The mental health needs of displaced people exposed to armed conflict
Authors: Alvin Kuowei Tay
Journal: The Lancet Public Health (2022)

Refugees and internally displaced people constitute the bulk of the 80 million people fleeing armed conflict and persecution globally.1UNHCRUNHCR projected global resettlement needs. UN High Commissioner for Refugees: UNHCR, 2022Google Scholar The war in Ukraine has led to the largest exodus of refugees and internally displaced people since the Second World War, with 6·5 million people internally displaced, 3·6 million refugees having fled to neighbouring countries, including 1·5 million children.2UNHCRUkraine situation: flash update #5.https://data2.unhcr.org/en/documents/details/91589Date: 2021Date accessed: April 1, 2022Google ScholarOf particular concern in all humanitarian crises is the mental health of refugees and internally displaced people who are exposed to armed conflict. Exposure to armed conflict confers distinct risks to psychiatric disorders, including major depressive disorder, generalised anxiety disorder, and post-traumatic stress disorder.3Steel Z Chey T Silove D Marnane C Bryant RA 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: 537-549Crossref PubMed Scopus (1275) Google ScholarExtending this body of work, Cristina Mesa-Viera and colleagues4Mesa-Vieira C Haas AD Buitrago-Garcia D et al.Mental health of migrants with pre-migration exposure to armed conflict: a systematic review and meta-analysis.Lancet Public Health. 2022; 7: e469-e481Summary Full Text Full Text PDF Scopus (5) Google Scholar examined the associations of armed conflict (levels of intensity), location (country of origin vs host country), age, sex, and migration status (being a refugee or an internally displaced person) with current and lifetime prevalence of post-traumatic stress disorder, major depressive disorder, and generalised anxiety disorder in a pooled sample of refugees and internally displaced people (n=15 984). The main strength of their analysis is the inclusion of data on refugees and internally displaced people, countries of origin and host countries, as well as focusing on studies that used diagnostic interviews. The authors found that exposure to armed conflict, characterised by the intensity of the conflict in the country of origin, and migrating to a low-income or middle-income country, were associated with an increased prevalence of mental health disorders, although not uniformly replicated across all three disorders.Notably, the pooled prevalence for these three mental health disorders yielded by diagnostic interviews was much higher compared with the rates reported in the Global Burden of Disease, Injuries and Risk Factors Study and WHO Mental Health Survey. A cautionary note is warranted, however, when applying western-derived psychiatric categories to culturally and linguistically diverse populations. An additional issue is whether the serial changes to the modern classification systems, namely the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders and the 11th revision of the International Classification of Diseases, were reflected in the diagnostic criteria applied in those studies.Caveats notwithstanding, the finding of an increased risk of psychiatric morbidity related to exposure to armed conflict warrants further discussion. Firstly, exposure to armed conflict does not inevitably lead to psychiatric comorbidity. As shown in Mesa-Viera and colleagues’ work, although increased levels of conflict exposure, quantified by the number of civilian deaths due to conflict, was associated with an increased prevalence of major depressive disorder, the same pattern did not emerge for post-traumatic stress disorder. Further, their analysis of the intensity of conflict was modelled on the proportion of civilian deaths using the Uppsala Conflict Data Program and Peace Research Institute Oslo dataset. Although this population-based approach offers a broad-brush picture of the intensity of the armed conflict, the forms of exposure (either directly or indirectly), the types of exposure (eg, human rights violations, sexual and gender-based violence, health threats, and witnessing atrocities), and the timing of exposure5Mellor R Werner A Moussa B Mohsin M Jayasuriya R Tay AK Prevalence, predictors and associations of complex post-traumatic stress disorder with common mental disorders in refugees and forcibly displaced populations: a systematic review.Eur J Psychotraumatol. 2021; 121863579Crossref PubMed Scopus (4) Google Scholar (although not factored in because of the lack of systematic data) all influence the risk of psychiatric disorders.5Mellor R Werner A Moussa B Mohsin M Jayasuriya R Tay AK Prevalence, predictors and associations of complex post-traumatic stress disorder with common mental disorders in refugees and forcibly displaced populations: a systematic review.Eur J Psychotraumatol. 2021; 121863579Crossref PubMed Scopus (4) Google ScholarSecond, the absence of a significant association between armed conflict intensity and post-traumatic stress disorder does not imply evidence of absence, but rather the heterogeneity in post-traumatic stress disorder might have been accounted for by factors during and after migration. Specifically, the postmigration environment plays a pivotal role in post-traumatic recovery and adaptation amongst war survivors. For example, supportive immigration policies, access to adequate housing, health care, basic services, socioeconomic opportunities, and community support are all contextual factors that mitigate the risk of psychiatric morbidity in refugees and internally displaced people.6Porter M Haslam N Predisplacement and postdisplacement factors associated with mental health of refugees and internally displaced persons: a meta-analysis.JAMA. 2005; 294: 602-612Crossref PubMed Scopus (1057) Google Scholar Migrating to a low-income or middle-income country was associated with an increased risk of generalised anxiety disorder (but not other disorders); of greater interest, however, is whether the presence of modifiable contextual factors would reverse the odds of these disorders.Third, the implications of the results need to be