Advice and guidance on the health needs of migrant patients for healthcare practitioners.
Migrants may be at increased risk of mental health problems as a result of their experiences prior to, during, or after migration to the UK. Some vulnerable migrant groups may be at particular risk of psychological distress and mental disorders.
Mental health problems may present in different ways in people from different cultures, for example with physical rather than emotional, behavioural or cognitive symptoms. Familiarise yourself with both the cultural background and individual situation of the patient.
Always work with a professional interpreter to explore mental health concerns. Do not request interpreting from family members or friends.
Where needed, support migrants to access appropriate services for mental health and wellbeing. Promote positive coping strategies and culturally appropriate advice. Consider applying trauma-informed practice principles when working with migrants affected by trauma.
Coronavirus (COVID-19) has negatively impacted the living and working conditions of migrants, thereby increasing the risk of mental health concerns during the pandemic.
Mental health is fundamental to general health and wellbeing; mental health affects physical health and physical health affects mental health. The 2 are inseparable in overall wellbeing. No Health without Mental Health, the cross-government mental health outcomes strategy for people of all ages, sets out to realise the ambition to mainstream mental health, and establish parity of esteem between services for people with mental and physical health problems.
Although most migrants will not suffer from mental health problems, some may be at increased risk as a result of their experiences prior to, during, or after migration to the UK. Issues such as ‘homesickness’, anxiety or sleep disorders may arise for anyone who is separated from family and friends, or integrating into a new community due cultural differences and language barriers. Other stressors include concerns about immigration status, financial difficulties, access to services, and discrimination.
Certain individuals, particularly those from vulnerable migrant groups, may experience elevated risk of mental disorders. Almost all people who have been affected by emergencies (for example, war and conflict, environmental disasters) will experience psychological distress. The World Health Organization (WHO) also found:
- in a humanitarian crisis, the prevalence of depression and anxiety is more than doubled
- among those who have experienced war or conflict in the past 10 years, 1 in 5 will have depression, anxiety, post-traumatic stress disorder, bipolar disorder or schizophrenia. 1 in 11 will have a moderate or severe mental health disorder
- in conflict-affected settings, depression is more common in women than in men
Remain alert to the possibility of mental health problems and be aware that they may present in unfamiliar ways. For example, some people may express psychological distress in a very physical manner (‘somatisation’), describing physical symptoms rather than directly talking about emotions or exhibiting behavioural and cognitive symptoms. Individuals may bring their own socio-cultural constructs when determining what is a normal and abnormal experience. Children may manifest symptoms in a non-specific way such as behavioural problems or bed wetting.
Check for previous history of mental illness, epilepsy and substance misuse.
Stress and psychological distress
Rates of disorders related to extreme stress are higher in people who are forcibly displaced. In cases where past experience of traumatic events are not the only source of psychological distress, most emotional suffering is directly related to current stresses and worries and uncertainty about the future. While being a migrant alone does not make individuals significantly more vulnerable for mental disorders, migrants can be exposed to various stress factors that influence their mental wellbeing.
Psychological and social distress among refugees manifests in a wide range of problems (PDF, 497KB) including:
- emotional (sadness, grief, fear, frustration, anxiety, anger and despair)
- cognitive (loss of control, helplessness, worry, ruminations, boredom, and hopelessness)
- physical (fatigue, problems, sleeping, loss of appetite, medically unexplained, physical complaints)
- behavioural and social problems (withdrawal, aggression, interpersonal difficulties, bed wetting, substance use, sleep disturbance in children)
In cases of sexual violence, psychological distress may cause long-standing maladaptation.
WHO has produced a guidance note with advice on protecting and supporting the mental health and psychosocial wellbeing of refugees, asylum seekers and migrants in Europe. It explains the challenges to mental health and psychosocial wellbeing faced by refugees and migrants and describes common mental health and psychosocial responses they may experience. These experiences and responses can vary widely, and change over time. For instance, they may feel elated on first arrival, or be affected by multiple losses and grieving for people and places left behind. They may feel overwhelmed, distressed and anxious, or numb and detached. Some may have reactions that impair their ability to care for themselves and their family, or make them more vulnerable to danger.
Post-traumatic stress disorder
Some migrants may be affected by post-traumatic stress disorder (PTSD), which develops following a stressful event or situation of an exceptionally threatening or catastrophic nature. This is likely to cause pervasive distress in almost anyone. Rates of PTSD are higher in survivors of human trafficking and refugees than in migrants who are not forcibly displaced. In a study of survivors of human trafficking, 78% of women and 40% of men screened positive for anxiety, depression or PTSD.
PTSD sufferers may not present for treatment for months or years after the onset of symptoms despite the considerable distress experienced. PTSD may present with a range of symptoms including re-experiencing, avoidance, hyper-arousal, depression, emotional numbing, drug or alcohol misuse and anger as well as unexplained physical symptoms. The symptoms of PTSD are extreme and encompass more than just remembering the event or dreams, but a combination of disabling recall, dreams and memories.
Consider the possibility of Complex PTSD (CPTSD) which develops in a subset of people with PTSD arising after exposure to an event or series of events of an extremely threatening or horrific nature, most commonly prolonged or repetitive events from which escape is difficult or impossible. This includes torture, slavery, genocide campaigns, prolonged domestic violence, repeated childhood sexual or physical abuse.
