Mental Health of Migrants and Refugees

Research on the mental health of migrants and refugees has largely focused on the three phases of pre-migration, migration, and post-migration [Reference Bhugra, Gupta, Bhui, Craig, Dogra and Jd12], as well as a five-phase model encompassing pre-departure, journey, interception, destination, and return [Reference Zimmerman, Kiss and Hossain13]. A majority of forced migrants are internally displaced people who often have significant mental health problems, which, although urgent, are difficult to manage due to numerous obstacles [Reference Cratsley, Brooks and Mackey14]. A growing body of evidence indicates that a large proportion of migrants and refugees suffer from the consequences of traumatic events and develop mental disorders such as post-traumatic stress disorder, depressive and anxiety disorders, and relapses into psychotic episodes [Reference Hassan, Ventevogel and Jefee-Bahloul15]. Beyond childhood trauma, there is increasing evidence that bullying, social exclusion, and discrimination during adolescence and adulthood have been linked to an increased risk of developing psychotic disorders. Such forms of trauma may also contribute to the elevated risk of psychosis among migrants or individuals with visible minority status [Reference Varchmin, Montag, Treusch, Kaminski and Heinz16]. A substantial increase in the risk of developing non-affective psychosis has been observed in those exposed to trauma or discrimination, with the highest risk associated with vulnerability to ethnic discrimination, as indicated by visible minority status [Reference Brandt17, Reference Selten, van der Ven and Termorshuizen18].

A recent meta-analysis of international studies on serious mental disorders among refugees and asylum seekers found that the most prevalent disorder was major depressive disorder (MDD) (32%), followed by PTSD (31%), recurrent episodes of MDD (16%), and bipolar disorders (BPD_ (5%). The prevalence of psychotic disorders was 1% [Reference Patanè, Ghane, Karyotaki, Cuijpers, Schoonmade, Tarsitani and Sijbrandij19]. Similar findings were reported in a meta-analysis of research conducted in Germany, with PTSD at 29.9% (95% CI 20.8–38.7%) and depressive symptoms at 39.8% (95% CI 29.8–50.1%) [Reference Hoell, Kourmpeli, Salize, Heinz, Padberg and Habel20]. Another systematic review and meta-analysis by Lindert et al. [Reference Lindert, Ehrenstein and Priebe21] found that the rate of mental disorders among refugees was twice as high as among economic migrants in Europe, with 44% of refugees suffering from depression, 40% from anxiety disorders, and 36% from PTSD [Reference Lindert, Ehrenstein and Priebe21]. Similarly, Steel et al. [Reference Steel, Chey and Silove22] reported prevalence rates of 30.6% for PTSD and 30.8% for depression in adult refugees, compared to rates of 1–12% for both disorders in the general population [Reference Close, Kouvonen and Bosqui23]. These data suggest that nearly one in three people who have experienced conflict suffer from a psychological trauma disorder.

Morina et al. [Reference Morina, Akhtar, Barth and Schnyder24] highlighted that civilians affected by war are at an increased risk of mental health problems, including post-traumatic stress disorder (PTSD), anxiety, and depression. Koenen et al. [Reference Koenen, Ratanatharathorn, Ng, McLaughlin, Bromet, Stein and Karam25], based on the results of a WHO Mental Health Survey, demonstrated that PTSD can be particularly long-lasting in the context of war. The effects of the current crisis on mental health may therefore be enduring [Reference Bryant, Edwards, Creamer, O’Donnell, Forbes, Felmingham, Silove, Steel, McFarlane, Van Hooff, Nickerson and Hadzi-Pavlovic26].

Furthermore, forcibly displaced individuals from countries with severe human rights violations have a higher prevalence of psychopathological symptoms [Reference Lindert, von Ehrenstein, Wehrwein, Brähler and Schäfer27]. The consequences can be long-lasting, with studies showing that a history of depression and PTSD increases the risk of dementia [Reference Rapp, Hellweg and Heinz28]. Gender-based violence, which is often underreported due to social stigma and inadequate treatment options, further exacerbates the psychological burden in affected regions, both in the short and long term [Reference Tadesse29, Reference Lokot, Hartman and Hashmi30]. This increased risk may not only result from war trauma but may also be influenced by socio-economic factors following displacement [Reference Bogic, Njoku and Priebe31]. The findings of a cross-sectional study of refugee women who experienced multiple severe traumas related to war in their home countries and danger encountered during their migration suggest that family violence was key to their current mental health problems [Reference Moran, Jesuthasan, Schalinski, Kurmeyer, Oertelt-Prigione, Abels, Stangier, Starck, Gutermann, Zier, Wollny, Richter, Krüger and Schouler-Ocak32]. Therefore, culturally sensitive assessment and treatment need to place special emphasis on these family dynamics.

