Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress
Clinical Collections
Advances in Alzheimer’s

At a glance: The ONWARDS insulin icodec trials

A round-up of the ONWARDS phase 3 clinical trials evaluating the novel weekly insulin icodec in people with diabetes.
ADVANCED SEARCH
Log in
Top
BMC International Health and Human Rights
Published in: BMC International Health and Human Rights 1/2015

Open Access 01-12-2015 | Research article

Long-term mental health of war-refugees: a systematic literature review

Authors: Marija Bogic, Anthony Njoku, Stefan Priebe

Published in: BMC International Health and Human Rights | Issue 1/2015

Login to get access

Abstract

Background

There are several million war-refugees worldwide, majority of whom stay in the recipient countries for years. However, little is known about their long-term mental health. This review aimed to assess prevalence of mental disorders and to identify their correlates among long-settled war-refugees.

Methods

We conducted a systematic review of studies that assessed current prevalence and/or factors associated with depression and anxiety disorders in adult war-refugees 5 years or longer after displacement. We searched Medline, Embase, CINAHL, PsycINFO, and PILOTS from their inception to October 2014, searched reference lists, and contacted experts. Because of a high heterogeneity between studies, overall estimates of mental disorders were not discussed. Instead, prevalence rates were reviewed narratively and possible sources of heterogeneity between studies were investigated both by subgroup analysis and narratively. A descriptive analysis examined pre-migration and post-migration factors associated with mental disorders in this population.

Results

The review identified 29 studies on long-term mental health with a total of 16,010 war-affected refugees. There was significant between-study heterogeneity in prevalence rates of depression (range 2.3–80 %), PTSD (4.4–86 %), and unspecified anxiety disorder (20.3–88 %), although prevalence estimates were typically in the range of 20 % and above. Both clinical and methodological factors contributed substantially to the observed heterogeneity. Studies of higher methodological quality generally reported lower prevalence rates. Prevalence rates were also related to both which country the refugees came from and in which country they resettled. Refugees from former Yugoslavia and Cambodia tended to report the highest rates of mental disorders, as well as refugees residing in the USA. Descriptive synthesis suggested that greater exposure to pre-migration traumatic experiences and post-migration stress were the most consistent factors associated with all three disorders, whilst a poor post-migration socio-economic status was particularly associated with depression.

