Solvig Ekblad

Mental health of recently resettled refugees from the Middle East in Sweden: the impact of pre-resettlement trauma, resettlement stress and capacity to handle stress

The pathways to symptoms of common mental disorder and post-traumatic stress symptoms among refugees during resettlement need to be better specified. We aim to identify models of these different mental health outcomes among refugees during resettlement, taking pre-migration, migration and post-migration stress conditions, a person’s capacity to handle such stress and socio-demographic variables into consideration. A new questionnaire developed to better cover resettlement stress, as well as pre-resettlement trauma exposures and different measures of a person’s capacity to handle stress, was administered to 124 Middle Eastern refugees that had been granted permanent residency in Sweden only a few months before responding. We found four dimensions of resettlement stress: social and economic strain, alienation, discrimination and status loss and violence and threats in Sweden, that account for 62% of the total variance in resettlement stress. Social and economic strain and alienation are important for explaining symptoms of common mental disorder. In the model of core post-traumatic stress symptoms, pre-resettlement trauma exposure seems to have the strongest impact. A person’s capacity to handle stress plays significant, direct and mediating roles in both models. The impact of resettlement stressors in the context of the whole migration process for different mental health outcomes is discussed.

Amidst peril and pain: The mental health and well-being of the world's refugees.

There are approximately 40,000,000 refugees and displaced people in the world. This volume offers mental-health professionals, scientists and policy administrators a conceptual, factual and clinical resource for understanding and addressing the challenges posed by this growing problem.

Lay Concepts of Depression among the Baganda of Uganda: A Pilot Study

The literature indicates that although depression is highly prevalent, it is rarely recognized as such. The aim was to test the use of case vignettes in exploring the explanatory models of various subtypes of depression, in six individual interviews, and four focus-group discussions. Depressive symptoms presented in these vignettes seem to be conceptualized as a problem related to cognition (thinking too much) rather than emotion (sadness) and the resulting condition is referred to as ‘illness of thoughts.’ Worrisome thoughts resulting from various socioeconomic problems are seen as important aetiological factors for the illness of thoughts and require no medication as it is believed that there is no medication for thoughts. There are culturally accepted ways of dealing with and healing the condition. Once illness becomes recurrent or chronic, other explanations about causes and a different course of action have to be considered. Further exploration of the relationship between thoughts and emotions among the Baganda may be an important avenue for further research.

Self-reported life event patterns and their relation to health among recently resettled Iraqi and Kurdish refugees in Sweden.

This paper presents the findings of a longitudinal study of life events in refugees belonging to different language groups from Iraq. Eighty-six individuals were included in the study. Data regarding life events and self-reported health measurements were collected after baseline assessment with 3-monthly intervals on three occasions. Posttraumatic stress disorder was diagnosed by means of a structured interview at baseline. The results indicate that the subjects were influenced to a great extent by political events and the situation of significant others in the home country. Further, the number of negative life events in the host country showed a significant association with self-rated deteriorated health. In subjects with posttraumatic stress disorder, the effects of certain life events were more pronounced.

Gender-related mental health differences between refugees and non-refugee immigrants - a cross-sectional register-based study

BackgroundBeing an immigrant in a high-income country is a risk factor for severe mental ill health. Studies on mental ill health among immigrants have found significant differences in mental health outcome between immigrants from high income countries and low-income countries. Being an asylum seeker or a refugee is also associated with mental ill health. This study aimed to assess if there is a difference in mental ill health problems between male and female refugee and non-refugee immigrants from six low-income countries in Sweden.MethodsA cross-sectional, population-based study design was used comparing refugees with non-refugees. The study size was determined by the number of persons in Sweden fulfilling the inclusion criteria at the time of the study during 2006. Outcome: Mental ill health, as measured with the proxy variable psychotropic drugs purchased. Refugee/Non-refugee: Sweden grants asylum to refugees according to the Geneva Convention and those with a well-grounded fear of death penalty, torture or who need protection due to an internal or external armed conflict or an environmental disaster. The non-refugees were all family members of those granted asylum in Sweden. Covariates: Gender and origin. Potential confounders: Age, marital status, education and duration of stay in Sweden. Background variables were analysed using chi square tests. The association between outcome, exposure and possible confounders was analysed using logistic regression analyses. Multiple logistic regression analysis was used to adjust for potential confounders.ResultsThe study population comprised 43,168 refugees and non-refugees, of whom 20,940 (48.5%) were women and 24,403 (56.5%) were refugees. Gender, age, origin, marital status and education were all associated with the outcome. For female, but not male, refugees there was a significantly higher likelihood of purchasing psychotropic drugs than non-refugees (OR = 1.27, 95% CI = 1.15 - 1.40).ConclusionsFemale refugees from low-income countries seem to be a risk group among immigrant women from low-income countries, whereas male refugees had the same risk patterns as non-refugee immigrants from low-income countries. This underlines the need for training of clinicians in order to focus on pre-migration stress and the asylum process, among female newcomers.

