Post-migration Living Difficulties Research Articles

A brief transdiagnostic psychological intervention for Afghan asylum seekers and refugees in Austria: a randomized controlled trial

BackgroundAsylum seekers and refugees are at great risk for developing mental disorders. Afghan refugees are a particularly vulnerable group with a low average education and mental health literacy level. Traumatic experiences and hardship before and during migration are predictive of mental health problems. However, post-migration living difficulties (PMLDs) also account for a large proportion of mental distress in such populations, which, critically, are not sufficiently considered in treatment protocols and research investigations. Indeed, the evidence base for the treatment of refugees and asylum seekers is sparse and limited mainly to trauma-specific treatments, where refugees may likely suffer from other mental health problems such as depression or anxiety.Methods/designThis trial is the first evaluation of a short-term, transdiagnostic treatment protocol for treatment-seeking Afghan refugees which addresses mental health problems and PMLDs while using an adapted version of the Problem Management Plus (PM+) protocol. Here, we will investigate the efficacy of an intervention manual with a prospective, single-center, randomized, assessor-blind, two-group trial among refugees who are on a waiting list for professional mental health treatment. Furthermore, we will investigate participants’ subjective experiences with the intervention manual via in-depth interviews. One hundred twenty people will be assessed and randomly allocated to either the intervention arm or a treatment-as-usual arm. Clinical psychologists will conduct the treatment, and the sessions will take place with a Dari interpreter. The protocol consists of six 90-min sessions. The primary endpoint is the general symptom distress measure, assessed with the General Health Questionnaire 28 (GHQ-28). Secondary endpoints are the Post-Migration Living Difficulties Checklist (PMLDC), the International Trauma Questionnaire (ITQ), the World Health Organization Quality of Life Questionnaire (WHOQOL-BREF), the Psychological Outcome Profile (PSYCHLOPS), service and health care use (assessed with several items), and the Immigrant Integration Index (IPL-12).DiscussionThis trial may provide substantial evidence for a brief transdiagnostic psychological intervention. Here, we intend to contribute to the treatment of mental health problems among Afghan refugees. The assessment of subjective experience with this treatment manual, as well as the evaluation of its clinical applicability, may optimize treatment acceptance and outcomes across a wide range of mental health problems among refugees.Trial registrationGerman Clinical Trials Register (DRKS) registration number: DRKS00016538. Universal Trial Number: U1111-1226-3285. Registered on January 7, 2019. https://www.drks.de/drks_web/setLocale_EN.do

Influence of post-migration living difficulties on post-traumatic symptoms in Chinese asylum seekers resettled in Italy.

Little is known about mental health and resettlement difficulties of Chinese asylum seekers fleeing China due to religious persecutions. This study explores main post-migration living difficulties (PMLD) in this population, with a focus on their role in post-traumatic stress disorder (PTSD). A total of 67 patients (95.52% women, mean age 34.75 ± 7.63) were included in the study. The Harvard Trauma Questionnaire (HTQ) was used to assess PTSD, the List of Migration Experiences (LiMEs) was used for pre-migration and post-migration experiences (potentially traumatic events as well as living difficulties). The t-test was used to examine the differences in pre-migration and post-migration mean scores. Logistic regression was used to test the effect of pre-migration traumatic experiences (PMTE) and most frequent PMLD on having a PTSD. A total of 49 patients scored above the HTQ cut-off score for PTSD. As expected, traumatic experiences were concentrated in the pre-migration phase, while living difficulties were present in both phases but more frequently in the post-migration period. PMTE were significantly related to PTSD (OR 1.29, p = .01). However, three PMLD ('Feeling that you do not know where you will lend up tomorrow', 'Loneliness and boredom' and 'Not being able to find work') showed a significant interaction with PMTE, suggesting that their presence in the post-migration phase has a modulation effect by increasing the likelihood of PTSD. This study extends to Chinese asylum seekers the previous evidence that PMLD have a significant role in the likelihood to have a PTSD after landing in the host country.