Conclusions

There is a need for more methodologically consistent and rigorous research on the mental health of long-settled war refugees. Existing evidence suggests that mental disorders tend to be highly prevalent in war refugees many years after resettlement. This increased risk may not only be a consequence of exposure to wartime trauma but may also be influenced by post-migration socio-economic factors.
Literature
1.
UNHCR. 2014 Global Trends: World at War. Geneva: United Nations High Commissioner for Refugees; 2015.
2.
Fazel M, Wheeler J, Danesh J. Prevalence of serious mental disorder in 7000 refugees resettled in Western countries: A systematic review. Lancet. 2005;365:1309–14.PubMed
3.
Tempany M. What research tells us about the mental health and psychosocial wellbeing of Sudanese refugees: a literature review. Transcult Psychiatry. 2009;46:300–15.PubMed
4.
Mollica RF, Sarajlic N, Chernoff M, Lavelle J, Sarajlic IV, Massagli MP. Longitudinal study of psychiatric symptoms, disability, mortality, and emigration among Bosnian refugees. JAMA. 2001;286:546–54.PubMed
5.
Lie B. A 3-year follow-up study of psychosocial functioning and general symptoms in settled refugees. Acta Psychiatr Scand. 2002;106:415–25.PubMed
6.
Roth G, Ekblad S, Agren H. A longitudinal study of PTSD in a sample of adult mass-evacuated Kosovars, some of whom returned to their home country. Eur Psychiat. 2006;21:152–9.
7.
Johnson H, Thompson A. The development and maintenance of post-traumatic stress disorder (PTSD) in civilian adult survivors of war trauma and torture: A review. Clin Psychol Rev. 2008;2:36–47.
8.
Steel Z, Chey T, Silove D, Marnane C, Bryant R, van Ommeren M. Association of torture and other potentially traumatic events with mental health outcomes among populations exposed to mass conflict and displacement: A systematic review and meta-analysis. JAMA. 2009;302:537–49.PubMed
9.
Porter M, Haslam N. Predisplacement and postdisplacement factors associated with mental health of refugees and internally displaced persons: A meta-analysis. JAMA. 2005;294:602–12.PubMed
10.
Robjant K, Hassan R, Katona C. Mental health implications of detaining asylum seekers: systematic review. Br J Psychiatry. 2009;194:306–12.PubMed
11.
Beiser M, Hou F. Language acquisition, unemployment and depressive disorder among Southeast Asian refugees: a 10-year study. Soc Sci Med. 2001;53:1321–34.PubMed
12.
Silove D, Steel Z, Bauman A, Chey T, McFarlane A. Trauma, PTSD and the longer-term mental health burden amongst Vietnamese refugees: A comparison with the Australian-born population. Soc Psych Psych Epid. 2007;42:467–76.
13.
Carlson EB, Rosser-Hogan R. Cross-cultural response to trauma: A study of traumatic experiences and posttraumatic symptoms in Cambodian refugees. J Trauma Stress. 1994;7:43–58.PubMed
14.
D’Avanzo CE, Barab SA. Depression and anxiety among Cambodian refugee women in France and the United States. Issues Ment Health Nurs. 1998;19:541–56.PubMed
15.
Marshall GN, Schell TL, Elliott MN, Berthold SM, Chun CA. Mental health of Cambodian refugees 2 decades after resettlement in the United States. J Am Med Assoc. 2005;294:571–9.
16.
Lindert J, Ehrenstein O, Priebe S, Mielck A, Elmar B. Depression and anxiety in labor migrants and refugees: A systematic review and meta-analysis. Soc Sci Med. 2009;69:246–57.PubMed
17.
Porter M. Global evidence for a biopsychosocial understanding of refugee adaptation. Transcult Psychiatry. 2007;44:418–39.PubMed
18.
Thoms ONT, Ron J. Public health, conflict and human rights: Toward a collaborative research agenda. Confl Heal. 2007;1:11.
19.
Murthy RS, Lakshminarayana R. Mental health consequences of war: a brief review of research findings. World Psychiatry. 2006;5:25–30.PubMedPubMedCentral
20.
Bowling A. Research Methods in Health: Investigating health and health services. Philadelphia: Open University Press; 2002.
21.
de Jong JT, Komproe IH, Van Ommeren M, El Masri M, Araya M, Khaled N, et al. Lifetime events and posttraumatic stress disorder in 4 postconflict settings. JAMA. 2001;286:555–62.PubMed
