Depression-level symptoms among Syrian refugees: findings from a Canadian longitudinal study

Trajectories of psychological distress and social integration in newly resettled refugees: findings from the Building a New Life in Australia longitudinal study

PURPOSE

Refugees are at greater risk of mental illness due to stressors encountered post-resettlement. However, few longitudinal studies have examined the within-person effects of these stressors, especially with respect to social integration. This study aims to examine what factors are associated with psychological distress in a longitudinal sample of refugees resettled in Australia.

METHODS

This study used data from three Waves of the Building a New Life in Australia study, collected between 2013 and 2018. The eligible sample included 1881 adult respondents, clustered in 1175 households. We conducted multilevel mixed-effects growth modelling incorporating time-variant and time-invariant covariates with psychological distress, using the Kessler Psychological Distress Scale (K6).

RESULTS

Rates of high psychological distress increased across the 5-year follow-up period. Social integration stressors (e.g. discrimination, lower sense of belonging, loneliness, lower English proficiency) were associated with higher levels of psychological distress over time. Refugees reporting loneliness not only had a greater risk of elevated psychological distress at each time point, but the difference in risk increased over each time point. Refugees who were exposed to traumatic events, older, female and of Middle Eastern background were also more likely to report higher levels of psychological distress over time.

CONCLUSIONS

These findings highlight the importance of identifying refugees who may encounter difficulties with social integration in the early years of resettlement. Newly arrived refugees may benefit from longer-term resettlement programmes that address post-migratory stressors, particularly with regards to loneliness, to reduce the prevalence of elevated psychological distress during the early years of resettlement.

Influence of post-migration living difficulties on mental health among refugees and asylum seekers: A scoping-review on clinical tools

BACKGROUND

The literature indicates an increasing interest in the mental health of refugees (R) and asylum seekers (AS) - particularly how it could be affected by previous exposure to trauma and violence - but less has been written about the issues they are forced to face during the post-migration period and how these also can affect mental health. Research shows that the mental health of R/AS is highly influenced by their post-migration conditions and may deteriorate due to post-migration social health-related determinants; in addition, a lack of language skills, discrimination, separation from family, poverty, and other stressors can contribute to social isolation. The difficulty in asking for help in case of psychological distress and, consequently, in accessing care, contributes to the worsening of their clinical condition.

AIMS

The primary purpose of this study is to identify and provide a review of the clinical tools used to screen migrants (R/AS) at risk of developing psychological distress, identifying post-migration difficulties.

METHODS

We searched studies in PubMed, Embase, Scopus, Cochrane (Central), and Cinahl (ultimate) with the last search on 14 April 2023, using a combination of keywords and Medical Subject Headings (MeSH).

RESULTS

Our systematic search identified 1,878 records. After removing duplicates, we screened 1,238 records by title and abstract, retaining 97 for full text review. Of these, 68 met full eligibility criteria (1995-2023). A total of 30 social scales have been identified, as well as structured or semi-structured questionnaires and interviews. Translated into multiple languages, the tools can be self-administered or administered by trained professionals. PMLD is known for its effectiveness in evaluating the post-migration period and predicting mental health issues.

CONCLUSIONS

Considering the limited number of studies and, consequently, the limited number of tools found, it can be inferred that not enough attention is given to post-migration in the broader sense.

A Scoping Review of Instruments Used in Measuring Social Support among Refugees in Resettlement

This study aimed to systematically review current research on the application of existing social support scales in research with refugees in resettlement, assess their quality, and identify gaps in measurement to enhance research and practice. A scoping review was conducted on the extant literature published until March 2023. A team of researchers conducted search, sorting, and data extraction processes following best practices for scale development and validation. Of the 1185 studies collected from the search process, 41 articles were retained in the final analysis, from which 17 distinct social support instruments used in research with resettled refugees were identified. An assessment of all 17 instruments showed the presence of one or more limitations associated with construct, criterion, convergent, and/or discriminant validity. Test of reliability was assessed in all studies, with a range of 0.80 to 0.90. Our findings show that most of the research evaluating social support among resettled refugees is conducted without measurement instruments adequately validated in the resettlement context. This analysis highlights the need for rigorously developed social support scales that reflect the lived experiences, needs, and priorities of resettled refugees.

