Post-traumatic stress disorder (PTSD) among displaced populations in the aftermath of mass atrocities
Post-traumatic stress disorder (PTSD) is one of the most widely reported psychological disorders among refugees, asylum-seekers and internally displaced persons (IDPs). The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) categorizes PTSD under Trauma- and Stressor-Related Disorders and uses exposure to a traumatic or stressful event as a diagnostic criterion (American Psychiatric Association, 2013).Some of the most common traumatic events that may lead to PTSD are sudden death of a loved one, a natural disaster, a serious accident, war, rape or other violent personal assault. According to the DSM-5, the symptoms of PTSD fall into four categories including (1) intrusive thoughts such as repeated memories, upsetting dreams or flashbacks of the traumatic event, (2) avoiding reminders such as people, places, activities, objects and situations that bring on distressing memories (3) negative feelings about oneself or others such as feelings of hopelessness for the future or difficulty maintaining relationships with others and (4) increased arousal and reactive symptoms which may include aggressive or self-destructive behavior, outbursts of anger or being easily irritable. Many people who go through traumatic events may temporarily experience similar symptoms. However, for a person to be diagnosed with PTSD, the symptoms must persist for longer than a month or sometimes years with no progress (American Psychiatric Association, 2013). PTSD can be treated through psychotherapy, medication or a combination of the two. According to the treatment guidelines set by the American Psychological Association (APA) in 2017, the most effective types of therapy in the treatment of PTSD are prolonged exposure (PE), cognitive processing therapy (CPT) and trauma-focused cognitive behavioral therapy (CBT) (Watkins et al., 2018). Refugees and internally displaced persons (IDPs) fleeing conflict-affected areas are often affected by serious traumatic events such as the death or disappearance of loved ones; experiences of physical, emotional or sexual violence; or witnessing different forms of violence during the period leading up to their forced migration. While the major traumatic experiences are often encountered before migration and during the migration journey, forced migrants, unlike non-migrant victims of traumatic events, are often persistently and uniquely exposed to additional stressors in the post-migratory phase because of the social, economic and cultural challenges of living and functioning in an unfamiliar environment. Poor access to social services and employment opportunities, declining possibilities for self-sufficiency, changing family structures, perceptions of discrimination and marginalization, cultural and linguistic barriers, and other socioeconomic disadvantages increase refugees’ vulnerabilities to mental health problems (Alpak et al., 2015; Porter and Haslam, 2005). In addition, these challenges may also hinder refugees’ access to and use of mental health services and other support mechanisms. This article reviews the key literature on PTSD prevalence among displaced populations and the relevant risk factors that shape development of PTSD. It also discusses the main challenges facing refugees and asylum seekers in access to mental health services.
Overview of current situation
A large and growing body of literature has investigated the association between forced migration and psychological disorders. In a systematic review of cumulative findings concerning the prevalence of psychological disorders among randomly-selected adult refugee populations resettled in high-income OECD countries, which excluded studies based on self-reported questionnaires or those that included refugees that are referred to health care services, Fazel et al. (2005) found that refugees are ten times more likely to experience PTSD than members of the age-matched general population. However, there is substantial variation in PTSD prevalence rates estimated by studies reporting on different samples of displaced populations, which often stems from the heterogeneity of the studied groups and the differences in methodological approaches. Subjects’ ethno-cultural background, conflict dynamics in countries of origin, migration journeys, duration of stay in asylum or destination country, the level of social inclusion in the host country, legal status, and socio-demographic background are some key factors that affect the prevalence of psychiatric diseases, including post-traumatic stress disorder (PTSD), depression and anxiety among adult refugee populations living in a host country (Gerritsen et al., 2004). In another systematic review, Morina et al. (2018) examined thirty-eight studies that mainly used well-established clinical diagnostic interviews conducted by trained interviewers or medical practitioners to evaluate prevalence rates of common psychiatric disorders among adult refugees and IDPs originating from conflict-affected territories. The eligible studies included assessments based on clinical diagnosis by mental health care specialists, clinical assessment provided by trained interviewers and mental health evaluation by means of a self-administered questionnaire. The study showed that the range for PTSD prevalence varies between 3% and 88% among different groups, yielding the highest reported prevalence in comparison to other disorders such as depression (5-80%), and anxiety disorders (1-81%).
