The effects of trauma on the psychiatric status of refugees and the responsibility of resettlement countries to meet these psychosocial needs, are issues that have become increasingly contentious. Within the field, critics (1) claim that the psychiatric impact of trauma on refugees has been overstated, that it is inappropriate to assign diagnoses such as post-traumatic stress disorder (PTSD) to normative manifestations of human suffering (anxiety, arousal, mistrust and sad memories) arising from mass conflict, and that interventions such as counselling are culturally alien to most non-Western populations. Although motivated by human rights concerns, this critique should not be distorted in ways that lead to the neglect of the legitimate mental health needs of refugees.
Lie's study (2) in this issue of the Journal therefore is timely in addressing the issue of refugee trauma and its consequences. It follows a long legacy of research in Norway dating back to the pioneering work of Eitinger after World War II. As Lie illustrates, longitudinal studies amongst resettled refugees face daunting challenges. Sampling is difficult even in countries where registers of refugees are kept. Refugees may be hesitant to participate in studies, resettlement services do not always regard research as a priority, and longitudinal studies commonly are bedevilled by attrition at follow-up.
Nevertheless, several recent follow-up studies amongst refugees have yielded consistent results. Trauma has been confirmed as a potent risk factor, with trauma ‘load’ as well as the type of trauma experienced (particularly concentration camp experiences, torture and rape used as a political weapon) increasing the risk of adverse mental outcomes. Where there is a combination of PTSD and depressive symptoms, the level of personal, familial, social and occupational disability can be substantial (3), dispelling any claim that such reactions are irrelevant to future adaptation.
Does this mean that all refugees are traumatized? Clearly, this is not the case, with the majority of studies reporting that most refugees are free of mental disturbances. Nevertheless, the follow-up data reported by Lie are ominous – PTSD symptoms actually increased over the 3-year period of resettlement. Attrition in the study meant that the follow-up group included a proportionately larger number of refugees exposed to extreme trauma, however. Nevertheless, a recent longitudinal study undertaken in Sweden (4) also showed a substantial increase in prevalence of PTSD amongst refugees, in this instance from Kosovo. PTSD rates increased from 45% at baseline to 78% at 18-month follow-up. In addition, a 3-year longitudinal study of Bosnian refugees (3) has shown that post-traumatic symptoms, particularly depression, tend to persist during the period of repatriation.
Together, these follow-up studies paint a worrying picture in relation to the capacity of refugees to adapt, at least in the immediate time period after exposure to trauma. Clinicians are aware that the early years of resettlement for refugees can be emotionally turbulent. Nevertheless, if one follows up refugee patients long enough, even the most disturbed often make gradual progress. Time is a powerful healer and this maxim may be particularly relevant to refugee adaptation. Only a few studies have followed up refugees for extensive periods, but the results provide systematic support for these clinical observations. A 10-year follow-up study in Canada (5) found that South-east Asian refugees showed substantial improvement in symptoms over time to the point where they had lower rates of illness than Canadian-born citizens. An earlier study (6) reported long-term improvements on most indices of psychiatric distress in Hmong refugees 10 years after resettlement in the USA. Retrospective studies, although limited by possible recall bias, support these findings. Vietnamese refugees (n=1161) living for an average of 11 years in Sydney, Australia (7), showed half the rates (8.2%) of common affective disorders compared with base rates in the general Australian population. Premigration trauma was the strongest predictor of mental disturbance. In those exposed to lower levels of trauma, rates of disorder were high in the immediate post-traumatic period but declined gradually to the level of non-traumatized Vietnamese by the end of the 10-year period. The small subgroup with extreme levels of premigration trauma and highest rates of early mental disturbance showed an incremental decline in psychiatric disorder over time, although their risk to mental disturbance remained four times greater than controls even 10 years after exposure.
These long-term studies are based on refugee groups arriving in North America and Australia in an epoch in which they were offered favourable resettlement conditions, including permanent residency and full access to work and educational opportunities. In contrast, asylum seekers arriving in many Western countries now face daunting challenges. Temporary residency, detention, restrictions on rights to work, to study, to language classes and to health care, as well as administrative obstacles to family reunion, all generate insecurity and fear, anxieties already provoked by past trauma experiences. Lie's study supports past research in demonstrating how powerful some of these postmigration stresses are in perpetuating post-traumatic stress symptoms. At a communal level, the insecurities suffered by refugees are intensified by the upsurge in hostility towards immigrants, a tendency that has been fuelled by fears of global terrorism.
In summary, two consistent risk factors have emerged from the cumulative body of research on the determinants of mental disorder in refugees: past trauma and post-migration stress. Although preventing trauma inflicted on refugees in source countries may be beyond our control, recipient countries can exert an influence on the post-migration challenges faced by incoming refugees. In our response, it is important that we extend our deliberations beyond the short-term goal of immigration control to a more global perspective on public health. If not, post-traumatic symptoms in asylum seekers may be prolonged and intensified and society in the global sense might ultimately bear the cost.
Providing effective and humane resettlement services, clarifying refugee claims in a timely manner, encouraging family reunion, countering tendencies towards racism and xenophobia in the wider society, offering opportunities for work and education, and providing targeted mental health interventions for the most psychologically needy, together will ensure that most refugees regain their capacity for self-sufficiency and productivity, an outcome that will benefit refugees themselves as well as the receiving societies.
Acta Psychiatrica Scandinavica
Derrick Silove and Solvig Ekblad
Invited Guest Editors