Age and environmental factors predict psychological symptoms in adolescent refugees during the initial post-resettlement phase.

BACKGROUND: Adolescent refugees are at high risk of developing mental disorders but are often not recognised early. This pilot study aimed to identify early putative risk factors associated with psychological symptoms in newly resettled refugee youth at potential risk of subsequently developing mental disorders. METHODS: Newly resettled adolescent refugees were recruited through English language schools in Melbourne, Australia. Participants were assessed with the MINI-Kid, Achenbach Youth Self-Report and Reaction of Adolescents to Traumatic Stress scale. Parents completed a mental health screening separately. Linear regression models were used to identify predictive factors associated with symptom ratings. RESULTS: Seventy-eight, ostensibly well, refugee adolescents (mean age = 15.0 ± 1.6 years) resettled in Australia for 6.1 ± 4.2 months were assessed. Levels of anxiety, depression and post-traumatic stress symptoms were considerably lower than in mainstream population data. Prior displacement was a key determinant of symptomatology. Transitory displacement, irrespective of duration, was associated with elevated scores for depression (t (47) = -4.05, p < 0.0001), avoidance/numbing (U = 466, p < .05) and total trauma (U = 506, p < .05) symptoms. Older age was a unique predictor of depression (F (1,74) = 8.98, p < .01), internalising (F(1,74) = 6.28, p < .05) and total (F(1,74) = 4.10, p < .05) symptoms, whilst parental depression symptoms (t = 2.01, p < 0.05), displacement (t = 3.35, p < 0.01) and, expectedly, trauma exposure (t = 3.94, p < 0.001) were unique predictors of post-traumatic stress symptoms. CONCLUSIONS: Displaced status, older age, and parental symptoms predicted psychological symptoms in adolescent refugees in an initial relatively asymptomatic post-resettlement phase. The early recognition of at-risk refugee youth may provide an opportunity for preventative mental health interventions.

Moral injury related to immigration detention on Nauru: a qualitative study.

Background: Immigration detention is associated with detrimental mental health outcomes but little is known about the underlying psychological processes. Moral injury, the experience of transgression of moral beliefs, may play an important role. Objective: Our aim was to explore moral injury appraisals and associated mental health outcomes related to immigration detention on Nauru. Methods: In this retrospective study, we conducted in-depth interviews with 13 individuals who had sought refuge in Australia and, due to arriving by boat, had been transferred to immigration detention on Nauru. At the time of the study, they lived in Australia following medical transfer. We used reflexive thematic analysis to develop themes from the data. Results: Major themes included 1) how participants' home country experience and the expectation to get protection led them to seek safety in Australia; 2) how they experienced deprivation, lack of agency, violence, and dehumanization after arrival, with the Australian government seen as the driving force behind these experiences; and 3) how these experiences led to feeling irreparably damaged. The participant statement 'In my country they torture your body but in Australia they kill your mind.' conveyed these three key themes in our analysis. Conclusion: Our findings suggest that moral injury may be one of the processes by which mandatory immigration detention can cause harm. Although refugees returned to Australia from offshore detention may benefit from interventions that specifically target moral injury, collective steps are needed to diminish deterioration of refugee mental health. Our results highlight the potentially deleterious mental health impact of experiencing multiple subtle and substantial transgressions of one's moral frameworks. Policy makers should incorporate moral injury considerations to prevent eroding refugee mental health.

Antecedentes: La detención de inmigrantes está asociada con resultados perjudiciales en la salud mental, pero se conoce poco acerca de los procesos psicológicos subyacentes. El daño moral y la experiencia de transgredir las creencias morales pueden desempeñar un rol importante.Objetivos: Nuestro objetivo fue explorar las evaluaciones de daño moral y los resultados asociados a la salud mental relacionados con la detención de inmigrantes en Nauru.Métodos: En este estudio retrospectivo, realizamos entrevistas en profundidad a 13 individuos que habían solicitado refugio en Australia y, debido a que llegaron en barco, habían sido transferidos a centros de detención de inmigrantes en Nauru. En el momento del estudio, se encontraban viviendo en Australia tras un traslado médico. Utilizamos un análisis temático reflexivo para desarrollar temas a partir de los datos.Resultados: Los temas principales incluyeron 1) cómo la experiencia del país de origen de los participantes y la expectativa de obtener protección los llevaron a buscar seguridad en Australia; 2) cómo experimentaron la privación, la falta de acción, la violencia, la deshumanización posterior a su llegada, con el gobierno australiano visto como la fuerza impulsora detrás de estas experiencias; y 3) cómo estas experiencias los llevaron a sentirse irreparablemente dañados. La declaración de los participantes 'En mi país torturan tu cuerpo, pero en Australia matan tu mente', transmitió estos tres temas en nuestro análisis.Conclusiones: Nuestros hallazgos sugieren que el daño moral puede ser uno de los mecanismos por los cuales la detención migratoria obligatoria puede causar daño. Sin embargo, los refugiados retornados de la detención en alta mar a Australia pueden beneficiarse de las intervenciones que se enfocan específicamente en el daño moral, se necesitan pasos colectivos para disminuir el deterioro de la salud mental de los refugiados. Nuestros resultados resaltan el impacto potencialmente deletéreo en la salud mental de experimentar múltiples transgresiones sutiles y sustanciales de los marcos morales de uno. Los diseñadores de políticas públicas deberían incorporar consideraciones relacionadas al daño moral para prevenir la erosión de la salud mental de los refugiados.

To strive, to seek, to find, and not to yield: Narratives on the road to asylum.

