SPECIAL GROUPS

Mental health care needs ofrefugeesTom Craig

Peter Mac Jajua

Nasir Warfa

AbstractThe numbers of refugees and asylum seekers shows little sign of

decreasing. An increased prevalence of stress-related common mental

disorders in these populations is well documented. The causes of these

conditions vary according to stresses experienced and the journeys indi-

viduals take in their migration to new countries and cultural settings. The

mental health practitioner must be informed of the cultural idioms by

which suffering is expressed in the refugee’s community, the social stigma

associated with particular traumatic experiences and with mental illness.

Because of their experiences of victimization, refugees may be reluctant

to disclose experiences of trauma and, as is typical of common mental

disorder worldwide, the presentation of mental distress in the first

instance is often in the guise of somatic complaints. The specific needs

of this group will include dealing with traumatic experiences without

pathologizing normal human responses.

Keywords asylum seekers; mental health needs; post-traumatic stress

disorder; refugees

The 1951 Geneva Convention defines a refugee as someone who

has ‘a well-founded fear of being persecuted for reasons of race,

religion, nationality, membership of a particular social group or

Tom Craig MBBS PhD FRCPsych is Professor of Social and Community

Psychiatry at the Institute of Psychiatry, London, UK. He qualified from

the University of the West Indies and trained in psychiatry. His research

interests include the mental health of homeless and marginalized

people. Conflict of interest: none declared.

Peter Mac Jajua MSc is a mental health nurse at the Centre for Forensic

Mental Health, London, UK. He qualified from Queen Mary University,

London, where he trained in transcultural mental health care. He carried

out a systematic review on psychological therapies in the treatment of

depression in adult refugees. His main areas of interest include refugee

mental health care, ethnicity, employment and social inclusion. Conflict

of interest: none declared.

Nasir Warfa PhD is Lecturer and Researcher in Transcultural Psychiatry

at the Centre for Psychiatry, Barts and The London Medical School,

Queen Mary University of London, UK. He carried out a comparative

PhD study of Somali refugees’ mental health and wellbeing in the USA

and UK. His research interests include the mental health of refugees

and socially excluded groups and the socioeconomic and psychological

impact of widespread substance misuse (khat). Conflict of interest:

none declared.

PSYCHIATRY 8:9 3

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..’.1 A further distinction of ‘asylum

seeker’ is made for people who have left their country of origin,

have applied to be recognized as a refugee and are awaiting

a decision from the host government. In the UK, asylum seekers

must apply for recognition as refugees at the earliest point of

arrival and those whose refugee status is accepted are accorded

the same legal, social, education and other welfare rights as those

of a British citizen. A more temporary provision, of Exceptional

Leave to Enter/Remain, can be granted to people who do not

meet the criteria for refugee status but who, nevertheless, cannot

be returned to their countries of origin on humanitarian grounds.

Statistics

Currently, there are more than 31.7 million ‘people of concern’ to

the United Nations, including 3 million Colombians, 2.6 million

Iraqis, 1.6 million Sudanese and 1.0 million Somalis. Refugees

and asylum seekers constitute about 30% of this population, or

9.6 million people worldwide. At the time of the previous edition

of this article,2 there had been five consecutive years in which

a decrease in the numbers of asylum seekers had been reported.

Since then, numbers have again been on the rise with an

approximate 12% increase since 2007. Nevertheless, this is still

below the peak reported by the United Nations High Commis-

sioner (UNHCR) in 2001. The recent rise has been attributed

mainly to asylum applications from Iraq, Somalia and

Afghanistan.3

During 2008, there were some 383,000 applications for

asylum or refugee status in the industrialized world, the majority

to Europe (290,000), but, as the number of participating coun-

tries providing information to UNCR has increased since 2007, it

is unwise to make direct comparisons across years for all coun-

tries. There is also variation between countries from one year to

the next. This may be due to changes in government policy. The

example is given of Sweden and Norway: in Sweden, there was

a reduction by two-thirds in the numbers of Iraqui asylum

seekers in 2007e2008, whereas the number of Iraqui asylum

seekers during the same period of time increased three-fold in

Norway and Finland. Table 1 shows illustrative data reported by

the United Nations High Commissioner for Refugees for 2005 and

2008.3 Presenting these figures in relation to the size of the

national population provides a crude way of reflecting capacity.

