Mina Fazel

Prevalence of serious mental disorder in 7000 refugees resettled in western countries: a systematic review

BACKGROUND About 13 million people are classified as refugees worldwide, and many more former refugees have been granted citizenship in their new countries. However, the prevalence of post-traumatic stress disorder, major depression, or psychotic illnesses in these individuals is not known. We did a systematic review of surveys about these disorders in general refugee populations in western countries. METHODS We searched for psychiatric surveys that were based on interviews of unselected refugee populations and that included current diagnoses of post-traumatic stress disorder, major depression, psychotic illnesses, or generalised anxiety disorder. We did computer-assisted searches, scanned reference lists, searched journals, and corresponded with authors to determine prevalence rates of these mental disorders and to explore potential sources of heterogeneity, such as diagnostic criteria, sampling methods, and other characteristics. FINDINGS 20 eligible surveys provided results for 6743 adult refugees from seven countries, with substantial variation in assessment and sampling methods. In the larger studies, 9% (99% CI 8-10%) were diagnosed with post-traumatic stress disorder and 5% (4-6%) with major depression, with evidence of much psychiatric comorbidity. Five surveys of 260 refugee children from three countries yielded a prevalence of 11% (7-17%) for post-traumatic stress disorder. Larger and more rigorous surveys reported lower prevalence rates than did studies with less optimum designs, but heterogeneity persisted even in findings from the larger studies. INTERPRETATION Refugees resettled in western countries could be about ten times more likely to have post-traumatic stress disorder than age-matched general populations in those countries. Worldwide, tens of thousands of refugees and former refugees resettled in western countries probably have post-traumatic stress disorder.

Mental health of displaced and refugee children resettled in high-income countries: risk and protective factors.

We undertook a systematic search and review of individual, family, community, and societal risk and protective factors for mental health in children and adolescents who are forcibly displaced to high-income countries. Exposure to violence has been shown to be a key risk factor, whereas stable settlement and social support in the host country have a positive effect on the childs psychological functioning. Further research is needed to identify the relevant processes, contexts, and interplay between the many predictor variables hitherto identified as affecting mental health vulnerability and resilience. Research designs are needed that enable longitudinal investigation of individual, community, and societal contexts, rather than designs restricted to investigation of the associations between adverse exposures and psychological symptoms. We emphasise the need to develop comprehensive policies to ensure a rapid resolution of asylum claims and the effective integration of internally displaced and refugee children.

The mental health of refugee children

The UK is facing a major increase in the number of people seeking asylum each year, of whom approximately a quarter are children. The stressors to which refugees are exposed are described in three stages: (1) while in their country of origin; (2) during their flight to safety; and (3) when having to settle in a country of refuge. The evidence concerning the impact of displacement on children’s mental health is reviewed and a framework for conceptualising the risk factors is proposed. The available literature shows consistently increased levels of psychological morbidity among refugee children, especially post-traumatic stress disorder, depression, and anxiety disorders. The principles underlying the delivery of mental health care for these children are also considered. It is argued that much primary prevention can be undertaken in the school context. Some key aspects of British immigration law are examined and the tension between the law and the best interests of the child principle is discussed. There is particular concern for the plight of unaccompanied children. Attention to the mental health needs of this vulnerable group is urgently required.

The emerging evidence for Narrative Exposure Therapy: A review

Individuals who have experienced multiple traumatic events over long periods as a result of war, conflict and organised violence, may represent a unique group amongst PTSD patients in terms of psychological and neurobiological sequelae. Narrative Exposure Therapy (NET) is a short-term therapy for individuals who have PTSD symptoms as a result of these types of traumatic experiences. Originally developed for use in low-income countries, it has since been used to treat asylum seekers and refugees in high-income settings. The treatment involves emotional exposure to the memories of traumatic events and the reorganisation of these memories into a coherent chronological narrative. This review of all the currently available literature investigates the effectiveness of NET in treatment trials of adults and also of KIDNET, an adapted version for children. Results from treatment trials in adults have demonstrated the superiority of NET in reducing PTSD symptoms compared with other therapeutic approaches. Most trials demonstrated that further improvements had been made at follow-up suggesting sustained change. Treatment trials of KIDNET have shown its effectiveness in reducing PTSD amongst children. Emerging evidence suggests that NET is an effective treatment for PTSD in individuals who have been traumatised by conflict and organised violence, even in settings that remain volatile and insecure.

Mental health interventions in schools in high-income countries

Mental health services embedded within school systems can create a continuum of integrative care that improves both mental health and educational attainment for children. To strengthen this continuum, and for optimum child development, a reconfiguration of education and mental health systems to aid implementation of evidence-based practice might be needed. Integrative strategies that combine classroom-level and student-level interventions have much potential. A robust research agenda is needed that focuses on system-level implementation and maintenance of interventions over time. Both ethical and scientific justifications exist for integration of mental health and education: integration democratises access to services and, if coupled with use of evidence-based practices, can promote the healthy development of children.

School and community-based interventions for refugee and asylum seeking children: a systematic review.

