Review of Refugee Mental Health Assessment: Best Practices and Recommendations

[Psychodiagnostics in Psychosocial Centers for Refugees]

OBJECTIVE

Accurate psychodiagnostics is crucial for diagnosing and ensuring quality treatment for individuals with mental health disorders. However, there is limited understanding of psychodiagnostic practices within Psychosocial Centers (PSZ) when dealing with refugees, particularly in the presence of language and cultural barriers and resource constraints. This study aims to evaluate the current status and potential pathways for enhancing culturally sensitive diagnostics in this context.

METHODS

We conducted an online survey using a self-developed questionnaire with representatives from 32 PSZ to examine psychodiagnostic practices, barriers, and perceived development potentials, and analyzed the data descriptively.

RESULTS

Most centers prefer individual case assessments over standardized diagnostics. Key barriers to using standardized questionnaires and interviews include communication difficulties (unfamiliarity with question formats, reading and writing difficulties) and resource limitations (time, translation). When conducting diagnostics, time constraints and prioritizing complex cases are the primary challenges. Additional assessments are needed for several disorders and languages. Employees are interested in receiving training in the field of culturally sensitive diagnostics.

DISCUSSION

Diagnostic practice in the PSZs is characterized by numerous challenges that differ from the challenges in standard care. In order to ensure appropriate standardized diagnostics and care for mentally distressed people with a refugee or migrant background, further expansion of the linguistic and cultural adaptation of established diagnostic instruments is essential.

CONCLUSION

In the care of psychologically distressed refugees, culturally sensitive standardized diagnostics offer critical benefits for both practitioners and affected individuals. Existing resources are being referred to.

Cross-culturally adapting the GHQ-12 for use with refugee populations: Opportunities, dilemmas, and challenges

This article discusses the opportunities, dilemmas, and challenges involved in the cross-cultural adaptation (CCA) of psychological scales for use with refugee populations. It draws on insights derived from an attempt to adapt the 12-item General Health Questionnaire (GHQ-12) to the particular culture and context of Eritrean refugees residing in Israel. Multiple techniques including expert translations, a focus-group discussion, a survey, and piloting, were employed to attain a cross-cultural and conceptually equivalent measure. During the CCA process, the research team encountered issues pertaining to conceptual non-equivalence, the structure of the measure's responses and scoring system, and acceptability. These issues required the team to move beyond semantic translation by adapting certain items. This study demonstrates the compromises which need to be made in the adaptation process and indicates the potential bias which each of these compromises introduces. Despite its limitations, CCA does appear to significantly improve detection of mental health symptoms in refugee populations. Overall, the results of the present study provide support for the notion that the sensitive and appropriate assessment of individuals from refugee backgrounds requires adopting a rigorous, systematic, and contextual approach to instrument adaptation, with an emphasis on the integration of idioms of distress as well as the adaptation of Likert-type scales.

Barriers and facilitators to refugees and asylum seekers accessing non hospital based care: A mixed methods systematic review protocol

Context

Social exclusion is characterised by and represents a form of disadvantage and marginalisation of vulnerable groups of people in society, who cannot fully participate in the normal activities of daily living. People who are socially excluded such as asylum seekers and refugees have complex healthcare needs and tend to present more to the acute hospital setting as emergency presentations. Little is known about barriers and facilitators experienced by this group to accessing nonhospital based care.

Objectives

This mixed methods systematic review, will critically examine the concept of barriers and facilitators for refugees and asylum seekers to accessing non hospital based care.

Methods

This methodological review will follow the Joanna Briggs Institute guidance for conducting mixed methods reviews. The following databases will be searched: Central Medline, PubMed, Embase, CINAHL, and the Cochrane Library. Relevant grey literature will be included. Title and abstract screening, followed by full-text screening will be undertaken independently by two reviewers. The Joanna Briggs Institute extraction tool will be adapted for data extraction.

Discussion

This mixed method review will comprehensively evaluate quantitative and qualitative data, synthesise both barriers and facilitators and follow a systematic approach through establishing use of mixed methods research across asylum seekers and refugees, and how they affect accessing non-hospital based care. It will explore conceptual models of access to healthcare and how they influence these factors.

