Refugee children have fewer contacts to psychiatric healthcare services: an analysis of a subset of refugee children compared to Danish-born peers

"I had no idea there were psychiatric clinics for children": A qualitative study of how migrant parents reach Swedish mental health services for their children

Migrant children have repeatedly been shown to underutilize psychiatric services and to face barriers to care, yet few studies have examined the experience of migrant parents who are successful in their help-seeking efforts for their children's mental health. The aim of this study was to gain a deeper understanding of facilitators and obstacles to reaching care among migrant parents in contact with child psychiatric services. We explored how migrant parents in Stockholm, Sweden, experienced the process of reaching child mental health services. Participants were recruited from out-patient mental health clinics. Ten in-depth interviews were conducted; qualitative analysis of transcripts was undertaken using thematic content analysis. Parents described a desire to reach services but difficulties doing so on their own. We identified a strong dependence on referring agents, such as schools and child health centers, for parents to gain contact. Informants expressed a high degree of trust toward these agents. Contrary to previous studies, stigma was not described as an obstacle to help-seeking but was recognized by informants as a potential barrier to care had they not emigrated. Although participants in our study had differing educational backgrounds and residency times in Sweden, a common experience of reliance on others for reaching services was evident in the data. Our findings highlight the role of referring agents as bridging contacts between different welfare services. Understanding the specific local resources and services that are available to migrant parents, and strengthening these across different sectors, could potentially help reduce barriers to care.

Mental health problems and help-seeking behaviours of Syrian refugee adolescents: mediating role of self-stigma

BACKGROUND

Although common mental health problems have been widely studied with self-stigma, few studies have focused on the mediating effect of self-stigma in the relationship between mental health problems and help-seeking behaviours of refugee adolescents. Therefore, the purpose of the present study was to examine whether self-stigma mitigates the adverse effects of stress, anxiety, and depression symptoms on the help-seeking behaviours of Syrian adolescents living in Turkey.

METHODS

The participants of this study included 488 Syrian refugee adolescents (boys, 63.73%; girls, 3627%) living in Turkey. Participants completed the Depression Anxiety Stress Scale and General Help-Seeking Scale and Self-Stigma of Seeking Psychology Help Scale.

RESULTS

The findings revealed that stress (β = 0.19, p < 0.01), anxiety (β = 0.12, p < 0.05), and depression (β = 0.17, p < 0.01) had significant and positive predictive effects on self-stigma, but not on help-seeking behaviours. Also, self-stigma (β = -0.12, p < 0.01) had a significant negative predictive effect on help-seeking behaviours. With regard to the indirect effects, the findings showed that self-stigma fully mediated the associations between stress - help-seeking [effect = -0.05, 95% confidence interval (CI) -0.11 to -0.01], anxiety - help-seeking (effect = -0.04, 95% CI -0.09 to -0.01)], and depression - help-seeking (effect = -0.05, 95% CI -0.12 to -0.01).

CONCLUSIONS

Our findings highlight the potential negative effects of self-stigma on the help-seeking behaviours of Syrian refugee adolescents, both directly and indirectly. These results can be used to develop and implement effective and efficient interventions to address the unmet mental health needs of refugee adolescents.

The role of school-based creative expression interventions in the aftermath of migration: A qualitative exploration of parents' and teachers' perspectives

This study explored supportive relational processes for immigrant children's well-being between peers, teachers, and parents in the development of school-based creative interventions in European multi-ethnic societies. Within the present study, we integrated the perspectives of teachers and parents to broaden the dominant focus on the assessment of individual symptomatology within the existing body of studies of school-based interventions studies. As a part of a larger multi-method study on the implementation of a creative expression program for immigrant children ages 8-12 years in three schools in Belgium, we conducted focus group discussions to learn parents' and teachers' perspectives on the role of school-based creative interventions in children's coping with histories of migration and life in exile. Parents and teachers identified the need for the intervention to foster emotional expression impacting children's self-esteem and social connectedness with peers and to foster emotional connections between parents, teachers, and children. Parents also stressed the importance of the intervention within society as a forum to engage with social conditions, promote cultural belonging, and social integration. Results identified the importance of school-based interventions in terms of individual benefits as well as connectedness and coherence in entire communities, thereby strengthening the development of transcultural research evidence for school-based interventions in multi-ethnic societies.

Internet-based transdiagnostic treatment for emotional disorders in Arabic- and Farsi-speaking refugees: study protocol of a randomized controlled trial

BACKGROUND

Refugee populations have an increased risk for mental disorders, such as depression, anxiety, and posttraumatic stress disorders. Comorbidity is common. At the same time, refugees face multiple barriers to accessing mental health treatment. Only a minority of them receive adequate help. The planned trial evaluates a low-threshold, transdiagnostic Internet-based treatment. The trial aims at establishing its efficacy and cost-effectiveness compared with no treatment.

METHODS

N = 131 treatment-seeking Arabic- or Farsi-speaking patients, meeting diagnostic criteria for a depressive, anxiety, and/or posttraumatic stress disorder will be randomized to either the intervention or the waitlist control group. The intervention group receives an Internet-based treatment with weekly written guidance provided by Arabic- or Farsi-speaking professionals. The treatment is based on the Common Elements Treatment Approach (CETA), is tailored to the individual patient, and takes 6-16 weeks. The control group will wait for 3 months and then receive the Internet-based treatment.

DISCUSSION

The planned trial will result in an estimate of the efficacy of a low-threshold and scalable treatment option for the most common mental disorders in refugees.

TRIAL REGISTRATION

German Registry for Clinical Trials DRKS00024154. Registered on February 1, 2021.

Comparison of Hospitalization for Nonaffective Psychotic Disorders Among Refugee, Migrant, and Native-Born Adults in Sweden and Denmark

Importance

Determining whether migrants with nonaffective psychotic disorders (NAPDs) experience poorer outcomes after illness onset is essential to ensure adequate health care provision to these disadvantaged populations.

Objective

To compare cumulative hospital days for NAPDs during the first 5 years of illness among refugee, nonrefugee, and second-generation migrants and their Swedish and Danish peers.

Design, Setting, and Participants

This was a prospective cohort study of individuals treated for incident NAPDs in inpatient or outpatient settings between January 1, 2006, and December 31, 2013, and followed up for 5 years. This population-based study used Swedish and Danish national registries. Included participants were individuals in Sweden and Denmark, aged 18 to 35 years, treated for incident NAPDs. Data analyses were conducted from November 2022 to August 2023.

Exposures

Population group (determined according to residency in either country, not both countries), categorized as refugee (migrants whose residence in Sweden or Denmark was registered as refugee status or family reunification with a refugee), nonrefugee (all other individuals born outside Sweden and Denmark), second generation (individuals born in Sweden or Denmark with at least 1 parent born abroad), or native born (individuals born in Sweden or Denmark with both parents born in these countries).

Main Outcome and Measures

Total hospital days for NAPDs during the first 5 years of illness, analyzed using a hurdle model. Among those ever admitted, total number of admissions and mean admission length were examined.

Results

In total, 7733 individuals in Sweden (mean [SD] age, 26.0 [5.1] years; 4919 male [63.6%]) and 8747 in Denmark (mean [SD] age 24.8 [5.0] years; 5324 male [60.9%]) were followed up for 5 years or until death or emigration. After adjusting for a range of sociodemographic and clinical factors, the odds of experiencing any hospital days for NAPD were significantly higher among migrant groups compared with their native-born peers (Sweden: second generation, odds ratio [OR], 1.17; 95% CI, 1.03-1.33; P = .01; nonrefugee migrant, OR, 1.45; 95% CI, 1.21-1.73; P < .001; refugee, OR, 1.25; 95% CI, 1.06-1.47; P = .009; Denmark: second generation, OR, 1.21; 95% CI, 1.05-1.40; P = .01; nonrefugee migrant, OR, 1.33; 95% CI, 1.14-1.55; P < .001). These odds were highest among nonrefugee (Sweden: OR, 2.53; 95% CI, 1.59-4.03; P < .001; Denmark: OR, 2.61; 95% CI, 1.70-4.01; P < .001) and refugee (Sweden: OR, 1.96; 95% CI, 1.43-2.69; P < .001; Denmark: OR, 2.14; 95% CI, 1.42-3.21; P < .001) migrants from Africa and those who had arrived within 3 to 5 years (Sweden: nonrefugee migrants, OR, 1.93; 95% CI, 1.26-2.95; P = .002; refugees, OR, 2.38; 95% CI, 1.46-3.88; P < .001; Denmark: nonrefugee migrants, OR, 1.66; 95% CI, 0.96-2.85; P = .07; refugees, OR, 3.40; 95% CI, 1.13-10.17; P = .03). Among those ever hospitalized, refugees in both countries (Sweden, incidence rate ratio [IRR], 1.30; 95% CI, 1.12-1.51; P < .001; Denmark, IRR, 1.47; 95% CI, 1.24-1.75; P < .001) and second-generation migrants in Denmark (IRR, 1.22; 95% CI, 1.07-1.39; P = .003) experienced more days hospitalized for NAPDs than native-born individuals.