In a study conducted in Turkey, Başterzi [Reference Başterzi33] found that the most common psychological problems among refugees included psychosis, anxiety disorders, PTSD, and depression. Refugee children are also vulnerable to behavioral disorders, addiction, introversion, and tendencies towards crime and violence [Reference Derince34].

Tarricone et al. [Reference Tarricone, D’Andrea, Jongsma, Tosato, Gayer-Anderson and Morgan35] found that the cumulative effect of social disadvantage before, during, and after migration is associated with an increased likelihood of psychosis in migrants, regardless of ethnicity or length of stay in the host country. Public health initiatives that address the social disadvantages faced by migrants throughout the migration process, as well as post-migration psychological support, could help reduce the excess incidence of psychosis among migrants. A Canadian study also found that a sense of belonging to Canada was a significant predictor of mental health [Reference Beiser and Hou36].

In a scoping review, Hilario et al. [Reference Hilario, Oliffe, Wong, Browne and Johnson37] identified that the mental health of young migrants is shaped by a myriad of social and economic factors at individual, family, community, and societal levels. The review highlighted the need for mental health services to focus on first-generation migrant youth and those who migrated before the age of six, to address high levels of stress or the likelihood of mental illness. In addition, the mental health of young people after migration is influenced by their parents’ settlement experiences in terms of employment, household income, and integration. Parental depression, in particular, is consistently associated with poorer mental health outcomes in migrant youth. This suggests that the experiences of young people living with parental mental illness should be a key focus for future research and targeted interventions [Reference Hilario, Oliffe, Wong, Browne and Johnson37].

Improving Mental Health Care for Migrants and Refugees

As discussed above, there is considerable research evidence that both migrant and refugee groups are particularly vulnerable to receiving substandard healthcare, partly due to racist and discriminatory attitudes, behaviors, and policies within the health system [Reference Varchmin, Montag, Treusch, Kaminski and Heinz16, Reference Williams, Khanna Roy, MacIntyre and Faber38, Reference Sultani, Heinsch, Vincent and Brosnan39].

Furthermore, having fled war and conflict, endured torture or traumatic events, and living with ongoing uncertainty [Reference Kenny40], these individuals often face access barriers to health care and are at high risk of experiencing long-term poor physical and mental health outcomes in their host countries [Reference Willey, Desmyth and Truong41]. A meta-analysis and systematic review have highlighted that racism is strongly associated with poor health outcomes, with the relationship particularly strong for mental health, and less so for physical health [Reference Paradies, Ben, Denson, Elias, Priest and Pieterse42]. Racism can be defined as organized system within societies that cause avoidable and unfair inequalities in power, resources, capacities, and opportunities across racial or ethnic groups [Reference Berman and Paradies43]. Several studies have highlighted the negative impact of racial discrimination on mental health, particularly concerning the development of affective, psychotic, and substance use disorders [Reference Paradies, Ben, Denson, Elias, Priest and Pieterse42, Reference Henssler, Brandt, Müller, Liu, Montag and Sterzer44, Reference Lazaridou, Heinz, Schulze and Bhugra45].

According to Bäärnhielm and Schouler-Ocak [Reference Bäärnhielm and Schouler-Ocak46], there is a significant gap between the mental health care needs of migrants, refugees, and minority groups and the services available to them, emphasizing the need to improve accessibility and adapt systems, services, and interventions. Health professionals play a crucial role in ensuring the quality of care, and their ability to meet new challenges depends on their competence, knowledge, skills, and attitudes toward their patients’ needs. To enhance their capabilities, mental health professionals require training in cultural diversity and structural competence. Cultural competence encompasses professional values, including sensitivity, non-discrimination, and responsiveness to the psychiatric needs of all patients. Psychiatrists may enhance their intercultural performance during the mental health assessment using the Cultural Formulation Interview (CFI) of the DSM-5. It is supportive in clinical practice, where psychiatrists must consider each patient within the context of the patient’s culture and their own cultural values and prejudices [Reference Schouler-Ocak, Graef-Calliess, Tarricone, Qureshi, Kastrup and Bhugra47]. Cultural competence is vital for understanding, treating, and supporting migrant and refugee patients and for addressing racial discrimination. “Cultural competence” is typically described as a multidimensional set of cognitive orientations, cultural knowledge, skills, sensitivities, and attitudes [Reference Mews, Schuster, Vajda, Lindtner-Rudolph, Schmidt and Bösner48]. (Self-)critical reflection, including an examination of internalized prejudices and value hierarchies, is crucial [Reference Schenk, Sonntag, Beck, Khan, Peppler and Schouler-Ocak49]. The development and application of cultural competence appear to be influenced less by organizational characteristics and more by the level of the individual actors. Therefore, in addition to personnel development, appropriate organizational structures and an economic incentive system are required to promote socio-cultural diversity within mental health care systems [Reference Schenk, Sonntag, Beck, Khan, Peppler and Schouler-Ocak49].

