Asylum Seeker and Refugee Mental Health
Various asylum seeker and refugee mental health research studies are looking at the mental health needs of refugees and asylum seekers, including the impact of immigration detention on child asylum seekers. Prof Suresh Sundram and Dr Debbie Hocking have collaborated in the area of forced migrant mental health for 10 years. Between them, they have investigated the social determinants of mental health, and the prevalence and types of mental disorders in refugees and asylum seekers. They have also produced a mental health screening tool - the STAR-MH - for use by non mental health trained professionals to screen for posttraumatic stress disorder and depression to enable onward referral to appropriate health care providers. Their current work focuses on understanding the prevalence and nature of psychiatric disorder in young people with asylum seeking experiences and the development of a similar screening tool.
Papers by Prof Sundram and Dr Hocking
Tho’ Much is Taken, Much Abides: Asylum Seekers’ Subjective Wellbeing
The influence of psychosocial factors on the subjective wellbeing of asylum-seekers residing in host Western countries has scarcely been explored qualitatively. Qualitative data derived from a mixed methods prospective study investigated the subjective wellbeing of 56 community-dwelling asylum-seekers and refugees at baseline and an average of 15.7 months later. Positive and negative experiences over time were explored in relation to self-perceived emotional health. Nineteen positive and 15 negative categories of experience emerged. Distinct psychosocial and protective factors were salient regarding the valence of experiences over time, with positive experiences comprising employment, improved financial circumstances, and social support or connectivity. Negative experiences included news of adversity from one’s homeland, un(der)employment, poor health, and factors relating to the refugee determination process. Positive and negative experiences were contemporaneous, indicating that employment and social support may ameliorate the detrimental impact of traversing the protracted process of refugee status determination for asylum seekers in particular.
Development and validation of a mental health screening tool....
Development and validation of a mental health screening tool for asylum-seekers and refugees: the STAR-MH
- Background: There is no screening tool for major depressive disorder (MDD) or post-traumatic stress disorder (PTSD) in asylum-seekers or refugees (ASR) that can be readily administered by non-mental health workers. Hence, we aimed to develop a brief, sensitive and rapidly administrable tool for non-mental health workers to screen for MDD and PTSD in ASR.
- Methods: The screening tool was developed from an extant dataset (n = 121) of multiply screened ASR and tested prospectively (N = 192) against the M.I.N.I. (Mini International Neuropsychiatric Interview) structured psychiatric interview. Rasch, Differential Item Functioning and ROC analyses evaluated the psychometric properties and tool utility.
- Results: A 9-item tool with a median administration time of six minutes was generated, comprising two ‘immediate screen-in’ items, and a 7-item scale. The prevalence of PTSD &/or MDD using the M.I.N.I. was 32%, whilst 99% of other diagnosed mental disorders were comorbid with one or both of these. Using a cut-score of ≥2, the tool provided a sensitivity of 0.93, specificity of 0.75 and predictive accuracy of 80.7%.
- Conclusions: A brief sensitive screening tool with robust psychometric properties that was easy to administer at the agency of first presentation was developed to facilitate mental health referrals for asylum-seekers and new refugees.
Social factors ameliorate psychiatric disorders in community-based...
Social factors ameliorate psychiatric disorders in community-based asylum seekers independent of visa status
The impact of industrialised host nations’ deterrent immigration policies on the mental health of forced migrants has not been well characterised. The present study investigated the impact of Australia’s refugee determination process (RDP) on psychiatric morbidity in community-based asylum-seekers (AS) and refugees. Psychiatric morbidity was predicted to be greater in AS than refugees, and to persist or increase as a function of time in the RDP. The effect on mental health of demographic and socio-political factors such as health cover and work rights were also investigated. Psychiatric morbidity was measured prospectively on five mental health indices at baseline (T1, n1⁄4131) and an average of 15.7 months later (T2, n1⁄456). Psychiatric morbidity in AS significantly decreased between time points such that it was no longer greater than that of refugees at T2. Caseness of PTSD and demoralisation reduced in AS who gained protection; however, those who maintained asylum-seeker status at T2 also had a significant reduction in PTS and depression symptom severity. Reduced PTS and demoralisation symptoms were associated with securing work rights and health cover. Living in the community with work rights and access to health cover significantly improves psychiatric symptoms in forced migrants irrespective of their protection status.
Demoralisation syndrome does not explain the psychological profile of...
Demoralisation syndrome does not explain the psychological profile of community-based asylum-seekers
- Background: Demoralisation syndrome (DS) has been advanced as a construct that features hopelessness, meaninglessness, and existential distress. Demoralisation and DS have predominantly been considered secondary only to illness; hence there is scant research on demoralisation or DS in populations affected by extreme environmental stress.
- Aims: The current study aimed to determine the prevalence of demoralisation, its predictors, and the relevance of DS in a community-based forced-migrant population.
- Method: A convenience sample of 131 adult asylum-seekers (n = 98) and refugees (n = 33) without recognised mental disorders in Melbourne, Australia, were assessed cross-sectionally on posttraumatic stress, anxiety, depression, post-migration stress, and demoralisation. Socio-demographic data were analysed with relevant clinical data. Predictive aims were investigated using bivariate statistical tests and exploratory aims were investigated using correlational and linear regression analyses.
