Refugee mental health, beyond high-income countries

It's easy to imagine that refugees are more likely to experience depression, anxiety, and PTSD — research has shown this to be the case time and time again. 

However, much of this research focuses on refugees to higher-income countries, despite the fact that they are much more likely to come to live in lower- or middle-income countries. The information we have about the mental health of refugees is, therefore, likely to be skewed, and may only paint a partial picture of mental health amongst those seeking a safer place to call home. 

Harvard's Julia R. Pozuelo and team sought to correct this bias with their latest research project. Recently published in BMJ Mental Health, their paper explores the experiences of refugees in three East-African countries: Kenya, Uganda, and Ethiopia. A total of 8,303 refugees and 7,612 local community members residing in the three countries provided data for the study, with participants were living both in capital cities and inside and nearby refugee camps.

Participants completed a standard measure for depressive symptoms (known as the Patient Health Questionnaire 9, or PHQ-9) alongside a disability assessment which assessed for mobility issues, ability to engage in life activities, cognition, and participation in community activities. 

Next, participants reported their exposure to violence — the team later divided these reports into either objective or self-reported exposures. Objective exposure to violence was determined by comparing participant reports to data on externally verified conflict locations and details. Participants also indicated whether they had ever been victims or witnesses of violence of torture, either in their own countries or since leaving. 

Finally, the team explored socioeconomic outcomes. All participants reported their employment status, as well as the amount of income they received from their work, and how satisfied they were with their life on a five-point scale. Information on how varied their diet was in the week preceding the data collection was also gathered. 

Compared to the general population, there was a higher level of depressive symptoms and functional impairment in refugees: overall, 31% of refugees were moderately or severely depressed, while just 10% of the host population experienced the same level of symptoms. Some subsections of the refugee population experienced more severe depression, with women, older people, and those who had been refugees for longer tending towards higher scores on the PHQ-9. 

Rates of functional impairment were also substantial. A significant proportion of refugees had moderate or severe issues with walking and standing, as well as performing household chores, concentrating, and learning. At least partially as a result of these difficulties, they also experienced issues with participating in their communities. The same demographic measures held here, too, meaning women, older people, and those who had been refugees for a longer period of time were more affected. 

The majority of refugees (72%) in this study had been exposed to violence or torture, either as a witness (62%) or as a victim (64%). This interwove with the above measures, with results showing that those exposed to more violence are more likely to experience severe depression, alongside a significant chance of functional impairment. Exposure to violence, along with higher levels of depression and functional impairment, was also linked to a reduction in income, lower life satisfaction, and lower dietary diversity. 

To many of us, it may seem obvious which of the measured factors lead to which outcomes. However, the relationship between these variables is likely to be complex and nuanced. While this study demonstrates the interplay between socioeconomic outcomes, violence, and mental health, the findings are correlational, making it impossible to pick apart the direction of relationships between these factors. Further research is merited to more fully understand these relationships, and to help shape interventions to be as effective as they can be.

The authors highlight the importance of screening refugees for mental health concerns on arrival, and the pressing need for expansion of evidence-based treatment to prevent issues spiralling over time. Beyond the obvious humanitarian imperative to provide treatment, these findings also pose a convincing economic argument for improved mental health treatments for refugees, with higher mental wellbeing being associated with relatively more socioeconomic stability.

Read the paper in full: https://mentalhealth.bmj.com/content/26/1/e300773.info