A prospective longitudinal study of depression, perceived stress, and perceived control in resettled Syrian refugees' mental health and psychosocial adaptation

This prospective study examined the psychosocial adaptation of a community sample of newly resettled Syrian refugees in Canada (N = 235). Specifically, depressive symptoms, perceived stress, and perceived control were collected in Arabic at baseline and 1-year follow-up. Two theory-informed, cross-lagged panel models demonstrated that higher baseline depressive symptoms predicted lower perceived self-efficacy and lower perceived control at 1-year follow-up. Similarly, baseline depressive symptoms were concurrently correlated with higher perceived helplessness, lower perceived self-efficacy, and lower perceived control. Secondary regression analyses further demonstrated that baseline depressive symptoms predicted lower perceived social support and higher anxiety symptoms, though neither were assessed at baseline. Empirical results identify a potentially broad, precipitating, and persistent effect of depressive symptoms on Syrian refugees' psychosocial resources and adaptation post-migration, which is consistent with both the transactional model of stress and coping and the self-efficacy theory of depression, respectively. Clinically, the study results highlight the importance of early screening for depressive symptoms among refugee newcomers within a culturally and trauma-informed, integrated health setting. Furthermore, this study underscores the value and need for theoretically guided longitudinal studies to advance future research on refugee mental health and psychosocial adaptation.

A mixed methods systematic review of mental health self-care strategies for Arabic-speaking refugees and migrants

BACKGROUND

Self-care strategies can improve mental health and wellbeing, however, the evidence on preferred strategies among Arabic-speaking refugees and migrants is unclear. This mixed methods systematic review aimed to identify and synthesise the global research on mental health self-care strategies used by these populations.

METHODS

English and Arabic language studies reporting on positive mental health self-care strategies to address symptoms of posttraumatic stress disorder, generalised anxiety and depression in the target populations were identified by systematically searching eight electronic databases and grey literature. Studies were deemed eligible if they were published from 2000 onwards and included Arabic-speaking migrants, refugees or asylum seekers aged 12 years and above. A narrative synthesis of study characteristics and relevant key findings was undertaken. The review protocol was registered on PROSPERO (registration number CRD42021265456).

RESULTS

Fifty-nine records reporting 57 studies were identified, the majority appearing after 2019. There were 37 intervention studies that incorporated a self-care component and 20 observational studies that reported on self-generated self-care practices. Across both study types, four broad groups of mental health self-care were identified-social, psychological, religious/spiritual, and other (e.g., expressive arts and exercise). Psychological strategies were the most reported self-care practice overall and featured in all intervention studies. Religious/spiritual and social strategies were more common in the observational studies. Intervention studies in diverse settings reported statistical improvements on a range of outcome measures. Observational studies reported a range of individual and community benefits. Linguistic, cultural and religious considerations, inherent in the observational studies, were variably addressed in the individual and group interventions.

CONCLUSION

Overall, study participants experienced self-care as helpful although some encountered challenges in practicing their preferred strategies. Further research on mental health self-care strategies among Arabic-speaking refugees and migrants is needed in Western resettlement countries to guide mental health service delivery and primary healthcare initiatives for new arrivals and in transit countries.

Resettlement, mental health, and coping: a mixed methods survey with recently resettled refugee parents in Canada

BACKGROUND

Resettlement experiences of refugee parents are under-researched despite evidence indicating higher risk of poor mental health. The current study integrates family systems and social determinants of refugee mental health frameworks to examine: (1) Refugee parents' experiences of resettlement stressors and mental health; (2) Perceived impacts of resettlement stressors on individual and family indicators of well-being; and (3) Refugee parents' coping strategies and resources.

METHODS

The study draws on data from a mixed methods survey conducted with 40 Government-Assisted Refugee parents who had resettled to Hamilton, Canada within the past 4 years. Quantitative and qualitative data were analyzed separately and then integrated at the results stage using a weaving approach.