- Results: Seventy nine percent of the sample met criteria for demoralisation (asylum-seekers = 83%; refugees = 66%), with asylum-seekers being 2.55 (95% C.I. = 1.03 6.32, Z = 2.03, p = .04) times more likely to be demoralised than refugees. No relationship between demoralisation and time in the refugee determination process emerged. The regression model explained 47.5% of variance in demoralisation scores for the total sample F(9,111) = 13.07, p b .0001, with MDD and anxiety score making unique significant contributions.
- Conclusions: Demoralisation was widespread through the asylum-seeker and refugee population and its prevalence was attributable to a range of social and psychiatric factors. However, DS had little explanatory power for psychiatric morbidity, which was more suggestive of a pan-distress symptom complex.
To strive, to seek, to find, and not to yield: Narratives on the road to asylum
This study aimed to explore the ecological influences on subjective well-being identified by current and former community-dwelling asylum seekers engaged in the process of Refugee Status Determination in Australia. This article presents the qualitative component of a prospective mixed-methods study of 131 asylum seekers and refugees (T1, N = 131; T2, N = 56). The Framework Analysis method was employed to qualitatively analyse the narrative data derived from 187 semi-structured interviews documenting pre-, peri-, and post-migration experiences, and the impact of Australia’s asylum policies and procedures. Four overarching themes comprising 15 sub-themes emerged: The Refugee Status Determination process (Waiting; Uncertainty; Worry); Psychosocial factors (Un/employment & gainful activity; Medicare; Accommodation; Family separation & loneliness; Loss); Health and well-being (Mental health; Physical health & somatic issues; Hopelessness; Helplessness); and Protective factors (Hope; Support & social connectivity; Religion). The complex interface between the Refugee Status Determination process, un/employment, and mental health concerns was the most salient finding. Policy implications are discussed in relation to the application of the Convention and Protocol Relating to the Status of Refugees and the Guidelines on the Judicial Approach to Expert Medical Evidence.
Mental Disorders in Asylum Seekers
The refugee determination process (RDP) and social factors putatively impact on the psychiatric morbidity of adult asylum seekers (ASs) living in the community. Clinical and socio demographic data relevant to AS experience in the RDP were collected using self-report measures to assess posttraumatic stress (Harvard Trauma Questionnaire–Revised) and depressive and anxiety symptoms (25-item Hopkins Symptom Checklist), and the Mini-International Neuropsychiatric Interview 6.0 psychiatric interview was used to establish a cut-off for caseness. The prevalence of major depressive disorder (MDD) and posttraumatic stress disorder (PTSD) was 61% and 52%, respectively. Unemployment and greater numbers of both potentially traumatic events and RDP rejections were predictors of symptom severity. Unemployed ASs were more than twice as likely to have MDD (odds ratio, 2.61; 95% confidence interval [CI], 1.11– 6.13; p = 0.03), and ASs with at least one RDP rejection were 1.35 times more likely to develop PTSD for each additional rejection (95% CI, 1.00–1.84; p = 0.05). Reducing the asylum claim rejection rate and granting work rights are likely to reduce the rate of PTSD and MDD in community based ASs.
Age and environmental factors predict psychological symptoms in...
Age and environmental factors predict psychological symptoms in adolescent refugees during the initial post-resettlement phase
Adolescent refugees are at high risk of developing mental disorders but are often not recognised early. This pilot study aimed to identify early putative risk factors associated with psychological symptoms in newly resettled refugee youth at potential risk of subsequently developing mental disorders.
Newly resettled adolescent refugees were recruited through English language schools in Melbourne, Australia. Participants were assessed with the MINI-Kid, Achenbach Youth Self-Report and Reaction of Adolescents to Traumatic Stress scale. Parents completed a mental health screening separately. Linear regression models were used to identify predictive factors associated with symptom ratings.
Seventy-eight, ostensibly well, refugee adolescents (mean age = 15.0 ± 1.6 years) resettled in Australia for 6.1 ± 4.2 months were assessed. Levels of anxiety, depression and post-traumatic stress symptoms were considerably lower than in mainstream population data. Prior displacement was a key determinant of symptomatology. Transitory displacement, irrespective of duration, was associated with elevated scores for depression (t (47) = -4.05, p < 0.0001), avoidance/numbing (U = 466, p < .05) and total trauma (U = 506, p < .05) symptoms. Older age was a unique predictor of depression (F (1,74) = 8.98, p < .01), internalising (F(1,74) = 6.28, p < .05) and total (F(1,74) = 4.10, p < .05) symptoms, whilst parental depression symptoms (t = 2.01, p < 0.05), displacement (t = 3.35, p < 0.01) and, expectedly, trauma exposure (t = 3.94, p < 0.001) were unique predictors of post-traumatic stress symptoms.
Displaced status, older age, and parental symptoms predicted psychological symptoms in adolescent refugees in an initial relatively asymptomatic post-resettlement phase. The early recognition of at-risk refugee youth may provide an opportunity for preventative mental health interventions.