22.
Maercker A, Michael T, Fehm L, Becker ES, Margraf J. Age of traumatisation as a predictor of PTSD or major depression in young women. Br J Psychiatry. 2004;184:482–7.PubMed
23.
Perkonigg A, Kessler RC, Storz S, Wittchen HU. Traumatic events and posttraumatic stress disorder in the community: Prevalence, risk factors and comorbidity. Acta Psychiatr Scand. 2000;101:46–59.PubMed
24.
Sanderson S, Tatt I, Higgins J. Tools for assessing quality and susceptibility to bias in observational studies in epidemiology: A systematic review and annotated bibliography. Int J Epidemiol. 2007;36:666–76.PubMed
25.
Shamliyan T, Kane R, Dickinson S. A systematic review of tools used to assess the quality of observational studies that examine incidence or prevalence and risk factors for diseases. J Clin Epidemiol. 2010;63:1061–70.PubMed
26.
Boyle MH. Guidelines for evaluating prevalence studies. Evid Based Ment Health. 1998;1:37–9.
27.
The World Health Organization (WHO). Composite International Diagnostic Interview (CIDI), Version 2.1. Geneva: World Health Organization; 1997.
28.
Westermeyer J. DSM-III psychiatric disorders among Hmong refugees in the United States: A point prevalence study. Amn J Psychiatry. 1988;145:197–202.
29.
Perera S, Gavian M, Frazier P, Johnson D, Spring M, Westermeyer J, et al. A Longitudinal Study of Demographic Factors Associated With Stressors and Symptoms in African Refugees. Am J Orthopsychiatry. 2013;83:472–82.PubMed
30.
Jaranson JM, Butcher J, Halcon L, Johnson DR, Robertson C, Savik K, et al. Somali and Oromo refugees: correlates of torture and trauma history. Am J Public Health. 2004;94:591–8.PubMedPubMedCentral
31.
Lhewa D, Banu S, Rosenfeld B, Keller A. Validation of a Tibetan translation of the Hopkins Symptom Checklist 25 and the Harvard Trauma Questionnaire. Assessment. 2007;14:223–30.PubMed
32.
Thapa S, Hauff E. Psychological distress among displaced persons during an armed conflict in Nepal. Soc Psychiatry Psychiatr Epidemiol. 2005;40:672–9.PubMed
33.
Sandanger IM. Concordance between symptom screening and diagnostic procedure: the Hopkins Symptom Checklist-25 and the Composite International Diagnostic Interview I. Soc Psychiatry Psychiatr Epidemiol. 1998;33:345–54.PubMed
34.
Ventevogel P, De Vries G, Scholte W, Shinwari N, Faiz H, Nassery R, et al. Properties of the Hopkins Symptom Checklist-25 (HSCL-25) and the Self-Reporting Questionnaire (SRQ-20) as screening instruments used in primary care in Afghanistan. Soc Psychiatry Psychiatr Epidemiol. 2007;42:328–35.PubMed
35.
Berlin JA. Invited commentary: benefits of heterogeneity in meta-analysis of data from epidemiologic studies. Am J Epidemiol. 1995;142:383–7.PubMed
36.
Thompson SG. Systematic review: why sources of heterogeneity in meta-analysis should be investigated. BMJ. 1994;309:1351–5.PubMedPubMedCentral
37.
Blettner M, Sauerbrei W, Schlehofer B, Scheuchenpflug T, Friedenreich C. Traditional reviews, meta-analyses and pooled analyses in epidemiology. Int J Epidemiol. 1999;28:1–9.PubMed
38.
Ioannidis JP, Patsopoulos NA, Rothstein HR. Reasons or excuses for avoiding meta-analysis in forest plots. BMJ. 2008;336:1413–5.PubMedPubMedCentral
39.
Petitti DB. Approaches to heterogeneity in meta-analysis. Stat Med. 2001;20:3625–33.PubMed
40.
Stroup DF, Berlin JA, Morton SC, Olkin I, Williamson GD, Rennie D, et al. Meta-analysis of observational studies in epidemiology: A proposal for reporting. JAMA. 2000;283:2008–12.PubMed
41.
Borenstein M, Hedges LV, Higgins JPT, Rothstein HR. Introduction to Meta-Analysis. Wiley: Chichester; 2009.
42.
Higgins JPT, Thompson SG. Quantifying heterogeneity in a meta-analysis. Stat Med. 2002;21:1539–58.PubMed
43.
44.
Bennett DA, Emberson JR. Editorial: Stratification for exploring heterogeneity in systematic reviews. Evid Based Med. 2009;14:162–4.PubMed
45.
Ramo D, Liu H, Prochaska J. Tobacco and marijuana use among adolescents and young adults: A systematic review of their co-use. Clin Psychol Rev. 2012;32:105–21.PubMed
