Refugee blues: a UK and European perspective

Mental health and mental health help-seeking behaviors among first-generation voluntary African migrants: A systematic review

PURPOSE

Mental health challenges are highly prevalent in African migrants. However, understanding of mental health outcomes in first-generation voluntary African migrants is limited, despite the unique challenges faced by this migrant subgroup. This review aimed to synthesize the literature to understand the mental health challenges, help-seeking behavior, and the relationship between mental health and mental health help-seeking behavior in first-generation voluntary African migrants living outside Africa.

METHODS

Medline Complete, EMBASE, CINAHL Complete, and APA PsychINFO were searched for studies published between January 2012 to December 2023. Retrieved articles were processed, data from selected articles were extracted and synthesized to address the study aims, and included studies were evaluated for risk of bias.

RESULTS

Eight studies were included, including four quantitative and four qualitative studies, which focused on women with postnatal depression. Mental health challenges reported in the quantitative studies were depression, interpersonal disorders, and work-related stress. Risk (e.g., neglect from health professionals and lack of social/spousal support) and protective (e.g., sensitivity of community services and faith) factors associated with mental health were identified. Barriers (e.g., cultural beliefs about mental health and racial discrimination) and facilitators (sensitizing African women about mental health) of mental health help-seeking behavior were also identified. No significant relationship was reported between mental health and mental health help-seeking behavior, and the risk of bias results indicated some methodological flaws in the studies.

CONCLUSION

This review shows the dearth of research focusing on mental health and help-seeking behavior in this subgroup of African migrants. The findings highlight the importance of African migrants, especially mothers with newborns, examining cultural beliefs that may impact their mental health and willingness to seek help. Receiving countries should also strive to understand the needs of first-generation voluntary African migrants living abroad and offer mental health support that is patient-centered and culturally sensitive.

Criminalization of Asylum Seekers in Israel: Toward an Agentic Research Perspective that Opposes Othering and Estrangement

At the start of the millennium, asylum seekers (ASs) from Eritrea and South Sudan began arriving in Israel as a consequence of armed conflicts in their countries. In their first months of stay, their civil status was not regulated. Later on, the state regulated it based on the Prevention of Infiltration Law (1954), originally designed to prevent Palestinian-Arab refugees from returning to the country. The African ASs represent less than one-third of the undocumented immigrants in Israel but their skin color highlights their alienness thus they are prone to both official and unofficial criminalization. This paper deals with state violence directed at the African ASs through practices of criminalization and othering as applied by Israeli politics and the justice system towards undocumented African migrants in Israel as dangerous and undesirable others. The discussion presents implications for an agentic human rights action-based model for further inquiry and practice that resists othering.

Rapid mental health screening in conflict zones: a translation and cross-cultural adaptation into Arabic of the shortened Revised Child Anxiety and Depression Scale (RCADS-25)

Background

During conflict, children and adolescents are at increased risk of mental health problems and in particular, anxiety and depression. However, mental health screening in conflict settings is problematic and carries risk making the need for fast, easy-to-administer, screening instruments paramount. The shortened version of the Revised Child Anxiety and Depression Scale (RCADS-25) is one method of rapidly assessing anxiety and depressive symptoms in youths. This self-report questionnaire demonstrates good internal consistency and diagnostic capacity in clinical and non-clinical populations. Nevertheless, few studies have tested the psychometric properties of translated versions of the RCADS-25 limiting its applicability worldwide.

Objectives

To expand the reach and utility of the RCADS-25, the present study sought to develop an Arabic version of the instrument (RCADS25-Arabic) and to explore its reliability and underlying factor structure. In light of changes to DSM classification, the effects of removing indicator variables for obsessive-compulsive disorder on the psychometrics of the RCADS25-Arabic were also explored.

Method

The scale was back translated into Modern Standard Arabic and administered to 250 Arabic speaking schoolchildren between 8 and 15 years of age in Syria. Mean and standard deviation were used to characterise the sample and summarize scores. The reliability and factor structure of the RCADS25-Arabic was explored using confirmatory factor analysis.

