Mental Healt lth and Psychosocia ial Services for refugees: a Procrustean bed? Joop de Jong
Procrustes ’ myt yth Proto-terrorist One size fits all ‘ All animals are equal ’ Squeezing life into preconceived ideas Parallel myths asylum seekers & refugees: Tailored care & equity
Outline talk lk 3 The plight of 4 The lack of arriving in a safe Evidence Based country Treatment (EBT) 2 Epidemiology of mental health 5 Culture as problems and confounder filters through care Our care 1 Predictors of ill system fails health and the 6 asylum seekers possibility of Recommendations and refugees prevention in MHPSS
Risk factors adults Protective factors adults Young Older More education Less education, Low SES Work, income, participation, No work education Unwelcome, Social exclusion Stabillized and housing Presence family, partner, children Number shocking life events Length asylum procedure, Social network and support lack of activity Limited health skills, no insight Security status health care system Physical unsafety Religion Restoring resources (social capital, Low return on investment job at same level)
Protective & ri risk factors refugee children helpfu ful for universal prevention (blu lue) ) & selective prevention (red) Risk factors child development Protective factors child development Exposure extreme stress during and re-exposure after flight Unaccompanied , female Social support and cohesion within family Repeated migration guest country Discrimination Presence & wellbeing parents Low SES family Positive experience school Solo parent Psychiatric problems parents Foster family same ethnicity Limited sport, movemen t
What does this implicate for us? The public mental health building SOCIETY-AT-LARGE / COMMUNITY FAMILY & (INTER)NATIONAL INDIVIDUAL Economy, governance and early warning Rural development and food production Include women and children in the UNIVERSAL Free media and press Community empowerment distribution of economic growth PREVENTION Resolve underlying root causes of violence Decreasing dependency and learned Family reunion/family tracing (Inter)national laws helplessness Family/network building Defining and condemning human rights Public health and health education Improvement of physical aspects to eliminate a disease or violations Peace education and conflict resolution Resilience groups for children Research in schools and the community disorder state before it can Setting standards for intervention Public (psycho-) education, community occur Expanding security institutions sensitization and awareness raising Military’s role of last resort Security measures Reinforcing peace initiatives, conflict resolution Arms and landmine control Prevent the reemergence of violence Transnational collaborative projects Humanitarian operations: Conflict prevention & resolution DDR (child) soldiers SELECTIVE shelter, food, water and sanitation Crisis intervention Reparation, compensation families PREVENTION (Co-occurring) Natural disasters: standards Vocational skills training Public health and disease control Voluntary repatriation Mental health and psychosocial support shorten the course Reparation and compensation (MHPSS) Crisis intervention Peace-keeping and peace-enforcing troops. Reconciliation and mediation skills Involve the family in rehabilitation and INDICATED Peace agreements between groups reconstruction PREVENTION War tribunals and the persecution of perpetrators reduce chronicity Human rights advocacy <complications and >rehabilitation De Jong 2010 SSM
Outline talk lk 3 The plight of 4 The lack of arriving in a safe Evidence Based country Treatment (EBT) 2 Epidemiology of mental health 5 Culture as problems and confounder filters through care Our care system fails 1 Key predictors 6 asylum seekers and the possibility Recommendations of prevention and refugees in MHPSS
Prevalence rates Syrian refugees in in camp and non-camp settings in in Europe • Depression 30% (14.5-44%) Georgiadou et al 2018. Poole et al 2018 • PTSD 30% Alpak et al 2014. Tinghog et al 2016 • Anxiety 13.5-92% Ben Farhat et al 2018. Georgiadou et al 2018 • Likely <10% of those in need, receive MHPSS →