Conclusions and Relevance

In this prospective cohort study of individuals with NAPDs, results suggest that refugee, nonrefugee, and second-generation migrants experience more days hospitalized for these disorders than their native-born peers. Patterns were consistent across 2 countries with different models of psychosis care and immigration and integration policies.

Psychiatric Diagnoses Among HIV-Exposed and HIV-Unexposed Uninfected Children: A Danish Nationwide Cohort Study

This nationwide registry-based cohort study aimed to compare the risk of psychiatric diagnoses among HIV-exposed uninfected (HEU) children with a matched comparison group of HIV-unexposed uninfected (HUU) children, born in Denmark. We hypothesized that HEU children had an increased risk of psychiatric diagnoses and that this increased risk may differ by sex and age. All HEU children born in Denmark between year 2000 and 2020 were included. Each HEU child was matched by year of birth, maternal age at birth, and maternal immigration status to 10 HUU children. The primary outcome was risk of any psychiatric diagnosis (International Classification of Diseases, 10th Revision F00-F99). Incidence rate ratios (IRRs) were estimated using Poisson regression. Analyses stratifying by sex and age were also conducted. In total, 550 HEU children and 5500 HUU children were included. HEU children had an increased risk of any psychiatric disorder [IRR 1.45; 95% confidence interval (CI): 1.04-2.04] in the unadjusted analysis, but in the adjusted analysis, the risk was only significant for children aged 6-11 years [adjusted incidence rate ratio (aIRR) 1.93; 95% CI: 1.14-3.28]. Stratifying by sex, girls aged 6-11 years had an increased risk of any psychiatric disorder (aIRR 3.04; 95% CI: 1.27-7.28), while boys had an increased risk at age 12-20 years (aIRR 2.47; 95% CI: 1.18-5.17). In conclusion, HEU girls aged 6-11 years and HEU boys aged 12-20 years had an increased risk of any psychiatric disorder compared with HUU girls and boys, respectively. These findings highlight the importance of addressing the mental health needs of HEU children/adolescents.

"I can't describe how I could get better, but I would like to" - Conception of health and illness of refugee youth in Germany

Introduction and objective

Almost half of all the people displaced worldwide are children and adolescents. Many refugee children, adolescents, and young adults suffer from psychological stress. However, their utilization of (mental) health services is low, probably due to a lack of knowledge about (mental) health and (mental) health care. The current study aimed to explore concepts of (mental) health and illness of refugee youth as well as assess their mental health literacy (MHL) to arrive at conclusions for improving mental health care access and use.

Method

From April 2019 to October 2020, we conducted 24 face-to-face interviews with refugee children and adolescents in an outpatient clinic (n = 8), in youth welfare facilities (n = 10), and at a middle school (n = 6). A semi-structured interview was used to assess knowledge about mental and somatic health and illness as well as corresponding health strategies and care options. The material was evaluated using qualitative content analysis.

Results

Participants (N = 24) were between 11 and 21 years old (M = 17.9, SD = 2.4). The coded material was assigned to four thematic main areas: (1) conception of illness, (2) conception of health, (3) knowledge about health care structures in their country of origin, and (4) perceptions of mental health care structures in Germany. Compared to somatic health, the interviewed refugee children and adolescents knew little about mental health. Furthermore, respondents were more aware of opportunities of somatic health promotion, but almost none knew how to promote their mental health. In our group-comparative analysis we observed that younger children possess little knowledge about mental health-related topics.

Conclusion

Our results show that refugee youth have more knowledge about somatic health and somatic health care than about mental health (care). Accordingly, interventions to promote the MHL of refugee youth are necessary to improve their utilization of mental health services and to provide adequate mental health care.

Differences in all-cause and cause-specific mortality due to external causes and suicide between young adult refugees, non-refugee immigrants and Swedish-born young adults: The role of education and migration-related factors

BACKGROUND

International migration has increased during the past years and little is known about the mortality of young adult immigrants and refugees that came to Sweden as children. This study aimed to investigate 1) the risk of all-cause and cause-specific mortality in young accompanied and unaccompanied refugees and non-refugee immigrants compared to Swedish born individuals; and 2) to determine the role of educational level and migrations-related factors in these associations.

METHODS

This register linkage study is based on 682,358 individuals (633,167 Swedish-born, 2,163 unaccompanied and 25,658 accompanied refugees and 21,370 non-refugee immigrants) 19-25 years old, who resided in Sweden 31.12.2004. Outcomes were all-cause mortality and mortality due to suicide and external causes. Hazard ratios (HR) and 95% confidence intervals (CI) were calculated using Cox regression models with a maximum follow-up to 2016.

RESULTS

After adjusting for covariates, all-cause mortality was significantly lower in non-refugee immigrants (aHR 0.70, 95% CI 0.59-0.84) and refugees (aHR 0.76, 95% CI 0.65-0.88) compared to Swedish-born individuals. The same direction of association was observed for mortality due to suicide and external causes. No differences between accompanied and unaccompanied refugees were found. Risk estimates for all migrant groups varied with educational level, duration of residency, age at arrival and country of birth. Further, the mortality risk of migrants arriving in Sweden before the age of 6 years did not significantly differ from the risk of their Swedish-born peers. Low education was a considerable risk factor.

CONCLUSION

In general, young adult refugees and non-refugee immigrants have a lower risk of all-cause and cause-specific mortality than Swedish-born individuals. The identified migrant groups with higher mortality risk need specific attention.

Perceptions of Parents' Mental Health and Perceived Stigma by Refugee Youth in the U.S. Context

Refugees are at an increased risk of mental health problems due to the multiple traumas experienced. Mental health help-seeking and utilization remains low among resettled refugees in the US, however, with stigma as a major barrier. The goal of this paper was to explore second-generation youth's perceptions of parents' mental health and perceived stigma. Data includes in-depth interviews with 62 Bosnian youth resettled in St. Louis. Results indicate that from the perspective of their children, first-generation refugee parents continue to face mental health challenges. The findings show that parents' and youth's understanding of mental health is tied to cultural stigma surrounding mental health. Additionally, intergenerational trauma might be affecting the child-parent relationship. As mass violence around the world continues and people are at continued risk of becoming refugees, this study contributes by advancing research on the long-term mental health and well-being of refugees and their children.

Risk of Psychiatric Disorders Among Refugee Children and Adolescents Living in Disadvantaged Neighborhoods

Importance

Refugee children and adolescents are at increased risk of mental health difficulties, but little is known about how the characteristics of the neighborhood in which they resettle may affect vulnerability and resilience.

Objective

To test whether neighborhood socioeconomic disadvantage is associated with risk of psychiatric disorders among refugee children and adolescents and examine whether the association differs by sex, age at arrival, and family structure.

Design, Setting, and Participants

This quasi-experimental register-based cohort study included refugees in Denmark aged 0 to 16 years at the time of resettlement from 1986 to 1998. A refugee dispersal policy implemented during those years assigned housing to refugee families in neighborhoods with varying degrees of socioeconomic disadvantage in a quasi-random (ie, arbitrary) manner conditional on refugee characteristics observed by placement officers. Cox proportional hazard models were used to examine the association between neighborhood disadvantage and risk of psychiatric disorders, adjusting for relevant baseline covariates.

Exposures

A neighborhood disadvantage index combining information on levels of income, education, unemployment, and welfare assistance in the refugees' initial quasi-randomly assigned neighborhood.

Main Outcomes and Measures

First-time inpatient or outpatient diagnosis of a psychiatric disorder before age 30 years.

Results

Median (IQR) baseline age in the sample of 18 709 refugee children and adolescents was 7.9 (4.7-11.7) years; 8781 participants (46.9%) were female and 9928 (53.1%) were male. During a median (IQR) follow-up period of 16.1 (10.2-20.8) years, 1448 refugees (7.7%) were diagnosed with a psychiatric disorder (incidence rate, 51.2 per 10 000 person-years). An increase of 1 SD in neighborhood disadvantage was associated with an 11% increase in the hazard of a psychiatric disorders (hazard ratio [HR], 1.11; 95% CI, 1.03-1.21). This association did not differ between male and female individuals, refugees who arrived at different ages, or those from single- vs dual-parent households. In secondary analyses using prescribed psychiatric medication as the outcome, a similar association with neighborhood disadvantage was found (HR, 1.08; 95% CI, 1.03-1.14).

