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Experts sound alarm over mental health toll borne by migrants and refugees

Experts sound alarm over mental health toll borne by migrants and refugees

Hazardous journeys and harsh conditions in camps linked with depression, anxiety and psychosis

The Idomeni refugee camp in Greece
People wait to be transferred from the Idomeni camp in Greece. Photograph: Anadolu Agency/Getty Images

As concern mounts about the conditions faced by refugees and migrants in camps across Europe, and more people die trying to reach the continent, the mental health of those who have risked everything in the hope of starting a new life in Europe is gaining more attention.

A report last year by the German Federal Chamber of Psychotherapists said 40%-50% of people arriving in Germany suffered from post-traumatic stress disorder (PTSD), with half also suffering from depression.

“They have nightmares or flashbacks to pictures or scenes. These memories feel very intense, and it is just like they are reliving the traumatising experience,” the report said. Other symptoms include jumpiness, sleep disorders, problems with concentration, and emotional numbness.

“It is shameful that people suffering with such psychological injuries do not get the help they need,” the report said.

Post-traumatic stress is just the tip of the iceberg. “PTSD is very important, but it is also the disorder that everyone jumps to, including the media. We see much more depression and anxiety disorders, and also, surprisingly, a lot of epilepsy and psychotic disorders, including schizophrenia,” said Dr Inka Weissbecker, global mental health and psychosocial adviser at the International Medical Corpsin Washington.

“There are huge amounts of anxiety – we see children bursting into tears when helicopters or airplanes fly over the camps, and we can’t understand why, until we realise what they’re associating it with,” said Harriet Zych, a nurse who worked in Idomeni – site of Europe’s largest informal refugee camp, on Greece’s northern border with Macedonia – before Greek police moved people to other locations in May.

“We came across many people in a state of collapse, whose problems turn out to be psychological rather than physical,” she said. “One man hit himself with a rock on his head until he became unconscious when he found out he couldn’t cross the border.”

Nikos Gionakis, a psychologist with the Athens-based mental health unit Babel, tells the story of Hassan, 34, who fled Syria with his four children. “Passing from Turkey to Greece, he was forced to get into a boat by smugglers. Two of his kids drowned as the boat sank. He was referred to Babel because of depression. He blames himself for not having been able to protect his kids,” Gionakis said.

The UN refugee agency, the UNHCR, says mental health disorders can hinder integration into host populations, creating long-term problems for European countries that are accepting refugees fleeing from conflicts in Syria and elsewhere.

In a paper to the European commission last year, the European Psychiatric Association said: “Acute and long-term psychiatric care needs to be provided to all asylum seekers in order to avoid reaching chronic conditions of mental disorders.”

Aid workers in Greece say diagnosis, never mind treatment, is almost impossible in the chaos of the camps and detention centres in southern Europe.

“You cannot say how many people are suffering from PTSD because diagnosis takes too long, and with such a stream of people, it is impossible. I am a trained psychologist with 40 years’ experience; it would take me two and a half hours to diagnose someone with PTSD,” said Renos Papadopoulos, director of the Centre for Trauma, Asylum, and Refugees at Essex University, who recently returned from Greece. “There is no evidence [on the prevalence of PTSD] because there cannot be evidence. The situation is complete chaos.”

“We don’t do diagnosis,” said Zoi Marmouri, a psychologist working for Médecins Sans Frontières in Idomeni. Even if diagnosis were possible, World Health Organisation (WHO) guidelines stipulate that clinical treatment is not appropriate for refugees on the move.

“Therapies should not be started without assurances that there can be follow-up. You have the potential to retraumatise people,” said Claire Whitney, Middle East mental health and psychosocial support adviser at the International Medical Corps.

The most effective treatments for PTSD include cognitive behaviour therapy with a trauma focus, eye movement desensitisation and reprocessing therapy, as well as narrative exposure therapy. But these take time as they involve slowly exposing people to their trauma, while building up their capacity to deal with it. “It cannot be rushed,” said Whitney. “When people actually have PTSD, it is one of the most complex problems to treat.”

The WHO says refugees and migrants needing diagnosis should be referred to existing non-governmental or state services. But even for those who make it into host communities, cost, stigma and language problems can lock them out of treatment.

“We have serious lacks in the services we can provide. If they need hospitalisation, there aren’t any specialised units for this,” said Gionakis.

International funds have been pledged for psychosocial support, although neither Britain’s Department for International Development nor the EU were able to provide a full breakdown.

