Mental Health and Refugees
Original Editor - Shaimaa Eldib
According to the World Health Organization (WHO), mental health is “a state of well-being in which the individual realizes 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".  Mental health conditions are considered a leading cause for disability all over the world. It accounts for around 13 % of the global burden of disease and responsible for 33% of total years lived with disability. It is estimated that people who have severe mental health disorders, for example, severe depression, bipolar disorder and schizophrenia 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 as it is expected to affect at least 1 of 3 people all over their life-time . Also, there are major economic consequences of this high prevalence. Around $16.3 trillion was estimated to be the cost of mental ill-health globally between 2011 and 2030  and this has serious implications on standers of livings and socioeconomic development. There are many barriers in treating mental illness, for example, stigma, discrimination  and governmental apathy  which exacerbating the current state of mental healthcare all over the world.
The United Nations High Commissioner for Refugees (UNHCR)  defines a refugee as set out in the 1951 Convention The 1951 Convention and its 1967 Protocol: The primary and universal definition of a refugee that applies to States is contained in Article 1(A)(2) of the 1951 Convention, as amended by its 1967 Protocol, defines a refugee as someone who:
"owing to a well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion, is outside the country of his nationality and is unable or, owing to such fear, is unwilling to avail himself of the protection of that country; or who, not having a nationality and being outside the country of his former habitual residence, is unable or, owing to such fear, is unwilling to return to it. 
According to UNHCR 65.6 million people have been forcibly displaced worldwide. There were 20 people newly displaced every minute of 2016. Europe Initially welcomed more than a million refugees and forced migrants between 2015 and 2016. Those who forced to leave their home countries lived in overcrowded reception facilities that have an effect, turned into long term detention centres with poor health and safety conditions , while waiting for resettlement or asylum decisions. All these conditions created medical challenges and increased need for utilisation of health services. 
Refugees Mental Health
Currently, the responsibility of mental health support for the refugee is shared by a network of organizations like the World Health Organization (WHO), the United Nations High Commissioner for Refugees (UNHCR), Governments and Non‐Governmental Organizations. Many refugees are affected by Post-traumatic Stress Disorder (PTSD) due to the circumstances that they faced during their migration, which might affect the quality of their life.
Post-Traumatic Stress Disorder
"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." According to the American Psychiatric Association (APA) and the DSM-5, Post Traumatic Stress Disorder (PTSD) 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”. 2 PTSD presents with persisting, 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 being irritable, having angry outbursts. This disorder is considered the only major mental disorder that may have a known cause. Reactions like fear, horror, and helplessness may be portrayed as the person's physical integrity is being threatened. 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. 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. Some studies on refugees in western countries showed that 9% suffered from PTSD and around 5% from depression. However, there were also studies that obtained results showing 30% among tested cases whom suffered from PTSD. These findings suggest that most refugees are in a traumatized state and are in need of counselling.
Some studies explored the biological effect of this disorder, the findings showed :
- Higher heart rate to sudden loud tones which suggests central sensitization.
- Diminished the volumes of the hippocampus and anterior cingulate cortex which may explain conditions like: depression and substance abuse.
- 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.
The evidence showed 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 . Comprehensive programmes for mental health-care should be included in policy planning such as counselling and psychotherapy , pharmacotherapies, and psychosocial interventions. 
Gaps in Refugee Mental Health
These videos describe the gaps in refugee health and their experiences.
Role of Physiotherapy in Mental Health with Refugee Population
Physiotherapy in mental health is a specialty within physiotherapy. It is implemented in different health and mental health settings: psychiatry and psychosomatic medicine. It is person-centered and caters for children, adolescents, adults and older people with common (mild, moderate) and severe, acute and chronic mental health problems, in primary and community care, inpatients and outpatients. Physiotherapists in mental health provide 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. Physiotherapy in mental health aims to optimize wellbeing 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 interprofessional care.
Physiotherapists should be aware that there are several factors that have a major influence on asylum seeker and refugee mental health:
- The experiences that the refugee exposed to in the origin country or in the refugee camps.
- The experiences in the route to the host country, the process of immigration and the experience of the new life in the host country.
- Limited or poor health literacy .