Barriers to Access Mental Health Care

Difficulties in accessing healthcare often exacerbate existing mental disorders [Reference Laban, Komproe and HBPE50] and delays in help-seeking can produce poor outcomes. There are a number of factors at play: from language barriers, poor knowledge of the healthcare systems in new settings, stigma of mental illnesses, differing explanatory models, anxieties regarding the perspectives in the host country [Reference Kleinman51, Reference Claus, Braakman, Schouler-Ocak, Van de Vliet, Sabbe and van den Ameele52], and so forth Language barriers and intercultural communication challenges are significant obstacles, making it much harder for individuals to access the healthcare system. The availability of qualified interpreters, language and cultural mediators is inconsistent, and they are not regularly utilized and not available. This can lead to misunderstandings, misdiagnoses, and inappropriate treatment, with potentially serious consequences for the individuals involved [Reference Kleinman51].In intercultural psychotherapy, language plays a crucial role, as many languages lack equivalent terms for various mental disorders [Reference Bhugra, Gupta, Schouler-Ocak, Graeff-Calliess, Deakin and Qureshi53]. For example, the term “depression” does not exist in many languages, even though sadness and unhappiness are recognized and described [7, Reference Bhugra, Gupta, Schouler-Ocak, Graeff-Calliess, Deakin and Qureshi53, 54]. Consequently, psychotherapists and psychiatrists must be sensitive to cultural and contextual communication aspects [Reference Bäärnhielm and Mösko55]. Without interpreters, effective communication between professionals and patients from different cultural backgrounds is sometimes impossible. In psychiatry and psychotherapy [Reference Schouler-Ocak, Graef-Calliess, Tarricone, Qureshi, Kastrup and Bhugra47, Reference Bhugra, Gupta, Schouler-Ocak, Graeff-Calliess, Deakin and Qureshi53], language competence is a key factor in the utilization of healthcare services by migrants.

Inequalities between migrants and non-migrants in terms of health and access to healthcare services persist in many European countries. Legal barriers make it difficult for refugees and migrants to access healthcare. Economic constraints also play a role, as many migrants cannot afford healthcare costs [Reference Lebano, Hamed, Bradby, Gil-Salmerón, Durá-Ferrandis, Garcés-Ferrer, Azzedine, Riza, Karnaki, Zota and Linos56].

In Europe, healthcare delivery and access are, not surprisingly, heterogeneous [Reference Lebano, Hamed, Bradby, Gil-Salmerón, Durá-Ferrandis, Garcés-Ferrer, Azzedine, Riza, Karnaki, Zota and Linos56], making comparisons challenging. Data is often lacking, complicating the ability to draw firm conclusions. Countries apply different standards when prioritizing the healthcare needs of refugees, with some focusing on mental health care, preventive care (vaccinations), and long-term care, especially for an aging migrant population [Reference Lebano, Hamed, Bradby, Gil-Salmerón, Durá-Ferrandis, Garcés-Ferrer, Azzedine, Riza, Karnaki, Zota and Linos56, Reference Priebe57].

Political, social, and legal stressors can hinder the integration process [Reference Urzúa, Caqueo-Urízar and Henríquez58] as well as an understanding of the new cultures and acculturation. Social factors such as grief, culture shock, social exclusion, and a mismatch between the expectations and attitudes of the host country also affect acculturation [Reference Bhugra, Gupta, Schouler-Ocak, Graeff-Calliess, Deakin and Qureshi53, Reference Ekoh, Iwuagwu, George and Walsh59] and insecurities regarding perspectives in the host country can stop people from seeking help [Reference Schouler-Ocak, Graef-Calliess, Tarricone, Qureshi, Kastrup and Bhugra47, Reference Bhugra60].