Development of the Refugees and Asylum Seekers Occupational Satisfaction (RASOS) Assessment Tool

The objective of this study was to develop an occupation-centered and client-centered assessment tool for refugees and asylum seekers. A preliminary tool outline was produced based on a literature review, while considering previous published tools' strengths and limitations. A qualitative study was undertaken via focus groups to improve on the tool's design and adequacy for its purpose, resulting in the creation of a pilot version of the tool. Convenience sampling included 8 Greek and Cypriot professional and student occupational therapists with experience in the field, 8 international expert occupational therapists, 4 laypeople, 4 humanitarian professionals, and 5 refugees and asylum seekers. Basic qualitative content and thematic analysis led to topics regarding tool modifications that concerned categorization, formation/structure, wording, administration, and assessment scale. Corresponding tool revisions ensued. This study led to the development of the pilot version of the Refugees and Asylum Seekers Occupational Satisfaction (RASOS), which can also be used to identify underlying personal and environmental factors that contribute to self-perceived low satisfaction. A future quantitative study is required to establish the psychometric properties of the tool.

The refugee and asylum seeker mental health treatment screener (RAS-MT-screener): Feasibility and psychometric properties of a questionnaire detecting refugees' and asylum seekers' need and urgency for mental health treatment

OBJECTIVE

Refugees and asylum seekers are highly vulnerable to the development of mental health problems, yet oftentimes their need is underestimated. We aimed to develop a culturally sensitive screening tool for primary care settings assessing the urgency and need for mental health treatment to close this gap.

METHOD

Items for the screening tool were selected out of an item pool generated by a group of clinical experts based on the data obtained from n = 307 asylum seekers in a refugee state registration and reception center in Germany. Out of these, n = 111 attended a psychosocial walk-in clinic, and clinicians' ratings of urgency and need for mental health treatment were added.

RESULTS

The resulting questionnaire comprised 8 items assessing urgency and 13 items assessing need for mental health treatment. Sensitivity was =0.74 and specificity =0.70. Participants of clinical and non-clinical samples differ highly significantly (p < .001). Cross-cultural validity was shown by comparing measurement invariance for different countries of origin.

CONCLUSION

The RAS-MT-Screener is a clinically and cross-culturally valid screening tool in primary care settings for the urgency and need for mental health treatment with acceptable psychometric properties. Future research on its external and construct validity is warranted.

Barriers and facilitators to refugees, asylum seekers and people experiencing homelessness accessing non hospital based care: A mixed methods systematic review protocol

Context: Social exclusion is characterised by and represents a form of disadvantage and marginalisation of vulnerable groups of people in society, who cannot fully participate in the normal activities of daily living.  Socially excluded groups consist of, but are not limited to the following groups: people experiencing homelessness, asylum seekers and refugees.  People from socially excluded groups have complex healthcare needs including infectious and non-communicable diseases. People from socially excluded groups tend to present more to the acute hospital setting as emergency presentations.  Little is known about barriers and facilitators experienced by these groups to accessing non hospital based care. Objectives: This mixed methods systematic review, will critically examine the concept of barriers and facilitators for refugees, asylum seekers and people experiencing homelessness, to accessing non hospital based care. Methods:  This methodological review will follow the Joanna Briggs Institute guidance for conducting mixed methods reviews.  The following databases will be searched: Central Medline, PubMed, Embase, CINAHL, and the Cochrane Library. Relevant grey literature will be included. Title and abstract screening, followed by full-text screening will be undertaken independently by two reviewers. The Joanna Briggs Institute extraction tool will be adapted for data extraction.   Discussion: This mixed method review will comprehensively evaluate quantitative and qualitative data, synthesise both barriers and facilitators and follow a systematic approach through establishing use of mixed methods research across a number of marginalised groups, and how they affect accessing non hospital based care.   It will explore conceptual models of access to healthcare and how they influence these factors.

Diagnostic test accuracy of screening tools for post-traumatic stress disorder among refugees and asylum seekers: A systematic review and meta-analysis

Background

Refugees and asylum seekers often experience traumatic events resulting in a high prevalence of post-traumatic stress disorder (PTSD). Undiagnosed PTSD can have detrimental effects on resettlement outcomes. Immigration medical exams provide an opportunity to screen for mental health conditions in refugee and asylum seeker populations and provide links to timely mental health care.

Objective

To assess the diagnostic accuracy of screening tools for PTSD in refugee and asylum seeker populations.

Methods

We systematically searched Medline, Embase, PsycINFO, CENTRAL and CINAHL up to 29 September 2022. We included cohort-selection or cross-sectional study designs that assessed PTSD screening tools in refugee or asylum seeker populations of all ages. All reference standards were eligible for inclusion, with a clinical interview considered the gold standard. We selected studies and extracted diagnostic test accuracy data in duplicate. Risk of bias and applicability concerns were addressed using QUADAS-2. We meta-analyzed findings using a bivariate random-effects model. We partnered with a patient representative and a clinical psychiatrist to inform review development and conduct.