Treatment gap in in nor ormal l tim times versus dis isaster, , war, refugees, , ID IDPs Peace & Disaster Post-disaster/conflict: treatment gap larger: treatment gap larger due to Situation in times of peace Beneficiary factors Service delivery factors • • 24% of cases in HIC and 6% in • Expression psychopathology • Few resources (infrastructure, LMIC receive treatment (depression, anxiety, ptsd) human, policies) • Same for child and adolescent • Different EMs, CCDs/CS/IOD, • Even fewer professionals: exodus or mental health illness behavior genocide • Suffering experienced in • Delivery models not prepared for spiritual, religious, family, mass stress, due to social or community terms colonial history • Beneficiaries belong to • Psychologists little training in different ethnic group than (trauma-focused) therapy providers • PHC workers idem MHPSS • (Self)stigma MHPSS • Survivors in rural areas, intellectuals in cities • State sector weak: private practice at the expense of the public sector and the rural areas
Specific physical morbidity and issues migrants • genetics/farmacokinetics • depending on origin -> CDs (tb, hepatitis B/C, STD) • skin -> vit D shortage -> skin disease different • cultural influence -> infibulation, circumcision • sexual abuse, limited knowledge contraception -> • not always easy for health personnel to discuss even though refugees want it • inactive life conditions: overweight, DM, CV, arthrosis • torture
Outline talk lk 3 The plight of 4 The lack of arriving in a safe Evidence Based country Treatment (EBT) 2 Epidemiology of mental health 5 Culture as problems and confounder filters through care Our care 1 Key predictors of system fails ill health and 6 asylum seekers political violence Recommendations and the possibility and refugees of prevention in MHPSS
Pli light of f arriving in in a new country ry Family problems * Asylum procedures * Work * Discrimination Low SES Religion * Strongest relation psychopathology
Study Iraqi Asylum Seekers: Gr 2 > 2 yrs in the Netherlands and similar findings in California Results Gr 1 Gr 2 One or more psychiatric disorder 42.0% 66.2 % Overall Quality of life (mean) 2.88 2.23 Perceived Qol general health (mean) 3.06 2.74 Physical and Role Disability (mean) 17.31 19.25 Days of disability (mean) 5.37 7.68 Physical diseases (mean) 0.85 0.84 Physical complaints (mean) 5 0.83 1.62 Laban CJ et al 2004 JNMD. Song et al 2017 JNMD. Laban CJ et al 2008 SPPE
Outline talk lk 3 The plight of 4 The lack of arriving in a safe Evidence Based country Treatment (EBT) 2 Epidemiology of mental health 5 Culture as problems and confounder filters through care Our care 1 Key predictors of system fails ill health and 6 asylum seekers political violence Recommendations and the possibility and refugees of prevention in MHPSS
World Health Organizatio ion Guidelines for r Management of f Acute Stress, PTSD, and Bereavement Tol et al. 2014 PLOS Med Mental health condition Recommendation Acute traumatic stress CBT with a trauma focus (CBT-T) should be considered in adults Benzodiazepines or antidepressants should NOT be offered to adults and children Insomnia Relaxation techniques, NO benzodiazepines Secondary nonorganic enuresis No punitive responses, simple behavioral interventions Hyperventilation Paper bag should not be offered to children PTSD CBT-T, EMDR, stress management for adults & youth SSRIs and TCAs NOT first line treatment for adults & youth Bereavement (without a mental No structured psychological interventions, NO disorder) benzodiazepines
Barriers to the mental health interventions for refugee populations What is is proble lematic wit ith the exis xisting evid idence? • Most evidence exists for PTSD by specialized professionals • Often CMD, problems with daily tasks survival & recovery • For scalability, interventions should be short, simple , to be carried out in PC or in the community • Lack of family interventions • The length of treatments difficult for AS & R • Lack of adaptation to language & culture • Limited knowledge MH & stigma among refugees • Limited availability & capacity MH professionals to deliver specialized services when indicated
6.2 & 6.3 IASC Psychosis and severe 6.2 & 6.3 guidelines emotional disorders mhGAP-HIG Cross-cutting Mild-moderate tools emotional disorders Psychological interventions Wellbeing /sub- IASC guidelines clinical problems WHO van Ommeren ISTSS 2016
STRENGTHS for scali ling up of f PM+ for refugees & other groups Proble lem Management Plu lus (P (PM+) (a (adults) & & EASE (y (youth) • What • Problem-solving counselling ( problem management) plus behavioural strategies for stress management, behavioural activation, strengthening social supports • Formats • 5 sessions individual and group face-to-face/app • RCTs in Kenya, Pakistan & Nepal, 4 currently in Middle East, Europe Sijbrandij et al. 2018,2019 EJTTS
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