Growing inequalities in resources within and between countries, the construction of border walls and tighter border controls, and a lack of perspectives in the host country further complicate the integration of migrants and refugees [Reference Patel61]. Additionally, public hostility towards migrants and refugees is increasing in many European countries, making them increasingly unwelcome and placing them in a political atmosphere that frightens them. This tightening of reception conditions, driven by fears of terrorism, leads to insecure residence permits, social exclusion, and difficulties in accessing psychosocial care. In this context, ethical principles and the foundations of modern ethical codes are often compromised.

Asylum Seekers Benefit Act

European Union legislation stipulates that Member States have a legal obligation to provide for the social and health needs of asylum seekers. This includes granting access to healthcare services. In September 2020, the European Commission introduced a New Pact on Migration and Asylum, setting out a fairer approach to managing migration and asylum. The Pact includes provisions for health checks to facilitate the early identification of migrants’ healthcare needs [62]. In Germany, e.g., the social and health benefits available to asylum-seekers are governed by the Asylum Seeker Benefits Act. Asylum-seekers are individuals who have submitted an asylum application and are awaiting the outcome of their asylum determination process [Reference Gottlieb and Schülle63]. Previously, healthcare entitlement was limited to the first 18 months or until permanent protection status (refugee status or subsidiary protection) was granted. However, this period has now been extended to 36 months. The limited entitlements cover healthcare for acute illnesses and pain, preventive services and immunizations, as well as services related to pregnancy and childbirth (AsylbLG Art. 4). Access to further, mostly specialized, services can be granted on a case-by-case basis (AsylbLG Art. 6).

In contrast, Italy guarantees two constitutional rights to everyone residing in the country, whether permanently or temporarily: healthcare and education. While it may not be possible to address factors before and during migration, post-migration factors can certainly be addressed. Ensuring a dignified welcome for people arriving in the country is therefore a crucial strategy for safeguarding the health of the individual and the wider community.

It is important to note that in many countries and settings, civil society and NGOs often take the lead in demonstrating the social feasibility of innovative social models. These may be influenced by a number of cultural, social, political, and economic factors. Liaising with community organizations and NGOs can help both sides to learn about what is needed and what is available.

Europe is currently hosting millions of forcibly displaced people from Ukraine. Many countries have taken significant steps to enable their rapid integration. With the European Union (EU)‘s Temporary Protection for Ukrainian refugees extended until March 2025, EU Member States will continue hosting refugees and providing protection and access to vital services, including education, healthcare, and employment [11].

The Asylum Seekers Benefits Act has shown that legislation can be amended quickly when necessary. As a result, refugees from Ukraine were granted immediate access to psychiatric care, including special consultation hours with psychiatrists and psychotherapists. Private accommodation was arranged, unemployment benefits were provided from day one in the host countries, work permits were issued promptly, and children were swiftly enrolled in schools. The treatment of Ukrainian refugees illustrates how better conditions are possible and achievable in many countries. Extending these conditions to other asylum seekers could significantly improve their health conditions.

Ethical Principles in Mental Health Care

The term “ethics” is derived from the ancient Greek word “ethos” which refers to the moral norms and values guiding human behavior [Reference MacKenzie64]. This concept encompasses an integrative understanding of morality. The ethical challenges involved in the treatment of migrants and refugees are deeply connected to systemic and cultural issues, as well as to the core principles of professional practice. As Norvoll et al. [Reference Norvoll, Hem and Pedersen65] suggest it is crucial to address the moral aspects of health care and health policy, particularly concerning the treatment of migrants and refugees at individual, structural, and organizational levels.

It is ethically unacceptable to treat people differently on the basis of what the UK calls protected factors such as gender, age, sexual orientation, religion, disability, or ethnic origin. However, access to healthcare for migrants and refugees in many European countries is still very different and regulated by different national laws.

Specific Ethical Challenges in the Care of Refugees, Asylum Seekers and Migrants

A growing number of immigrants, refugees, and asylum seekers worldwide have limited or no proficiency in the host country’s language(s), which significantly hampers their ability to access regular mental health services. Besides cultural barriers, these language barriers pose significant challenges to medical treatment, especially for those whose access to health care is already limited due to factors such as unfamiliarity with local health care systems or unclear insurance status [Reference Schouler-Ocak, Graef-Calliess, Tarricone, Qureshi, Kastrup and Bhugra47, Reference Forray, Oltean and Hanft-Robert66, Reference Schouler-Ocak67].