Conclusions and Relevance

In this cohort study, neighborhood disadvantage was associated with an increase in risk of psychiatric disorders. The results suggest that placement of refugee families in advantaged neighborhoods and efforts to enhance the neighborhood context in disadvantaged areas may improve mental health among refugee children and adolescents.

How schools in Germany shape and impact the lives of adolescent refugees in terms of mental health and social mobility

Schools are relevant settings for supporting refugee adolescents' mental health. As education and migration are important social determinants of health, we aim to integrate the qualitative findings of our mixed-methods study into a broader discussion regarding the role of schools and the potential effects on refugee adolescents' lives and mental health, as well as the impact of the COVID-19 pandemic. In this article, we present the findings of school-based actors' (i.e., teachers and school psychologists) perception of refugee adolescents' access to mental health care. The interviews highlight the importance of schools and social activities as main stabilizers and sources of support for refugee adolescents’ mental health and the role trusting school-parent relationships play in mental health care help-seeking. Our data indicate that schools lack the resources to properly address these needs. However, these structural gaps are rooted into historical segregation and discrimination in the German educational system and left unaddressed, can increase stigma and intergenerational social inequalities, especially in connection to the COVID-19 pandemic. We conclude our article with a set of recommendations that could be relevant and implemented across different contexts to strengthen the role of the school setting in promoting the mental health and well-being of refugee adolescents.

•

Schools have the potential be sites of support for refugee minors' mental health.

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Yet, German schools have historically been sites of segregation and discrimination.

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Social activities are main stabilizers for mental health, but schools lack resources.

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School closings during the COVID19 pandemic in Germany exacerbated these challenges.

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We recommend anti-racist education practices and inclusionary strategies in schools.

Differences in psychiatric care utilization between refugees, non-refugee migrants and Swedish-born youth

BACKGROUND

The study aimed to examine differences in, and characteristics of psychiatric care utilization in young refugees who came to Sweden as unaccompanied or accompanied minors, compared with that of their non-refugee immigrant and Swedish-born peers.

METHODS

This register-linkage cohort study included 746 688 individuals between 19 and 25 years of age in 2009, whereof 32 481 were refugees (2896 unaccompanied and 29 585 accompanied) and 32 151 non-refugee immigrants. Crude and multivariate Cox regression models yielding hazard ratios (HR) and 95% confidence intervals (CI) were conducted to investigate subsequent psychiatric care utilization for specific disorders, duration of residence and age at migration.

RESULTS

The adjusted HRs for psychiatric care utilization due to any mental disorder was significantly lower in both non-refugee and refugee immigrants when compared to Swedish-born [aHR: 0.78 (95% CI 0.76-0.81) and 0.75 (95% CI 0.72-0.77, respectively)]. Within the refugee group, unaccompanied had slightly lower adjusted risk estimates than accompanied. This pattern was similar for all specific mental disorders except for higher rates in schizophrenia, reaction to severe stress/adjustment disorders and post-traumatic stress disorder. Psychiatric health care utilization was also higher in immigrants with more than 10 years of residency in Sweden entering the country being younger than 6 years of age.

CONCLUSIONS

For most mental disorders, psychiatric health care utilization in young refugees and non-refugee immigrants was lower than in their Swedish-born peers; exceptions are schizophrenia and stress-related disorders. Arrival in Sweden before the age of 6 years was associated with higher rates of overall psychiatric care utilization.

Assessing Virtual Mental Health Access for Refugees during the COVID-19 Pandemic Using the Levesque Client-Centered Framework: What Have We Learned and How Will We Plan for the Future?

During the COVID-19 pandemic, mental health services rapidly transitioned to virtual care. Although such services can improve access for underserved populations, they may also present unique challenges, especially for refugee newcomers. This study examined the multidimensional nature of access to virtual mental health (VMH) care for refugee newcomers during the COVID-19 pandemic, using Levesque et al.'s Client-Centered Framework for Assessing Access to Health Care. One hundred and eight structured and semi structured interviews were conducted in four Canadian provinces (8 community leaders, 37 newcomer clients, 63 mental health or service providers or managers). Deductive qualitative analysis, based on the Client-Centered Framework, identified several overarching themes: challenges due to the cost and complexity of using technology; comfort for VMH outside clinical settings; sustainability post-COVID-19; and communication and the therapeutic alliance. Mental health organizations, community organizations, and service providers can improve access to (virtual) mental health care for refugee newcomers by addressing cultural and structural barriers, tailoring services, and offering choice and flexibility to newcomers.

Are all children treated equally? Psychiatric care and treatment receipt among migrant, descendant and majority Swedish children: a register-based study

AIMS

Underutilisation of mental health services among migrant youth has been demonstrated repeatedly, but little is known about potential discrepancies in terms of treatment receipt for those who do reach services. This study examines the type and level of care received among migrant children and descendants of migrants, particularly investigating disparities in treatment receipt given a specific diagnosis.

METHODS

We used register data of the total population aged 6-17 years in Stockholm, followed from 2006 to 2015, comprising 444 196 individuals, categorised as refugees, non-refugee migrants, descendants of migrants and Swedish-born. To identify recommended treatments for specific diagnoses we used official clinical guidelines. We report logistic regression estimated odds ratios (ORs) and 95% confidence intervals (CIs) of diagnosis receipt, treatment provision and level of care where a diagnosis was first registered.

RESULTS

Migrant children had a lower likelihood of receiving a wide range of psychiatric diagnoses, including mood disorder (OR 0.58; 95% CI 0.52-0.64), anxiety disorder (OR 0.62; 95% CI 0.57-69) and neurodevelopmental disorder (OR 0.59; 95% CI 0.55-0.63). Moreover, when these diagnoses were set, migrant children had a lower likelihood of receiving the recommended treatments for these conditions compared to the majority individuals with the same diagnosis (OR of receiving psychotherapy for anxiety disorder and depression: 0.71; 95% CI 0.62-0.95 and 0.50; 95% CI 0.33-0.75, respectively; OR for receiving ADHD-medication: 0.49; 95% CI 0.43-0.54).

CONCLUSIONS

Migrant children risk underdiagnosis of various mental health conditions, and, when reaching mental health services, risk not receiving the optimal care available.

Beliefs About Causes and Cures of Prolonged Grief Disorder Among Arab and Sub-Saharan African Refugees

Background

Many refugees have experienced the death of a loved one under traumatic circumstances. Accordingly, the prevalence of Prolonged Grief Disorder (PGD) among refugees is high. Culture-specific symptoms of PGD have been described previously, but beliefs about causes and cures of PGD among refugees remain unknown. We therefore aimed at identifying illness beliefs and treatment expectations regarding PGD among refugees.

Method

We focused on refugees from Arab countries (n = 14) and from Sub-Sahara Africa (n = 9) and applied qualitative and quantitative methods. In a semi-structured interview, participants first answered questions about assumed causes and potential cures for prototypical PGD symptoms according to ICD-11 that were presented in a vignette as representatives of their own culture. In the quantitative part, they completed the Cause Subscale of the Illness Perception Questionnaire (IPQ-R) that included additional culture-specific items. Interviews were analyzed with Qualitative Content Analysis.

Results

In both groups of refugees, PGD symptoms were predominantly attributed to a close relationship to the deceased, lack of social support, personal vulnerabilities, and circumstances of the death. Participants also named a number of flight-related causes (e.g., inability to perform or participate in rituals, feeling isolated in the host country). None of the participants attributed PGD symptoms to supernatural causes. Descriptive analyses of responses on the IPQ-R indicated that participants predominantly attributed PGD symptoms to psychological causes. Participants believed that PGD can be cured and predominantly mentioned social and religious support. Psychological help was only mentioned by a minority of participants. In both groups, participants emphasized that a therapist must be familiar with the patient's culture and rituals. Participants also mentioned stigma associated with seeking psychological help.

Conclusion

Results suggest specific beliefs of refugees regarding causes and cures of PGD as well as similarities with Western conceptualizations. A culture-sensitive approach to the treatment of PGD in refugees that can include knowledge of culture-specific rituals and incorporating religious beliefs as well as decreasing stigma and increasing mental health literacy seem important. The study is limited by its focus on only two groups of refugees and its small sample size.