Results

Our review includes 28 studies (4,373 participants) capturing 16 different screening tools. Nine of the 16 tools were developed specifically for refugee populations. Most studies assessed PTSD in adult populations, but three included studies focused on detecting PTSD in children. Nine studies looked at the Harvard Trauma Questionnaire (HTQ) with diagnostic cut-off points ranging from 1.17 to 2.5. Meta-analyses revealed a summary point sensitivity of 86.6% (95%CI 0.791; 0.917) and specificity of 78.9% (95%CI 0.639; 0.888) for these studies. After evaluation, we found it appropriate to pool other screening tools (Posttraumatic Stress Disorder Checklist, the Impact of Event Scale, and the Posttraumatic Diagnostic Scale) with the HTQ. The area under the curve for this model was 79.4%, with a pooled sensitivity of 86.2% (95%CI 0.759; 0.925) and a specificity of 72.2% (95%CI 0.616; 0.808).

Conclusions

Our review identified several screening tools that perform well among refugees and asylum seekers, but no single tool was identified as being superior. The Refugee Health Screener holds promise as a practical instrument for use in immigration medical examinations because it supports the identification of PTSD, depression, and anxiety across diverse populations. Future research should consider tool characteristics beyond sensitivity and specificity to facilitate implementation in immigration medical exams.

Registration

Open Science Framework: 10.17605/OSF.IO/PHNJV.

The impact of experiencing severe physical abuse in childhood on adolescent refugees' emotional distress and integration during the COVID-19 pandemic

Background

Accumulating evidence highlights the importance of pre- and post- migration stressors on refugees' mental health and integration. In addition to migration-associated stressors, experiences earlier in life such as physical abuse in childhood as well as current life stress as produced by the COVID-19-pandemic may impair mental health and successful integration - yet evidence on these further risks is still limited. The present study explicitly focused on the impact of severe physical abuse in childhood during the COVID-19 pandemic and evaluated the impact of these additional stressors on emotional distress and integration of refugees in Germany.

Methods

The sample included 80 refugees, 88.8% male, mean age 19.7 years. In a semi-structured interview, trained psychologists screened for emotional distress, using the Refugee Health Screener, and integration status, using the Integration Index. The experience of severe physical abuse in childhood was quantified as a yes/no response to the question: "Have you been hit so badly before the age of 15 that you had to go to hospital or needed medical attention?" Multiple hierarchical regression analyses further included gender, age, residence status, months since the start of the COVID-19 pandemic and length of stay in Germany to predict emotional distress and integration.

Results

Two regression analyses determined significant predictors of (1) emotional distress (adjusted R ² = 0.23): duration of being in the pandemic (ß = 0.38, p < 0.001) and severe physical abuse in childhood (ß = 0.31, p = 0.005), and significant predictors of (2) integration (adjusted R ² = 0.53): length of stay in Germany (ß = 0.62, p < 0.001), severe physical abuse in childhood (ß = 0.21, p = 0.019) and emotional distress (ß = -0.28, p = 0.002).

Conclusion

In addition to migration-associated stressors, severe physical abuse in childhood constitutes a pre-migration risk, which crucially affects the well-being, emotional distress and integration of refugees in Germany.

Screening Tools for Mental Disorders Among Female Refugees: a Systematic Review

Female refugees are particularly vulnerable to mental disorders but assessment may be complex and challenging. Various screening tools have been developed for this population, but little is known about their usefulness. The main aim is to examine the literature on the effectiveness of screening tools for mental health problems among female refugees. Systematic review of PubMed, PsycINFO and Embase to locate all published work. Comprehensive search terms were used and inclusion and exclusion criteria were formulated. The initial search yielded 877 articles, of which 757 were removed after titles and abstracts were reviewed. Then, 121 full-text versions of articles were examined and 96 excluded according to the criteria. A total of 25 articles were included in this systematic review in accordance with the PRIMSA guidelines. Twenty screening tools were evaluated. There is a lack of tools used to screen refugee women, and in particular those in emergency settings. Cultural factors may not be accounted for in the development of screening instruments. Further research in this field can help inform public health policies to address social, educational and occupational inclusion for refugee women in different contexts.