Together, these studies indicate a strong association between involuntary migration and mental health problems. However, there remain gaps in the research, as the majority of the studies conducted in this field focus on refugee populations living in Western countries, and little attention has been paid to asylum-seekers, refugees and IDPs sampled in less developed countries. In fact, the absence of studies on the mental health of displaced populations in developing countries is particularly problematic as a larger proportion of forced migrants are hosted in less developed countries and communities in the Global South. According to the annual Global Trends report by UNHCR (2018), countries in developed regions hosted a mere 16% of recognised refugees in 2017, while the overwhelming majority of refugees are living in the countries of first asylum such as Turkey, Pakistan, Uganda and Sudan, which often share borders with conflict-affected home countries of refugees. Therefore, the disproportionate attention given to Western countries may generate biased results that may not generalize to the majority because the studied group represents a narrow sub-sample of the overall displaced population.
Table 1 below provides a summary of the major risk factors for PTSD as derived from a set of studies dealing with specific geographies and migrant populations. The sources are systematically selected to account for the heterogeneity in prevalence rates across studies and to include sources that focus on groups with different displacement statuses (e.g. IDPs, asylum seekers and refugees) and residing in different settings (urban areas, refugee camps, reception centers). As shown in Table 1, there are several risk factors in developing PTSD and mediating factors that hasten severity in different migrant populations and different areas in the world. Some of the most commonly reported risk factors and mediating factors that are associated with PTSD in displaced populations are discussed below with reference to the pertinent studies.
Table 1. List of reviewed studies
Multiple exposure to trauma
Research indicates that prior exposure to traumatic events, such as detention and abuse, traumatic loss of loved ones or exposure to conflict, either before or during the migratory process, is the strongest predictor of expression of PTSD symptoms among displaced populations. Notwithstanding the individual variation of such experiences, refugees and internally displaced persons are often exposed to both repeated and ongoing traumatic triggers in the context of conflict, persecution, displacement, and post-displacement. Research shows that the extent of exposure to traumatic events is likely to increase the risk of developing PTSD among displaced populations (International Society for Traumatic Stress Studies, 2017). A study conducted in the Netherlands with 410 refugees and asylum seekers found that multiple traumatic events are associated with all negative health outcomes (depression, anxiety, general health and chronic conditions), including the diagnosis of PTSD (Gerritsen et al., 2006). A study conducted in a refugee camp in Southeastern Turkey among randomly-recruited Syrian refugees (n=352) similarly suggested that experiencing multiple traumas and having personal or family history of a psychiatric disorder significantly increases the likelihood of PTSD diagnosis (Alpak et al., 2015). Other studies provide contradictory evidence. A study conducted in the Netherlands with 54 Somalian asylum seekers with a PTSD prevalence rate of 31.5% found no association between the number of traumatic events experienced and the severity of the PTSD (Roodenrijs et al., 1998), but the finding may be interpreted with caution given the small sample number.
Legal status (asylum seeker vs refugee)
Several studies have revealed that PTSD prevalence rates are higher for asylum seekers in comparison to refugees, which indicates that additional stress factors may be imposed by precarious and uncertain life situations in destination countries. A number of researchers have reported increased levels of psychiatric distress in asylum-seekers who have been waiting to receive a decision on their asylum claim (Silove et. al, 1997; Gerritsen, 2006), or those with insecure or temporary residence/protection status (Georgiadou et al., 2018, Steel et al., 2011). In a study conducted by Silove et al. (1997), 14 out of 43 asylum-seekers (37%) met full criteria for diagnosis of PTSD, and the major risk factors associated with the positive diagnosis were greater exposure to pre-migration trauma as well as post-displacement stressors such as delays in processing refugee applications, difficulties in dealing with immigration officials, obstacles to employment, discrimination, and loneliness and boredom. In another study, Loyd et. al (2018) argue that the complex and lengthy processes of refugee status determination leading up to resettlement processes among refugees under temporary protection in Turkey support ongoing traumatization for affected refugees. Other stressors highlighted by studies focusing on asylum-seekers show that prolonged detention periods and restricted access to social services can compound the effects of past traumas (Silove et al., 2017). For example, in terms of health access, while in many destination countries refugees can access specialized mental health services, asylum-seekers often have limited access to support and services. The barriers to accessing mental health services may leave PTSD symptoms untreated, which can have detrimental implications on both mental and physical health indicators, ranging from functional and emotional impairment, drug and alcohol abuse and sleep problems, to chronic pain and increased likelihood of suicide attempts (American Psychological Association, 2004). In a study among displaced persons from former Yugoslavia with untreated war-related PTSD, Priebe et al. (2009), showed that 83.7% of participants still have active PTSD, demonstrating that PTSD may reoccur even after long periods of time if left untreated in the past .