War Psychiatry: Identifying and Managing the Neuropsychiatric Consequences of Armed Conflicts

War refugees and veterans have been known to frequently develop neuropsychiatric conditions including depression, post-traumatic stress disorder (PTSD), and anxiety disorders that tend to leave a long-lasting scar and impact their emotional response system. The shear stress, trauma, and mental breakdown from overnight displacement, family separation, and killing of friends and families cannot be described enough. Victims often require years of mental health support as they struggle with sleep difficulties, recurring memories, anxiety, grief, and anger. Everyone develops their coping mechanism which can involve dependence and long-term addiction to alcohol, drugs, violence, or gambling. The high prevalence of mental health disorders during and after the war indicates an undeniable necessity for screening those in need of treatment. For medical health professionals, it is crucial to identify such vulnerable groups who are prone to developing neuropsychiatric morbidities and associated risk factors. It is pivotal to develop and deploy effective and affordable multi-sectoral collaborative care models and therapy, which primarily depends upon family and primary care physicians in the conflict zones. Herein, we provide a brief overview regarding the identification and management of vulnerable populations, alongside discussing the challenges and possible solutions to the same.

Parental post-traumatic stress and psychiatric care utilisation among refugee adolescents

Parental psychiatric morbidity related to experiences of war and trauma has been associated with adverse psychological outcomes for children. The aim of this study was to investigate parental post-traumatic stress in relation to psychiatric care utilization among children of refugees with particular attention on the child's own refugee status, sex of both child and parents, and specific psychiatric diagnoses. This was a register study in a population of 16 143 adolescents from refugee families in Stockholm County born 1995-2000 and followed between 2011 and 2017 (11-18 years old). Parental post-traumatic stress, identified in three levels of care, was analysed in relation to child and adolescent psychiatric care use. Cox regression analysis was used to estimate hazard ratios (HR) and 95% confidence intervals (CI), adjusted for duration of residence and demographic and socioeconomic variables. Having a mother with post-traumatic stress was associated with higher psychiatric care utilization, with adjusted HR 2.44 (95% CI 1.90-3.14) among foreign-born refugee children and HR 1.77 (1.33-2.36) among Swedish-born children with refugee parents, with particularly high risks for children with less than five years of residence (HR 4.03; 2.29-7.10) and for diagnoses of anxiety and depression (HR 2.71; 2.11-3.48). Having a father with post-traumatic stress was not associated with increased HRs of psychiatric care utilization. Similar results were seen for boys and girls. Treatment for post-traumatic stress should be made available in refugee reception programmes. These programmes should use a family approach that targets both parents and children.

Mental health service use among migrant and Swedish-born children and youth: a register-based cohort study of 472,129 individuals in Stockholm

PURPOSE

Migrant children underutilize mental health services (MHS), but differences according to age, reason for migration, type of problem, and time have not been thoroughly analyzed. We aimed to explore utilization of MHS among migrant children and youth and to study if the hypothesized lower utilization could be explained by fewer neurodevelopmental assessments.

METHODS

A cohort of the population aged 0-24 years in Stockholm, comprising 472,129 individuals were followed for maximum 10 years, between January 1, 2006 and December 31, 2015. We categorized individuals as accompanied refugee migrants, unaccompanied refugee migrants and non-refugee migrants, or Swedish-born. We used survival and logistic analyses to estimate rates of utilization of MHS.

RESULTS

Migrant children and youth utilized less MHS than the majority population, with hazard ratios ranging from 0.62 (95% CI: 0.57; 0.67) to 0.72 (95% CI: 0.69; 0.76). Refugee and non-refugee children utilized less mental health care than their Swedish peers, apart from the youngest refugees (0-10 years) who had similar utilization as Swedish-born. The lower rates were partly explained by all migrant youths' lower risk of being diagnosed with a neurodevelopmental condition. Time in Sweden had a major impact, such that unaccompanied refugee minors had a higher utilization in their first 2 years in Sweden (OR: 3.39, 95% CI: 2.96; 3.85).

CONCLUSION

Migrant youth use less MHS compared with native-born peers, and this is partly explained by fewer neurodevelopmental diagnoses. Strengthening the awareness about unmet needs, and the referring capacity by professionals in contact with migrant children could help reduce barriers to care.

Pilot Wellness Program With Adapted Social-Emotional Learning and COVID-19 Curriculum for Refugee Youth

Refugee children are less likely than their non-refugee peers to receive timely diagnoses and treatment for mental and/or behavioral health problems, despite facing multiple risk factors including potential exposure to trauma during premigration, migration, and postmigration experiences. Social-Emotional Learning offers preventive mental health education for children through well-established, evidenced-based curricula. Although there are clear benefits of Social-Emotional Learning curricula, which can help children achieve long-term success emotionally and academically, Social-Emotional Learning curricula are not easily accessible for refugee children, often because of language and socioeconomic barriers. In this pilot study, we evaluated the feasibility and acceptability of an adapted Social-Emotional Learning program that included culturally specific, multilingual, trauma-informed wellness, and physical education during the COVID-19 pandemic: EMPOWER (Emotions Program Outside the Clinic With Wellness Education for Refugees). We used the Intervention Mapping framework which guided the (1) planning, (2) program development, and (3) mixed-method evaluation of the feasibility and acceptability of the EMPOWER pilot. We found that this adaptation was well-received by Afghan refugee families and that COVID-19 safety measures were well-understood after participation. Challenges emerged around videoconferencing connectivity and around finding a common language for discussing emotions. Future iterations of the program and evaluations will require continued partnerships with community members and organizations. As we continue and expand EMPOWER, we aim to evaluate short-term improvement in Social-Emotional Learning competence as well as long-term mental and behavioral health outcomes for children and their families.

Effect and process evaluation of a multicomponent public health intervention to increase the use of primary care-based mental health services amongst children with a migrant background in Stockholm, Sweden: a protocol for a mixed-methods study

INTRODUCTION

The overall aim of the project is to understand how to increase access to, and use of, primary care-based mental health services for children and youth from a migrant background with mild to moderate mental health problems.

METHODS AND ANALYSIS

The study will be undertaken in Haninge municipality in Stockholm, Sweden. The study has three intervention components: (1) A health communication intervention targeting parents of children/youth with a migrant background; (2) Training of professionals and volunteers who potentially have contact with parents and children with a migrant background, in order to increase the number of referrals to primary care-based mental health services, and (3) Increasing access to care at a primary care-based mental health service for children, using various strategies to lower barriers to care. The complex multicomponent intervention will be studied with an effect and a process evaluation methodology.

ETHICS AND DISSEMINATION

All planned studied are approved by the Swedish Ethical Review Authority dnr 2017-135-31/5, 2019-06275, 2020-03640, 2020-06341, 2020-03642 and 2020-04180. Informed consent, written or verbal, will be obtained from all participants. The results of the project will be published continually in peer-reviewed scientific journals and disseminated to relevant stakeholders nationally and within Haninge municipality.

Attention deficit hyperactivity disorder in first- and second-generation immigrant children and adolescents: A nationwide cohort study in Sweden

BACKGROUND

Studies on the incidence of Attention Deficit Hyperactivity Disorder (ADHD) among immigrant children and adolescents is limited and results are mixed. The aim of this study was to compare the ADHD risk between first- and second-generation immigrants aged 4-16 years and their native peers in Sweden.

METHODS

This was an open nationwide retrospective cohort study. We included 1,902,526 native and 805,450 children and adolescents with an immigrant background, born 1987-2010, and aged 4-16 years at baseline. We identified participants using national population data and participants were observed until they received an ADHD diagnosis in the National Patient Register, turned 18 years, migrated, died, or until the end of the study, whichever came first. ADHD risks were adjusted for birth year and age and maternal income at baseline.

RESULTS

For both males and females, the ADHD risk was lower among most immigrant groups. However, the combination of a Swedish-born mother and foreign-born father was associated with an increased risk of ADHD. The ADHD risk varied substantially between immigrants from different regions of the world. For example, immigrants from other Scandinavian countries, North America, and Latin America and the Caribbean had higher rates of ADHD compared with natives.

CONCLUSIONS

Future research should examine the underlying factors behind the differences in ADHD risks between certain immigrant subgroups and natives, such as family structure, cultural and language barriers and potential differences in health care utilization among immigrant families.

Underutilisation of psychiatric care among refugee adolescents in Stockholm

Aim

Refugee children have been shown to underutilise psychiatric services in Scandinavia. The aim of this study was to investigate determinants of psychiatric care utilisation in adolescents in refugee families.

Methods

The study used regional data on healthcare use linked to sociodemographic data from national registers in a total population of 93 537 adolescents in the Stockholm County born in 1995‐2000, including 18 831 with a refugee background. Cox regression analyses were fitted to estimate Hazard ratios (HRs) of psychiatric care utilisation in the age‐span 11‐18 years.

