Mental Health and Forced Displacement

Introduction[edit | edit source]

According to the World Health Organization (WHO), mental health is “a state of well-being in which the individual realises his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community".[1][2]

Mental health conditions are considered a leading cause for disability globally, accounting for around 13% of the global burden of disease, and 33% of total years lived with disability.[3][4] It is estimated that people who have severe mental health disorders, for example, severe depression, bipolar disorder and schizophrenia[5] are more likely to die prematurely than those who have not been affected. The problems of mental health are highly prevalent globally, affecting people across all regions of the world. They are expected to affect at least 1 out of 3 people across their life-time.[6][7]

There are major economic consequences of this high prevalence in mental health conditions; it is estimated that mental ill-health will lead to the loss of $US16.1 trillion between 2011 and 2030.[8] This cost has serious implications on standards of livings and socioeconomic development.[9] There are many barriers to treating mental illness including stigma, discrimination[10][5] and governmental apathy,[9] which further exacerbate the current state of mental health care all over the world.

Displaced Person Crisis[edit | edit source]

According to the United Nations High Commissioner for Refugees (UNHCR), 89.3 million people have been forcibly displaced worldwide as a result of conflicts, violence, fear of persecution and human rights violations in 2021; it is estimated that there will be more than than 100 million people displaced in 2022.[11] There were 20 people newly displaced every minute of 2016.[12] Those who are forced to leave their home countries often live in overcrowded reception facilities while waiting for resettlement or asylum decisions.[13] These facilities have, in effect, turned into long-term detention centres and have poor health and safety conditions.[14] All these factors create medical challenges and an increased need for displaced persons to utilise health services. [15]

Mental Health and Displacement[edit | edit source]

Migrants can be exposed to various stress factors which affect their mental health and well-being before and during their migration journey and during their settlement and integration. While most migrants do not experience mental health problems, people displaced as a result of conflicts, violence, fear of persecution and human rights violations can lead to at increased risk of mental health problems. This is particularly true for persons who have experienced violence and trauma, including exploitation, torture or sexual and gender-based violence. Issues can range from low to moderate levels of anxiety and depression through to more severe mental disorders.

Currently, the responsibility of mental health support for displaced persons is shared by a wide network of organisations depending on where the displaced person is based. These organisations include: the World Health Organization (WHO), the United Nations High Commissioner for Refugees (UNHCR), Governments and Non‐Governmental Organisations.[16]

When individuals and families seek safety by leaving their homes, cultures, and communities because of the threat of violence and persecution, emotional distress can be heightened. About one third of displaced persons will experience high rates of depression, anxiety, and post-traumatic stress disorders (PTSD) as a result of the circumstances they faced during their migration, which can significantly affect the quality of their life.[16] [17] However, systematic reviews show that prevalence estimates of mental health disorders vary widely from 4% to 80% including:[18][19]

While most displaced persons with PTSD and depression show a reduction in symptoms over time, particularly if there are low resettlement stressors,[24][25] others may experience years of symptoms, particularly those with PTSD.[26][27] Because of this, early access to mental health care should be prioritised, as post-migration stressors such as prolonged detention, insecure immigration status, and limitations on work and education, can worsen mental health.

Post-Traumatic Stress Disorder[edit | edit source]

"When something traumatic happens in your life it rocks you to the core. The world is no longer a safe place. It becomes somewhere that bad things can and do happen." [28]

According to the American Psychiatric Association (APA) and the DSM-5, Post Traumatic Stress Disorder is defined as a “psychiatric disorder in which patients have experienced or witnessed a significant traumatic event. Examples of such an event include natural disasters, serious accidents, terrorist acts, war/combat, rape, or other violent personal assaults. PTSD presents with persistent, recurrent and disturbing memories or flashbacks of a witnessed or experienced trauma, avoidance of reminders of the traumatic event along with other symptoms such as negative thoughts and feelings, difficulty with concentration and sleep, feeling detached from people and current experiences, as well as exaggerated startle responses and arousal / reactive symptoms such as irritability, and angry outbursts.[29] Reactions like fear, horror, and helplessness may be portrayed as the person's physical integrity is being threatened.[30] Difficulties in emotional regulation, cognitive functioning, self-perception, relationships, somatisation and hopelessness may occur due to severe stress as a result of overwhelming circumstances and disturbing experiences.[31]