Does Duration of Residency in the United States Influence Psychological Symptoms and Postmigration Stressors Among Refugees? Potential Implications of Populism for Refugee Mental Health

After relocation, refugees may experience significant difficulty adjusting to a host culture, and this difficulty may persist even after many years following resettlement. However, the influence of time on postmigration living difficulties (PMLD) and psychological distress has not been extensively investigated. In this investigation, we used regression analyses to examine whether length of residence in the United States would moderate the relationship between psychological symptoms and PMLD in a sample of 52 adult East African refugees. The sample was predominantly male (female n = 13) with a mean age of ∼37 years ( SD = 20.91) and mean length of residence in the United States of 9.9 years ( SD = 5.85). The moderating effect of years living in the United States on the depression–PMLD relationship was significant, and explained an additional 9% of variance in PMLD. The relationship between depressive symptoms and PMLD became significantly related at ∼7 years of residence in the United States, and became more positive as values in the sample approached the longest duration in the United States (30 years). No such moderating effect was found for the association between posttraumatic stress disorder symptoms and PMLD. These results highlight the risk of marginalization as well as the need for early and sustained psychosocial interventions for refugee populations in the United States.

Changes in Post-migration Living Difficulties Predict Treatment Outcome in Traumatized Refugees.

Background: Refugee mental health is affected by traumatic stressors as well as post-migration living difficulties (PMLD). However, their interaction and causal pathways are unclear, and so far, no distinct treatment recommendations regarding exile-related stressors exist.Methods: In a 3-year follow-up study, PMLD and symptoms of post-traumatic stress (PTS), depression and anxiety were examined in a clinical sample of severely traumatized refugees and asylum seekers (N = 71).Results: In regression analysis, reduction in PMLD predicted changes over time in depression/anxiety, but not in PTS. The opposite models with PMLD changes as outcome variable proved not significant for PTS, and significant, though less predictive, for depression/anxiety.Conclusions: In addition to well-established trauma-focused interventions for the treatment of PTS, psychosocial interventions focusing on PMLD might contribute to a favorable treatment response in traumatized refugees, particularly with regard to depression and anxiety.

Recently resettled refugee women-at-risk in Australia evidence high levels of psychiatric symptoms: individual, trauma and post-migration factors predict outcomes

BackgroundDespite increasing numbers of refugee women-at-risk being resettled and their potential vulnerability, there exists no empirical research into the psychiatric health of this unique subgroup with which to guide policy and practice. This research aimed to investigate psychiatric symptom status of a sample of refugee women-at-risk recently resettled in Australia, as well as factors contributing to symptoms of trauma, anxiety, depression, and somatization. The level of psychiatric symptomatology is compared to reference groups of women from Sudan and Burma, who entered Australia under the Humanitarian Entry Programme, and who did not meet criteria as women-at-risk.MethodsThis is a cross-sectional survey of 104 refugee women-at-risk across several ethnic groups including a demographic questionnaire, the Harvard Trauma Questionnaire, Post-migration Living Difficulties Checklist, and Hopkins Symptom Checklist to assess individual factors, traumatic experiences, post-migration problems, and symptoms of trauma, anxiety, depression, and somatization. A series of multiple hierarchical regression analyses examined factors predicting psychiatric symptoms.ResultsSubstantial proportions of participants reported psychiatric distress in symptomatic ranges, including for traumatization (41%), post-traumatic stress disorder (20%), anxiety (29%), and depression (41%), as well as significant symptoms of somatization (41%). These findings are significantly higher than those derived from reference groups of women from Sudan or Burma, resettled in the same area and utilizing a similar methodology. Higher numbers of trauma events and post-migration living difficulties predicted higher trauma, depression, and somatic (but not anxiety) symptoms. Having children predicted higher trauma, anxiety, and somatic symptoms. Greater English fluency predicted higher anxiety symptoms. Region of birth predicted anxiety and depression symptoms. Age predicted trauma and anxiety symptoms.ConclusionsFindings suggest that recently arrived refugee women-at-risk are at high risk of psychiatric disorders. The results indicate a need for comprehensive psychiatric assessment to identify women in need of treatment very early after resettlement, with implications for medical practice, service delivery, and policy programs.