Mental Health Screening Approaches for Resettling Refugees and Asylum Seekers: A Scoping Review

Refugees and asylum seekers often face delayed mental health diagnoses, treatment, and care. COVID-19 has exacerbated these issues. Delays in diagnosis and care can reduce the impact of resettlement services and may lead to poor long-term outcomes. This scoping review aims to characterize studies that report on mental health screening for resettling refugees and asylum seekers pre-departure and post-arrival to a resettlement state. We systematically searched six bibliographic databases for articles published between 1995 and 2020 and conducted a grey literature search. We included publications that evaluated early mental health screening approaches for refugees of all ages. Our search identified 25,862 citations and 70 met the full eligibility criteria. We included 45 publications that described mental health screening programs, 25 screening tool validation studies, and we characterized 85 mental health screening tools. Two grey literature reports described pre-departure mental health screening. Among the included publications, three reported on two programs for women, 11 reported on programs for children and adolescents, and four reported on approaches for survivors of torture. Programs most frequently screened for overall mental health, PTSD, and depression. Important considerations that emerged from the literature include cultural and psychological safety to prevent re-traumatization and digital tools to offer more private and accessible self-assessments.

Professional mental health support seeking in Women of Refugee Background resettled in Australia: An exploratory study of facilitators and barriers

The present study is the first to investigate factors influencing professional mental health support seeking in Women of Refugee Background (WoRB) in Australia. WoRB are a vulnerable population with a range of complex mental health needs. Despite this, research has indicated that WoRB are an underrepresented population in the utilisation of mental health support services. This is a particular concern in Australia, due to an increasing number of WoRB being resettled. A multivariate logistical regression was conducted on a sample of 450 WoRB resettled in Australia from the Building a New Life in Australia (BNLA) data set to investigate factors associated with seeking professional mental health support. Several factors were identified as being significantly associated with professional mental health support seeking in WoRB resettled in Australia, including age, resettlement location, marital status, prearrival trauma involving violence against women, language barriers and health-related variables, including mental distress and long-term disability. The current study provides a unique insight into professional mental health support seeking from a gendered perspective in WoRB resettled in Australia. Insights into factors that influence seeking professional mental health support in this highly vulnerable population must inform mental health practice, service delivery and policies.

A Systematic Review of Autobiographical Memory and Mental Health Research on Refugees and Asylum Seekers

Research examining trauma, memory, and mental health among refugee and asylum-seeking people has increased in recent years. We systematically reviewed empirical work focusing on the link between autobiographical memory and mental health among these populations. The review protocol was registered with PROSPERO (CRD42018095888). Six major databases were searched in August-2020 with no time limit for publication. Following PRISMA Statement guidelines, 22 articles reporting ten quantitative, nine qualitative, and three mixed-method studies were selected from 254 articles identified in the initial search. A basic convergent and qualitative meta-integration technique was employed for data extraction. Four recurrent themes were extracted: (1) memory activation method, (2) memory features, (3) memory content, and (4) refugee mental health. Theme 1 illustrates that narrative interviews, important event recall, and cue word methods were used in most studies. Theme 2 highlights that memories of refugee people were often less specific, inconsistent, and negative-focused. Retrieval failure was also common among these people. Theme 3 reveals that refugee and asylum-seeking people frequently discussed their abandoned identities, lost resources, injustices, ongoing sufferings, and pointless futures. Finally, theme 4 identifies the prevalence of various mental health conditions like Post-traumatic Stress Disorder, depression, helplessness, and anger among these people. The results are discussed in the context of the current autobiographical memory and mental health theories, considering refugee-specific experiences in the asylum process and refugee status.

Pre-migration traumatic experiences, post-migration perceived discrimination and substance use among Russian and Kurdish migrants-a population-based study

BACKGROUND AND AIMS

The associations between traumatic events, substance use and perceived discrimination have been rarely studied among migrants in host countries. We examined whether pre-migration potentially traumatic experiences (PTEs) or perceived discrimination (PD) are associated with substance use among migrants with voluntary (Russians) and forced (Kurds) migration backgrounds.

DESIGN

Cross-sectional interview and health examination data from the Finnish Migrant Health and Wellbeing Study were used. The target sample (n = 1000 for each group) was drawn from the national population register using stratified random sampling by participants' country of birth and native language.

SETTING

Population-based data were collected from six cities in Finland during 2010-12.

PARTICIPANTS

The participation rates were 68% (Russians) and 59% (Kurds). The analytical sample size varied (Russians n = 442-687, Kurds n = 459-613), as some participants completed only interview, health examination or short interview. The majority of Kurds had a refugee background (75%) while Russians had mainly migrated for other reasons (99%).

MEASUREMENTS

The three main outcomes were self-reported binge drinking, daily smoking and life-time cannabis use. PTEs and PD were self-reported in the interview. Socio-demographic background, migration-related factors and current affective symptoms were adjusted for.