RESULTS

Results indicate significant exposure to economic and social stressors across multiple domains of daily life, as well as high levels of parental psychological distress. Parents drew linkages between resettlement stressors and negative mental health impacts that were compounded by intersecting risk factors of ill health, caregiving burden, single parenthood, and low levels of education and literacy. Most parents rated themselves as coping well or very well and described various coping strategies such as positive reframing, problem solving, planning, and turning to religion. Quantitative and qualitative findings indicate high frequency of positive parent-child interaction and low frequency of family conflict, and highlight the importance of family as a protective resource for coping with adversity. Exploratory regression analyses suggest that longer stay in Canada, poorer self-rated health, higher levels of resettlement stressors, and more conflict between adults in the household may be associated with greater psychological distress.

CONCLUSION

Study findings highlight both the resilience of refugee parents and the psychological toll of navigating their families through a new and challenging environment. Policies and programs to provide comprehensive social and economic supports to refugees beyond the first one to two years after arrival are necessary to mitigate the mental health impacts of displacement over time and strengthen individual and family resilience. Such programs should include culturally responsive and family-based models of mental health care that acknowledge collective experiences and impacts of adversity, as well as harness family resources to overcome past and present challenges.

Use of participatory action research to support Syrian refugee mothers in the resettlement period in Canada: A longitudinal study

Research has shown that refugees in a foreign country often experience physical and mental health challenges upon resettlement (Ahmad et al., 2021; Salam et al., 2022). In Canada, refugee women experience a range of physical and mental barriers, including poor access to interpreter services and transportation, and a lack of accessible childcare, all of which can negatively affect their successful integration (Stirling Cameron et al., 2022). Social factors that support Syrian refugees to settle successfully in Canada have been unexplored systematically. This study examines these factors from the perspectives of Syrian refugee mothers living in the province of British Columbia (BC). Framed by principles of intersectionality and community-based participatory action research (PAR), the study draws on Syrian mothers' perspectives of social support in early, middle, and later phases of resettlement. A qualitative longitudinal design consisting of a sociodemographic survey, personal diaries, and in-depth interviews was used to gather information. Descriptive data were coded, and theme categories were assigned. Six themes emerged from data analysis: (1) Steps in the Migration Journey; (2) Pathways to Integrated Care; (3) Social Determinants of Refugee Health; (4) COVID-19 Pandemic Impacts and Ongoing Resettlement; (5) Strength-Based Capabilities of Syrian mothers; (6) Peer Research Assistant's Research (PRAs) Experience. Results from themes 5 and 6 are published separately. Data obtained in this study contribute to the development of support services that are culturally appropriate and accessible to refugee women living in BC. Our objectives are to promote the mental health and improve the quality of life of this female population, and to enable it to access healthcare services and resources in a timely manner.

Effects of Posttraumatic Stress Disorder and Mental Disorders on the Labor Market Integration of Young Syrian Refugees

Civil war experience in the Syrian home country, insecurity and critical life events during migration, or adverse events in the receiving country might affect refugees' mental health. This paper addresses the effects of psychological distress and mental disorders on refugees' labor market integration in Germany between 2016 and 2021. We employ survey data from about 2700 young Syrians, delivering information on individuals' experience of migration and arrival in Germany in 2016. The survey data were successfully merged with register data, delivering detailed information regarding individuals' process of labor market integration and employment status from 2016 to 2021. Overall, the labor market integration of young refugees improved remarkably over time. In 2021, about 69% of the study population was integrated in a wider sense, and 30% was employed in fulltime contracts in 2021. However, the results indicate long-lasting effects of PTSD and mental disorders on individuals' labor market integration, whilst individuals' characteristics related to migration and arrival lose relevance over time and hardly affect labor market integration around five years after arrival. High PTSD scores in 2016 indicate a significantly reduced full-time employment probability in 2021. Anxiety and depression show significant negative effects on individuals' labor market integration, but with a less severe impact compared to a PTSD diagnosis.

