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Refugees who have fled war zones have a substantially higher risk of psychotic disorders than non-refugee migrants, suggests a recent study. Many refugees with mental health problems do not receive specialist help. Experts say nurses may be better placed than GPs to pick up mental health problems in refugees.

The humanitarian crises in the Middle East, North Africa and Central Asia have created more than 50 million refugees worldwide, with an estimated 117,234 in the UK.

Refugees and migrants sleep in the Greek port of Chios where they are being detained after arriving from Turkey

Picture credit: Getty

Refugees, many of whom have been subjected to rape, torture and persecution, are known to have an increased risk of mental health problems such as post-traumatic stress disorder (PTSD).

However, a recent BMJ study by researchers from the Karolinska Institutet in Sweden and University College London (UCL) (tinyurl.com/zkow3xc), found that refugees are also 66% more likely to develop schizophrenia or other non-affective psychotic disorders than non-refugee migrants.

The researchers studied more than 1.3 million people in Sweden, comparing the risk of non-affective psychosis between people born to Swedish-born parents and migrants, and between refugees and non-refugees within the migrant group. The increased rate among refugees was significant for all refugee-generating regions except sub-Saharan Africa. An explanation, suggest the researchers, is that most people from sub-Saharan Africa had been exposed to damaging ‘psychosocial adversities’, regardless of refugee status.

They conclude that their findings show ‘the need to take the early signs and symptoms of psychosis into account in refugee populations as part of any clinical mental health service response to current global humanitarian crises’.

Report co-author James Kirkbride, a psychiatric epidemiologist at UCL, says: ‘There’s an overlap between some of the symptoms of PTSD, schizophrenia and psychosis. Because of that it can be hard to determine which disorder they have. But that person is clearly in distress and will benefit from early intervention.’

Early symptoms

He says nurses who encounter refugees can play a pivotal role. ‘It is important for nurses to recognise early symptoms – bizarre thinking, hearing voices, hallucinations or delusions. It’s difficult if people don’t speak the same language and the intervention needs to be as culturally sensitive as possible.’

Cornelius Katona, medical director of the Helen Bamber Foundation, which provides therapeutic care and practical support to victims of human trafficking, war, violence and torture, says the clinical challenges facing health professionals working with refugees and asylum seekers should not be underestimated. ‘However diagnostic uncertainties should not result in under-detection and under-treatment of serious mental health problems,’ he adds.

In an editorial linked to the research, Professor Katona writes that ‘a robust mental health response to the refugee “crisis” must lie in a combination of clinical vigilance, recognition of vulnerability factors and, above all, a determination to minimise the aggravating effects of post-migration experiences’.

Freedom from Torture chief executive Susan Munroe voices a note of caution. ‘It is true that torture can lead to psychosis. But if people are having flashbacks about soldiers coming through the door, a health professional may not understand that this is not [necessarily a sign of] psychosis,’ she says. ‘Torture is outside most people’s frame of reference. What I would say to health professionals is stop and think. If your patient comes from a country where there is torture, this could be a true story.’

Freedom from Torture is preparing to study a cohort of patients in an acute mental health trust to find out if any have experienced unidentified torture. Professor Katona says the suffering endured by refugees in their country and on their journey to the UK can be further exacerbated by what happens when they arrive. ‘Many refugees and asylum seekers experience disbelief, detention and difficulty in accessing services,’ he says.

Refugees, migrants and asylum seekers

What is the difference between a refugee and a migrant?

According to the office of the United Nations High Commissioner for Refugees (UNHCR), refugees are persons ‘fleeing armed conflict or persecution’. Refugees are protected under international law and should not be returned to countries where their life or freedom would be threatened.

Migrants choose to leave their country, not because of a direct threat, but mainly to ‘improve their lives by finding work, or in some cases for education, family reunion, or for other reasons’. Countries deal with migrants under their immigration laws.

The UNHCR says blurring the two terms undermines public support for refugees and can have serious consequences for their safety.

In the UK, an asylum seeker is someone who has asked the government for refugee status and is awaiting the application outcome.