FINDINGS

Among Kurds, PTEs were associated with binge drinking [adjusted odds ratio (aOR) = 2.65, 95% confidence interval (CI) = 1.30-5.42] and PD was associated with life-time cannabis use (aOR = 3.89, 95% CI = 1.38-10.97) after adjusting for contextual factors. Among Russians, PTEs were associated with life-time cannabis use adjusting for contextual factors (aOR = 2.17, 95% CI = 1.12-4.18).

CONCLUSIONS

In Finland, pre-migration traumatic experiences appear to be associated with life-time cannabis use among the Russian migrant population (voluntary migration) and binge drinking among the Kurdish migrant population (forced migration). Perceived discrimination in Finland appears to be associated with life-time cannabis use among Kurdish migrants.

Trauma and resilient functioning among Syrian refugee children

Following the civil war in Syria, there has been a growing interest in the impact of war, violent conflict, and refuge on the development and mental health of refugee children in general and Syrian refugee children in particular. The objective of this paper is threefold: (a) to critically review the existing literature on the psychological functioning of Syrian refugee children, with a particular focus on those residing in the urban areas or camps in Turkey; (b) to identify the main theoretical and methodological problems of this emerging literature; and (c) to suggest guidelines for how to improve research and practice in this field. The reviewed literature predominantly focuses on psychological trauma, trauma-related symptomatology or other maladaptive functioning in children, and psychosocial interventions conducted toward alleviating these issues. This paper will summarize the research findings in the above-mentioned topics to discern what can be known from the existing literature on Syrian refugee children.

Measuring self-rated health status among resettled adult refugee populations to inform practice and policy - a scoping review

BACKGROUND

The health status of refugees is a significant factor in determining their success in resettlement and relies heavily on self-rated measures of refugee health. The selection of robust and appropriate self-rated health measurement tools is challenging due to the number and methodological variation in the use of assessment tools across refugee health studies. This study describes the existing self-report health measures which have been used in studies of adult refugees living in the community to allow us to address the challenges of selecting appropriate assessments to measure health within refugee groups.

METHODS

Electronic databases of Ovid Medline, CINAHL, SCOPUS, Embase and Scopus.

RESULTS

This review identified 45 different self-rated health measurements in 183 studies. Most of the studies were cross sectional explorations of the mental health status of refugees living in community settings within Western nations. A third of the tools were designed specifically for use within refugee populations. More than half of the identified measurement tools have been evaluated for reliability and/or validity within refugee populations. Much variation was found in the selection, development and testing of measurement tools across the reviewed studies.

CONCLUSION

This review shows that there are currently a number of reliable and valid tools available for use in refugee health research; however, further work is required to achieve consistency in the quality and in the use of these tools. Methodological guidelines are required to assist researchers and clinicians in the development and testing of self-rated health measurement tools for use in refugee research.

Cognitive assessment of refugee children: Effects of trauma and new language acquisition

Each year, approximately 60,000 children of refugee background are resettled in Western countries. This paper reviews the effects of the refugee experience on cognitive functioning. The distinctive influences for these children include exposure to traumatic events and the need to acquire a new language, factors that need to be considered to avoid overdiagnosis of learning disorders and inappropriate educational placements. Prearrival trauma, psychological sequelae of traumatic events, developmental impact of trauma, and the quality of family functioning have been found to influence cognitive functioning, learning, and academic performance. In addition, the refugee child may be semiproficient in several languages, but proficient in none, whilst also trying to learn a new language. The influence that the child's limited English proficiency, literacy, and school experience may have on academic and test performance is demonstrated by drawing on the research on refugees' English language acquisition, as well as the more extensive literature on bilingual English language learners. Implications for interventions are drawn at the level of government policy, schools, and the individual. The paper concludes with the observation that there is a major need for longitudinal research on refugee children's learning and academic performance and on interventions that will close the academic gap, thereby enabling refugee children to reach their educational potential.

Forced Migration, Social Exclusion and Poverty: Introduction

This special issue of the journal, which is part of a global research initiative on psychology and poverty reduction, focuses specifically on the experiences of refugees and asylum seekers. Application of contemporary constructions of relative poverty and social exclusion to understanding asylum and humanitarian refuge emphasises the relative financial and social disadvantages experienced by many of these forced migrants, which may lead subsequently to them having negative experiences of resettlement and poor mental health and overall wellbeing. We argue that governments need to be cognisant of the poverty pitfalls of forced migration and to examine carefully their policies on social inclusion to ensure that current and future humanitarian and climate change refugees arriving on their shores are not forced into relative poverty.