46.
Sallis J, Prochaska J, Taylor W. A review of correlates of physical activity of children and adolescents. Med Sci Sports Exerc. 2000;32:963–75.PubMed
47.
Gerritsen A, Bramsen I, Deville W, Loes HM, Van Willigen LH, Hovens JE, et al. Physical and mental health of Afghan, Iranian and Somali asylum seekers and refugees living in the Netherlands. Soc Psychiatry Psychiatr Epidemiol. 2006;41:18–26.
48.
Bhui K, Abdi A, Abdi M, Pereira S, Dualeh M, Robertson D, et al. Traumatic events, migration characteristics and psychiatric symptoms among Somali refugees - preliminary communication. Soc Psychiatry Psychiatr Epidemiol. 2003;38:35–43.PubMed
49.
Buseh AG, McElmurry BJ, Fox PG. Acculturative stress and depressed mood among Liberian men residing in a large U.S. Midwestern city. Int J Psychiatr Nurs Res. 2000;6:695–713.
50.
Delic-Ovcina L. The case of adult Bosnian Muslim male refugees in Chicago: Current health behavior outcomes and PTSD symptomatology. Dissertation Abstracts International: Section B. Sci Eng. 2011;71:B7354.
51.
Hinton L, Jenkins C, McPhee S, Wong C, Lai K, Le A, et al. Survey of depressive symptoms among Vietnamese-American men in three locales: prevalence and correlates. J Nerv Ment Dis. 1998;186:677–83.PubMed
52.
Bogic M, Ajdukovic D, Bremner S, Franciskovic T, Galeazzi G, Kucukalic A, et al. Factors associated with mental disorders in long-settled war refugees: refugees from the former Yugoslavia in Germany, Italy and the UK. Br J Psychiatry. 2012;200:216–23.PubMed
53.
Caspi Y, Poole C, Mollica R, Frankel M. Relationship of child loss to psychiatric and functional impairment in resettled Cambodian refugees. J Nerv Ment Dis. 1998;186:484–91.PubMed
54.
Chung RC, Kagawa S. Predictors of psychological distress among Southeast Asian refugees. Soc Sci Med. 1993;36:631–9.PubMed
55.
Mollica RF, McInnes K, Poole C, Tor S. Dose-effect relationships of trauma to symptoms of depression and post-traumatic stress disorder among Cambodian survivors of mass violence. Br J Psychiatry. 1998;173:482–8.PubMed
56.
Onyut L, Neuner F, Ert V, Schauer E, Odenwald M, Elbert T. Trauma, poverty and mental health among Somali and Rwandese refugees living in an African refugee settlement - an epidemiological study. Confl Heal. 2009;3:6.
57.
Sabin MP, Cardozo BLMM, Nackerud LP, Kaiser RM, Varese L. Factors Associated With Poor Mental Health Among Guatemalan Refugees Living in Mexico 20 Years After Civil Conflict. JAMA. 2003;290:635–42.PubMed
58.
Steel Z, Silove D, Phan T, Bauman A. Long-term effect of psychological trauma on the mental health of Vietnamese refugees resettled in Australia: A population-based study. Lancet. 2002;360:1056–62.PubMed
59.
Kolassa I, Ertl V, Eckart C, Onyut L, Kolassa S, Elbert T. Spontaneous remission from PTSD depends on the number of traumatic event types experienced. Psychol Trauma. 2010;2:169–74.
60.
Blair RG. Risk factors associated with PTSD and major depression among Cambodian refugees in Utah. Health Soc Work. 2000;25:23–30.PubMed
61.
Craig C, Sossou M, Schnak M, Essex H. Complicated grief and its relationship to mental health and well-being among Bosnian refugees after resettlement in the United States: Implications for practice, policy, and research. Traumatology. 2008;14:103–15.
62.
von Lersner U, Wiens U, Elbert T, Neuner F. Mental health of returnees: Refugees in Germany prior to their state-sponsored repatriation. BMC Int Health Hum Rights. 2008;8:8.
63.
Birman D, Tran N. Psychological distress and adjustment of Vietnamese refugees in the United States: Association with pre- and postmigration factors. Am J Orthop. 2008;78:109–20.
64.
Hollifield M, Warner T, Jenkins J, Sinclair-Lian N, Krakow B, Eckert V, et al. Assessing war trauma in refugees: Properties of the Comprehensive Trauma Inventory-104. J Trauma Stress. 2006;19:527–40.PubMed
65.