Defining a combined constellation of complicated bereavement and PTSD and the psychosocial correlates associated with the pattern amongst refugees from West Papua.

Refugees are at risk of experiencing a combined constellation of complicated bereavement and posttraumatic stress disorder (PTSD) symptoms following exposure to complex traumas associated with personal threat and loss. Features of identity confusion are central to both complicated bereavement and PTSD and these characteristics may be particularly prominent amongst refugees from traditional cultures displaced from their homelands, families, and kinship groups. We investigate whether a combined pattern of complicated bereavement and PTSD can be identified amongst West Papuan refugees participating in an epidemiological survey (n = 486, response rate: 85.8%) in a remote town in Papua New Guinea. Latent class analysis was applied to derive subpopulations of refugees based on symptoms of complicated bereavement and PTSD. Associations were examined between classes and traumatic loss events, post-migration living difficulties (PMLDs), and psychosocial support systems. The four classes identified comprised a complicated bereavement class (11%), a combined posttraumatic bereavement class (10%), a PTSD class (11%), and a low symptom class (67%). Symptoms of identity confusion were prominent in the posttraumatic bereavement class. Compared with the low symptom class, the combined posttraumatic bereavement class reported greater exposure to traumatic loss events (OR 2.43, 95% CI 1.11-5.34), PMLDs (OR 2.24, 95% CI 1.01-4.6), disruptions to interpersonal bonds and networks (OR 3.3, 95% CI 1.47-7.38), and erosion of roles and identities (OR 2.18, 95% CI 1.11-4.27). Refugees appear to manifest a combined pattern of complicated bereavement and PTSD symptoms in which identity confusion is a prominent feature. This response appears to reflect the combined impact of high levels of exposure to traumatic losses, PMLDs, and disruption of relevant psychosocial systems.

Factor structures of Complex Posttraumatic Stress Disorder and PTSD in a community sample of refugees from West Papua

ObjectivesThe intention to include a category of Complex Posttraumatic Stress Disorder (CPTSD) in ICD-11 has renewed interest in this construct. Although growing evidence from high income countries supports the construct validity of CPTSD, little parallel research has been undertaken across cultures. We tested theoretically supported CPTSD structures (a one-factor, six-factor, one-factor higher-order, and two-factor higher order structure) in a community sample of West Papuan refugees living in a remote town, Kiunga, in Papua New Guinea (PNG). ProceduresA community-wide survey was conducted (2016–2017; response rate 85.5%) amongst 486 West Papuans. Culturally adapted measures were applied to assess cumulative traumatic exposure, postmigration living difficulties (PMLDs), CPTSD symptoms, and functional impairment. FindingsA six factor structure for CPTSD provided the best fit to the data, consistent with our past study amongst West Papuans. ConclusionsThe cross-cultural validity of our findings is supported by the isolation of West Papuan participants from services treating traumatic stress. To further support the universal applicability of CPTSD, our findings need to be confirmed amongst other refugee groups from diverse cultural backgrounds.

Postmigration Living Difficulties, Help-Seeking and Community Resilience in the Initial Stages of Migration: Coproducing Community Practice with Recent Irish Migrants to London

ABSTRACTThis article describes a community-based participatory action research (CBPAR) project that examined the postmigration living difficulties (PMLD), help-seeking and community resilience of recent Irish migrants to London (n = 176). The majority of respondents were young adults, in managerial or professional occupations and in good or very good health. Mixed methods indicate inadequate planning for relocation and poor social support as the main difficulties in the initial stages of migration. Community factors promoting resilience included employment opportunities, local and transnational supports, and cultural familiarity and acceptance. Community participation in the action orientated phase of this CBPAR is discussed.