Pressures of post-migration environment
Post-migration stressors can maintain and trigger PTSD symptoms caused by pre-migration trauma. In a study that investigates the impact of pre- and post-migration factors on PTSD symptoms of Tamil asylum seekers, refugees and immigrants in Australia, Steel et al. (1999) report that 20.3% of the PTSD symptoms could be explained by traumatic events before migration such as torture and captivity, and post-migration stress such as general health problems and daily stressors contributed 14.3% of the variance of PTSD symptoms, accounting for more than a third of the predictive power of the model. Stressors linked to post-migration experiences are dependent on the distinct contexts of destination country and community of settlement. De Jong et al. (2001) suggested that displaced people and refugees in low-income countries usually encounter problems with respect to access to food, shelter, physical security, and human rights violations, whereas refugees living in the West are more likely to experience problems related to the asylum procedure, including asylum interviews and the high level of bureaucracy, as well as challenges linked to the process of acculturation. Research indicates that increased duration of stay in displacement/refugee camps or temporary accommodation centers may mediate the effect of pre-migration trauma on PTSD (Getnet et al. 2019). Individuals in such temporary protection settings may be further exposed to post-migration traumas and abuses, as these spaces are often poorly designed, do not sufficiently address the needs of displaced populations, and often limit residents’ freedom of mobility. In a study among Rohingya refugees residing in refugee camps in Bangladesh, Riley et al. (2017) show that, in addition to the direct effect of trauma exposure on PTSD symptoms, the high level of environmental stressors associated with life in the camps serve as a mediator between past trauma and PTSD symptoms and heighten the risk of PTSD indirectly. Life outside the camps, on the other hand, imposes other post-displacement challenges on refugees and asylum seekers related to integration, such as limited access to social services, lack of employment or education opportunities, or social exclusion, which can contribute to the maintenance of PTSD symptoms that stem from prior exposure to trauma. Additionally, the process of acculturation is reported to account for high levels of variance in PTSD symptoms among refugees as found by Kartal and Kiropoulos (2016) in a study of Bosnian refugees resettled to Austria and Australia. The study found that acculturative stress explained 57% of variance in PTSD symptoms, and that different host countries may present different stressors, as the acculturative stress for Bosnian refugees resettled in Austria was associated with greater experiences of cultural loss and nostalgia, contributing to more severe PTSD symptoms compared to those resettled in Australia.
Post-migration stressor: Protracted/resolved conflict at home
Some two-thirds of all refugees live in a protracted refugee situation, which is defined by UNHCR (2018) as one in which 25,000 or more refugees from the same country have been forced to live in exile for five or more years in a given host country. Past studies show that the protracted nature of a conflict situation and generalized violence at home can increase the risk of PTSD among populations displaced from conflict-affected regions. These stressors may stem from worry over significant others who remain in the home country/region, the fear of never being able to go back home, or the emotional importance attached to the homeland. A study conducted in Sweden among Kurdish and Iraqi refugees demonstrated that concerns about friends and family left behind and ongoing political problems in Iraq were major life events that negatively influenced the self-rated health measurements of subjects with PTSD diagnosis more than it influenced the self-rated health among persons without PTSD (Sondergaard et al., 2001). Similarly, separation of families during resettlement may be a particularly significant trigger of PTSD symptoms among refugees and asylum seekers. Miller et al. (2018) shows that separation from a family member explains 7% of the variance in PTSD symptoms in a study conducted with 165 recently-resettled refugees from Afghanistan, Iraq, and the Great Lakes Region of Africa to the United States. In another study, Hauff and Vaglum (1994) draw on data indicating separation from a spouse as a risk factor for developing chronic PTSD among Vietnamese refugees in Norway.
Access to Mental Health Services
As argued by Bains et al. (2018), identifying PTSD is often difficult because patients may not feel comfortable discussing the details of their traumas without building trust. Developing a positive therapeutic relationship and establishing conditions of trust and safety in working with refugees and asylum seekers are essential in the treatment of PTSD. In case of ongoing rights violations and generalized violence at the origin country, refugees may fear the consequences of telling their stories. Furthermore, language barriers and the use of interpreters may diminish the quality of the MHPSS services. While in some cases, it may prove helpful to have interpreters from the same cultural background to provide a more secure atmosphere, inner-group tensions within a given community may result in lower trust between migrants and interpreters, which may reduce the quality of translation and make it more challenging to establish diagnostic criteria.
