Refugee Mental Health: What You Need to Know

The Most Common Mental Health Diagnoses Among Refugees

Many factors affect the experience of a displaced person. For instance, being unable to obtain refugee status—as in, a foreign government does not recognize the individual’s need—is associated with much higher rates of severe symptoms related to mental health disorders.

Displaced persons may experience many mental health disorder symptoms, including:

• Nightmares or flashbacks
• Aggression and anger
• Irritability
• Psychosis
• Suicidal thoughts

They may also withdraw from engaging with friends or loved ones or turn to substances in an attempt to cope with the discomfort.

When treating refugees, mental health clinicians must consider the traumas experienced before and during being displaced as well as other illnesses that may have varying causes.

Having a greater number of traumatic experiences also leads to an increase in symptom severity.

Particular types of traumatic stress can create more severe mental health issues. Studies point out that being a victim of torture, in particular, leads to more severe outcomes and requires specialized assessment and treatment.

Older adults find the trauma of displacement to be just as unsettling as young or working-age adults do. Children are most impacted of all. Overall, the trauma of relocation is often something patients have to work through as families.

Providers can learn how to help refugee families. According to the National Child Traumatic Stress Network, clinicians can take the following steps:

• Learn about the family’s culture
• Understand that children and parents may adjust to a new culture differently
• Acknowledge the family’s hardships as well as strengths
• Use interpreters as often as possible
• Collaborate with other professionals in the family’s community

The conclusion should surprise no one. The worse a refugee’s situation, and the harder time they have getting officials to recognize their need for help, the greater their symptoms of mental illness will be.

Some of the most common mental health conditions refugees and IDPs may face include:

Post-Traumatic Stress Disorder

PTSD is one of the most common disorders experienced by refugees. Recorded rates of PTSD in refugees varies widely, from 10-40% depending on specific groups.

PTSD manifests in an inability to control upsetting memories, becoming triggered by similar situations, and perhaps even losing touch with reality. Untreated, PTSD is tough to manage and can lead to severe depression, substance use, or suicidal behaviors.

Anxiety and Depression

Both anxiety and depression are extremely prevalent in refugee communities.

Displaced persons may fear that they will experience their trauma again, worry obsessively about their home or children, or see danger around every corner. Anxiety can interfere with daily activities and make life incredibly challenging.

Depression can be equally debilitating. Many refugees lose interest in activities they once enjoyed, and even the people closest to them can’t make them feel better.

“What’s the point?” and “I hate everything” are common refrains for those who experience depression, a disorder which may be situational or biological.

Obsessive Compulsive Disorder

Some individuals who lived through a traumatic event may end up engaging in obsessive-compulsive behavior. “Obsessive” means thinking about something without control. “Compulsive” means taking obsessive action, sometimes even when the individual doesn’t want to.

The OCD cycle involves a trigger, causing the person to think an unpleasant thought, after which they take action to soothe themselves. It can involve tics, repeated handwashing, religious obeisance or confessing, among many other symptoms.

Substance Use Disorder

Research shows that substance use among refugees is growing in the U.S. Because of trauma histories, refugees may be especially vulnerable to developing substance use disorders and they may turn to drugs and alcohol at various stages of their experience.

Refugees may use substances to cope with trauma symptoms related to war, displacement, and violence. In refugee camps, people may turn to drugs and alcohol to numb feelings of isolation and uncertainty.

Once resettled in new countries, they may use substances to cope with separation from family, the stress of finding employment, as well as adapting to a new culture.

According to a 2016 study, refugee populations face the following challenges in connecting with substance use treatment:

• Lack of awareness of substance addiction treatment
• Navigating a treatment system in a new country
• Lack of culturally informed treatments
• Language barriers/lack of interpreters
• Mistrust of authority figures, including medical providers

Health professionals routinely screen refugees for mental health conditions. Addiction disorders are often not included in such screenings, and culturally informed addiction treatment is often unavailable.

The lack of appropriate treatment options can prevent clinicians from making referrals. When treatment does exist, providers are likely not able to easily accommodate patients who do not speak English, as interpreter services can be expensive.

Grief

Displaced persons are often impacted by grief. Many refugees have lost loved ones or are uncertain of the fate of loved ones. Others have lost their homes and ways of life, at least temporarily.

Without support, they may experience complicated bereavement or prolonged grief reactions. Such unresolved grief can lead to worse mental health outcomes.

Alienation

Many displaced persons feel a sense of extreme alienation, living in a new place and sometimes forced to interact with people who speak a language they may not understand.

Displaced persons often face all these challenges without the family, jobs, and pets they left behind, as well as possessions and other trappings of a life well-lived. They require solid support while they are rebuilding their lives.

Chronic Stress

Chronic stress can worsen mental health issues and strain family systems. A 2017 article in World Psychiatry points out that adverse conditions imposed on refugees, including prolonged detention and insecure residency status, can compound past traumas.

Even outside detention centers, refugees face daily stressors. These include separation from supports, difficulty finding employment, inadequate food and water, as well as potential negative interactions from people in the community.

Physical Symptoms Related to Mental Health Disorders

Poor mental health doesn’t always manifest in psychological ways. Mental health conditions can have both mental and somatic (physical) symptoms. Many cultures only acknowledge the physical symptoms of psychological conditions.