- Refugees health is also affected by infectious diseases, neurological diseases, cancer and chronic diseases that could result in poly-morbidity.
- Also neurological injuries/ diseases, traumatic injuries (e.g., spinal cord injuries ) or post-traumatic(e.g., chronic pain syndrome).
- Result of starvation ( e.g., epilepsy, ataxia, and paraesthesia)
- Communication Problems, intercultural problems and demand attention problems.
- Psychological problems. 
A study on mental health and service needs among a group of refugees in Malaysia showed that refugees emphasized concerns about accessing opportunities for permanent resettlement and worries about economic survival. Close to all the 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 compliment 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 device exercise programs tailored to patient needs. Interventions include: Relaxation and deep breathing exercises. Various stretching exercises, calisthenics, walking, running, aerobic exercises and swimming can be performed either indoors or outdoors, for patients with substance abuse disorder, gynecological disorders and other conditions. Range of motion, strength, endurance and coordination exercises.
Postural management: Regular changes in body positions are essential for prevention of poor posture, muscle tightness, spasms and decreased joint movement. Balance, equilibrium and gait training. Ergonomic advice: Includes adaptations at home and equipment to make patients independent.
The burden of depression, anxiety and other mental disorders call for concerted, intersectoral response. Not only to raise public awareness, but also to provide treatment and prevention strategies that can reduce this large and growing health problem, including the economic losses attributable to them. The correlations between poor mental health and an increased prevalence of musculoskeletal conditions, multiple areas of pain, chronic and preventable diseases, emphasizes the need for an effective and holistic multidisciplinary approach to the management of these conditions.[4,21]
- The world health report 2001 – Mental Health: New Understanding, New Hope"(PDF). WHO. Retrieved 4 May 2014.
- Mental health: strengthening our response. World Health Organization. August 2014. Retrieved 4 May 2014.
- Murray CJ, Vos T, Lozano R, Naghavi M, Flaxman AD, Michaud C, Ezzati M, Shibuya K, Salomon JA, Abdalla S, Aboyans V. Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. The lancet. 2012 Dec 15;380(9859):2197-223
- Funk M. Global burden of mental disorders and the need for a comprehensive, coordinated response from health and social sectors at the country level. Retrieved on. 2016 Oct;30.
- Thornicroft G, Brohan E, Rose D, Sartorius N, Leese M, INDIGO Study Group. Global pattern of experienced and anticipated discrimination against people with schizophrenia: a cross-sectional survey. The Lancet. 2009 Jan 31;373(9661):408-15.
- Steel Z, Marnane C, Iranpour C, Chey T, Jackson JW, Patel V, Silove D. The global prevalence of common mental disorders: a systematic review and meta-analysis 1980–2013. International journal of epidemiology. 2014 Apr 1;43(2):476-93.
- Vigo D, Thornicroft G, Atun R. Estimating the true global burden of mental illness. The Lancet Psychiatry. 2016 Feb 1;3(2):171-8.
- Bloom DE, Cafiero E, Jané-Llopis E, Abrahams-Gessel S, Bloom LR, Fathima S, Feigl AB, Gaziano T, Hamandi A, Mowafi M, O’Farrell D. The global economic burden of noncommunicable diseases. Program on the Global Demography of Aging; 2012 Jan.
- Caulfield A, Vatansever D, Lambert G, Van Bortel T. WHO guidance on mental health training: a systematic review of the progress for non-specialist health workers. BMJ open. 2019 Jan 1;9(1):bmjopen-2018.
- Lasalvia A, Zoppei S, Van Bortel T, Bonetto C, Cristofalo D, Wahlbeck K, Bacle SV, Van Audenhove C, Van Weeghel J, Reneses B, Germanavicius A. Global pattern of experienced and anticipated discrimination reported by people with major depressive disorder: a cross-sectional survey. The Lancet. 2013 Jan 5;381(9860):55-62.
- Fitzpatrick J. Revitalizing the 1951 refugee convention. Harv. Hum. Rts. J.. 1996;9:229.
- Zimmermann A, Dörschner J, Machts F, editors. The 1951 Convention relating to the status of refugees and its 1967 protocol: A commentary. Oxford University Press; 2011 Jan 27.