Language is the most crucial tool in psychiatry and psychotherapy, making treatment impossible if there is no shared language and no translation between therapist and patient [Reference Morina, Maier and Schmid Mast68]. To facilitate communication, the use of professionally trained interpreters is indispensable.

Moreover, understanding cultural and social norms is essential for accurately interpreting psychiatric and psychological symptoms within the healthcare system. This underscores the importance of diversifying healthcare teams and employing interpreters not only as language mediators but also as cultural mediators. Unfortunately, health insurance companies rarely fund either, which is an untenable situation.

According to the Code of Ethics of the EPA, the fundamental values are

• – Responsibility and ethical demands: “Psychiatrists must uphold the responsibilities and ethical demands of the medical profession and specific to psychiatry and working with mental health.

• – Non-discrimination: Psychiatrists should consider the ethical principles of respect for autonomy, beneficence, non-maleficence, and justice for all patients regardless of migration status. Psychiatrists shall not discriminate based on age, race, ethnicity, nationality, religion, sex, gender, sexual orientation, social standing, criminal background, disability, disease, political affiliations, or migration status.

• – Psychiatrists must never endorse and participate in discriminatory action.

• – Cultural sensitivity: Practicing ethical psychiatry requires awareness, sensitivity, and empathy for the patient as an individual, including their cultural values and beliefs.

• – Advocacy for Universal Healthcare: Psychiatrists hold the obligation to advocate for universal health care for everyone, and fair and appropriate prevention, care, treatment, and rehabilitation for individuals with mental disorders within available resources in their respective countries.

• – Respect and communication: Psychiatrists must stay respectful in communications with patients, patient relatives, and staff. Psychiatrists should promote education of patients, families, and other professionals to empower decision-making processes” [69].

• – Decision-making and informed consent: Psychiatrists shall not act as proxy decision makers for their patients and need to stay respectful of patients’ decisions and ensure patients’ rights to express their will (e.g., coercion, restraint, compulsory medication). Psychiatrists should inform patients about diagnostic and therapeutic procedures, promote their autonomy, and always seek their informed consent.

• – Rejection of discriminatory practices: Psychiatrist shall not act as a proxy for migration policy.

In communications with patients, psychiatrists must overcome language and cultural barriers, ensuring that they provide security, attention, and adequate time according to the patient’s condition, within available resources. This includes respecting the principles of autonomy and dignity, confidentiality, and appropriate care for gravely ill or disabled patients, including those under involuntary (compulsory) care and treatment.

In many European countries, the ethical principles in dealing with refugees are not taken sufficiently seriously, which contradicts the UN Resolution 46/119 of the Principles for the Protection of Persons with Mental Illness. According to this resolution, psychiatrists should oppose discriminatory practices that limit their benefits and entitlements, deny parity, restrict treatment options, or limit their access to proper medications for patients with mental disorders. In some countries, psychiatry is misused to write reports on the mental health conditions of these migrants, so that they can be deported by the police. This contradicts fundamental values that psychiatrists should act according to and uphold the obligation to advocate for universal health care for everyone, including fair and appropriate prevention, care, treatment, and rehabilitation for migrant and refugee patients with mental disorders within available resources in their respective countries.

The treatment of Ukrainian refugees is a good example of how better conditions are possible and achievable in many countries. Extending these conditions to other asylum seekers could significantly improve their health conditions.

Recommendations

The primary duty of a physician is to promote the health and well-being of individual patients by providing competent, timely, and compassionate care in accordance with good medical practice and professionalism [70]. Therefore, the EPA recommends strategies to mitigate the impact of war, displacement, and related trauma. According to the aims of this position statement, EPA calls urgently for:

• • Action to identify issues related to the mental health of migrants and refugees, bearing in mind that these are heterogenous groups and needs will differ.

• • The development of strategies to enable mental health professionals to appropriately treat those severely traumatized by torture, violence, rape, death, and other traumatic experiences.

• • Member societies to raise awareness and improve the basic knowledge and skills of psychiatric and mental health professionals regarding the care of migrants and refugees.

• • The demand for equal treatment of all migrants and refugees, without any discrimination and exclusion.

• • Adherence to the ethical principles when dealing with mentally ill refugees and migrants, in accordance with the UN Resolution 46/119 of the Principles for the Protection of Persons with Mental Illness.

• • Commitment to medical ethics, including beneficence, respect for patients (autonomy), non-maleficence, justice, and the imperatives to improve standards of psychiatric practice and to apply psychiatric expertise to the service of society (including seeking equity in prevention, treatment, and rehabilitation of psychiatric disorders) and treating people fairly.