Results

Psychiatric care use was lower in the large majority of adolescents in refugee families that originated in low‐ and middle‐income countries, with adjusted HRs 0.34 (95% CI 0.28‐0.42) and 0.51 (95% CI 0.46‐0.56), respectively, compared with the Swedish majority population. Among the foreign‐born refugee adolescents, psychiatric care use increased with duration of residence in Sweden and was higher in children who obtained residency as asylum seekers compared with those who settled in family reunification.

Conclusion

Adolescents in newly settled refugee families with a background in low‐ and middle‐income countries should be a priority in mental health assessment of refugee children and referral to psychiatric care facilitated for children in need.

Feasibility and acceptability of Problem Management Plus with Emotional Processing (PM+EP) for refugee youth living in the Netherlands: study protocol

BACKGROUND

Refugee youth experience hardships associated with exposure to trauma in their homelands and during and after displacement, which results in higher rates of common mental disorders. The World Health Organization (WHO) developed Problem Management Plus (PM+), a non-specialist-delivered brief psychological intervention, for individuals who have faced adversity. PM+ comprises problem-solving, stress management, behavioural activation and strengthening social support. However, it does not include an emotional processing component, which is indicated in trauma-exposed populations.

OBJECTIVE

This pilot randomized controlled trial (RCT) aims to evaluate the feasibility and acceptability of PM+, adapted to Syrian, Eritrean and Iraqi refugee youth residing in the Netherlands, with and without a newly developed Emotional Processing (EP) Module.

METHODS

Refugee youth (N = 90) between 16 and 25 years of age will be randomized into PM+ with care-as-usual (CAU), (n = 30), PM+ with Emotional Processing (PM+EP) with CAU (n = 30) or CAU only (n = 30). Inclusion criteria are self-reported psychological distress (Kessler Psychological Distress Scale; K10 > 15) and impaired daily functioning (WHO Disability Assessment Schedule; WHODAS 2.0 > 16). Participants will be assessed at baseline, one-week post-intervention and three-month follow-up. The main outcome is the feasibility and acceptability of the adapted PM+ and PM+EP. The secondary outcomes are self-reported psychological distress, functional impairment, post-traumatic stress disorder (PTSD) symptom severity and diagnosis, social support, and self-identified problems. The pilot RCT will be succeeded by a process evaluation including trial participants, participants' significant others, helpers, and mental health professionals (n = 20) to evaluate their experiences with the PM+ and PM+EP programmes.

RESULTS AND CONCLUSION

This is the first study that evaluates the feasibility of PM+ for this age range with an emotional processing module integrated. The results may inform larger RCTs and implementation of PM+ interventions among refugee youth.

TRIAL REGISTRATION

Registered to Dutch Trial Registry, NL8750, on 3 July 2020. Medical Ethical Committee of the Amsterdam University Medical Centre, location Vrije Universiteit Medical Centre, Protocol ID: 2020.224, 1 July 2020.

Towards more equitable education: meeting health and wellbeing needs of newly arrived migrant and refugee children-perspectives from educators in Denmark and Sweden

Purpose - In 2015, Scandinavia experienced the arrival of many refugee children. Research has documented a higher prevalence of mental health problems among refugee compared to non-migrant children. Education and schools play an important role in the health and wellbeing of children, especially those who are vulnerable, and equity in education may help combat social and health inequalities. This study investigated educators’ views on the health and wellbeing needs of migrant children in Copenhagen, Denmark, and Malmö, Sweden, and how schools may address these issues. Methods - We carried out 14 semi-structured interviews with education professionals in both cities and conducted a thematic analysis inspired by the Street Level Bureaucracies theory. Results - Most interviewees recognized NAMR pupils had specific migration-related needs but some expressed being unable to cope with more complex issues due to a lack of vital health and wellbeing services within schools. Recent policies in Denmark further devolved migrant education to municipalities; while in Sweden new policies centralized and standardized procedures. Conclusion - To summarize, educational leaders and staff we interviewed in both countries felt that the lack of resources, professional training, standardized procedures and accountability measurement, together with inflexible systems, inhibited them from providing equitable education, thus possibly reinforcing migration-related health inequalities.

Psychiatric healthcare utilisation among refugee adolescents and their peers in Denmark

PURPOSE

To investigate the psychiatric healthcare utilisation of refugees vis-à-vis their peers in Denmark during the ages 15-22.

METHODS

This paper utilises comprehensive full-population registry data from 1995 to 2016 to explore the psychiatric healthcare utilisation during the transition from childhood to adulthood for refugees (N = 13,027), a comparison group of children of labour migrants from Morocco, Pakistan, and Turkey (N = 13,413), and the majority population (N = 693,043) in Denmark. To test for population differences in types of admission for particular types of disorders, odds ratios for a first contact during ages 15-22 were calculated using logistic regression. For those with at least one diagnosis-specific hospital contact, differences in the amount and type of treatment were tested using negative binomial regression to estimate means ratios of days hospitalised, days in outpatient care, number of outpatient contacts, consultations with psychiatrists in private practice, and prescribed medicine purchases.

RESULTS

Refugees and the comparison group were generally less likely than the majority population to have a first contact for most disorders (adjusted ORs 0.03-0.88), but not for schizophrenia for boys (adjusted ORs 0.92-2.13). Among those who did have a first contact, youths from the ethnic minority groups tended to have more or similar inpatient and emergency room contacts (MRs 0.89-2.10), hospitalisations of refugee girls being an exception (MR 0.46; CI [0.23-0.94]), but fewer outpatient contacts, consultations with psychiatrists in private practice, and prescribed medicine purchases (MRs 0.23-0.94).

CONCLUSIONS

The results suggest that refugee and other ethnic minority groups may face barriers both to initial contact and to completing adequate treatment beyond the first contact.

Risk of psychiatric diagnoses in children and adolescents of parents with torture trauma and war trauma

OBJECTIVE

Evidence point to intergenerational effects of trauma in refugee populations. This study estimates the risk of psychiatric diagnoses in children of severely traumatized refugees. The unique clinical sample consisted of refugee parents treated for torture trauma and war trauma, and outcomes were investigated using population-level data.

METHOD

A nationwide register study, following all children residing in Denmark. The exposure was parental torture trauma and war trauma, and outcomes were any psychiatric disorder, mood, neurotic, behavioural and emotional disorders and disorders of psychological development. Children's hazard of being diagnosed was estimated using Cox proportional hazards regression. Study participants were followed from the date of birth or immigration to their 18th birthday.

RESULTS

The cohort included 3 346 993 children of which 19 294 were identified as offspring to traumatized refugees. During the study period, 205 610 children were diagnosed with a psychiatric disorder. Children with parents from the Middle East and Northern Africa had a hazard ratio of 0.78 (95% CI: 0.72, 0.84) for those treated for parental trauma and 0.79 (95% CI: 0.76, 0.81) for those not treated compared with children of non-traumatized Danish-born parents. For children of parents from former Yugoslavia, the corresponding estimates were 0.69 (95% CI: 0.58, 0.81) and 0.69 (95% CI: 0.65, 0.73).

CONCLUSION

The results suggest that children of parents with and without registered torture trauma and war trauma have a lower risk of being diagnosed with a psychiatric disorder compared to children of Danish-born parents. These findings contradict research done on the transmission of trauma but supports evidence suggesting mental health services underutilization by refugee and ethnic minority populations.

Risk of childhood psychiatric disorders in children of refugee parents with post-traumatic stress disorder: a nationwide, register-based, cohort study

BACKGROUND

Children of refugees are often exposed to the consequences of parental post-traumatic stress disorder (PTSD), potentially leaving them vulnerable to intergenerational transmission of psychopathology. The present study aimed to determine whether parental PTSD is associated with childhood psychiatric morbidity among children of refugees.

METHODS

This study is a two-generation nationwide cohort study using the Danish Immigration Services database. We followed up children younger than 18 years with at least one refugee parent until psychiatric contact, end of the study, their 18th birthday, emigration, or death. We excluded children if their parents were diagnosed only with psychiatric diagnoses other than PTSD or if they had received a psychiatric contact before parental PTSD diagnosis. Information on parental PTSD and offspring psychiatric morbidity was obtained from the Danish Psychiatric Central Research Register. We used Cox proportional hazards regression models to assess the risk of psychiatric contacts among children of refugees with PTSD compared with children of refugees with no psychiatric diagnosis.