Nicholson BL. The influence of pre-emigration and post-migration stressors on mental health: A study of Southeast Asian refugees. Soc Work Res. 1997;21:19–31.
66.
Hunt N, Gakenyi M. Comparing refugees and nonrefugees: The Bosnian experience. J Anxiety Disord. 2005;19:717–23.PubMed
67.
Stige S, Sveaasstorture N. Living in exile when disaster strikes at home. Torture. 2010;20:76–91.PubMed
68.
Schweitzer R, Melville F, Steel Z, Lacherez P. Trauma, post-migration living difficulties, and social support as predictors of psychological adjustment in resettled Sudanese refugees. Aust N Z J Psychiatry. 2006;40:179–87.PubMed
69.
Matheson K, Jorden S, Anisman H. Relations between trauma experiences and psychological, physical and neuroendocrine functioning among Somali refugees: Mediating role of coping with acculturation stressors. J Immigr Minor Health. 2008;10:291–304.PubMed
70.
Mollica RF, Wyshak G, de Marneffe D, Khuon F, Lavelle J. Indochinese versions of the Hopkins Symptom Checklist-25: A screening instrument for the psychiatric care of refugees. Am J Psychiatry. 1987;144:497–500.PubMed
71.
Mollica RF, Caspi-Yavin Y, Bollini P, Truong T, Tor S, Lavelle J. The Harvard Trauma Questionnaire: Validating a cross-cultural instrument for measuring torture, trauma and posttraumatic stress disorder in Indochinese refugees. J Nerv Ment Dis. 1992;180:111–6.PubMed
72.
Regier DA, Myers JK, Kramer M, Robins LN, Blazer DG, Hough RL, et al. The NIMH Epidemiologic Catchment Area program. Historical context, major objectives, and study population characteristics. Arch Gen Psychiatry. 1984;41:934–41.PubMed
73.
Sheehan D, Lecrubier Y, Sheehan K, Amorim P, Janavs J, Weiller E, et al. Mini International Neuropsychiatric Interview (MINI): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. J Clin Psychiatry. 1998;59 Suppl 20:22–33. quiz 34–57.PubMed
74.
The ESEMeD ⁄MHEDEA 2000 Investigators. Prevalence of mental disorders in Europe: Results from the European Study of the Epidemiology of Mental Disorders (ESEMeD) project. Acta Psychiatr Scand. 2004;109 suppl 420:21–7.
75.
Kessler RC, Chiu WT, Demler O, Merikangas KR, Walters EE. Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62:617–27.PubMedPubMedCentral
76.
Wittchen HU, Jacobi F. Size and burden of mental disorders in Europe: A critical review and appraisal of 27 studies. Eur Neuropsychopharmacol. 2005;15:357–76.PubMed
77.
Flores G. The Impact of Medical Interpreter Services on the Quality of Health Care: A Systematic Review. Med Care Res Rev. 2005;62:255–99.PubMed
78.
Bhopal R, Vettini A, Hunt S, Wiebe S, Hanna L, Amos A. Review of prevalence data and evaluation of methods for cross-cultural adaptation of UK surveys on tobacco and alcohol in ethnic minority groups: A challenge for epidemiology. BMJ. 2004;328:76–80.PubMedPubMedCentral
79.
Farooq S, Fear C, Oyebode F. An investigation of the adequacy of psychiatric interviews conducted through an interpreter. Psychiatr Bull. 1997;21:209–13.
80.
Department of Economic and Social Affairs (DESA). World Economic and Social Survey 2004: International Migration. New York: United Nations; 2004.
81.
Steel Z, Silove D, Bird K, McGorry P, Mohan P. Pathways from war trauma to posttraumatic stress symptoms amongst Tamil asylum seekers, refugees and immigrants. J Trauma Stress. 1999;12:421–35.PubMed
82.
Gorst-Unsworth C, Goldenberg E. Psychological sequelae of torture and organized violence suffered by refugees from Iraq: Trauma-related factors compared with social factors in exile. Brit J Psychiat. 1998;172:90–4.PubMed
83.
Rumbaut R. The agony of exile: A study of the migration and adaptation of Indochinese refugee adults and children. In: Refugee Children: Theory, Research, and Services. Edited by Ahearn FL, Athey JL. Baltimore. Johns Hopkins Univ Press. 1991;53:91.
84.
Piccinelli M, Wilkinson G. Gender differences in depression: Critical review. Brit J Psychiat. 2000;177:486–92.PubMed
85.
Somers JM, Goldner EM, Waraich P, Hsu L. Prevalence and incidence studies of anxiety disorders: a systematic review of the literature. Can J Psychiatry. 2006;51:100–13.PubMed