This study aimed to explore the ecological influences on subjective well-being identified by current and former community-dwelling asylum seekers engaged in the process of Refugee Status Determination in Australia. This article presents the qualitative component of a prospective mixed-methods study of 131 asylum seekers and refugees (T1, N = 131; T2, N = 56). The Framework Analysis method was employed to qualitatively analyse the narrative data derived from 187 semi-structured interviews documenting pre-, peri-, and post-migration experiences, and the impact of Australia's asylum policies and procedures. Four overarching themes comprising 15 sub-themes emerged: The Refugee Status Determination process (Waiting; Uncertainty; Worry); Psychosocial factors (Un/employment & gainful activity; Medicare; Accommodation; Family separation & loneliness; Loss); Health and well-being (Mental health; Physical health & somatic issues; Hopelessness; Helplessness); and Protective factors (Hope; Support & social connectivity; Religion). The complex interface between the Refugee Status Determination process, un/employment, and mental health concerns was the most salient finding. Policy implications are discussed in relation to the application of the Convention and Protocol Relating to the Status of Refugees and the Guidelines on the Judicial Approach to Expert Medical Evidence.

Development and validation of a mental health screening tool for asylum-seekers and refugees: the STAR-MH.

BACKGROUND: There is no screening tool for major depressive disorder (MDD) or post-traumatic stress disorder (PTSD) in asylum-seekers or refugees (ASR) that can be readily administered by non-mental health workers. Hence, we aimed to develop a brief, sensitive and rapidly administrable tool for non-mental health workers to screen for MDD and PTSD in ASR. METHODS: The screening tool was developed from an extant dataset (n = 121) of multiply screened ASR and tested prospectively (N = 192) against the M.I.N.I. (Mini International Neuropsychiatric Interview) structured psychiatric interview. Rasch, Differential Item Functioning and ROC analyses evaluated the psychometric properties and tool utility. RESULTS: A 9-item tool with a median administration time of six minutes was generated, comprising two 'immediate screen-in' items, and a 7-item scale. The prevalence of PTSD &/or MDD using the M.I.N.I. was 32%, whilst 99% of other diagnosed mental disorders were comorbid with one or both of these. Using a cut-score of ≥2, the tool provided a sensitivity of 0.93, specificity of 0.75 and predictive accuracy of 80.7%. CONCLUSIONS: A brief sensitive screening tool with robust psychometric properties that was easy to administer at the agency of first presentation was developed to facilitate mental health referrals for asylum-seekers and new refugees.

Tho' Much is Taken, Much Abides: Asylum Seekers' Subjective Wellbeing.

The influence of psychosocial factors on the subjective wellbeing of asylum-seekers residing in host Western countries has scarcely been explored qualitatively. Qualitative data derived from a mixed methods prospective study investigated the subjective wellbeing of 56 community-dwelling asylum-seekers and refugees at baseline and an average of 15.7 months later. Positive and negative experiences over time were explored in relation to self-perceived emotional health. Nineteen positive and 15 negative categories of experience emerged. Distinct psychosocial and protective factors were salient regarding the valence of experiences over time, with positive experiences comprising employment, improved financial circumstances, and social support or connectivity. Negative experiences included news of adversity from one's homeland, un(der)employment, poor health, and factors relating to the refugee determination process. Positive and negative experiences were contemporaneous, indicating that employment and social support may ameliorate the detrimental impact of traversing the protracted process of refugee status determination for asylum-seekers in particular.

Social factors ameliorate psychiatric disorders in community-based asylum seekers independent of visa status.

The impact of industrialised host nations' deterrent immigration policies on the mental health of forced migrants has not been well characterised. The present study investigated the impact of Australia's refugee determination process (RDP) on psychiatric morbidity in community-based asylum-seekers (AS) and refugees. Psychiatric morbidity was predicted to be greater in AS than refugees, and to persist or increase as a function of time in the RDP. The effect on mental health of demographic and socio-political factors such as health cover and work rights were also investigated. Psychiatric morbidity was measured prospectively on five mental health indices at baseline (T1, n=131) and an average of 15.7 months later (T2, n=56). Psychiatric morbidity in AS significantly decreased between time points such that it was no longer greater than that of refugees at T2. Caseness of PTSD and demoralisation reduced in AS who gained protection; however, those who maintained asylum-seeker status at T2 also had a significant reduction in PTS and depression symptom severity. Reduced PTS and demoralisation symptoms were associated with securing work rights and health cover. Living in the community with work rights and access to health cover significantly improves psychiatric symptoms in forced migrants irrespective of their protection status.

Mental disorders in asylum seekers: the role of the refugee determination process and employment.

The refugee determination process (RDP) and social factors putatively impact on the psychiatric morbidity of adult asylum seekers (ASs) living in the community. Clinical and sociodemographic data relevant to AS experience in the RDP were collected using self-report measures to assess posttraumatic stress (Harvard Trauma Questionnaire-Revised) and depressive and anxiety symptoms (25-item Hopkins Symptom Checklist), and the Mini-International Neuropsychiatric Interview 6.0 psychiatric interview was used to establish a cutoff for caseness. The prevalence of major depressive disorder (MDD) and posttraumatic stress disorder (PTSD) was 61% and 52%, respectively. Unemployment and greater numbers of both potentially traumatic events and RDP rejections were predictors of symptom severity. Unemployed ASs were more than twice as likely to have MDD (odds ratio, 2.61; 95% confidence interval [CI], 1.11- 6.13; p = 0.03), and ASs with at least one RDP rejection were 1.35 times more likely to develop PTSD for each additional rejection (95% CI, 1.00-1.84; p = 0.05). Reducing the asylum claim rejection rate and granting work rights are likely to reduce the rate of PTSD and MDD in community-based ASs.