Migration Challenges and Traumatic Experiences of an Asian Immigrant in Inside Out and Back Again by Thanhha Lai

The purpose of this paper is to be able to understand how to cope up and overcome traumatic experiences as an immigrant of a discordant country. Such countries whose citizens make a fine distinction and discriminating judgement between eastern and western society. Based on this award winning book by Thanhha Lai through a series of poems, a young girl chronicles the life-changing year of 1975, when she, her mother and brothers left Vietnam and resettled in Alabama, USA. The traumatic experiences started when Ha has to leave her native country where she have lived for 10 years of her life. The war has reached the city, escaping the bombs and away from the Viet Cong, Ha and her family must to get into a ship. A ship sailing towards the land of hope: USA. Ha, as one of the first young generation Asian immigrants, experiences post-migration living difficulties (PMLD) which were the biggest challenge. Those challenges includes: the long waiting for an American sponsor, language difficulties, bullying at school, unaccepted by the neighbors, changing their religion and belief for the sake of being welcomed by the community, food, finding a job, facing the racist, being abused, exploitation and many other difficulties. (Hannam University)

Corrigendum to “Impact of Postmigration Living Difficulties on the Mental Health of Afghan Migrants Residing in Istanbul”

Corrigendum to “Impact of Postmigration Living Difficulties on the Mental Health of Afghan Migrants Residing in Istanbul”

Impact of Postmigration Living Difficulties on the Mental Health of Afghan Migrants Residing in Istanbul

Background. The sociopolitical situation in Afghanistan continually pushes Afghans to seek safety and better socioeconomic prospects in neighboring and foreign countries. In this paper we examine the mental health of Afghan migrants residing in Istanbul, Turkey, an understudied population at high risk of psychopathology. Methods. We surveyed 158 Afghan migrants to assess psychological distress using a culturally grounded measure of mental health, the Afghan Symptom Checklist [ASCL], and used hierarchical regression analysis to examine the impact of postmigration living difficulties (PMLDs) on mental health. Results. We found that depressive, somatoform, anxiety-like symptoms occurred often, as did a number of culturally salient idioms of distress. Regression analyses showed that while socioeconomic variables and poor physical health status significantly predicted psychological distress, PMLDs exerted the strongest negative effect. The most pressing PMLDs for Afghans in Turkey are poverty, unemployment, lack of treatment for health problems, fears of being deported and related legal challenges, and family-related stressors. Conclusion. Our results point to the importance of the critical need to create culturally sensitive interventions to remediate high levels of psychological distress by addressing related PMLD stressors in a highly vulnerable Afghan migrant population residing in Turkey.

The Psychological Consequences of Pre-Emigration Trauma and Post-Migration Stress in Refugees and Immigrants from Africa

Over 50 million people have been displaced, some as a result of conflict, which exposure can lead to psychiatric sequelae. The aims of this study were to provide estimates of pre-emigration trauma, post-migration stress, and psychological sequelae of immigrants and refugees from predominantly Sub-Saharan Africa who immigrated toSweden. We also examined the predictors of the psychiatric sequelae as well as acculturation within the host country. A total of 420 refugees and immigrants were enrolled using stratified quota sampling. A battery of questionnaires including the Harvard Trauma Questionnaire, Post-Migration Living Difficulties Scale, the Cultural Lifestyle Questionnaire; and the Hopkins Checklistwere administered. Descriptive statistics, Chi square analyses, Pearson correlations, analysis of variance, and logistic and linear regression were performed to test the aims of the study. Eighty-nine percent of participants reported at least one traumatic experience prior to emigration. Forty-seven percent of refugees reported clinically significant PTSD and 20% reported clinically significant depressive symptoms. Males reported a significantly greater number of traumatic events [F(1, 198)=14.5, p<0.001] and post-migration stress than females [F(1, 414)=5.3, p=0.02], particularly on the financial, discrimination, and healthcare subscales. Females reported a higher prevalence of depressive symptoms when compared to males [F(1, 419)=3.9, p=0.05]. Those with a shorter duration in Sweden reported higher rates of PTSD [F(63, 419)=1.7, p<0.001]. The greater number of traumatic events was found to be significantly associated with the severity of PTSD symptoms [F(34, 419)=9.6, p<0.001]. Using regression analysis, 82 and 83% of the variances associated with anxiety and depression, respectively, was explained by gender, education, religion, PTSD and post-migration stress. Sixty-nine percent of the variance associated with PTSD included education, number of traumatic events, depressive symptoms and post-migration stress. Forty-seven percent of the variance for acculturation was accounted for by a model that included age, education, duration in Sweden, anxiety, depression, and post-migration stress. These predictors were also significant for employment status with the exception of depressive symptoms. Multidimensional interventions that provide treatments to improve psychiatric symptoms in combination with advocacy and support to reduce stress (e.g., financial, access to health care) are recommended. The focus of the intervention may also be modified based on the gender of the participants.

