Problems and stressors facing migrants and refugees
Migrants and refugees often face various problems and stressors which can take place at various stages of the migration process:
Pre-migration: lack of livelihoods and opportunities for education and development, exposure to armed conflict, violence, poverty and/or persecution.
Migration travel and transit: exposure to challenging and life-threatening conditions including violence and detention and lack of access to services to cover their basic needs.
Post-migration: barriers to accessing health care and other services to meet their basic needs as well as poor living conditions, separation from family members and support networks, possible uncertainty regarding work permits and legal status (asylum application), and in some cases immigration detention.
Integration and settlement: poor living or working conditions, unemployment, assimilation difficulties, challenges to cultural, religious, and gender identities, challenges with obtaining entitlements, changing policies in host countries, racism and exclusion, tension between host population and migrants and refugees, social isolation and possible deportation.
Risk and protective factors for mental health conditions
All of the above-mentioned stressors can increase the risk of developing mental health conditions. For example, unemployment, poor socioeconomic conditions, and lack of social integration among migrants and refugees are risk factors for mental health conditions such as depression. At the same time, these stressors can also exacerbate pre-existing social and mental health problems.
Factors that negatively impact the mental health and well-being of migrant and refugee children include socioeconomic deprivation, discrimination, racism, low family cohesion, and frequent school changes. Children who have been separated from migrating parents are at heightened risk of developing depression, anxiety, suicidal ideation, conduct disorder, and substance use problems.
On the other hand, the impact of stressors can be buffered by protective factors such as access to employment and services, social support, proficiency in the language of the host country, and family reunification. Among resettled refugee children, protective factors include better socioeconomic status, access to education, a perceived sense of safety, contacts with family, living and socialising alongside other people of the same ethnic origin, a stable and cohesive family structure and good parental mental health.
Prevalence of mental health conditions
Many migrants and refugees will experience distress (e.g. feelings of anxiety and sadness, hopelessness, difficulty sleeping, fatigue, irritability, anger and/or aches and pains). For most people, these reactions will improve over time.
Some studies show that the prevalence of common mental disorders (e.g. depression, anxiety and post-traumatic stress disorder (PTSD)) is higher among migrants and refugees than among host populations. Asylum seekers tend to be at elevated risk of suicide. There is also consistent evidence that the incidence of psychoses is higher among migrant populations in a number of countries, and this has been linked with the cumulative effect of social disadvantages before, during and after migration.
Responding to the mental health needs of migrants and refugees
A comprehensive, multi-disciplinary and inclusive approach is needed to address the mental health needs of migrants and refugees.
Overcoming barriers to receiving mental health care
Addressing barriers to receiving mental health care should include:
- provision of clear information on mental health care entitlements and how to receive services (e.g. through reception centers, community outreach, schools, religious or cultural settings);
- outreach to at-risk groups (e.g. unaccompanied minors, persons with disabilities, persons who identify as LGBTIQ+);
- facilitation of affordable and non-discriminatory access to care regardless of legal status, ensuring financial coverage of mental health services and care provided;
- facilitation of communication (e.g. through engaging interpreters and cultural mediators);
- providing person-centred care that is respectful of cultural differences; and
- facilitating the engagement of multiple sectors and systems (e.g. law enforcement, protection, social services and education) to integrate mental health considerations and support and ensure referral and access to mental health services.
Integrating mental health in primary health care
Making mental health care available through general health care can help identify migrants and refugees with mental health conditions and can make care more accessible and cost effective (e.g. see WHO mhGAP intervention guides mhGAP-HIG and mhGAP-IG). The delivery of interventions may require adaptation to migrant and refugee populations to take into account language and cultural considerations. Interventions provided should be consistent with the national guidelines and policies on mental health of the host country.
Ensuring continuity of care
When providing mental health care, an important consideration is related to the length of stay of the migrant or refugee in the host country. The continuity and quality of mental health care of migrants and refugees on the move can be improved by creating international protocols for assuring continuity of care, improving communication among different social and mental health service providers and providing key written information tailored to their needs that migrants and refugees can take with them and share with different providers.
Addressing social determinants and promoting social integration and inclusion
Migration management policies and provision that have proved to have a negative effect on the mental well-being of migrants (e.g. separation of families and children) should be avoided. The social integration of migrants and refugees can be facilitated by equal access to employment opportunities and decent work, vocational training, financial support, social protection services, and legal and law enforcement agencies, as well as mental health care and psychosocial support. The recognition of skills and qualifications acquired pre-migration can also help their integration into the employment sector. Activities and events that promote the social inclusion of migrants and refugees include community forums or peer-mentorship programmes organized by members of the same refugee or migrant group who are already well-integrated into the local community. Special attention is required to support asylum seekers.
WHO response
WHO is the lead International agency in providing technical advice on mental health.
WHO developed a Global Action Plan (2019-2023) to promote the health of migrants and refugees, approved by the World Health Assembly in May 2019. The Global Action Plan describes overarching priorities and guiding principles to promote the health of migrants and refugees and to contribute to achieving the aim of the 2030 Agenda for Sustainable Development – to leave no one behind. The Global Action Plan highlights how the many barriers that migrants and refugees experience in accessing health-care services can precipitate negative mental health outcomes.
The plan recommends priorities and options for action by the Secretariat in coordination and collaboration with the International Organization for Migration (IOM), the United Nations High Commissioner for Refugees (UNHCR) and other relevant partners.
In May 2021, the World Health Assembly endorsed an update of the Comprehensive Mental Health Action Plan (2013-2030), with the overall goal to promote mental well-being, prevent mental disorders, provide care, enhance recovery, promote human rights and reduce the mortality, morbidity and disability of persons with mental disorders.
WHO is committed to supporting Member States in promoting the physical and mental health of migrants and refugees by strengthening health care services, as appropriate and acceptable to country contexts and financial situations, and in line with their national priorities and legal frameworks and competence. WHO is also committed to ensuring that essential components are addressed, including the provision of treatment and care for mental and behavioural disorders.
In line with the Global Action Plan, WHO is operational on mental health in a range of countries and territories that host large numbers of migrants and refugees. These include Bangladesh, Colombia, Pakistan, Iraq, Jordan, Lebanon, Libya, Pakistan, South Sudan, Sudan, Turkey and Uganda.
WHO has close working relationship with other UN partners, including IOM and UNHCR to meet the mental health needs of migrants and refugees.
WHO co-chairs the Inter-Agency Standing Committee Reference Group on Mental Health and Psychosocial Support in Emergency Settings that provides advice and support to organizations working in emergencies and helps ensure that the mental health response is coordinated and effective. Emergency situations often cause displacement and may lead to people becoming refugees or internally displaced.
WHO’s advice and tools are used by most large international humanitarian organizations active in mental health. WHO and partners have published a range of practical tools and guidelines to meet the mental health needs of people affected by emergencies, including migrants and refugees.
(1) World Migration Report 2020. International Organization for Migration, Geneva.