Thus, although the number of applications to Cyprus fell by

almost half in the previous year, it still receives more applica-

tions per capita than the UK.

Refugees and psychiatric disorders

The spectrum of mental ill-health among refugees differs in

degree and presentation rather than in any absolute way from

that of the host population. The most common disorders are

those characterized by anxiety and depression, such as post-

traumatic stress disorder (PTSD) and major depression, reflecting

the experience of trauma and loss that these populations

experience.

51 � 2009 Elsevier Ltd. All rights reserved.

SPECIAL GROUPS

Asylum applications, 2005e2008

Country Total Per 1000 inhabitants Annual change

2005 2008 2005 2008 2007e08

Cyprus 7750 3920 9.3 4.6 �42%

France 49,730 35,160 0.8 0.6 20%

UK 30,840 30,550 0.5 0.5 8%

USA 48,770 49,020 0.2 0.2 �3%

Italy 9550 31,160 0.2 0.5 122%

Source: United Nations High Commissioner for Refugees, 2008.3

Table 1

Prevalence

Perhaps not surprisingly, given that most studies have been of

selected help-seeking populations, there is considerable

discrepancy in rates of disorder between different studies; for

example, the reported rate of PTSD in adults varies between

3e86%. In children and adolescents, who comprise as much as

half the world’s refugees, high rates of PTSD, depression and

behavioural problems are commonly reported with some

evidence for persisting disturbance up to two years following

re-settlement.4 A systematic review of psychiatric surveys based

on unselected refugee populations identified 20 studies providing

results for 6743 adults from seven countries and five surveys of

just 260 refugee children from three countries. Of the adults, 9%

were diagnosed with PTSD, 4% with generalized anxiety

disorder (GAD) and 5% with major depression. Only two studies

included psychotic disorders, with a prevalence of 2%. The

studies of children recorded a prevalence of 11% for PTSD. These

rates are considerably lower than those reported in some studies,

reflecting the more rigorous criteria, including interview-based

assessments rather than reliance on self-report questionnaires.

Nevertheless, these numbers are clinically important. We

conclude, for example, that refugees are approximately ten times

more likely to have PTSD than age-matched native populations

in the countries surveyed.5

Although the attention of most studies has been on PTSD and

major depression, increased rates of mental disorder relative to

the domiciled population of GAD, panic disorder, substance

abuse and self-harm are also commonly reported.6 Co-occur-

rence of various combinations of these disorders is also common.

There is little accurate information about the prevalence of

illicit drug and alcohol abuse and dependency amongst refugee

communities, even though refugees are at greater risk of expo-

sure to the main risk factors for drug use, being concentrated in

poorer areas of cities in which drug use is endemic and rates of

unemployment are high. Some substance-misuse problems may

reflect drug use pre-migration, which may even be considered

less pathological in the home environment. For example, the

chewing of Khat is a common social activity among men of

Somali, Ethopian and Yemeni heritage, but appears to have

become problematic among young male migrants from these

countries, possibly reflecting a way of coping with boredom or

managing stress-related symptoms. There is some concern

PSYCHIATRY 8:9 35

among elders in this community that this excessive use might be

a gateway to the use of alcohol and other drugs.

Risk factors

It is accepted that these increased rates of disorder are brought

about by exposure to trauma and other stressors. By definition,

all refugees are fleeing their home countries for fear of violence

or persecution.

