self-evident rights as the majority ethnic German population. We are confident, however, that this equality will not remain a utopian vision.’ (Machleidt, 2013).

 

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Thank you very much

Any comments and/or questions are welcome