The prevalence of traumatic experiences is common. It is found that more than two-thirds of persons in the general population may experience a significant traumatic event at some point in their lives.[32] Some studies on refugees in western countries showed that 9% suffered from PTSD and around 5% from depression. However, other studies suggest that the prevalence of PTSD is around 30%.[16] These findings suggest that many refugees are in a traumatised state and are in need of counselling.[16]

It has been found that the biological effects of PTSD include:

  • Higher heart rate to sudden loud tones which suggests central sensitisation.
  • Diminished volumes of the hippocampus and anterior cingulate cortex which may explain conditions like: depression and substance abuse.[30]
  • Changes in brain and pre-existing vulnerability and neurotoxicity as origins of brain volume reductions in PTSD.
  • Amygdala and dorsal anterior cingulate cortex are hyper(re)active, whereas the ventral medial prefrontal cortex is hypo(re)active in PTSD and this may explain attentional bias towards the threat, impaired emotional regulation.[30]

Evidence suggests that trauma-focused cognitive behavioural therapy or eye movement desensitisation and reprocessing should be considered in individuals with PTSD. Psychological treatments can reduce symptoms of PTSD.[33] Comprehensive programmes for mental health-care should be included in policy planning such as counselling and psychotherapy, pharmacotherapies, and psychosocial interventions.[16]

Gaps in Refugee Mental Health[edit | edit source]

These videos describe the gaps in refugee health and their experiences.

Role of Rehabilitation Professionals[edit | edit source]

Person-centred rehabilitation services for mental health are implemented in many different health and mental health settings: psychiatry and psychosomatic medicine cater for children, adolescents, adults and older people with mild to severe, acute and chronic mental health problems, in primary and community care, inpatient and outpatient settings.

Mental health rehabilitation professionals provide a wide range of services including health promotion, preventive health care, treatment and rehabilitation for individuals, groups and in‐group therapeutic settings. They create a therapeutic relationship to provide assessment and services specifically related to the complexity of mental health within a supportive environment applying a model including biological and psychosocial aspects. Rehabilitation professionals in mental health aim to optimise well-being and empower the individual by promoting functional movement, movement awareness, physical activity and exercises, bringing together physical and mental aspects. It is based on the available scientific and best clinical evidence. Physiotherapists in mental health contribute to the multidisciplinary team and inter-professional care.[37]

Rehabilitation professionals should be aware that there are several factors that have a major influence on mental health in displaced persons:

A study on mental health and service needs among a group of displaced persons in Malaysia showed that displaced persons emphasise concerns about accessing opportunities for permanent resettlement and worries about economic survival.[41] Almost all participants in the study reported that they would be interested in taking part in supportive group services. Therefore, as service providers, high attention to mental well-being and coping strategies must be incorporated while evaluating basic needs, even in temporary settings.

Physiotherapists are effective members of multidisciplinary teams of doctors, nurses, dietitians, therapists and social workers. Physiotherapy management can complement medication and psychotherapy within the multidisciplinary team. The role and tasks of physiotherapists in these teams will vary, from management of pain, increasing joint mobility, relaxation exercises, improvement of strength, endurance and balance, gait training and to devise exercise programmes tailored to patient needs. Interventions might include: relaxation and deep breathing exercises;[5] various stretching exercises, callisthenics, walking, running, aerobic exercises and swimming. These can be performed either indoors or outdoors and may be useful for patients with substance abuse disorders,[16] gynaecological disorders and other conditions; range of motion, strength, endurance and coordination exercises.

Postural management: Regular changes in body positions are essential to prevent poor posture, muscle tightness, spasms and decreased joint movement.[20] Balance, equilibrium and gait training may be beneficial as is ergonomic advice. This advice might include adaptations at home and equipment to make patients independent.[20]

The burden of depression, anxiety and other mental disorders call for concerted, intersectoral responses. The aim is not only to raise public awareness, but also to provide treatment and prevention strategies that can reduce this large and growing health problem and its associated economic cost.[3] The correlations between poor mental health and an increased prevalence of musculoskeletal conditions, multiple areas of pain, chronic and preventable diseases emphasise the need for an effective and holistic multidisciplinary approach to managing these conditions.[4][21]

References[edit | edit source]

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