Pre-migration: many refugees and asylum seekers have experi-

enced severe pre-migration trauma, including protracted mental

and physical torture, mass violence and genocide, witnessing the

killings of family members and friends, sexual abuse, kidnap of

children, destruction and looting of personal property, starvation

and lack of water and shelter.7 To these terrors of violence and

persecution can be added multiple losses e of family and friends,

money, employment and status. These traumatic events pre-

migration are established risk factors for long-term mental health

problems, the risk being greater the worse the degree of the

traumatic exposure.

Post-migration: arrival in a safe haven may provide initial relief

but it is not uncommon for frustration and disillusionment to

develop as new problems emerge. These include language and

cultural barriers, concerns about legal status and entitlements,

unemployment, homelessness, isolation, lack of access to

education and healthcare services, and family separation. It is

these post-migration problems that are most open to being

addressed by the host country, yet there is surprisingly little

public acceptance of the importance of tackling these problems.

For example, everyone accepts the need to give immediate

humanitarian aid in the crisis and to preventing further violence,

but are less forthcoming on their support for the refugee’s needs

for employment, education, family reunification and religious

and cultural support, despite good reasons for thinking that

addressing these needs quickly might lessen or avert future ill-

health. There is evidence from at least one study that a protracted

asylum procedure is a risk factor for psychiatric problems.8 It

also seems likely that some of the difference in reported rates of

mental health problems reflects variations in how easily migrants

from different countries can integrate with the host population

and find employment.

2 � 2009 Elsevier Ltd. All rights reserved.

SPECIAL GROUPS

Clinical services

Although all refugees in the UK are entitled to NHS care,

including specialist secondary care if needed, access is not

always straightforward, requiring at the very least some famil-

iarity with how healthcare is organized. Apparent difficulties

with access have prompted the development of specialist refugee

health teams connected to primary care, especially in cities

where there are large migrant populations. These teams provide

information and advice to refugees, facilitate access to healthcare

and provide support to frontline services. They often work in

loose partnership with a variety of refugee community organi-

zations that deliver immigration advice and assistance with

housing and welfare benefits.

Diagnosis

The avoidance of precipitate diagnostic judgements is essential

for a balanced assessment. Once trauma has been disclosed, the

acknowledgement of symptoms of anxiety and PTSD are certain

to follow, although the significance of these symptoms needs

careful interpretation: not every symptom warrants treatment.

There is a risk of pathologizing and medicalizing an otherwise

normal human response to extreme adversity and one needs to

be careful in assuming that an initial reluctance to talk about the

experience is necessarily indicative of more severe pathology.

However, there is serious danger in dismissing too easily clini-

cally significant disorders as caused by trauma, and thus less

needy of intervention. As with most conditions, careful ques-

tioning on the intensity and duration of symptoms and their

impact on functional aspects of daily living are the best guides to

the need for treatment.

Treatment

For many people, supportive listening and practical assistance

with social issues will be enough. For others whose functional

ability remains impaired, additional intervention may be neces-

sary. By and large, these interventions will be based on standard

psychiatric practices, including pharmacological and psycholog-

ical therapies. There is substantial evidence for the efficacy of

psychological, psychosocial or ‘talking therapies’, although,

arguably, such therapies have been developed in industrialized

nations in the western hemisphere, so the extent to which the

concepts and therapeutic strategies they use are appropriate

among non-Western cultures has been questioned by some

experts, who point out that most asylum seekers come from

cultures where talking therapy is a quite alien concept. They

argue that a more acceptable model for counselling might be one

that starts with a background knowledge of the circumstances

from which the patient has fled and acknowledges the relevance

of practical advice and a more problem-focused (rather than

emotion-focused) approach.9 In the absence of empirical studies

testing the efficacy of specific psychotherapeutic approaches in

refugee populations, experts concur on the following broad

principles.

A holistic approach: physical and psychological problems are

often interwoven. Victims of torture may have physical as well as

emotional consequences of their experiences. Comorbid medical

PSYCHIATRY 8:9 35

conditions may mask psychological problems and both will

require treatment.