FINDINGS

Between Jan 1, 1995, and Dec 31, 2015, 102 010 refugees obtained residency permission in Denmark and 62 239 biological children of refugees were born in Denmark before Dec 31, 2015. 51 793 were eligible and included in the study (median follow-up 7·15 years [IQR 3·37-11·78]); of these, 1307 (2·5%) children had a psychiatric contact. 7486 (14·5%) children of refugees were exposed to parental PTSD. Parental PTSD significantly increased the risk of psychiatric contact in offspring (hazard ratio 1·49 [95% CI 1·17-1·89] for paternal PTSD, p=0·0011; 1·55 [1·20-2·01] for maternal PTSD, p=0·00084) after adjustment for sociodemographic variables.

INTERPRETATION

Children of refugees exposed to parental PTSD are at increased risk of psychiatric morbidity. Targeted screening and interventions are necessary to prevent psychiatric morbidity and ensure access to adequate care.

FUNDING

Section for Immigrant Medicine, Department of Infectious Diseases, Copenhagen University Hospital Hvidovre.

Common mental disorders among young refugees in Sweden: The role of education and duration of residency

BACKGROUND

Studies investigating risks of common mental disorders (CMDs) in refugee youth are sparse. The current study examined health care use due to CMDs in unaccompanied and accompanied refugee youth and Swedish-born, and the role of education and residency duration.

METHODS

This longitudinal cohort study included 746,517 individuals (whereof 36,347 refugees) between 19 and 25 years, residing in Sweden in 2009. Refugees were classified as unaccompanied/accompanied. Risk estimates of CMDs, measured as health care use and antidepressant treatment, between 2010-2016 were calculated as adjusted hazard ratios (aHR) with 95% confidence intervals (CI). Highest attained education in 2009, and residency duration were examined as potential modifiers.

RESULTS

Compared to Swedish-born youth, refugees had a lower risk of treated major depressive and anxiety disorders (aHR): 0.67 (95% CI 0.63-0.72) and 0.67 (95% CI 0.63-0.71) respectively), but a higher risk for posttraumatic stress disorders (PTSD). Compared to Swedish-born, unaccompanied had a nearly 6-fold elevated risk for PTSD (aHR: 5.82, 95% CI 4.60-7.34) and accompanied refugees had a 3-fold risk of PTSD (aHR: 3.08, 95% CI 2.54-3.74). Rates of PTSD decreased with years spent in Sweden. The risk of CMDs decreased with increasing education.

LIMITATIONS

The study lacked information on pre-migration factors. There may further be a potential misclassification of untreated CMDs.

CONCLUSION

Refugees had a lower risk of treated depressive and anxiety disorders but a higher risk for PTSD. In refugees, the rates of anxiety disorders increased slightly over time whereas the rates of PTSD decreased. Last, low education was an important predictor for CMDs.

'Tell Your Story': a randomized controlled trial of an online intervention to reduce mental health stigma and increase help-seeking in refugee men with posttraumatic stress

BACKGROUND

Refugees report elevated rates of posttraumatic stress disorder (PTSD), but are relatively unlikely to seek help for their symptoms. Mental health stigma is a key barrier to help-seeking amongst refugees. We evaluated the efficacy of an online intervention in reducing self-stigma and increasing help-seeking in refugee men.

METHODS

Participants were 103 refugee men with PTSD symptoms from Arabic, Farsi or Tamil-speaking backgrounds who were randomly assigned to either receive an 11-module online stigma reduction intervention specifically designed for refugees ('Tell Your Story', TYS) or to a wait-list control (WLC) group. Participants completed online assessments of self-stigma for PTSD and help-seeking, and help-seeking intentions and behaviors at baseline, post-intervention, and at a 1 month follow-up.

RESULTS

Intent-to-treat analyses indicated that, compared to the WLC, TYS resulted in significantly smaller increases in self-stigma for seeking help from post-treatment to follow-up (d = 0.42, p = 0.008). Further, participants in the TYS conditions showed greater help-seeking behavior from new sources at follow-up (B = 0.69, 95% CI 0.19-1.18, p = 0.007) than those in the WLC. The WLC showed significantly greater increases in help-seeking intentions from post-intervention to follow-up (d = 0.27, p = 0.027), relative to the TYS group.

CONCLUSIONS

This is the first investigation of a mental health stigma reduction program specifically designed for refugees. Findings suggest that evidence-based stigma reduction strategies are beneficial in targeting self-stigma related to help-seeking and increasing help-seeking amongst refugees. These results indicate that online interventions focusing on social contact may be a promising avenue for removing barriers to accessing help for mental health symptoms in traumatized refugees.

Perceptions of mental health and perceived barriers to mental health help-seeking amongst refugees: A systematic review

Despite elevated rates of psychological disorders amongst individuals from a refugee background, levels of mental health help-seeking in these populations are low. There is an urgent need to understand the key barriers that prevent refugees and asylum-seekers from accessing help for psychological symptoms. This review synthesises literature examining perceptions of mental health and barriers to mental health help-seeking in individuals from a refugee background. Our analysis, which complies with PRISMA reporting guidelines, identified 62 relevant studies. Data extraction and thematic analytic techniques were used to synthesise findings from quantitative (n = 26) and qualitative (n = 40) studies. We found that the salient barriers to help-seeking were: (a) cultural barriers, including mental health stigma and knowledge of dominant models of mental health; (b) structural barriers, including financial strain, language proficiency, unstable accommodation, and a lack of understanding of how to access services, and (c) barriers specific to the refugee experience, including immigration status, a lack of trust in authority figures and concerns about confidentiality. We discuss and contextualise these key themes and consider how these findings can inform the development of policies and programs to increase treatment uptake and ultimately reduce the mental health burden amongst refugees and asylum-seekers.

Do health reception policies in the Nordic region recognize the rights of asylum-seeking and resettled refugee children?

According to the United Nations Committee on the Rights of the Child, it is critical that refugee children's rights are upheld in all national policies covering vulnerable children. This article examines how health policies in the Nordic region recognize the health needs of newly arrived refugee children, and whether these policies respect their individual rights. The article maps out, compares and contrasts health reception policies in Denmark, Finland, Norway and Sweden, paying particular attention to how each addresses the rights and needs of refugee children. The policy documents were obtained through desk-research conducted from January 2017-January 2018. We analysed 34 national laws and guidelines that support the health reception of refugee children. We find that only a few health reception policies across the Nordic region have been written specifically for refugee children. The policies identified predominantly recognize refugee children's right of access to somatic healthcare services, and to emergency services. Their rights to mental health services or broader health-enabling contexts were addressed to a lesser extent. We conclude that there is a need for further recognition of refugee children as rights-holders, and for the intentions of health reception policies to be expanded to include mental health services and health-promoting initiatives. Further research is needed on whether and how the current policies play out in actual health reception practices.

Use of the emergency department as a first point of contact for mental health care by immigrant youth in Canada: a population-based study

BACKGROUND

Emergency department visits as a first point of contact for people with mental illness may reflect poor access to timely outpatient mental health care. We sought to determine the extent to which immigrants use the emergency department as an entryway into mental health services.

METHODS

We used linked health and demographic administrative data sets to design a population-based cohort study. We included youth (aged 10-24 yr) with an incident mental health emergency department visit from 2010 to 2014 in Ontario, Canada (n = 118 851). The main outcome measure was an emergency department visit for mental health reasons without prior mental health care from a physician on an outpatient basis. The main predictor of interest was immigrant status (refugee, non-refugee immigrant and non-immigrant). Immigrant-specific predictors included time since migration, and region and country of origin. We used Poisson models to estimate adjusted rate ratios (aRRs) and 95% confidence intervals (CIs).

RESULTS

The cohort included 2194 (1.8%) refugee, 6680 (5.6%) non-refugee immigrant and 109 977 (92.5%) nonimmigrant youth. Rates of first mental health contact in the emergency department were higher among refugee (61.3%) and non-refugee immigrant youth (57.6%) than non-immigrant youth (51.3%) (refugee aRR 1.17, 95% CI 1.13-1.21; non-refugee immigrant aRR 1.10, 95% CI 1.08-1.13). Compared with non-refugee immigrants, refugees had a higher rate of first mental health contact in the emergency department (aRR 1.06, 95% CI 1.02-1.11). We also observed higher rates among recent versus longer-term immigrants (aRR 1.10, 95% CI 1.05-1.16) and immigrants from Central America (aRR 1.17, 95% CI 1.08-1.26) and Africa (aRR 1.15, 95% CI 1.06-1.24) versus from North America and Western Europe.

INTERPRETATION

Immigrant youth are more likely to present with a first mental health crisis to the emergency department than non-immigrants, with variability by region of origin and time since migration. Immigrants may face barriers to access and use of outpatient mental health services from a physician. Efforts are needed to reduce stigma and identify mental health problems early, before crisis, among immigrant populations.