86.
Frans O, Rimmo PA, Aberg L, Fredrikson M. Trauma exposure and posttraumatic stress disorder in the general population. Acta Psychiatr Scand. 2005;111:291–9.PubMed
87.
Kessler RC, Sonnega A, Bromet E, Hughes M, Nelson CB. Posttraumatic stress disorder in the National Comorbidity Survey. Arch Gen Psychiatry. 1995;52:1048–60.PubMed
88.
Breslau N, Kessler RC, Chilcoat HD, Schultz LR, Davis GC, Andreski P: Trauma and posttraumatic stress disorder in the community: The. Detroit Area Survey of Trauma. Arch Gen Psychiatry. 1996;1998(55):626–32.
89.
Streiner DL, Norman GR. Biases in randomized controlled trials. Commun Oncol. 2009;6:527–9.
90.
91.
Sterne JAC, Gavaghan D, Egger M. Publication and related bias in meta-analysis: power of statistical tests and prevalence in the literature. J Clin Epidemiol. 2000;53:1119–29.PubMed
92.
Terrin N, Schmid CH, Lau J, Olkin I. Adjusting for publication bias in the presence of heterogeneity. Statist Med. 2003;22:2113–26.
93.
Peters JL, Sutton AJ, Jones DR, Abrams KR, Rushton L, Moreno SG. Assessing publication bias in meta-analyses in the presence of between-study heterogeneity. J R Stat Soc Ser A. 2010;173:1–17.
94.
95.
American Psychiatric Association (APA). Diagnostic And Statistical Manual of Mental Disorders: DSM-IV. 4th ed. Washington, DC: American Psychiatric Association; 1994.
96.
Hollifield M, Warner TD, Lian N, Krakow B, Jenkins JH, Kesler J, et al. Measuring trauma and health status in refugees: A critical review. JAMA. 2002;288:611–21.PubMed
97.
Turner SW, Bowie C, Dunn G, Shapo L, Yule W. Mental health of Kosovan Albanian refugees in the UK. Br J Psychiatry. 2003;182:444–8.PubMed
98.
Mezzich JE, Kirmayer LJ, Kleinman A, Fabrega Jr H, Parron DL, Good BJ, et al. The place of culture in DSM-IV. J Nerv Ment Dis. 1999;187:457–64.PubMed
99.
Bhugra D. Depression across cultures. Prim Care Psychiatry. 1996;2:155–65.
100.
Coyne JC, Kagee A. Mental health among Bosnian refugees. JAMA. 2000;283:55–6.PubMed
101.
Hinton DE, Lewis-Fernández R. Idioms of distress among trauma survivors: subtypes and clinical utility. Cult Med Psychiatry. 2010;34:209–18.PubMed
102.
Bonney C. Is resettlement in a Western country the most viable solution for Protracted Refugee Situations? Journal of Politics & International Studies. 2013;9:88–125.
103.
Bulletin of the World Health Organization. Galvanizing mental health research in low- and middle-income countries: role of scientific journals (joint statement). Bull World Health Organ. 2004;82:226–8.
104.
Kühne P, Rüßler H. Die Lebensverhältnisse der Flüchtlinge in Deutschland [The living conditions of refugees in Germany]. Campus-Verlag: Frankfurt; 2000.
Metadata
Title
Long-term mental health of war-refugees: a systematic literature review
Authors
Marija Bogic
Anthony Njoku
Stefan Priebe
Publication date
01-12-2015
Publisher
BioMed Central
Published in
BMC International Health and Human Rights / Issue 1/2015
Electronic ISSN: 1472-698X
DOI
https://doi.org/10.1186/s12914-015-0064-9

Other articles of this Issue 1/2015

BMC International Health and Human Rights 1/2015 Go to the issue

Reviewer acknowledgement

BMC International Health and Human Rights Reviewer Acknowledgement 2014

Research article

The impact of migration on the health status of Iranians: an integrative literature review

Research article

Circumstances leading to intimate partner violence against women married as children: a qualitative study in Urban Slums of Lahore, Pakistan

Research article

“Everywhere but not specifically somewhere”: a qualitative study on why the right to health is not explicit in the post-2015 negotiations

Research article

Cross sectional study on attitudes of Serbian mothers with preschool children: should a HIV-positive female teacher be allowed to continue teaching in school?

Correspondence

Lessons learned from the development of a new methodology to assess missed opportunities for vaccination in Latin America and the Caribbean