An emphasis on the practical: helping to problem-solve and to

achieve practical outcomes such as access to employment and

education may be of as much benefit e if not more e than

a conventional talking therapy.8

Cultural sensitivity: an understanding of the extent and nature

of the influence of culture must also take account of the impor-

tance of religion and spirituality for the individual. The practi-

tioner should be aware of religious and other socially determined

taboos and how these may shape the consultation or contribute

to the reluctance a refugee might have of disclosing sensitive

personal information through an interpreter who, in the worst

case, may be a member of a tribe or political party that is in

opposition to the refugee patient.

Discussing trauma: many recent asylum seekers have been

exposed to organized violence or torture perpetrated by

governments, security services or rebel groups. Women are just

as likely to have been tortured, the most common forms of

violence being beatings and sexual assault. There is no unique

pattern of long-term mental responses to torture. Experiences

commonly include anxiety, flashbacks, somatic symptoms and

a loss of a sense of a just world. Behavioural changes such as

increased dependency, compulsive care-giving or a fear of rela-

tionships are common. Many of those whose families have also

suffered describe guilt at having failed to avert violence, partic-

ularly towards loved ones. Rape and other sexual violation may

leave no long-term physical sign yet be profoundly shaming.

These are taboo subjects in many cultures and, compounded by

the distress the memories produce, many torture victims are very

reluctant to talk about their experiences. Counselling and the

notion of disclosing personal experiences to a relative stranger is

an alien experience for many refugees. Time is needed to build

up trust, allowing the trauma story to emerge gently so that it

becomes a familiar and comfortable theme rather than something

shamefully hidden away. Disclosure is best managed when the

social situation is stable and when both patient and health

worker are confident about managing the disclosures and the

distress that will emerge.

Psychoses and other severe mental illness: the same broad

principles apply to the care of the severely mentally ill patient

who may require hospitalization, perhaps against his or her

wishes. Incarceration in hospital and enforced treatment may be

reminiscent of earlier traumatic experience, precipitating

a resurgence of PTSD symptoms on top of those of the psychosis

itself. Risk assessments may be particularly difficult where there

are strong cultural and religious taboos regarding discussion of

suicide and self-harm. Finally, for chronic conditions, family

carers are particularly important. They are often isolated and

may not be in receipt of their entitled social support or welfare

benefits. The prevailing myth that minority ethnic cultures ‘look

after their own’ can also contribute to exclusion.

Refugee children: children of refugees may have been separated

from their parents, witnessed members of their family being

3 � 2009 Elsevier Ltd. All rights reserved.

SPECIAL GROUPS

tortured or experienced violence or torture themselves. They

may be living with just one parent, in fragmented families or

with unfamiliar carers. Some will have arrived alone and most, if

not all, will have experienced multiple losses. These experiences

will eventually emerge in the form of emotional distress and

aberrant behaviours. They may appear mature beyond their age

in some settings yet immature in others. The most common

conditions include anxiety, depression and conduct disorder. It is

not known whether there are any unique manifestations of these

disorders in refugees over and above what is commonly seen in

the general population. Despite their experiences, most refugee

children have many strengths and few need specific psychiatric

treatment. Where they do, the principles of management are

broadly the same e space and time to think about their experi-

ences, help to become part of the local community, to learn and

to make friends. Because refugee families underutilize formal

mental health services, schools can have a key role to play in

identifying problems and facilitating access to appropriate care.

Experiences at school may also be protective e an atmosphere of

warmth and stability can go a long way to restoring security.

Conclusions

While the majority of refugees hope that one day they will be

able to return to their homes, the challenge in the interim is one

of integration. Safety from persecution is just the first step. Next

comes the space to regain one’s dignity, to secure a job, money,

friends and a secure place to live and raise a family. The task of

the mental health professional and the assistance he or she offers

is focused ultimately on helping the patient achieve these basic

goals. It is likely that they will play only a relatively small part in

PSYCHIATRY 8:9 35

a wider multi-sector collaboration with social workers, refugee

organizations, housing and employment agencies. A

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