Advice and guidance on the health needs of migrant patients for healthcare practitioners.
Be aware that, whilst most migrants do not have mental health problems, some may be at increased risk as a result of their experiences prior to, during, or after migration to the UK.
Remember that mental health problems may present in different ways in people from different cultures, for example with physical rather than emotional symptoms.
Always use a professional interpreter to explore mental health issues rather than a family member or friend, and familiarise yourself with both the cultural background and individual understanding of the patient.
Remember that most people will be well and resilient. Feeling stressed is a normal response. Focus on promoting positive coping strategies.
Mental health is fundamental to general health and wellbeing; mental health affects physical health and physical health affects mental health. The two are inseparable in overall wellness.
‘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. It shows how government is working to improve the mental health and wellbeing of the population, and achieve better outcomes for people with mental 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 ‘home sickness’, anxiety or sleep disorders may arise for anyone who is separated from family and friends, or integrating into a new community or culture. These may be managed easily without medical or specialist interventions.
In addition to routine distress and anxiety, certain individuals, particularly those affected by emergencies, may experience elevated risk of mental disorders. This has been estimated by WHO and UNHCR in terms of projected prevalence over a 12 month period, before and after the emergency:
- 3% to 4% projected prevalence of severe disorders after the emergency (12 month prevalence), for example psychosis, severe depression, severely disabling form of anxiety disorder, compared to 2% to 3% before the emergency
- 15% to 20% projected prevalence of mild or moderate mental disorders after the emergency, for example mild and moderate forms of depression and anxiety disorders, including mild and moderate posttraumatic stress disorder, compared to 10% before
- traumatic events, loss and displacement increase risk of depression and anxiety disorders, including posttraumatic stress disorder
It is advised to remain alert to the possibility of mental health problems and be aware that they may present in unfamiliar ways. In particular, check for previous history of mental illness, epilepsy and substance misuse.
For example, some people may express psychological distress in a very physical manner (‘somatisation’), describing physical symptoms rather than directly talking about feelings. Remember patients may bring with them their own socio-cultural constructs in determining what is a normal and abnormal experience and hence in diagnosing mental illness. Children may manifest symptoms in a non-specific way such as behavioural problems or bed wetting.
Social support can be beneficial for anyone’s mental health. Find out what groups exist in your local area for particular communities so that you can signpost them to new arrivals.
Coping with psychological distress
The effects of stress can be buffered by basic services, safety, and social support. Principles of psychological first aid (PFA) may be helpful. Rates of disorders related to extreme stress are higher in refugees than in people who are not 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. Being a refugee or a migrant alone does not make individuals significantly more vulnerable for mental disorders, however migrants or refugees can be exposed to various stress factors that influence their mental wellbeing.
Of particular note is sexual violence: it is important to be aware that this may cause long standing maladaptation.
A comprehensive and effective psychosocial recovery programme must first address basic needs and support the majority of the population who need psychosocial support within their communities (such as basic listening services, information and community-led interventions). It must then address the most severely affected minority of the population through efficient referral systems and sufficient specialised care (Gluckman, 2011). The ideal approach is to train up people from the same migrant community to support their fellow migrants.
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, which is likely to cause pervasive distress in almost anyone. Rates of PTSD are higher in refugees than in migrants who are not forcibly displaced, but are still relatively low.
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. In a recent study, 78% of trafficked women and 40% of trafficked men taking part in the survey 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.
It is important to use specific clinical tools to make a diagnosis rather than over-diagnose PTSD. Its symptoms should be disabling and present after 4 weeks after the event. Generally PTSD is self-limiting and resolves by itself. It is unhelpful to excessively dwell on PTSD rather than positive coping. PTSD is a treatable disorder even when problems present many years after the traumatic event. There may, however, be more severe cases where there is need for a specialised treatment.
Psychological and social distress among refugees manifests in a wide range of problems 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)
The World Health Organization (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 which impair their ability to care for themselves and their family, or make them more vulnerable to danger. However, 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.
In responding to psychological and social distress among migrants, first acknowledge that stress is a normal response in adults and children. It is very important to strengthen family and community support for the migrant to help them integrate and cope with stress factors.
Stress response can be managed through a range of stress reduction strategies, including psychoeducation, sleep hygiene, breathing exercises, relaxation, recreational activities, and star charts. Guidance on the assessment and management of conditions specifically related to stress have been produced by WHO.
Only offer specialised treatment to those who have disabling stress symptoms that are severe and also PTSD. Offer all those suffering from acute stress and PTSD the opportunity to benefit from psychological interventions. This can be achieved by the use of interpreters and bicultural therapists.
For more information on recognition and for management guidelines please see the NICE guidelines on post-traumatic stress disorder.
Mind provides mental health support for patients and information for health professionals on certain migrant groups in the UK.
Mental health patient information is available in a range of languages from the Mental Health in Manchester website.
Meri Yaadain have produced language leaflets and audio clips in South Asian languages about dementia within South Asian Communities.
The Royal College of Psychiatrists has produced:
- resources in Arabic, Bengali, Brazilian (Portuguese), Chinese, French, Greek, Gujurati, Hindi, Persian, Polish, Punjabi, Romanian, Russian, Spanish, Tamil, Urdu and Welsh
- a leaflet on Post-traumatic Stress Disorder (PTSD) available in English, Chinese and Persian
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 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.
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.
The Mental Health Foundation has led a programme on improving the mental wellbeing of asylum seekers and refugees. It has produced a toolkit aimed at helping refugee and asylum-seeking women better understand mental health and ways to help themselves and others.
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) – Guide 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: Pocket Guide – one page of key principles
- Psychological First Aid for Children – (Save the Children, 2013) aims at developing skills and Competences to reduce the Common mental health and psychosocial responses
The PHE 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 PHE Public mental health leadership and workforce development framework provides a competency framework to better understand mental health needs and to guide workforce.
Other useful resources are available from:
- the Refugee Council works directly with refugees to support them to rebuild their lives
- Mothertongue - a multi-ethnic, culturally sensitive, professional counselling and listening service, where people are heard with respect to their chosen language
- Freedom from Torture - a medical foundation for the care of victims of torture
- Helen Bamber Foundation works with survivors of cruelty
- Rethink - a mental illness charity
- the Chinese Mental Health Association provides a range of services and accepts referrals from GPs and health professionals