- Müller M, Khamis D, Srivastava D, Exadaktylos AK, Pfortmueller CA. Understanding refugees' health. InSeminars in neurology 2018 Apr (Vol. 38, No. 02, pp. 152-162). Thieme Medical Publishers.
- Ellis BH, Winer JP, Murray K, Barrett C. Understanding the mental health of refugees: Trauma, stress, and the cultural context. InThe Massachusetts General Hospital textbook on diversity and cultural sensitivity in mental health 2019 (pp. 253-273). Humana, Cham.
- Fotaki M. A crisis of humanitarianism: refugees at the gates of Europe. International journal of health policy and management. 2019 Jun;8(6):321.
- Blitz BK, d’Angelo A, Kofman E, Montagna N. Health challenges in refugee reception: dateline Europe 2016. International journal of environmental research and public health. 2017 Dec;14(12):1484.
- Kotsiou OS, Kotsios P, Srivastava DS, Kotsios V, Gourgoulianis KI, Exadaktylos AK. Impact of the refugee crisis on the Greek healthcare system: A long road to Ithaca. International journal of environmental research and public health. 2018 Aug;15(8):1790.
- Silove D, Ventevogel P, Rees S. The contemporary refugee crisis: an overview of mental health challenges. World Psychiatry. 2017 Jun;16(2):130-9.
- Wilker S, Catani C, Wittmann J, Preusse M, Schmidt T, May T, Ertl V, Doering B, Rosner R, Zindler A, Neuner F. The efficacy of Narrative Exposure Therapy for Children (KIDNET) as a treatment for traumatized young refugees versus treatment as usual: study protocol for a multi-center randomized controlled trial (YOURTREAT). Trials. 2020 Dec;21(1):1-6.
- Post-traumatic stress disorder (PTSD). Available from: https://www.mind.org.uk/information-support/types-of-mental-health-problems/post-traumatic-stress-disorder-ptsd/about-ptsd/ (Accessed 18 May 2020).
- Ringold S, Burke A, Glass RM. Refugee mental health. JAMA. 2005 Aug 3;294(5):646
- Pitman RK, Rasmusson AM, Koenen KC, Shin LM, Orr SP, Gilbertson MW, Milad MR, Liberzon I. Biological studies of post-traumatic stress disorder. nature Reviews neuroscience. 2012 Nov;13(11):769-87.
- McFARLANE AC. The long‐term costs of traumatic stress: Intertwined physical and psychological consequences. World Psychiatry. 2010 Feb;9(1):3-10.
- Davidson JR, Hughes D, Blazer DG, George LK. Post-traumatic stress disorder in the community: an epidemiological study. Psychological medicine. 1991 Aug;21(3):713-21.
- Bisson J, Andrew M. Psychological treatment of post‐traumatic stress disorder (PTSD). Cochrane database of systematic reviews. 2007(3).
- TED Ex Talks. Bridging the Refugee Health Gap | Claire Jones | TEDxUQ. Available from: http://www.youtube.com/watch?v=3iogISgezbQ[last accessed 28/07/2020]
- Tanishq Suryavanshi. What is the Refugee Mental Health Crisis and How Can We Address it?. Available from: http://www.youtube.com/watch?v=eRfyQl_mSGs[last accessed 28/07/2020]
- TED. How we can bring mental health support to refugees | Essam Daod. Available from: http://www.youtube.com/watch?v=0g0S34XE2b8[last accessed 28/07/2020]
- Wångdahl J, Lytsy P, Mårtensson L, Westerling R. Health literacy among refugees in Sweden–a cross-sectional study. BMC public health. 2014 Dec 1;14(1):1030.
- Uba L. Cultural barriers to health care for southeast Asian refugees. Public health reports. 1992 Sep;107(5):544.
- Dadzie GM. Healthcare Accessibility for Syrian Refugees: Understanding Trends, Host Countries’ Responses and Impacts on Refugees’ Health.
- Shaw, S.A., Pillai, V. and Ward, K.P., 2019. Assessing mental health and service needs among refugees in Malaysia. International Journal of Social Welfare, 28(1), pp.44-52.