Results

Females were 127 and mean age was 12.11 ± SD 2.35. Males scored lower on anxiety (M 15.05 SD ± 8.0, t(248) = − 3.15, p = .003, d = 0.39) and internalizing factors (M 26.1 SD ± 13.1, t(248) = − 2.36, p = .0160, d = 0.31) with no statistical gender difference recorded for depression (t(248) = − 1.27, p = .202). Fit statistics were good for two- and one-factor solutions (χ²/df = 1.65, RMSEA 0.051, CFI .91, TLI .90 and χ²/df = 1.64 and RMSEA 0.051, CFI .91 and TLI .89 respectively). DIFFTEST showed no significant difference between models (χ²_diff (1) = 0.03, p < 0.86) indicating a one-factor (internalizing) solution was preferable. No improvement in scale integrity was found after deleting obsessive-compulsive disorder items.

Conclusion

The RCADS25-Arabic is useful for rapid screening of depression and anxiety but is better used to identify a one-factor internalizing construct. Obsessive-compulsive disorder items should be retained in the RCADS-25.

Severity profiles of posttraumatic stress, depression, anxiety, and somatization symptoms in treatment seeking traumatized refugees

BACKGROUND

Western countries are facing many challenges hosting refugees from several regions in the world. Many of them are severely traumatized and suffer from a variety of mental health symptoms, which complicates the identification and treatment of refugees at risk. This study examined subgroups based on a broad range of psychopathology, and several predictors, including trauma characteristics and gender.

METHODS

Participants were 1147 treatment-seeking, traumatized refugees. Latent profile analysis was conducted to identify different subgroups based on levels of posttraumatic stress disorder (PTSD), depression, anxiety, and somatic symptoms. Multinomial logistic regression was used to identify predictors of subgroup membership.

RESULTS

Three distinct subgroups were identified, reflecting Moderate (10.2%), Severe (43.0%), and Highly Severe (45.9%) symptom severity levels, respectively. Symptom severity of all psychopathology dimensions was distributed equally between the subgroups. Participants in the Severe and Highly Severe Symptoms subgroups reported more types of traumatic events compared to the Moderate subgroup. In particular, traumatic events associated with human right abuses, lack of human needs and separation from others predicted subgroup membership, as did gender.

LIMITATIONS

The results are confined to treatment-seeking, traumatized refugee populations.

CONCLUSIONS

Distinguishable symptom severity profiles of PTSD, depression, anxiety and somatic complaints could be identified in this large treatment-seeking refugee population, without qualitative differences in symptom distribution. Instead of focusing on specific mental disorders, classification based on overall symptom severity is of interest in severely traumatized patients. This knowledge will help to identify individuals at risk and to enhance existing treatment programs for specific patient groups.

A decennial review of psychotraumatology: what did we learn and where are we going?

On 6 December 2019 we start the 10th year of the European Journal of Psychotraumatogy (EJPT), a full Open Access journal on psychotrauma. This editorial is part of a special issue/collection celebrating the 10 years anniversary of the journal where we will acknowledge some of our most impactful articles of the past decade (also discussed below and marked with * in the reference list). In this editorial the editors present a decennial review of the field addressing a range of topics that are core to both the journal and to psychotraumatology as a discipline. These include neurobiological developments (genomics, neuroimaging and neuroendocrine research), forms of trauma exposure and impact across the lifespan, mass trauma and early interventions, work-related trauma, trauma in refugee populations, and the potential consequences of trauma such as PTSD or Complex PTSD, but also resilience. We address innovations in psychological, medication (enhanced) and technology-assisted treatments, mediators and moderators like social support and finally how new research methods help us to gain insights in symptom structures or to better predict symptom development or treatment success. We aimed to answer three questions 1. Where did we stand in 2010? 2. What did we learn in the past 10 years? 3. What are our knowledge gaps? We conclude with a number of recommendations concerning top priorities for the future direction of the field of psychotraumatology and correspondingly the journal.

Psychiatric Disorders in Refugees and Internally Displaced Persons After Forced Displacement: A Systematic Review