Somatisation and anger are associated with symptom severity of posttraumatic stress disorder in severely traumatised refugees and asylum seekers.

Most research on refugee mental health has focused on posttraumatic stress disorder (PTSD). Besides PTSD, however, traumatised refugees are often burdened by comorbid somatic and psychiatric conditions, as well as postmigration living difficulties (PMLD). It is unclear how these conditions interfere with presentation and treatment of PTSD. This preliminary cross-sectional study investigated 134 severely traumatised refugees and asylum seekers in treatment in two psychiatric outpatient units in Switzerland. Trauma exposure, PMLD, somatisation and explosive anger were assessed and related to symptom severity of PTSD using correlation and regression analyses. PTSD symptoms were significantly related to somatisation, anger, PMLD and trauma exposure. Regression analysis revealed that PTSD symptoms were mainly predicted by somatisation and anger. Symptom severity of PTSD is associated with somatisation, explosive anger and, to a lesser extent, PMLD. Standard PTSD treatment may benefit from implementing targeted strategies to assess and address these factors in traumatised refugees.

Challenging future, challenging past: the relationship of social integration and psychological impairment in traumatized refugees

BackgroundRefugees have been shown to present high prevalence rates of trauma-related mental disorders. Despite their psychological impairment, they are expected to meet high functional requirements in terms of social integration into, and financial independence from, the host society.MethodsThis cross-sectional study examined the relationship of mental health problems, post-migration living difficulties (PMLD), and social integration in a sample of 104 refugees seeking treatment for severe posttraumatic stress and comorbid symptoms in two outpatient clinics in Switzerland.ResultsDespite an average time of residence in Switzerland of over 10 years, participants showed poor integration and a high number of PMLD. Integration difficulties were closely associated with psychological symptoms, but not with socio-demographic parameters such as education or visa status.ConclusionsPsychological impairment in treatment-seeking traumatized refugees is associated with poor integration. To foster social integration, it is crucial to better understand and address the specific needs of this highly vulnerable population.

Traumatic events, post-migration living difficulties and post-traumatic symptoms in first generation immigrants: a primary care study.

To study potentially traumatic events (PTE), post-traumatic stress disorder (PTSD), anxiety, depression, somatization and post-migration living difficulties (PMLD) in primary care immigrants. Patients self-rated transculturally validated questionnaires. Those with and without PTSD were compared on all variables. The influence of the number of PTE and of PMLD on PTSD was measured. 391 patients completed the questionnaires. Prevalence of PTSD was 10.2%. PTE and PMLD were frequent in the whole sample but more common in PTSD subjects. Either the number of PTE and of PMLD significantly increased the likelihood to have a PTSD. PTE, PMLD, PTSD and related conditions (anxiety, depression and somatization) are frequent among immigrants in primary care, and either PTE and PMLD significantly influence resulting psychopathology. The implications in clinical practice are discussed.

Post-migration living difficulties as a significant risk factor for PTSD in immigrants: a primary care study

Background: recent research shows that severe/very severe post-migration living difficulties (PMLD) have a negative impact on the mental health and social integration of refugees and asylum seekers. This study focuses on the role of PMLD in primary care “ordinary” immigrants. Methods: 443 primary care immigrants were asked to complete a self-administered questionnaire measuring the number and severity of pre-migratory potentially traumatic events (PTE), PMLD, and the current prevalence of a post-traumatic stress disorder (PTSD). The frequency of PMLD was assessed in the whole sample and compared in patients with and without PTSD. The effect of the number of PMLD on the risk of having a PTSD was studied by means of a regression analysis, adjusted by the number of PTE. Results: 391 patients completed the questionnaire and were enrolled into the study. The prevalence of PTSD was 10.2%. In the whole sample the most frequent PMLD were “no permission to work” (38.6%) and “poverty” (34.5%). All PMLD (except “communication difficulties”) were more frequent in patients with a PTSD. The number of PMLD significantly increased the likelihood to have a PTSD independently from PTE. Conclusions: severe/very severe post-migration living difficulties (PMLD) increase significantly the risk of PTSD in primary care “ordinary” migrants. Our hypothesis is that they have a retraumatizing effect on individuals who are already vulnerable and with a low capacity to handle resettlement stress due to their previous traumatic history. The implications in clinical practice and for immigration policies are discussed.