considered. A third of refugees and internally displaced people across geographically distinct locations met the criteria for current post-traumatic stress disorder. There are two important considerations from a public health intervention perspective. First, it is important to distinguish between refugees living in humanitarian settings, internally displaced people, and those living in high-income countries because their needs, symptoms, and profiles are likely to differ. Second, most war survivors are capable of full recovery from the psychological effects of their traumatic experiences in the long term, whereas a minority with persistent and severe symptoms would require more intensive or specialised treatment.7Marshall GN Schell TL Elliott MN Berthold SM Chun CA Mental health of Cambodian refugees 2 decades after resettlement in the United States.JAMA. 2005; 294: 571-579Crossref PubMed Scopus (443) Google ScholarThe multitiered mental health and psychosocial support approach is the well-established guiding framework for refugees in humanitarian settings.8UNHCRStrengthening mental health and psychosocial support in 2021. UN High Commissioner for Refugees, Geneva2021Google Scholar Ensuring safety and security should be the immediate focus, followed by strengthening community support systems, brief and structured psychosocial interventions, and specialised services.8UNHCRStrengthening mental health and psychosocial support in 2021. UN High Commissioner for Refugees, Geneva2021Google Scholar For internally displaced people, however, evidence is needed whether psychosocial interventions can be safely implemented under conditions of ongoing threats and stress. At the same time, vulnerable groups such as children, women, older people, and people with pre-existing medical conditions and disabilities need to be given special consideration.9IASCIASC guidelines on mental health and psychosocial support in emergency settings. Inter-Agency Standing Committee, Geneva2007Google ScholarFor refugees in host countries, particularly those relocated to low-income and-middle income countries, it is important to ensure basic work rights, access to employment opportunities, health care, social services, and community support networks. Within high-income countries, mental health services for refugees need to be sustainably embedded in primary care and community-based settings, where refugees are likely to seek help in the first instance.10Trilesnik B Altunoz U Wesolowski J et al.Implementing a need-adapted stepped-care model for mental health of refugees: preliminary data of the state-funded project “RefuKey”.Front Psychiatry. 2019; (published online Sept 27.)https://doi.org/10.3389/fpsyt.2019.00688Crossref PubMed Scopus (10) Google Scholar In any setting, the mental health care provided to refugees and internally displaced people must be culturally adapted, effective, and tailored to the complexities of their lived experiences. Refugees and internally displaced people constitute the bulk of the 80 million people fleeing armed conflict and persecution globally.1UNHCRUNHCR projected global resettlement needs. UN High Commissioner for Refugees: UNHCR, 2022Google Scholar The war in Ukraine has led to the largest exodus of refugees and internally displaced people since the Second World War, with 6·5 million people internally displaced, 3·6 million refugees having fled to neighbouring countries, including 1·5 million children.2UNHCRUkraine situation: flash update #5.https://data2.unhcr.org/en/documents/details/91589Date: 2021Date accessed: April 1, 2022Google Scholar Of particular concern in all humanitarian crises is the mental health of refugees and internally displaced people who are exposed to armed conflict. Exposure to armed conflict confers distinct risks to psychiatric disorders, including major depressive disorder, generalised anxiety disorder, and post-traumatic stress disorder.3Steel Z Chey T Silove D Marnane C Bryant RA 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: 537-549Crossref PubMed Scopus (1275) Google Scholar Extending this body of work, Cristina Mesa-Viera and colleagues4Mesa-Vieira C Haas AD Buitrago-Garcia D et al.Mental health of migrants with pre-migration exposure to armed conflict: a systematic review and meta-analysis.Lancet Public Health. 2022; 7: e469-e481Summary Full Text Full Text PDF Scopus (5) Google Scholar examined the associations of armed conflict (levels of intensity), location (country of origin vs host country), age, sex, and migration status (being a refugee or an internally displaced person) with current and lifetime prevalence of post-traumatic stress disorder, major depressive disorder, and generalised anxiety disorder in a pooled sample of refugees and internally displaced people (n=15 984). The main strength of their analysis is the inclusion of data on refugees and internally displaced people, countries of origin and host countries, as well as focusing on studies that used diagnostic interviews. The authors found that exposure to armed conflict, characterised by the intensity of the conflict in the country of origin, and migrating to a low-income or middle-income country, were associated with an increased prevalence of mental health disorders, although not uniformly replicated across all three disorders. Notably, the pooled prevalence for these three mental health disorders yielded by diagnostic interviews was much higher compared with the rates reported in the Global Burden of Disease, Injuries and Risk Factors Study and WHO Mental Health Survey. A cautionary note is warranted, however, when applying western-derived psychiatric categories to culturally and linguistically diverse populations. An additional issue is whether the serial changes to the modern classification systems, namely the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders and the 11th revision of the International Classification of Diseases, were reflected in the diagnostic criteria applied in those studies. Caveats notwithstanding, the finding of an increased risk of psychiatric morbidity related to exposure to armed conflict warrants further discussion. Firstly, exposure to armed conflict does not