Refugees worldwide

According to the UNHCR, in 2015 there were more than 50 million refugees around the world, half women and children. The figure includes refugees outside their country and internally displaced people, asylum seekers and stateless people. See www.unhcr.org/5461e5ec3c.html

Refugees in Europe

More than one million refugees arrived in Europe in 2015, with more than 170,000 so far in 2016. See www.data.unhcr.org/mediterranean/regional.php

Refugees in the UK

Most recent UNHCR figures show that in mid-2015 there were 117,234 refugees, 37,829 pending asylum cases and 16 stateless persons in the UK (www.unhcr.org.uk/about-us/the-uk-and-asylum.html). The vast majority of refugees stay in their region of displacement and are hosted by developing countries. The top three countries of origin of asylum seekers in the UK are Eritrea (3,756), Iran (3,694) and Pakistan (3,254).

Source: UNHCR

‘The fact that they may be mistrustful, combined with language difficulties, could make it hard to establish rapport. Anyone working on the front line needs to take these factors into account.’

Traumatic events

Lucy Kralj is a registered general nurse and psychotherapist who has worked with refugees and asylum seekers in a specialist capacity for 12 years, both overseas and for the Helen Bamber Foundation. She says: ‘All nurses need to be aware that refugee displacement invariably involves trauma and loss. Asylum seekers and refugees are often traumatised by conditions in their country. These can exacerbate pre-existing symptoms and bring about further traumatic experiences.’

Organisations that support refugees and train practitioners

Refugees stuck at the Greek refugee camp in Idomeni due to closed borders with the Republic of Macedonia

Picture credit: REX

The Refugee Council offers time-limited therapeutic support to asylum seekers and refugees in London, Luton, Leeds and Birmingham. To make a referral, fill in an online form at bit.ly/RCtherapy

The Helen Bamber Foundation offers a free service to survivors of human cruelty, including modern slavery, human trafficking, extreme violence and state-sponsored torture. See www.helenbamber.org

Freedom from Torture accepts referrals from survivors or their friends, family or other advocates. All services are free to clients and it has five centres:

London provides medical consultation, therapies, housing and welfare advice (telephone 020 7697 7777).

North West in Manchester offers therapies to adults, children and families (telephone 0161 236 5744).

North East provides counselling, support and training to work with survivors of torture (telephone 0191 261 5825).

West Midlands provides therapy, advice and support to practitioners, and training for therapeutic and mental health services working with survivors (telephone 0121 314 6825).

Scotland provides assessment, counselling, psychotherapy and training for practitioners working with survivors (telephone 0141 420 3161).

She says nurses in all settings need to be aware of the close relationship between physical and psychological pain and distress. ‘Often physical symptoms that have no obvious physical explanation are dismissed as psychosomatic,’ she says.

Ms Kralj says there may be no physiological signs of abuse. ‘Torture is not designed to merely break a body – it is designed to crush a spirit, a psyche,’ she says. ‘The enduring consequences of torture will leave a mark on body and psyche, even if there are no enduring physiological conditions that can be directly attributed to the experiences of abuse.’

There is no national strategy for treating asylum seekers and refugees. There are specialist services in some urban areas, but none in others.

Freedom from Torture receives referrals from GPs, mental health teams and hospitals. But for every five referrals they receive, three meet their criteria and they are only able to take on one. The Helen Bamber Foundation is also fully stretched and is not currently taking on any new clients, so refugees will be presenting in GP surgeries and emergency services.

Professor Katona believes that nurses are often in the best position to detect mental health problems. ‘There needs to be greater vigilance for evidence of mental health problems among refugees and asylum seekers – and nurses in emergency departments may be in a better position than GPs or other doctors to pick those up,’ he says.

Ms Kralj warns that an unskilled attempt to extract a factual history from refugees can do more harm than good. ‘It is important not to pathologise but rather to meet the human being as they present – with humanity. It is also important to bear in mind that these patients may not be able to give a detailed history of symptoms as the trauma affects their capacity to interact with others. Nurses need to keep an open mind and remember the uniqueness of every person’s response to life events’.

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