Psychosocial Attributes of Housing and Their Relationship With Health Among Refugee and Asylum-Seeking Populations in High-Income Countries: Systematic Review

Objectives: Housing as a social determinant of health should provide not only shelter, but also a feeling of home. We explored psychosocial pathways creating a sense of home and influencing the relationship between housing and health among asylum seekers and refugees (ASR) in high-income countries. Methods: We performed a systematic review. To be included, studies had to be peer-reviewed, published between 1995 and 2022, and focus on housing and health of ASR in high-income countries. We conducted a narrative synthesis. Results: 32 studies met the inclusion criteria. The psychosocial attributes influencing health most often identified were control, followed by expressing status, satisfaction, and demand. Most attributes overlap with material/physical attributes and have an impact on ASR's mental health. They are closely interconnected with each other. Conclusion: Psychosocial attributes of housing play an essential role in the health of ASR; they are closely associated with material/physical attributes. Therefore, future research on housing and health of ASR should routinely study psychosocial attributes, but always in association with physical ones. The connections between these attributes are complex and need to be further explored. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/, identifier CRD42021239495.

Social connectedness as a determinant of mental health: A scoping review

Public health and epidemiologic research have established that social connectedness promotes overall health. Yet there have been no recent reviews of findings from research examining social connectedness as a determinant of mental health. The goal of this review was to evaluate recent longitudinal research probing the effects of social connectedness on depression and anxiety symptoms and diagnoses in the general population. A scoping review was performed of PubMed and PsychInfo databases from January 2015 to December 2021 following PRISMA-ScR guidelines using a defined search strategy. The search yielded 66 unique studies. In research with other than pregnant women, 83% (19 of 23) studies reported that social support benefited symptoms of depression with the remaining 17% (5 of 23) reporting minimal or no evidence that lower levels of social support predict depression at follow-up. In research with pregnant women, 83% (24 of 29 studies) found that low social support increased postpartum depressive symptoms. Among 8 of 9 studies that focused on loneliness, feeling lonely at baseline was related to adverse outcomes at follow-up including higher risks of major depressive disorder, depressive symptom severity, generalized anxiety disorder, and lower levels of physical activity. In 5 of 8 reports, smaller social network size predicted depressive symptoms or disorder at follow-up. In summary, most recent relevant longitudinal studies have demonstrated that social connectedness protects adults in the general population from depressive symptoms and disorders. The results, which were largely consistent across settings, exposure measures, and populations, support efforts to improve clinical detection of high-risk patients, including adults with low social support and elevated loneliness.

Effect of a self-help group intervention using Teaching Recovery Techniques to improve mental health among Syrian refugees in Norway: a randomized controlled trial

Background

Mental health symptoms among refugees are common, often related to chronic pain disorders, and their management is usually challenging. Studies evaluating the effect of group therapies among adult refugees to improve mental health symptoms are scarce.

Aims

To assess the effect of Teaching Recovery Techniques (TRT) on mental health and to reduce pain disorder among adult Syrian refugees.

Method

A randomized controlled trial was designed to study the effect of a self-help group intervention using TRT. The outcomes, mental health symptoms measured by Impact of Event Scale-Revised (IES-R) and General Health Questionnaire (GHQ-12) and chronic pain measured by Brief Pain Inventory (BPI), were reported as regression coefficients (B) with 95% confidence intervals.

Results

Seventy-six adults participated: 38 in the intervention and 38 in the control groups. Intention-to-treat analyses showed a significant effect on general mental health as measured by GHQ-12 with B (95% CI) of -3.8 (-7.2, -0.4). There was no effect of TRT on mental health when assessed by IES-R (-1.3 (-8.7, 6.2)) or on pain levels assessed by BPI (-0.04 (-4.0, 3.9)).

Conclusions

This self-help group intervention significantly improved general mental health symptoms among adult refugees but had no effect on trauma symptoms or chronic pain. Higher participation rates might be necessary to achieve the full potential of TRT.

Trial registration: The trial was registered with Clinical Trials.gov at https://clinicaltrials.gov/ct2/show/NCT03951909. To include user participation in the design of the interventions, the study was retrospectively registered on 19 February 2019.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13033-022-00557-4.