Background: Protracted armed conflicts not only shape political, legal, and socio-economic structures, but also have a lasting impact on people's human migration. In 2017, the United Nations High Commissioner for Refugees reported an unprecedented number of 65.6 million individuals who were displaced worldwide as a result of armed conflicts. To date, however, little is known about these people's mental health status. Therefore, we conducted a systematic review of the prevalence of psychiatric disorders among forcibly displaced populations in settings of armed conflicts. Methods: We undertook a database search using Medline, PsycINFO, PILOTS, and the Cochrane Library, using the following keywords and their appropriate synonyms to identify relevant articles for possible inclusion: "mental health," "refugees," "internally displaced people," "survey," and "war." This search was limited to original articles, systematic reviews, and meta-analyses published after 1980. We reviewed studies with prevalence rates of common psychiatric disorders-mood and anxiety disorders, psychotic disorders, personality disorders, substance abuse, and suicidality-among adult internally displaced persons (IDPs) and refugees afflicted by armed conflicts. Results: The search initially yielded 915 articles. Of these references 38 studies were eligible and provided data for a total of 39,518 adult IDPs and refugees from 21 countries. The highest prevalence were for reported for post-traumatic stress disorder (3-88%), depression (5-80%), and anxiety disorders (1-81%) with large variation. Only 12 original articles reported about other mental disorders. Conclusions: These results show a substantial lack of data concerning the wider extent of psychiatric disability among people living in protracted displacement situations. Ambitious assessment programs are needed to support the implementation of sustainable global mental health policies in war-torn countries. Finally, there is an urgent need for large-scale interventions that address psychiatric disorders in refugees and internally displaced persons after displacement.

The psychotherapeutic care of refugees in Europe: treatment needs, delivery reality and recommendations for action

The special issue of the European Journal of Psychotraumatology released on 7 November 2017 focused on traumatized refugees and on the mental health burden, screening instruments and interventions in different groups of refugees. This contribution takes up this discussion on the needs and challenges for mental healthcare of traumatized refugees from the point of view of the practitioners. It reports on the findings of a survey on the treatment situation and the delivery reality of healthcare for refugees in 14 European countries, identifies treatment gaps, and sets recommendations for action at the political and therapeutic levels. The survey was conducted by the Federal Chamber of Psychotherapists with the assistance of the Network for Psychotherapeutic Care in Europe. The findings underline the need for appropriate mental healthcare for this population.

Traumatized refugees: identifying needs and facing challenges for mental health care

In the past few years the number of refugees worldwide has increased dramatically. Many of them were traumatized in their homelands due to violent conflict or persecution, as well as during their flight, and are confronted with ongoing stressors in the exile countries. In order to contribute to enhancing the clinical knowledge, this special issue of the European Journal of Psychotraumatology focuses on traumatized refugees. It includes three review articles as well as four original articles on the mental health burden, screening instruments and interventions in different groups of refugees. The articles published in this special issue focus on important aspects of better understanding the needs of traumatized refugees, as well as on identifying and offering appropriate mental health care for this population. Future research recommendations are provided in the hope to contribute to improving mental health care strategies of this still underserved population.

Culture-sensitive psychotraumatology

BACKGROUND

Although there is some evidence of the posttraumatic stress disorder (PTSD) construct's cross cultural validity, trauma-related disorders may vary across cultures, and the same may be true for treatments that address such conditions. Experienced therapists tailor psychotherapy to each patient's particular situation, to the nature of the patient's psychopathology, to the stage of therapy, and so on. In addition, culture-sensitive psychotherapists try to understand how culture enhances the meaning of their patient's life history, the cultural components of their illness and help-seeking behaviors, as well as their expectations with regard to treatment. We cannot take for granted that all treatment-seeking trauma survivors speak our language or share our cultural values. Therefore, we need to increase our cultural competencies.

METHODS

The authors of this article are clinicians and/or researchers from across the globe, working with trauma survivors in various settings. Each author focused on one or more specific cultural aspects of working with trauma survivors and highlighted the following aspects.

RESULTS

As a result of culture-specific individual and collective meanings linked to trauma and trauma-related disorders survivors may be exposed to (self-)stigma in the aftermath of trauma. Patients who are reluctant to talk about their traumatic experiences may instead be willing to write or use other ways of accessing the painful memories such as drawing. In other cultures, community and family cohesion are crucial elements of recovery. While awareness of culture-specific aspects is important, we also need to beware of premature cultural stereotyping. When disseminating empirically supported psychotherapies for PTSD across cultures, a number of additional challenges need to be taken into account: many low and middle income countries have very limited resources available and suffer from a poor health infrastructure.

CONCLUSIONS

In summary, culture-sensitive psychotraumatology means assuming an empathic and non-judgmental attitude, trying to understand each individual's cultural background.