Diagnosing posttraumatic stress disorder in multicultural patients in a Stockholm psychiatric clinic

Our objective was to test the assessment of posttraumatic stress disorder (PTSD) and associated symptoms in a multicultural immigrant/refugee population at a psychiatric out-patient clinic. The pilot study included volunteer patients who were randomly assigned to an intervention group (N = 33), who received SCID diagnosis and a battery of life event questionnaires, and a referent group (N = 30), who received the standard diagnostic program. All were followed-up for 1 year. Forty percent of the intervention group, but none in the referent group, were judged to have PTSD. In the intervention group, positive significant correlations were found between HTQ and HSCL-25 and SCID, Axis I PTSD. Experience of trauma influenced the ill-health in the psychometric indices, and the psychometric indices correlated negatively with present and optimal functioning. A targeted trauma approach toward multicultural psychiatric patients using a multidisciplinary team and validated psychometric tools provided sensitive and accurate diagnostic information for this group.

A longitudinal perspective on depression and sense of coherence in a sample of mass-evacuated adults from Kosovo

Symptoms of depression and Sense of Coherence (SOC) in a sample of mass-evacuated adults from Kosovo were studied using a prospective design with a baseline study and follow-ups at 3 months and 6 months in Sweden, with an additional follow-up after 1.5 years in both Sweden and Kosovo. The 12-item version of the SOC, depression subscales of the General Health Questionnaire, and the Hopkins Symptom Check List-25 were used. At the additional follow-up after 1.5 years, the same measures were used together with clinical diagnostic assessment. Depression scores increased and SOC decreased over time. There was a significant negative correlation between SOC and symptoms of depression on all occasions, and SOC scores could not predict the diagnosis or symptoms of depression. Those who remained in Sweden became significantly more depressed than those who repatriated. The results are discussed in terms of postmigration stress and breakdown of SOC.

Obstacles to Transcultural Caring Relationships: Experiences of Health Care Staff in Pediatric Oncology

This qualitative study explores the caring situation of families with an immigrant background within the context of pediatric oncology care from the perspective of health care staff. Five focus group interviews and 5 complementary individual interviews were conducted after purposive and theoretical sampling, respectively. Grounded theory methodology revealed that obstacles to transcultural caring relationships are a main concern of the health care staff. These obstacles are divided into 4 main categories: linguistic, cultural and religious, social, and organizational. When health care staff fail to recognize obstacles to transcultural caring relationships, the result is inequity in care of families with an immigrant background. Equity in care for all does not mean identical treatment but, rather, care adjusted to the needs of the individual family regardless of background.

Screening for post-traumatic stress disorder among refugees in Stockholm

A screening procedure (The Health Leaflet; HL) to assist social workers in finding subjects with possible post-traumatic stress disorder (PTSD) in recently resettled refugees is presented. It is compared with two established self-rating instruments, the Harvard Trauma Questionnaire (HTQ) and Impact of Event Scale-22 (IES-22), as well as structured clinical interview. Aim: To validate the screening interview and the rating scales in comparison to a clinical assessment for PTSD, and examine the feasibility of lay screening for PTSD. Findings: The Health Screening Interview with a cut-off value of 10 points identified cases with fully developed PTSD with both sensitivity and specificity about 0.7. Only two items--difficulties concentrating and having been exposed to torture--contributed to the discriminatory performance of the HL interview. In the HTQ symptom subscale, emotional detachment and a feeling of going mad contributed to the discriminatory performance. In the IES-22, recurring strong affects about the events, as well as intrusive memories, were the items with the highest canonical correlation coefficients. In the HL, the single screening question about difficulties concentrating identified 31/32 individuals diagnosed with PTSD in this group, with a relative risk of 24. Conclusions: A mental health screening procedure during refugee reception performed by lay persons is clearly feasible and can assist in identifying subjects with trauma-related healthcare needs, thus leading to more realistic demands in refugee reception.

Focus Group Interview Research in Transcultural Psychiatry: Reflections on Research Experiences

We discuss the use of focus group interviews as a research method in transcultural psychiatry. Focus groups are a new method in health research that can provide a contextual basis for making culturally sensitive interpretations. We illustrate advantages as well as disadvantages of this method with examples from our own research with immigrants and refugees in Sweden.