Mental health outcomes in Syrian refugees: A systematic review

BACKGROUND

Syria is the main country of origin for refugees in the world. The prevalence of mental disorders in this population is high, but there is a lack of more comprehensive data on mental health issues in this population.

AIM

This study aims to review the literature for mental health outcomes in Syrian refugees.

METHODS

We performed a systematic quantitative literature review of original observational studies indexed on the MEDLINE via PubMed, Embase, Web of Science, PsycINFO, LILACS, and SciELO databases with quantitative data reporting mental health outcomes in Syrian refugees. A descriptive analysis was conducted, and the quality of the included studies was assessed using an adaptation from The National Institutes of Health (NIH) quality assessment tool for observational studies. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were followed.

RESULTS

A total of 64 studies were included. The majority were published between 2019 and 2020, and focused on the prevalence of post-traumatic stress disorder (PTSD), depression, and anxiety, with a wide range of variations. Other outcomes were difficulties in the post-migration period and promotive factors for mental health, such as resilience, positive coping strategies, and psychosocial well-being.

CONCLUSIONS

High prevalence rates of mental disorders were observed, as well as risk factors for their occurrence. Studies showed a very high variability of prevalence rates and heterogeneity in methodologies. There is a need for research focusing on other determinants and specific necessities for mental health, especially in the post-resettlement period.

The relationship between employment and health for people from refugee and asylum-seeking backgrounds: A systematic review of quantitative studies

Background

For the general population, the positive effects of paid employment on health and wellbeing are well established. However, less is known for people from refugee and asylum-seeking backgrounds. This review aims to systematically summarise the quantitative literature on the relationship between employment and health and wellbeing for refugees and asylum seekers.

Method

A search strategy was conducted in online databases, including MEDLINE, PsychINFO, EMCARE, SCOPUS, CINHAL, ProQuest and Web of Science. Articles were screened against inclusion and exclusion criteria. Studies published in English between 2000 to October 2021 were included if they used quantitative methods to consider the relationship between employment and health for refugees and asylum seekers in resettlement countries. Study quality was assessed using The Joanna Briggs Institute's Critical Appraisal Tools. Findings were synthesised using a narrative approach.

Results

Seventy-two papers were identified. The majority of papers (N = 58, 81%) examined the association between employment and mental health outcomes. Overall, while there were inconsistencies in the findings, employment had a positive effect on mental health particularly in reducing levels of psychological distress and depression. Though more limited in number, the papers examining physical health suggest that people who are employed tend to have better physical health than unemployed persons. There was some evidence to support the bi-directional relationship between employment and health. Poor mental and physical health negatively impacted the odds of employment and occupational status of refugees.

Conclusion

Good quality employment is an essential component of refugee resettlement and this review found that in general employment is also beneficial for refugee health, particularly aspects of mental health. More research regarding the effects of employment on physical health is required. The effects of refugee-specific factors such as gender roles, torture, and trauma on the relationship between employment and health also require further investigation.

Social Determinants of Mental Health Among Karen Refugees from Burma

Extant literature has documented a higher level of mental health issues among refugee populations compared with that of the general population. Mental health problems may significantly decrease refugees' quality of life and interfere with a successful transition to their country of resettlement. Using the social determinants of mental health framework, we examined factors affecting psychological distress among Karen refugees from Burma residing in a mid-size city in a northeastern state in the United States. A total of 201 participants completed face-to-face interviews conducted in the Karen language. Results showed that trauma and religious participation were positively associated and education and health status were negatively associated with psychological distress. The findings of this study reiterate the importance of trauma and health conditions to mental health and suggest potential points of interventions among the resettled Karen refugees.

Prevalence of common mental disorders in adult Syrian refugees resettled in high income Western countries: a systematic review and meta-analysis

BACKGROUND

The immense social upheaval and ongoing humanitarian crisis created by the 2011 war in Syria has forced millions of civilians to flee their homeland, many of whom seek refugee status in Western nations. Whilst it is known that the prevalence of mental illness is higher within refugee populations, this systematic review and meta-analysis aims to pool the prevalence rates of common mental disorders (namely posttraumatic stress disorder, depression and generalized anxiety disorder) in adult Syrian refugees resettled in high income Western countries.

