Judging psychiatric disorders in refugees – Author's reply

Abstract

Gregory Miller and colleagues are correct that accurate calculation of the worldwide prevalence of post-traumatic stress disorder (PTSD) in refugees is not possible. The problem is partly due, as they state, to sample heterogeneity and unreported characteristics. But, in my view, these facts further support the primary focus of my Comment: that accurate measurement of health outcomes in refugees is lacking. Although the systematic review by Fazel and colleagues did not include all possible contextual variables that might cause bias in refugee research, and did not include all possible refugee samples, it was nonetheless novel in pointing out how contextual variables in refugee research create measurement bias. Miller and colleagues clarify other biases. People from countries of origin that account for most of the world's refugees are often not included in well funded, sound research. Furthermore, although children make up 43% of all refugees, and many refugees reside in less developed countries, they are also not commonly included in research, and so representative data of the world's refugees are not available for systematic reviews such as that of Fazel and colleagues. The millions of internally displaced people within the borders of their own countries are also very unlikely to be included in good research. In fairness, however, my Comment stated that the article by Fazel and colleagues “adds to what is known about mental disorders in refugees resettled in western countries”, and did not imply that these data were representative of all refugees in the world. Nevertheless, the observations by both Fazel and colleagues and Miller and colleagues highlight how important it is that investigators, policy-makers, and service organisations recognise the need for more accurate information about refugee trauma and health so that they can make sound decisions about what to do with the scarce resources allotted to the study and assistance of survivors of conflict. I concede my misunderstanding of the statistics from which I inferred either higher or lower prevalence rates of mental disorder depending on the contextual research variable in Fazel and colleagues' study. The prevalence rates might not vary by the actual percentages I report because, as Miller and colleagues point out, “no predictor is credited with variance shared with other predictors: each correlated predictor no longer measures what it initially measured”. I trust that my error does not detract from the importance of Fazel and colleagues' work, which I think shows that contextual variables of the research itself compound the challenges of obtaining accurate prevalence data about the mental health of refugees. If my Comment incorrectly conveyed that psychiatric prevalence in refugees worldwide is low, then I share Miller and colleagues' concern. In addition to my primary focus being about the inadequacy of methods in refugee research, another message that I wanted to convey is that the resilience of refugees is all too often not honoured or included in research. It is important to know how some who are severely harmed do not develop PTSD or other impairing disorders so that these protective factors might help to guide prevention and treatment strategies. I also make it clear that the mental health effects of war to refugees and others involved in war, whether it is a 10% or a 31% prevalence rate, should be regarded as unacceptable. If I accurately understand the concern of Miller and colleagues, then I share it: we should use the good scientific methods that we have at our disposal to accurately assess the effects of war on the millions of refugees, asylum seekers, and internally displaced people around the world. I declare that I have no conflict of interest. Judging psychiatric disorders in refugeesIn a systematic review, Mina Fazel and colleagues (April 9, p 1309)1 report rates of psychiatric disorder in refugees relocated to high-income western countries, emphasising studies of more than 200 individuals. They note the substantial heterogeneity of the samples and the findings. Full-Text PDF