Immigration, trauma, living difficulties and psychopathology: a preliminary study in a primary care setting

Investigate the prevalence of Post-Traumatic Stress Disorder (PTSD), anxiety, depression and somatizations in a sample of immigrants visited in a transcultural primary care service. The relationship among psychopathological symptoms, pre-migratory events and post-migration living difficulties is also considered. We studied 101 outpatients, attending the "Caritas" Primary Care Unit for immigrants in Rome. All participants fulfilled a socio-demographic questionnaire, a checklist of traumatic events (Harvard Trauma Questionnaire, HTQ), a checklist of post-migration living difficulties (Post-Migration Living Difficulties, PMLD) and the following questionnaires: the HTQ for the assessment of post-traumatic symptoms, the Hopkins Symptom Checklist (HSCL-25) for anxiety and depression, the Bredford Somatic Inventory (BSI) for somatization. 40 patients (39.60%) had an anxiety disorder, 47 (46.13%) a depressive disorder, 16 (15.84%) a PTSD and 39 (38,6%) a somatization syndrome. All these syndromes were significantly correlated. The number of traumatic events and of post-migration difficulties significantly increased the scores on the psychopathological scales. The prevalence of psychopathological syndromes in our primary care transcultural unit was high. This not only in refugees, but also in immigrants for other reasons. Moreover, the levels of psychopathological distress were significantly influenced by the number of pre-migratory traumas and of living difficulties in the host country.

The role of post-migration living difficulties on somatization among first-generation immigrants visited in a primary care service

The role of post-migration living difficulties (PMLD) on somatization was studied in 101 first generation immigrants visited in primary care. Premigratory traumas and post-traumatic stress disorder (PTSD) were also assessed. About one third of patients somatized. Sociodemographic variables were similar in somatizers and non-somatizers. Premigratory traumas, PTSD and the likelihood to report at least one serious or very serious PMLD were higher in somatizers. Four kinds of PMLD were more frequent in somatizers: worries about unavailability of health assistance, working problems, discrimination and poor social help. Traumas and PTSD influenced the effect of PMLD on somatization. Findings suggest that in specific samples of primary care immigrants severe premigratory traumas increase the sensitivity to PMLD and in turn distress due to PMLD amplifies the tendency to somatize.

Cumulative Trauma, PTSD and Dissociation Among Ethiopian Refugees in Israel

Objective: The aim of this study was to examine the exposure of Ethiopian refugees to pre-, peri- and post-migration stressful events and their implications for both posttraumatic stress disorder (PTSD) and dissociation. Method: A random sample (N = 478) of three groups of refugees took part in the research (“Moses” immigrants, 1984, n = 165; “Solomon” immigrants, 1991, n = 169; “Family Reunification” immigrants, 1995, n = 144). Exposure to stressful events and posttraumatic symptoms were assessed via the Harvard Trauma Questionnaire (HTQ). Post-migration difficulties were assessed via the Post Migration Living Difficulties (PMLD) scale. Dissociation was evaluated using the Dissociation Experience Scale (DES). Results: Significant differences were found among the groups in the rates of PTSD (27%, 15%, and 26%, respectively), but no differences were found in dissociation. A significant relationship was found between PTSD symptoms and cumulative trauma among the three groups, but no such relationship was found between dissociation and cumulative trauma. The differences among the groups were discussed in light of the unique characteristics of cumulative trauma, PTSD and dissociation among Ethiopian refugees.