METHODS

Seven electronic databases (Medline, PsychInfo, CINAHL, PTSDpubs, SCOPUS, PubMed and Embase) were searched up to the 31st of December 2020. Using pre-determined inclusion and exclusion criteria, relevant articles were screened by title and abstract, and later by full text. A meta-analysis was used to estimate the prevalence rates for each mental illness.

RESULTS

Eleven studies met the eligibility criteria for the systematic review. Nine of these studies had a low-moderate risk of bias and were included in the meta-analysis. Of the 4873 refugees included in the meta-analysis, the total pooled prevalence rate of having any of the three mental disorders was 33% (CI 95%, 27-40%), 40% for anxiety (CI 95%, 31-50%), 31% for depression (CI 95%, 20-44%) and 31% for PTSD (CI 95%, 22-41%). A meta-regression revealed that the total pooled prevalence rate for having any of the three mental disorders was not influenced by age, host country, duration in host country, educational or marital status.

CONCLUSIONS

Despite significant study heterogeneity, the prevalence rates of common mental disorders in adult Syrian refugees resettled in high-income Western countries are significantly higher than reported rates in the general population.

Fear of COVID-19 and Depression, Anxiety, Stress, and PTSD among Syrian Refugee Parents in Canada

Introduction

The high frequency of COVID-19 has had an impact on the psychological health of all countries and socioeconomic groups around the world, with refugees suffering the brunt of the burden. The aim was to assess the relationship between fear of COVID-19 and depression, anxiety, stress, and PTSD among Syrian refugee parents residing in the Greater Toronto Area.

Methods

A convenience sample of 274 Syrian refugee parents residing in Ontario was recruited. Fear of COVID-19 was measured using the Fear of COVID-19 Scale (FCV-19S). Levels of depression, anxiety, stress and PTSD were assessed using the Depression Anxiety Stress Scales (DASS-21), and Primary Care PTSD screen (PC-PTSD). Multiple Linear Regression analyses were performed to assess the relationship between FCV-19S and the DASS-21 subscales and PC-PTSD.

Results

Severe levels of depression, anxiety, and stress were reported by 12.2%, 26.8%, and 9.7% of participants respectively, and 24.1% screened positive for PTSD. FCV-19S was associated with higher levels of stress (β = 0.27, p = 0.006), anxiety (β = 0.40, p <0.001), depression (β = 0.32, p = 0.001) and PTSD (β = 0.04, p = 0.015).

Discussion

Government initiatives should consider tackling fear concerning pandemics among Syrian refugee parents to help enhance their mental well-being.

Integration Is Correlated With Mental Health Help-Seeking From the General Practitioner: Syrian Refugees' Preferences and Perceived Barriers

Despite a seemingly higher need, refugees in Europe tend to underuse mental health (MH) services. To better understand this underuse, it is important to understand refugees' willingness and ability to seek help from their general practitioner (GP) when experiencing MH problems. We employed a combined vignette and survey design to explore how the GP fits into the larger context of help-seeking preferences among a sample of Syrian refugees in Norway (n = 92), and what barriers they perceive in accessing help from the GP. We also examined how indicators of integration relate to seeking help from the GP. We take an exploratory approach. Participants were presented a vignette of an individual with symptoms in line with ICD-10 and DSM-5 criteria for depression. Participants were somewhat likely to seek help from the GP; however, seeking help from one's relationship with Allah/God and one's partner was preferred. Furthermore, while the GP was rated a somewhat likely help-seeking source, most participants indicated an average of two barriers to seeking help from the GP. Finally, social ties to the majority population in the form of social integration and feelings of connectedness with the host country (psychological integration) were positively correlated with likelihood of seeking help from the GP. Taken together, these findings suggest that the GP is considered a viable source of help among Syrians with a refugee background in the current sample, but that this may be influenced by perceived barriers and social as well as psychological integration. Addressing these barriers and promoting psychosocial integration with the host country are key to facilitating access and usage amongst refugees in need of MH services.