In a one month period in February 2016 more than 43,000 refugees arrived into Greece alone. The mass exodus of peoples from the Middle East and North Africa since 2014 has raised questions as to how European nations can effectively provide good healthcare for the growing numbers of refugees. Many of these refugees have fled from extreme violence and persecution in their home countries as well as being subjected to hardships on their journey into Europe. A growing dimension in the public health response to the forced migration into Europe is how to identify and manage mental health issues that arise within refugee populations. Forced migrants may have endured years of emotional trauma that increase their risk of developing mental health problems.
Whilst data collection on the scale and magnitude of human suffering as a result of the refugee crisis are still ongoing, Hassan et al. 2016 have identified that Syrian refugees are frequently victims of torture, exploitation and gender-based violence. Migration is an incredibly stressful process and women in particular are susceptible to a wide range of stressors. Stressors, both pre- and post- migration, contribute to the risk of developing mental health problems and research suggests that refugee and asylum seeking women have high rates of depression, somatisation, PTSD, postnatal depression, and suicide.
Pre-migration stressors include events from prior to the decision to leave their home country up to the point of acceptance into the host country. Reasons for the migration can in itself be stressful (political or economic instability, natural disasters, etc.) as well as the journey itself. In particular, women may have to deal with rape and sexual violence which are known risk factors for depression and PTSD. Whilst traumatic life events pre-migration influence the mental wellbeing of refugees and asylum seekers, it is often their experience of resettlement that has a greater impact on mental health.
Upon resettlement refugee groups often have to deal with loss of support systems, personal livelihood and culture. Other factors such as poverty, unemployment, detention and experiences of discrimination also have a pertinent impact on refugee mental health. The UK’s dispersal policy of asylum seekers also contributes to isolation and loss of social networks with one study finding poor social support to be a greater risk factor for depression than a past history of torture in Iraqi refugees. Thus with the growing burden of mental health in refugees it is the responsibility of European governments to identify at risk groups and prevent negative life events post-migration, which precipitate mental illness. The impact of these stresses, for example, can be clearly seen in pregnant women as one study shows that postnatal depression may affect up to 42% of migrant women.
However, there still exists the pertinent issue on how to address mental health in refugee populations. It becomes problematic when applying Western paradigms of mental illness on refugee populations with culturally diverse understandings of psychiatric illness. Identifying ‘illness’ itself may be challenging when there are subjective interpretations of normal and abnormal behaviour. Divergent understandings of mental health also explain how Western mental health interventions may not be suited to refugee populations; psychotherapy is not an appropriate treatment in cultures where speaking about sexual violence and rape is taboo. Ultimately it is important to strengthen traditional resilience structures within refugee communities and work with these communities to develop culturally appropriate mental health interventions.
Much more work is needed in identifying the risk factors for psychiatric disorders that refugee and asylum seeking women have. It is also important to keep in mind the cultural diversity in mental health and tailor interventions to suit these women. Identifying those at increased risk will allow us to give these women support and better address their mental health needs.
Kevin Kuriakose is a 4th year medical student at UCL. Luis Ribeiro is a 5th year medical student at Imperial College London.
 Ventevogel P, Schinina G, Strang A, Gagliato M HL. Mental health and Psychosocial Support for Refugees, Asylum Seekers and Migrants on the move in Europe: a Multi-Agency Guidance note, December 2015. 2015.http://mhpss.net/resource/mental-health-and-psychosocial-support-for-refugees-asylum-seekers-and-migrants-on-the-move-in-europe-2/
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