Universal or Targeted Antenatal Care for Immigrant Women? Mapping and Qualitative Analysis of Practices in Denmark

Inequity in immigrants’ health during pregnancy and childbirth has been shown. We studied the Danish regional organization of public midwifery-based antenatal care (ANC) for immigrant women to assess the strengths and weaknesses of organizing ANC as either universal or immigrant-targeted. A telephone survey in 2012 to all the Danish maternity wards (n = 20) was conducted. Semi-structured interviews with midwives providing targeted care (n = 6) were undertaken and characteristics of care were qualitatively analyzed, having the immigrant density of the facilities, the Danish ANC policy, and theories of cultural competence as the frame of reference. Six maternity wards were providing immigrant-targeted ANC. Targeted care implied longer consultations and increased attention to the individual needs of immigrant women. At these facilities, navigation in the health care system, body awareness, and use of interpreter services were key topics. The selection of women for targeted care was based on criteria (including names) that risk stigmatizing immigrant women. The arguments for not providing targeted care included that immigrant-targeted care was considered stigmatizing. Current universal care may overlook the needs of immigrant women and contribute to inequities. A strategy could be to improve dynamic cultural competencies of midwives, interpreter services, and flexibility of the care provision of the universal ANC system.

Barriers to Mental Health Help-Seeking Amongst Refugee Men

Rates of help-seeking for mental health problems are low amongst refugee communities, despite the high prevalence of PTSD reported amongst these individuals. Research suggests that the key barriers to seeking help for psychological problems include structural barriers (e.g., unstable housing), cultural barriers (e.g., mental health stigma), and barriers specific to refugees and asylum seekers (e.g., visa status). This study examined the effect of structural, cultural and refugee specific barriers on the relationship between PTSD symptom severity and intentions to seek help from professional, social, and community sources. Data was collected from 103 male refugees and asylum seekers with an Arabic-, Farsi-, or Tamil-speaking background. Participants completed measures indexing demographics, trauma exposure, PTSD symptoms, mental health stigma, and help-seeking intentions. Path analyses indicated that PTSD severity was associated with lower help-seeking intentions indirectly via mental health stigma (self-stigma for seeking help and self-stigma for PTSD) and visa security. PTSD severity was also associated with greater help-seeking intentions from community members indirectly via structural barriers. These findings are important to consider when identifying key barriers to mental health help-seeking and developing interventions designed to increase help-seeking for psychological problems, within this group.

Practitioner Review: Mental health problems of refugee children and adolescents and their management

BACKGROUND

Since 2010, the numbers of refugees have increased and around half are under 18 years of age. It is known that experience of organised violence, displacement and resettlement increases the risk for psychiatric disorders and psychosocial impairment. This review integrates recent research into the risk and protective factors for psychopathology with service and treatment issues.

METHODS

We draw on and critically evaluate key systematic reviews in the selected areas, innovative robust studies and relevant government reports.

RESULTS

Many refugee children show resilience and function well, even in the face of substantial adversities. The most robust findings for psychopathology are that PTSD, and posttraumatic and depressive symptoms are found at higher prevalence in those who have been exposed to war experiences. Their severity may decrease over time with resettlement, but PTSD in the most exposed may show higher continuity. More severe psychiatric disorders including psychosis may also occur. Service delivery needs to take into account socioeconomic and cultural influences but, given the high level of unmet need even in high-income countries, stepped care delivery is required. The evaluation of psychological interventions, often delivered in group settings, suggests that they can be effective for many distressed children; however, for the more impaired, a greater range of disorder-specific therapies will be required.

CONCLUSIONS

Child and adolescent mental health clinicians and service providers need to be aware of the specific needs of this population and systems for service delivery. There are significant knowledge gaps in understanding risk and vulnerability, service delivery and treatment effectiveness.

Optimising refugee children's health/wellbeing in preparation for primary and secondary school: a qualitative inquiry

Background

Children from refugee backgrounds are less likely to access appropriate health and social care than non-refugee children. Our aim was to identify refugee children’s health/wellbeing strengths and needs, and the barriers and enablers to accessing services while preparing for primary and secondary school, in a low socio-economic multicultural community in Australia.

Method

Ten focus groups were facilitated with Arabic-speaking refugee parents of children aged 2–5 years (n = 11) or in first year secondary school (n = 22); refugee adolescents starting high school (n = 16); and key service providers to refugee families (n = 27). Vignettes about a healthy child and a child with difficulties guided the discussions. Data was thematically analysed and feedback sought from the community via the World Café method.

Results

Personal resilience and strong family systems were identified as strengths. Mental health was identified as a complex primary need; and whilst refugees were aware of available services, there were issues in knowing how to access them. Opportunities for play/socialisation were recognised as unmet adolescent needs. Adults spoke of a need to support integration of “old” and “new” cultural values. Parents identified community as facilitating health knowledge transfer for new arrivals; whilst stakeholders saw this as a barrier when systems change. Most parents had not heard of early childhood services, and reported difficulty accessing child healthcare. Preschooler parents identified the family “GP” as the main source of health support; whilst parents of adolescents valued their child’s school. Health communication in written (not spoken) English was a significant roadblock. Differences in refugee family and service provider perceptions were also evident.

Conclusions

Refugee families face challenges to accessing services, but also have strengths that enable them to optimise their children’s wellbeing. Culturally-tailored models of care embedded within GP services and school systems may assist improved healthcare for refugee families.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-7183-5) contains supplementary material, which is available to authorized users.

School factors related to the emotional wellbeing and resettlement outcomes of students from refugee backgrounds: protocol for a systematic review

BACKGROUND

Schools can play a vital role in the resettlement of refugee children and their families. Yet, the body of research examining school environmental factors that support the mental health and acculturation of refugee children is methodologically heterogeneous, investigates numerous and disparate school factors, and is often "hidden" in broader qualitative studies. This limits the capacity to apply the findings in a practical manner.

METHODS

Based on PRISMA statement principles, we review the relevant literature to investigate the relationship between school climate and the emotional wellbeing and resettlement outcomes of refugee students. Six electronic databases will be systematically searched: MEDLINE, PsycINFO, Embase, CINAL, Web of Science, and ERIC, supplemented by a systematic review of the grey literature, relevant international websites, and sequential, site-specific internet searches. Finally, subject area experts will be consulted and backward and forward citation searches of included articles will be completed. Two independent reviewers will screen identified articles against eligibility criteria and extract data for included studies. Quality of included studies will be assessed using the Mixed Methods Appraisal Tool (MMAT) for mixed studies reviews. Data will be synthesised using a convergent qualitative narrative approach.

DISCUSSION

Given the centrality of school in the daily lives of resettled refugee children, it is vital to assess the impact of school climate on the psychosocial wellbeing and resettlement trajectories of this population. This review will identify evidence-based school factors which support good mental health and resettlement outcomes for refugee students and make recommendations for translation of this knowledge into the school environment.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42017077570.

Parental immigration and offspring post-traumatic stress disorder: A nationwide population-based register study

OBJECTIVES

The aim of this study was to investigate the association between parental immigration status and a diagnosis of post-traumatic stress disorder (PTSD) in their offspring.

METHODS

This nested matched case-control study was based on a Finnish national birth cohort for 1987-2010 and cases were diagnosed with PTSD by 2012 from the Care Register for Health Care. We identified 3639 cases and 14,434 controls individually matched for gender, place and date of birth (±30 days). Conditional logistic regression analyses were conducted to examine the association between parental immigration status, parents' region of birth and time since paternal immigration, and PTSD after controlling for confounding factors.

RESULTS

The likelihood of being diagnosed with PTSD was significantly increased among children with an immigrant father (OR 1.8, 95% CI 1.3 - 2.4) than those with two Finnish parents and one immigrant mother. There was no significant association between having an immigrant mother or two immigrant parents and receiving a diagnosis of PTSD. The likelihood of being diagnosed with PTSD was increased if the children's fathers had migrated less than five years before their birth (OR 1.4, 95% CI 1.03 - 1.9) and if their immigrant fathers had been born in North Africa or the Middle East (OR 2.1, 95% CI 1.4 - 3.3).

LIMITATIONS

The sample included a heterogeneous migrant group without information on the reason for migration. The cases were identified from hospital diagnosis that may have only included severe cases.

CONCLUSION

The increased likelihood of a diagnosis of PTSD underlines the need for psychosocial services among second-generation immigrants.

Mental health care utilisation and access among refugees and asylum seekers in Europe: A systematic review

BACKGROUND

Refugees and asylum seekers often have increased mental health needs, yet may face barriers in accessing mental health and psychosocial support (MHPSS) services in destination countries. The aim of this systematic review is to examine evidence on MHPSS service utilisation and access among refugees and asylum seekers in European Union Single Market countries.

