An ecological model for refugee mental health: implications for research

The paper by Ken Miller and Andrew Rasmussen presents a valuable stimulus for a discussion on research directions in the field of refugee mental health. The authors extend their earlier work on the importance of ‘daily stressors’ for populations affected by armed conflict to discuss the importance of post-migration stressors in refugee populations. While acknowledging the well-documented importance of conflict-related potentially traumatic events in the past for refugee mental health, the authors propose a model, which emphasises ongoing post-migration stressors such as poverty, unemployment, stigma and perceived discrimination, and increased family violence. The issues presented in the paper are timely, given the high number of refugees and asylum seekers worldwide, the majority of whom live in lowand middle-income countries where ongoing stressors are a daily reality. As mentioned by Miller and Rasmussen, more than 60 million people are estimated to have been forcibly displaced from their country of residence due to conflicts, human rights violations, generalised violence and persecution as of the end of 2015, including 21.3 million refugees and over 3 million asylum seekers (UNHCR, 2015). Displaced populations may encounter horrific and profoundly painful experiences and losses that – together with other chronic contextual difficulties – can form risks for severe psychological distress and a range of mental disorders through complex pathways. The consideration of this complexity is of importance for researchers in the field of global mental health, and research on mental health and psychosocial support in humanitarian settings in particular, in several ways. First, the proposed model has much in common with proposed shifts in thinking that have been advocated for at least 15 years, in which a predominantly trauma-focused model is complemented by more holistic psychosocial (IASC, 2007) or public mental health perspectives (Silove, 1999; de Jong, 2002; Rasco & Miller, 2004). In line with psychosocial and public mental health approaches, Miller and Rasmussen’s consideration of ongoing chronic stressors goes beyond a traditional biomedical (psychiatric) paradigm in which a single pathogen (e.g., conflict-related potentially traumatic events) is linked to a single mental health outcome for refugees (e.g., posttraumatic stress disorder). Rather, a focus on ongoing stressors allows an examination of social determinants of mental health in addition to violence exposure. In a public mental health approach social determinants are commonly studied through a socio-ecological lens, for example at the family, school, community and wider social levels. Family violence, unemployment, perceived discrimination and poverty are examples of social determinants of mental health, together with broader environmental factors such as unequal access to basic resources and opportunities to partake in occupational and recreational activities. Although there is considerable knowledge on the social determinants of mental health in general populations (Allen et al. 2014), relatively little of this research has focused on refugee populations. Further exploration of modifiable social determinants of refugee mental health (both protective and risk factors) is critical, as it may assist in identifying targets for socio-culturally-sensitive promotive and preventive interventions. What Miller and Rasmussen defined in the paper as ‘daily stressors’ (i.e., all stressors, major and minor, not related to conflict) are critical both before and after migration (e.g., pre-migration childhood adversities and exposure to violence). Unfortunately, for many people in areas of armed conflict, the experience of war and violence does not represent a sudden rupture in a life * Address for correspondence: M. Purgato, Department of Neuroscience, Biomedicine and Movement Sciences, Section of Psychiatry, University of Verona, Piazzale L.A. Scuro, 10 – 37134 Verona, Italy. (Email: marianna.purgato@univr.it) Epidemiology and Psychiatric Sciences (2017), 26, 139–141. © Cambridge University Press 2016 doi:10.1017/S204579601600069X COMMENTARY TO SPECIAL ARTICLE