Follow the NICE guidelines on post-traumatic stress disorder to assess, monitor and treat PTSD in migrants. This includes:
- using validated, brief screening instruments for PTSD as part of comprehensive physical and mental health screening for refugees and asylum seekers
- considering active monitoring for subthreshold PTSD symptoms within 1 month of a traumatic event
- actively monitoring or offering individual trauma-focused cognitive behavioural therapy (CBT) within 1 month of a traumatic event for those under 18 years of age with a diagnosis of acute stress disorder or clinically important symptoms of PTSD
- using specific clinical tools to make a PTSD diagnosis to avoid over-diagnosis
- ensuring that all aspects of management of PTSD is culturally and linguistically appropriate. This may involve working effectively with interpreters and offering a choice of therapists
Supporting migrants’ mental health
- addressing safety, basic needs, and social integration by providing support within an individual’s community (such as basic listening services, information and community-led interventions)
- removing barriers to mental health services
- facilitating engagement with care
- screening, diagnosing and treating mental disorders with specialised care
When responding to psychological and social distress among migrants, it is important to recognise that many stress responses are natural ways in which body and mind react to stressors and should not be considered abnormal. It is very important to:
- strengthen family and community support for the migrant to help them integrate and cope with stress factors
- manage stress response through a range of stress reduction strategies, including psychoeducation, sleep hygiene, breathing exercises, relaxation, recreational activities, and star charts
People from the same migrant community can be trained to support their fellow migrants. Principles of psychological first aid (PFA) may also be helpful.
Access to mental health services
Migrants who have paid the Immigration Health Surcharge and some other vulnerable migrant groups are entitled to free NHS mental health services. For further information, refer to the NHS entitlements page of the migrant health guide.
Other non-NHS services that support the mental health of migrants include:
- Refugee Council works directly with refugees to support them to rebuild their lives
- Freedom from Torture is a medical foundation for the care of victims of torture
- Helen Bamber Foundation works with survivors of trafficking and torture
- Rethink is a mental illness charity
- the Chinese Mental Health Association provides a range of services and accepts referrals from GPs and health professionals
Social support can be beneficial for mental health. Find out what groups exist in your local area for particular communities so that you can signpost new arrivals to appropriate social support.
Social prescribing may also be effective for improving migrants’ mental health and wellbeing, and help to increase their confidence, self-esteem, empowerment and social connectivity.
Resources for healthcare professionals
For more information on PTSD identification and management, refer to the NICE guidelines on post-traumatic stress disorder.
UNHCR has produced guidance on working with refugee children experiencing stress and trauma.
Mind has developed guidance on commissioning mental health services for vulnerable adult migrants (PDF, 1.97MB).
Culture, Health and Illness, 5th edition. By Cecil G Helman. London, Arnold. 2000. This text covers an array of relevant topics relating to globalisation and migration, and their impact on global health and medical care.
Other Tongues: Psychological Therapies in a Multilingual World. By Beverley Costa. PCCS Books. 2020. Practical suggestions for working therapeutically with multilingual clients.
Psychological first aid (PFA) is a set of simple rules and techniques that can be used by anyone (non-professionals and professionals) to respond to people in distress:
Psychological First Aid: Guide for Field Workers (WHO, World Vision and War Trauma Foundation, 2011) with simple instructions how to provide humane, supportive and practical help to adults and children suffering serious crisis events. A range of translations of this document are available on this website.
Psychological First Aid for Children (Save the Children, 2013) aims at developing skills and competences in staff to help reduce common mental health and psychosocial responses in children who have experienced traumatic events.
COVID-19: Psychological First Aid for Adults is a free online course produced by the UK Health Security Agency (UKHSA). It is the globally recommended training for supporting people during emergencies and offers guidance on delivering psychosocial care in the immediate aftermath of the emergency event. It is based on international guidance from the World Health Organisation, United Nations and partners.
COVID-19: Psychological First for Children and Young People is a free online course produced by the UKHSA for parents, carers and those working with children to deal with the impact of COVID-19 on children and young people.
The guide to community centred approaches for health and wellbeing proposes a preventive view through the ‘family of community’ centred approaches, mobilising assets within communities, promoting equity and increasing people’s control over their health and lives. It covers the following topics:
- strengthening communities
- volunteer and peer roles
- collaborations and partnerships
- access to community resources
The public mental health leadership and workforce development framework provides a competency framework to better understand mental health needs and to guide workforce.
The Afghan Mental Health Group has developed an Afghan Mental Health Guide for mental health professionals (psychologists and psychiatrists) working with Afghan sanctuary seekers.
Resources for migrants
City of Sanctuary has produced a mental health resource pack specifically aimed at supporting refugees and asylum seekers living in the community.
The Royal College of Psychiatrists has produced resources in a range of languages.
Meri Yaadain have produced language leaflets and audio clips in South Asian languages about dementia and COVID-19.
The Alzheimer’s Society publishes certain publications about dementia in a range of languages.
Healthtalkonline has videos of interviews with people from different black and minority ethnic backgrounds describing their experiences of having mental health problems, including some in languages other than English.
EACH has produced Asian Women, Domestic Violence and Mental Health - A Toolkit for Health Professionals (PDF, 398KB) which aims to disseminate culturally appropriate best practice for professionals working with Asian women experiencing domestic abuse and violence and enable better care of physical and mental health consequences among this risk group.
Urgent mental health support can be accessed through the NHS 24/7 crisis lines.