Background Research for effective psychological interventions for refugee and asylum-seeking children has intensified. The need for interventions in environments more easily accessed by children and families is especially relevant for newly arrived populations. This paper reviews the literature on school and community-based interventions aimed at reducing psychological disorders in refugee and asylum-seeking children. Methods and Findings Comprehensive searches were conducted in seven databases and further information was obtained through searching reference lists, grey literature, and contacting experts in the field. Studies were included if they reported on the efficacy of a school or community-based mental health intervention for refugee or asylum-seeking children. Two independent reviewers made the final study selection, extracted data, and reached consensus on study quality. Results were summarized descriptively. The marked heterogeneity of studies excluded conducting a meta-analysis but study effect-sizes were calculated where possible. Twenty one studies met inclusion criteria for the review reporting on interventions for approximately 1800 refugee children. Fourteen studies were carried out in high-income countries in either a school (n = 11) or community (n = 3) setting and seven studies were carried out in refugee camps. Interventions were either primarily focused on the verbal processing of past experiences (n = 9), or on an array of creative art techniques (n = 7) and others used a combination of these interventions (n = 5). While both intervention types reported significant changes in symptomatology, effect sizes ranged from 0.31 to 0.93 and could mainly be calculated for interventions focusing on the verbal processing of past experiences. Conclusions Only a small number of studies fulfilled inclusion criteria and the majority of these were in the school setting. The findings suggest that interventions delivered within the school setting can be successful in helping children overcome difficulties associated with forced migration.

Prevalence of Child Mental Health Problems in Sub-Saharan Africa: A Systematic Review

OBJECTIVE To assess the prevalence of child mental health problems in community settings in sub-Saharan Africa. DATA SOURCES A systematic search of MEDLINE, EMBASE, and PsychInfo, supplemented by tracking of references from identified articles and personal communications with local researchers. STUDY SELECTION Only community-based studies in sub-Saharan Africa that assessed the general psychopathology of children aged 0 to 16 years were included. For each eligible study, the following information was extracted: year of publication, country, population sampled, area type (rural or urban), sampling method and sample size (percentage boys), age range, assessment instrument, informant, diagnostic criteria, and prevalence rates of general psychopathology. MAIN OUTCOME MEASURE Pooled prevalence rate of psychopathology in children, identified by questionnaire and, specifically, by clinical diagnostic instruments. RESULTS Eleven studies met the inclusion criteria, 10 of which were included in the meta-analysis. The 10 studies provided data for 9713 children from 6 countries, with substantial variation in assessment methods. Overall, 14.3% (95% CI, 13.6%-15.0%) of children were identified as having psychopathology. Studies using screening questionnaires reported higher prevalence rates (19.8%; 95% CI, 18.8%-20.7%) than did studies using clinical diagnostic instruments (9.5%; 8.4%-10.5%). CONCLUSIONS Evidence suggests that considerable levels of mental health problems exist among children and adolescents in sub-Saharan Africa. One in 7 children and adolescents have significant difficulties, with 1 in 10 (9.5%) having a specific psychiatric disorder. There are clear sociodemographic correlates of psychopathology that may place children in areas of greatest deprivation at greatest risk.

A school-based mental health intervention for refugee children: An exploratory study.

This report describes an exploratory study of a school-based mental health service developed to address the psychological needs of refugee children. The service was made available in three schools and followed a consultative framework. Refugee children were discussed with the mental health team and children at greatest risk were seen. A questionnaire of psychological functioning was completed by teachers before and after the intervention. Data were collected on 47 refugee children and two control groups (ethnic minority and indigenous white children). Subgroup analyses compared children who were seen directly by the service with those for whom only consultation was provided. Refugee children had poorer overall adjustment at baseline particularly in the emotional and peer problem domains. The greatest improvements following the intervention were seen in hyperactivity for the refugee group and in peer problems for the refugees directly seen by the service. While further studies are necessary to assess its efficacy, this exploratory study indicates that an intervention which involves collaboration with teachers and parents, in an environment where children spend much of their time, can benefit vulnerable children.

Mental health interventions in schools in low-income and middle-income countries

Increasing enrolment rates could place schools in a crucial position to support mental health in low-income and middle-income countries. In this Review, we provide evidence for mental health interventions in schools in accordance with a public mental health approach spanning promotion, prevention, and treatment. We identified a systematic review for mental health promotion, and identified further prevention and treatment studies. Present evidence supports schools as places for promotion of positive aspects of mental health using a whole-school approach. Knowledge of effectiveness of prevention and treatment interventions is more widely available for conflict-affected children and adolescents. More evidence is needed to identify the many elements likely to be associated with effective prevention and treatment for children exposed to a range of adversity and types of mental disorders. Dissemination and implementation science is crucial to establish how proven effective interventions could be scaled up and implemented in schools.

The impact of recurrent abdominal pain: predictors of outcome in a large population cohort.

Aim: Recurrent abdominal pain is one of the commonest complaints of childhood, affecting approximately 10% of children at any one time. This study aims to describe the outcome of recurrent abdominal pain amongst 6‐year‐old children, and to identify risk factors (in both the children and their parents), which predict these outcomes.