Case report: manualized trauma-focused cognitive behavioral therapy with an unaccompanied refugee minor girl

BACKGROUND

There is uncertainty whether young traumatized refugees should be treated with culturally adapted psychotherapy or with an evidence-based western approach. As yet, empirical studies on culturally adapted treatments for unaccompanied young refugees in industrialized host countries are not available. Studies do, however, suggest that trauma-focused treatment is promising for this group.

OBJECTIVE

We describe the treatment of an unaccompanied refugee minor girl with posttraumatic stress disorder (PTSD) who underwent manualized trauma-focused cognitive behavioral therapy (TF-CBT; Cohen, Mannarino, & Deblinger, 2006).

METHODS

A 17-year-old girl from East Africa, who came to Germany without a caregiver, was treated for PTSD resulting from several traumatic experiences and losses in her home country and while fleeing. She lived in a group home for adolescents. Baseline, post, and follow-up data are reported.

RESULTS

The girl participated in 12 sessions of manualized TF-CBT. Her caregiver from the youth services received another 12 sessions in line with the treatment manual. Symptoms decreased in a clinically significant manner; at the end of the treatment, the girl was deemed to have recovered from PTSD. Treatment success remained stable over 6 months.

CONCLUSIONS

Manualized TF-CBT is feasible for young refugees without significant cultural adaptations. It can, however, be seen as culturally sensitive.

Impact of new traumatic or stressful life events on pre-existing PTSD in traumatized refugees: results of a longitudinal study

BACKGROUND

A significant proportion of trauma survivors experience an additional critical life event in the aftermath. These renewed experiences of traumatic and stressful life events may lead to an increase in trauma-related mental health symptoms.

METHOD

In a longitudinal study, the effects of renewed experiences of a trauma or stressful life event were examined. For this purpose, refugees seeking asylum in Germany were assessed for posttraumatic stress symptoms (PTS), Posttraumatic Stress Diagnostic Scale (PDS), anxiety, and depression (Hopkins Symptom Checklist [HSCL-25]) before treatment start as well as after 6 and 12 months during treatment (N=46). Stressful life events and traumatic events were recorded monthly. If a new event happened, PDS and HSCL were additionally assessed directly afterwards. Mann-Whitney U-tests were performed to calculate the differences between the group that experienced an additional critical event (stressful vs. trauma) during treatment (n=23) and the group that did not (n=23), as well as differences within the critical event group between the stressful life event group (n=13) and the trauma group (n=10).

RESULTS

Refugees improved significantly during the 12-month period of our study, but remained severely distressed. In a comparison of refugees with a new stressful life event or trauma, significant increases in PTS, anxiety, and depressive symptoms were found directly after the experience, compared to the group without a renewed event during the 12 months of treatment. With regard to the different critical life events (stressful vs. trauma), no significant differences were found regarding overall PTS, anxiety, and depression symptoms. Only avoidance symptoms increased significantly in the group experiencing a stressful life event.

CONCLUSION

Although all clinicians should be aware of possible PTS symptom reactivation, especially those working with refugees and asylum seekers, who often experience new critical life events, should understand symptom fluctuation and address it in treatment.

Prevention and public health approaches to trauma and traumatic stress: a rationale and a call to action

BACKGROUND

The field of trauma and traumatic stress is dominated by studies on treatments for those who experience adversity from traumatic experiences. While this is important, we should not neglect the opportunity to consider trauma in a public health perspective. Such a perspective will help to develop prevention approaches as well as extend the reach of early interventions and treatments. The purpose of this paper is to provide an introduction to a public health approach to trauma and traumatic stress and identify key opportunities for trauma professionals and our professional societies (such as the International Society for Traumatic Stress Studies [ISTSS] and the European Society for Traumatic Stress Studies [ESTSS]) to increase our societal impact by adopting such an approach.

METHOD

This paper reviews and summarizes key findings related to the public health impact of trauma. The special case of children is explored, and a case example of the Norwegian terrorist attacks in 2011 illustrates the potential for improving our response to community level traumatic events. We also discuss how professional organizations such as ESTSS and ISTSS, as well as individual trauma professionals, can and should play an important role in promoting a public health approach.

RESULTS

Trauma is pervasive throughout the world and has negative impacts at the personal, family, community, and societal levels. A public health perspective may help to develop prevention approaches at all of these levels, as well as extend the reach of early interventions and treatments.

CONCLUSIONS

Professional organizations such as ESTSS and ISTSS can and should play an important role in promoting a public health approach. They should promote the inclusion of trauma in the global public health agenda and include public health in their activities.