Many refugees are unable to accurately express how they’re feeling. This is especially true for those without significant language skills, or who did not grow up in cultures that talk about mental health,

Their physical symptoms may include:

• Headaches
• Stomachaches
• Muscle tension
• Pain
• Restlessness
• Insomnia
• Fatigue
• Gastrointestinal issues

When patients present with what seem to be only physical issues, their underlying psychological issues may not be addressed.

Children are especially likely to present with the above symptoms. Young people are still developing and are vulnerable, so it is especially important to care for their mental health.

Impact of Refugee Situations on Childhood Emotional Development

The data is clear: a traumatic past irrevocably shapes a child’s future. How it is dealt with will impact them through childhood, adolescence, and the rest of their lives.

Maintaining positive child and teen mental health is already a challenge for parents and guardians of well-adjusted children who haven’t experienced trauma. We must give children a sense of self and a sense of security, expose them to enough adversity to grow, and help them adapt to change in healthy ways.

When a child is displaced, all of these challenges become much harder. Leaving home puts children in a vulnerable position. They are at risk of:

• Hunger and deprivation
• Religious or ethnic persecution
• Discrimination and racism
• Sexual and physical violence
• Getting lost or separated from family
• Frequent moves and school changes
• Culture shock

Children who encounter such events are likelier to develop mental health conditions including PTSD, anxiety, depression, grief, and stress.

Symptoms of underlying mental health conditions include:

• Academic problems
• Trouble paying attention
• Behavioral difficulties
• Attachment issues
• Isolation and alienation
• Difficulty making friends
• Invasive memories and nightmares
• Sadness and irritability
• Becoming triggered by events similar to the trauma

Also, children are very likely to manifest physical symptoms of their trauma, known as “somatization.” In children, this often includes:

• Headaches and stomachaches
• Continual crying
• Unexplained pains in the body
• Insomnia
• Constant sleepiness or lethargy

Refugee children often do not come from populations that have access to evidence-based mental health care. They may also not trust authority figures, and may underreport their symptoms in order to avoid treatment.

It’s critical that doctors, nurses, teachers, administrators, and caregivers learn to recognize symptoms so they can request an assessment, if necessary.

Mental Health Assessments for the Refugee Population

Due to the unique nature of their experiences and trauma, typical mental health screenings are generally unhelpful in assessing refugees. Luckily, a number of refugee mental health guides and screenings are currently available.

Examples include:

CDC’s Guidance for Mental Health Screening During the Domestic Medical Examination for Newly Arrived Refugees
CDC guidelines help health care workers determine which newly arrived refugees require mental health care and support.

Steps in the process include reviewing refugees’ overseas documentation for signs of trauma and illness, asking directly about symptoms, screening for mental health and substance use, and developing an action plan and/or referral.

The Comprehensive Trauma Inventory – 104 (CTI-104)
The Comprehensive Trauma Inventory helps clinicians assess levels of war-related trauma experienced by refugees. The inventory consists of 104 statements about war experiences (e.g., “fleeing or hiding from soldiers or enemies”). Participants fill out the form by indicating if each event happened to them, and if so, how severely they were impacted.

It is also worth noting that most refugees, even adults, present first with somatic (physical) symptoms. It is important to screen each patient in order to discover if there are mental health issues. If we fail to do so, we miss opportunities to help.

The New Mexico Refugee Symptom Checklist – 121 (NMRSCL – 121)
Clinicians use the New Mexico Refugee Symptom Checklist to assess the health of refugees on a broad range of psychological and somatic symptoms. The checklist was developed with refugee populations and includes 121 symptoms (e.g., “fear or jumpiness at loud noises,” “rashes on your skin”).

Participants rank their experiences on how much each symptom has bothered them in the past year. Clinicians organize the number of symptoms into 12 different scales of mental and physical health conditions.

Stages of the Refugee Journey

Refugees go through many changes before they find a place to settle. They typically experience trauma throughout their journey. The nature of that trauma and any resulting mental health disorders may change over time.

From the preflight period to migration itself to post-migration, refugees are typically unable to find stability until they settle permanently. Even then, life poses challenges that native-born people in any given country do not experience. The settlement period can sometimes be as difficult as the three preceding stages.

Preflight

In this phase, also known as “premigration,” life in the refugee’s home country becomes increasingly difficult. They may lose jobs, family members may leave, violence could rise, children may leave school, or persecutions may increase.

For refugees who plan to relocate (as opposed to those who are forcibly displaced without warning), planning happens in this phase.

Migration

Also known as the “flight” period. This is a time of active travel for refugee individuals and families. The journey is often dangerous. Not everyone is allowed to leave their country, so some must do so in secrecy.

Risks such as exposure, unreliable or nonexistent transportation, detention, and medical emergencies are very real. Many people die during migration, especially children and older adults.

Post-Migration

When refugees finally resettle, which sometimes takes years, they often face challenges in accessing care and social services.

Although the physical journey is over, getting what they need in their new community can pose a challenge to refugee mental health.

Settlement

Also called the “integration period,” settlement is when a refugee permanently settles down in their new home. Now they must acquire work and housing, get children into school, and learn to navigate their new neighborhood, among other concerns. These steps require language skills, money, and other resources that are often hard to come by.

Each of these stages impacts refugee mental health differently. Preflight and migration are frightening, creating trauma for children and adults alike. The post-migration and settlement periods bring relief from imminent danger, but not from uncertainty. Any stage of the journey can have repercussions.