METHODS

Four peer-reviewed and eight grey literature databases were searched for quantitative and qualitative literature from 2007 to 2017. Access was categorised according to Penchansky and Thomas' framework and descriptive analyses were conducted. Quality of studies was assessed by the Newcastle-Ottawa scale and the Critical Appraisal Skills Programme checklist.

RESULTS

Twenty-seven articles were included. The findings suggest inadequate MHPSS utilisation. Major barriers to accessing care included language, help-seeking behaviours, lack of awareness, stigma, and negative attitudes towards and by providers.

CONCLUSIONS

Refugees and asylum seekers have high mental health needs but under-utilise services in European host countries. This underutilisation may be explained by cultural-specific barriers which need to be tackled to increase treatment demand. Training health providers on cultural models of mental illness may facilitate appropriate identification, referral, and care. Based on these findings, it is crucial to review policies regarding MHPSS provision across the EU.

What can we learn from unaccompanied refugee adolescents' perspectives on mental health care in exile?

Unaccompanied refugee adolescents who have fled war and persecution often have poor mental health. Yet, little is known about their own perspectives on what can relieve their mental health problems. The aim was to explore unaccompanied refugee adolescents' perspectives on healing and the mental healthcare offered to them when resettled. The study was based on methodical triangulation of participant observation in a Danish municipal institution for unaccompanied refugee minors, semi-structured individual interviews with experts, social workers and male refugee minors and a focus group interview with refugee minors. Results show that the refugee adolescents associated traditional conversational therapy with discussing negative and stigmatising aspects of their past and carrying risks of re-traumatisation. Instead, alternative activities were proposed, through which resources could be accumulated and they could be met without stereotype.Conclusion: To enhance the complex mental health needs of unaccompanied minors' mental healthcare, the perspective of the refugee adolescents should be taken into account. This calls for a holistic approach to mental healthcare in their daily lives, where they are met in a non-stigmatising manner in which their unique capabilities are the main focus. Moreover, a trusting relationship constitutes the fundament to support good mental health among refugee adolescents. What is Known: • Unaccompanied refugee adolescents are at risk of poor mental health outcomes, e.g., depression, anxiety, PTSD and psychosocial stress. • Stigma, lack of social support, stressful life events and lack of intercultural competency among mental health professionals are barriers to good mental health. What is New: • There is a need for informal and tailored health promotion initiatives in the refugee adolescents' everyday lives. • To treat the refugee adolescents as equal human beings through curiosity and receptiveness to their resources is important in order to build trust and address stigma.

Trends in mental health service utilisation in immigrant youth in Ontario, Canada, 1996-2012: a population-based longitudinal cohort study

OBJECTIVE

To describe trends in mental health service use of youth by immigration status and characteristics.

DESIGN

Population-based longitudinal cohort study from 1996 to 2012 using linked health and administrative datasets.

SETTING

Ontario, Canada.

PARTICIPANTS

Youth 10-24 years, living in Ontario, Canada.

EXPOSURE

The main exposure was immigration status (recent immigrants vs long-term residents). Secondary exposures were region of origin and refugee status.

MAIN OUTCOME MEASURE

Mental health hospitalisations, emergency department (ED) visits and outpatient visits within consecutive 3-year time periods. Poisson regression models estimated rate ratios (RR).

RESULTS

Over 2.5 million person years per period were included. Rates of recent immigrant mental health service utilisation were at least 40% lower than long-term residents (p<0.0001).Mental health hospitalisation and ED visit rates increased in long-term residents (hospitalisations, RR 1.09 (95% CI 1.08 to 1.09); ED visits, RR 1.15 (1.14 to 1.15)) and recent immigrants (hospitalisations RR 1.05 (1.03 to 1.07); ED visits, RR 1.08 (1.05 to 1.11)). Mental health outpatient visit rates increased in long-term residents (RR 1.03 (1.03 to 1.03)) but declined in recent immigrant (RR 0.94 (0.93 to 0.95)). Comparable divergent trends in acute care and outpatient service use were observed among refugees and across most regions of origin. Recent immigrant acute care use was driven by longer-term refugees (hospitalisations RR 1.12 (1.03 to 1.21); ED visits RR 1.11 (1.02 to 1.20)).

CONCLUSIONS

Mental health service utilisation was lower among recent immigrants than long-term residents. While acute care use is increasing at a faster rate among long-term residents than recent immigrants, the decrease in outpatient mental health visits in immigrants highlights a potential emerging disparity in access to preventative care.

Bibliometric analysis of global migration health research in peer-reviewed literature (2000-2016)

BACKGROUND

The health of migrants has become an important issue in global health and foreign policy. Assessing the current status of research activity and identifying gaps in global migration health (GMH) is an important step in mapping the evidence-base and on advocating health needs of migrants and mobile populations. The aim of this study was to analyze globally published peer-reviewed literature in GMH.

METHODS

A bibliometric analysis methodology was used. The Scopus database was used to retrieve documents in peer-reviewed journals in GMH for the study period from 2000 to 2016. A group of experts in GMH developed the needed keywords and validated the final search strategy.

RESULTS

The number of retrieved documents was 21,457. Approximately one third (6878; 32.1%) of the retrieved documents were published in the last three years of the study period. In total, 5451 (25.4%) documents were about refugees and asylum seekers, while 1328 (6.2%) were about migrant workers, 440 (2.1%) were about international students, 679 (3.2%) were about victims of human trafficking/smuggling, 26 (0.1%) were about patients' mobility across international borders, and the remaining documents were about unspecified categories of migrants. The majority of the retrieved documents (10,086; 47.0%) were in psychosocial and mental health domain, while 2945 (13.7%) documents were in infectious diseases, 6819 (31.8%) documents were in health policy and systems, 2759 (12.8%) documents were in maternal and reproductive health, and 1918 (8.9%) were in non-communicable diseases. The contribution of authors and institutions in Asian countries, Latin America, Africa, Middle East, and Eastern European countries was low. Literature in GMH represents the perspectives of high-income migrant destination countries.

CONCLUSION

Our heat map of research output shows that despite the ever-growing prominence of human mobility across the globe, and Sustainable Development Goals of leaving no one behind, research output on migrants' health is not consistent with the global migration pattern. A stronger evidence base is needed to enable authorities to make evidence-informed decisions on migration health policy and practice. Research collaboration and networks should be encouraged to prioritize research in GMH.

Psychological and psychosocial interventions for refugee children resettled in high-income countries

Large numbers of refugee children are arriving in high-income countries. The evidence to date suggests that they have mental health needs that are higher than for the general population and that these are exacerbated by the numbers of traumatic events they have experienced and the post-migration stressors they continue to be exposed to. The importance of a thorough and thoughtful assessment is discussed. Treatments of note are described for post-traumatic stress disorder, family functioning, general mental health problems and school environments. Future opportunities to operationalise outcome measures, develop multimodal interventions and utilise implementation science methodology are considered.

Immigrants' utilization of specialist mental healthcare according to age, country of origin, and migration history: a nation-wide register study in Norway

PURPOSE

As the immigrant population rises in Norway, it becomes ever more important to consider the responsiveness of health services to the specific needs of these immigrants. It has been questioned whether access to mental healthcare is adequate among all groups of immigrants. This study aims to examine the use of specialist mental healthcare services among ethnic Norwegians and specific immigrants groups.

METHODS

Register data were used from the Norwegian Patient Registry and Statistics Norway. The sample (age 0-59) consisted of 3.3 million ethnic Norwegians and 200,000 immigrants from 11 countries. Poisson regression models were applied to examine variations in the use of specialist mental healthcare during 2008-2011 according to country of origin, age group, reason for immigration, and length of stay.

RESULTS

Immigrant children and adolescents had overall significantly lower use of specialist mental healthcare than ethnic Norwegians of the same age. A distinct exception was the high utilization rate among children and youth from Iran. Among adult immigrants, utilization rates were generally lower than among ethnic Norwegians, particularly those from Poland, Somalia, Sri Lanka, and Vietnam. Adult immigrants from Iraq and Iran, however, had high utilization rates. Refugees had high utilization rates of specialist mental healthcare, while labour immigrants had low use.

CONCLUSION

Utilization rates of specialist mental healthcare are lower among immigrants than Norwegians. Immigrants from Poland, Somalia, Sri Lanka, and Vietnam, had generally quite low rates, while immigrants from Iran had high utilization rates. The findings suggest that specialist mental healthcare in Norway is underutilized among considerable parts of the immigrant population.