Despite high levels of mental health needs among displaced populations, there are a number of logistical, cultural, and situational barriers in accessing mental health and psychosocial support (MHPSS) services in destination countries and communities. A systematic review of twenty-seven studies conducted in European countries that assessed use of MHPSS services and access among refugees and asylum seekers demonstrates low uptake of MHPSS services due to barriers such as cultural differences in help-seeking behavior, stigma associated with being mentally ill, limited awareness of available services, and language barriers (Satinsky et al., 2019). Other factors that delay or impede access to mental health resources are poor mental health literacy, lack of access to specialized care, the high cost of treatment, and lack of access to interpreters (Slewa-Younan et al., 2017; International Society for Traumatic Stress Studies, 2017).
Another crucial aspect that requires attention during diagnosis and treatment of PTSD is the culturally-diverse traits and experiences of displaced persons. Misinterpretation of mental health symptoms due to the absence of culturally-appropriate diagnosis may hamper refugees’ access to treatment. According to Waldron and McKenzie (2008), mainstream mental health services in Western countries may fail to take into consideration the ethno-cultural contexts of trauma. By focusing on racialized and LGBT asylum seekers and refugees in Canada, they argue that measuring trauma and mental health problems of non-Western asylum-seekers through a Westernized lens can be problematic without an understanding of the social, political, and historical forces that shaped their individual and collective identities. Furthermore, they argue that the mental health impact of racism, oppression and heterosexism on communities and individuals deserve to get more attention by mental health providers. The discussion reflects a wider critique that trauma is overly medicalized by ascribing diagnoses and treatment based on defined scientific criteria that generalizes the meaning of trauma in a way that fails to capture the complexity of the distress asylum seekers and refugees may experience. Similarly, Karachiwalla (2011) argues that symptoms of mental health problems may manifest themselves differently in refugee populations, and there is an increasing need to shift the focus away from a generalized, biomedical model of care and adopt a “social determinants of health” approach that acknowledges the variation in cultural norms and expressions as well as social and economic factors.
PTSD treatment can also be delayed or obstructed by a negative asylum decision, which may result in the return or deportation of the rejected asylum seeker to his/her country of origin, where access to proper treatment can be much less likely. There is evidence to suggest that memory difficulties that result from PTSD can reduce the ability of asylum seekers to present their claims in a coherent way during the refugee status determination process (Bogner, et al., 2007; Herlihy et al., 2010; Sandalio, 2018). Individuals suffering from PTSD often have difficulty retrieving the details of past traumatic events or provide fragmentary and disorganized narratives, which may influence credibility judgements of asylum decision-makers (Rogers et al., 2014). In a study on the impact of torture and mental health problems on asylum decisions in Australia, Silove et al. (2006) found that survivors of torture did not receive more positive asylum decisions than other groups. The authors pointed out that the group with no experience of torture give a prevalence rate of PTSD that is lower than that reported by victims of torture (69% among victims and 37% among non-victims of torture), which might provide an explanation for the low acceptance rate of survivors of torture as refugees. Together, these findings show that the traumatic experience, that is often linked to the primary war-related event that causes them to flee, may work in the asylum-seekers’ disadvantage in the process of asylum due to its behavioral consequences.
Based on the above discussion, a set of recommendations can be developed to mitigate the risk factors for PTSD and improve displaced persons’ access to mental health services:
- Asylum policies and MHPSS programming should facilitate access of asylum-seekers and temporary protection holders to mental health services, regardless of their legal status, and should promote access to services for people with PTSD by reassuring them that PTSD is a treatable condition;
- Mental health services and facilities that implement evidence-based interventions should be considered an integral component of refugee settlements (e.g., reception centers, refugee camps, other spaces of collective residence);
- The institutions and camps that host displaced populations should offer better protection and security to minimize the post-displacement stressors that may trigger or mediate post-traumatic stress;
- Screening, assessment and interventions for PTSD and other mental health problems should be calibrated to be culturally and linguistically appropriate, and clinicians and MHPSS personnel should be trained in cultural competence and translational medicine;
- The pros and cons of working with interpreters of the same nationality with PTSD patients should be considered by taking into account potential lines of conflict that may exist;
- Taking into account the cultural variation in help-seeking behaviour and bias against receiving mental health support, regular screenings should take place among high-risk groups residing in institutions such as detention centers, reception centers or camps. Special sub-groups such as former child soldiers, survivors of torture and gender‐based violence may require specifically designed programs;
- Asylum officers involved in refugee status determination process should be trained and informed about the behavioural sequelae of PTSD, which may reduce the ability of asylum-seekers to tell their stories in a way that support recognition of protection needs;
- Waiting times for asylum decisions, refugee status determination processes and resettlement should be reduced to minimize the risks to mental health and well-being. Asylum-seekers with restricted mobility should be granted conditional release to access mental health support services when such services are not available on site;
- More research should be conducted in less developed countries of first asylum to enhance knowledge on mental health needs of refugees in protracted displacement;
- Specialized non-governmental organizations addressing the mental health needs of refugees should be supported by host states in order to reduce the needs gap.