inevitably lead to psychiatric comorbidity. As shown in Mesa-Viera and colleagues’ work, although increased levels of conflict exposure, quantified by the number of civilian deaths due to conflict, was associated with an increased prevalence of major depressive disorder, the same pattern did not emerge for post-traumatic stress disorder. Further, their analysis of the intensity of conflict was modelled on the proportion of civilian deaths using the Uppsala Conflict Data Program and Peace Research Institute Oslo dataset. Although this population-based approach offers a broad-brush picture of the intensity of the armed conflict, the forms of exposure (either directly or indirectly), the types of exposure (eg, human rights violations, sexual and gender-based violence, health threats, and witnessing atrocities), and the timing of exposure5Mellor R Werner A Moussa B Mohsin M Jayasuriya R Tay AK Prevalence, predictors and associations of complex post-traumatic stress disorder with common mental disorders in refugees and forcibly displaced populations: a systematic review.Eur J Psychotraumatol. 2021; 121863579Crossref PubMed Scopus (4) Google Scholar (although not factored in because of the lack of systematic data) all influence the risk of psychiatric disorders.5Mellor R Werner A Moussa B Mohsin M Jayasuriya R Tay AK Prevalence, predictors and associations of complex post-traumatic stress disorder with common mental disorders in refugees and forcibly displaced populations: a systematic review.Eur J Psychotraumatol. 2021; 121863579Crossref PubMed Scopus (4) Google Scholar Second, the absence of a significant association between armed conflict intensity and post-traumatic stress disorder does not imply evidence of absence, but rather the heterogeneity in post-traumatic stress disorder might have been accounted for by factors during and after migration. Specifically, the postmigration environment plays a pivotal role in post-traumatic recovery and adaptation amongst war survivors. For example, supportive immigration policies, access to adequate housing, health care, basic services, socioeconomic opportunities, and community support are all contextual factors that mitigate the risk of psychiatric morbidity in refugees and internally displaced people.6Porter M Haslam N Predisplacement and postdisplacement factors associated with mental health of refugees and internally displaced persons: a meta-analysis.JAMA. 2005; 294: 602-612Crossref PubMed Scopus (1057) Google Scholar Migrating to a low-income or middle-income country was associated with an increased risk of generalised anxiety disorder (but not other disorders); of greater interest, however, is whether the presence of modifiable contextual factors would reverse the odds of these disorders. Third, the implications of the results need to be considered. A third of refugees and internally displaced people across geographically distinct locations met the criteria for current post-traumatic stress disorder. There are two important considerations from a public health intervention perspective. First, it is important to distinguish between refugees living in humanitarian settings, internally displaced people, and those living in high-income countries because their needs, symptoms, and profiles are likely to differ. Second, most war survivors are capable of full recovery from the psychological effects of their traumatic experiences in the long term, whereas a minority with persistent and severe symptoms would require more intensive or specialised treatment.7Marshall GN Schell TL Elliott MN Berthold SM Chun CA Mental health of Cambodian refugees 2 decades after resettlement in the United States.JAMA. 2005; 294: 571-579Crossref PubMed Scopus (443) Google Scholar The multitiered mental health and psychosocial support approach is the well-established guiding framework for refugees in humanitarian settings.8UNHCRStrengthening mental health and psychosocial support in 2021. UN High Commissioner for Refugees, Geneva2021Google Scholar Ensuring safety and security should be the immediate focus, followed by strengthening community support systems, brief and structured psychosocial interventions, and specialised services.8UNHCRStrengthening mental health and psychosocial support in 2021. UN High Commissioner for Refugees, Geneva2021Google Scholar For internally displaced people, however, evidence is needed whether psychosocial interventions can be safely implemented under conditions of ongoing threats and stress. At the same time, vulnerable groups such as children, women, older people, and people with pre-existing medical conditions and disabilities need to be given special consideration.9IASCIASC guidelines on mental health and psychosocial support in emergency settings. Inter-Agency Standing Committee, Geneva2007Google Scholar For refugees in host countries, particularly those relocated to low-income and-middle income countries, it is important to ensure basic work rights, access to employment opportunities, health care, social services, and community support networks. Within high-income countries, mental health services for refugees need to be sustainably embedded in primary care and community-based settings, where refugees are likely to seek help in the first instance.10Trilesnik B Altunoz U Wesolowski J et al.Implementing a need-adapted stepped-care model for mental health of refugees: preliminary data of the state-funded project “RefuKey”.Front Psychiatry. 2019; (published online Sept 27.)https://doi.org/10.3389/fpsyt.2019.00688Crossref PubMed Scopus (10) Google Scholar In any setting, the mental health care provided to refugees and internally displaced people must be culturally adapted, effective, and tailored to the complexities of their lived experiences. I declare no competing interests. Mental health of migrants with pre-migration exposure to armed conflict: a systematic review and meta-analysisMigrants who are exposed to armed conflict are at high risk of mental health disorders. The mental health-care needs of migrants should be assessed soon after resettlement, and adequate care should be provided, with particular attention paid to young adults. Full-Text PDF Open Access