About the Author
Eleni Diker joined UNU-MERIT as a researcher in November 2018. She has an MSc degree in Public Policy and Human Development with a specialisation in Migration Studies from United Nations University / Maastricht University and a BA degree in Economics from Bogazici University in Turkey. After completing her master’s degree, she worked at the UN Migration Agency (IOM) in Istanbul for several years in resettlement, counter-trafficking and assisted voluntary return programs. Before joining UNU-MERIT, she was working as a researcher and project coordinator at Migration Research Center at Koc University (MiReKoc) in Turkey. At MiReKoc, she has been involved in a number of research projects concerning Syrian refugees in Turkey. She coordinated the Forced Migration Resource Center (FMRC) project and initiated side-projects of FMRC with the aim to increase the research capacities of actors in the forced migration field and build bridges between civil society and academia. Her work has included mapping of civil society organizations working towards addressing the needs of refugees in Turkey. Next to her role at UNU-MERIT, she is the co-founder, fund-raiser and project developer at BoMoVu, an NGO dedicated to the social empowerment of underserved groups through sports and body movement.
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 This briefing is written by Eleni Diker from UNU-Merit/Maastricht University.
 A refugee is a person who has been granted refugee status based on the Article 1 of the 1951 UN Convention (as modified by the 1967 Protocol), which defines a refugee as someone who “owing to 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/her nationality and is un able or, owing to such fear, is unwilling to avail himself/herself of the protection of that country.” See UN General Assembly , Convention relating to the Status of Refugees, UN Treaty Series vol. 189 (New York: UN General Assembly, 1951), 176. https://www.refworld.org/docid/3be01b964.html
 An asylum-seeker is a person who has applied for protection as a refugee in a country other than that of his/her origin country and is awaiting the determination of his or her status.
 Internally displaced persons (IDPs) are “persons or groups of persons who have been forced or obliged to flee or to leave their homes or places of habitual residence, in particular as a result of or in order to avoid the effects of armed conflict, situations of generalized violence, violations of human rights or natural or human-made disasters, and who have not crossed an internationally recognized State border.” See UN High Commissioner for Refugees (UNHCR), Guiding Principles on Internal Displacement, 22 July 1998, ADM 1.1,PRL 12.1, PR00/98/109. https://www.refworld.org/docid/3c3da07f7.html
 The studies reviewed by Fazel et al. (2005) are reported in 24 publications that explore mental disorders among refugees in Australia (n=1199 refugees), Canada (n=364), Italy (n=40), New Zealand (n=223), Norway (n=129), the UK (n=120), and the USA (n=4668). The studies examine a total of 6743 adult refugees. Out of 20 studies, 14 specifically examine PTSD among a total of 5499 adult refugees, mainly originating from countries in southeast Asia, former Yugoslavia, the Middle East, and Central America.
 The studies reviewed in the article by Morina et al. (2018) provide data for a total of 39,518 adult IDPs and refugees from 21 countries including Iran, Syria, Jordan, Lebanon, and Turkey, Mexico, Colombia, Croatia and Georgia, Thailand, Myanmar, Sri Lanka, Nepal, China, and Cambodia, Sudan, Uganda, Liberia, Nigeria, Kenya, The Gambia, Senegal, and Ethiopia.
 According to Kartal and Kiropoulos (2016), acculturation can be defined as “the result of stress and conflict arising out of contact and participation between the two cultures”.
This definition has limitations, as it does not cover smaller populations in prolonged conditions of displacement or situations where refugees from one origin country are dispersed to different asylum countries in smaller numbers.