Some experts warn there is a risk of overdiagnosing PTSD. “They are distressed, yes, but is this PTSD? Often it will not be. These are instead normal reactions to an abnormal situation,” said Papadopoulos.

The UNHCR and other agencies saymuch of the emotional suffering experienced by refugees and migrants is directly related to present-day stresses and concern about the future.

“People live in very difficult and inhumane conditions here in camps that are too crowded. Basic needs are not met,” says Gionakis.

The UNHCR advocates “psychological first aid”, which encourages those interacting with refugees to respond in a culturally sensitive and humane way that avoids distressing people further.

“The humanitarian principle of ‘do no harm’ is a huge part of it,” said Whitney. “What everyone was advising, for the most part, was really to focus on the most basic kinds of support, which do contribute to mental health. Often, basic needs must be provided before people are ready – and willing – to engage with therapy.”

Mental health problems aren’t all in the brain

An open letter to the BBC written by a group of psychologists and other mental health professionals has attracted more than 1,000 signatures. The letter outlines concerns regarding the recent In the Mind season of programmes exploring mental health issues and, in particular, the almost total lack of any social perspective on mental health in the programmes. The psychologist, Richard Bentall also wrote about this in an excellent piece in the Guardian last week.

I share these concerns, though not because I believe that mental health problems have no biological basis, nor because I think environmental factors invariably play a role in mental ill health; I simply wouldn’t know. But because I do know from listening to the stories of dozens of fellow service users, that adverse life experience such as physical and sexual abuse, racism, bullying and neglect is depressingly common on a psychiatric ward, and understood by a great many patients to have played at least a significant role in the development of their problems. Moreover, it is striking how often problems with housing, for example, or the stress of being assessed for benefits (which are, ironically enough, supposed to support the most vulnerable) are understood by patients to be the trigger for a relapse.

In this context, it seems to me that the decision of the BBC to portray mental health problems simply as brain disorders is a highly troubling one. While some people do undoubtedly interpret their mental health in this way, there are many who do not, many indeed who would resist the attachment of any diagnostic label, who see their mental health difficulties as a natural, rational response to adverse experience. In failing to represent their perspective, the BBC has not only presented an extremely one-sided picture, it has broadcast a message to such individuals, and to society generally, that their experience doesn’t matter.

Of course, it would be rather convenient if it didn’t. It would be especially convenient for David Cameron. It would mean that when he talks about our need to “focus on mental health”, at the same time as bringing in benefit changes that have been found to have led to the suicide of at least one person and beenimplicated in the deaths of dozens of others, we might almost be able to take him seriously. It would mean that we wouldn’t have to worry about creating a more equal society. Mental health problems are repeatedly shown to be most prevalent in countries with the highest levels of financial and social inequality. What a relief to realise it doesn’t matter!

This is why mental health must be seen as an urgent political and social issue, as well as a biological and psychological one. And it’s not just a question of responding to the needs of people with mental health problems, though this is of course important, but of being prepared, as a society, to consider what we might do to reduce people’s risk of developing them in the first place. I’d like to see a programme on that.

Open Dialogue: The radical new treatment having life-changing effects on people’s mental health

“If it wasn’t for Open Dialogue I wouldn’t be here now. This time last year, I was suicidal. I had totally lost faith in the mental-health services; I felt I’d been put in the ‘too difficult’ box.”

Suzanne Chapman has been in and out of the mental-health system since attempting suicide twice in her early twenties. Now 49, she’s had every treatment for depression and bipolar disorder: medication, therapy, ECT. For long periods of her life, the drugs worked.

But three years ago, she hit her worst crisis: a bout of depression that made her unable to function. “On Christmas Day, my daughter gave me a potato to peel and I just stared at it. I had no idea what to do with it. I had no strength; I would just lie on the settee or shuffle about the house. I wasn’t coherent, I wasn’t sleeping, I’d lost three stone. I felt so dark, so alone, so worthless.” None of the drugs that had helped in the past made much difference. Suzanne had to give up her job as an administrator and her husband, Simon, a police officer, took three months off to look after her. The couple have two daughters, aged 27 and 25, and a two-year-old granddaughter.

By the time Suzanne was offered an experimental treatment called Open Dialogue last October, she was desperate. It’s a pioneering approach that enables patients and their families to develop their own route to recovery. After just three sessions, Suzanne’s husband noticed a “miraculous” improvement; he now says, “I’ve got my wife back.” Suzanne accepts that she will never be free of depression, but says it’s now firmly under control.

Open Dialogue is currently being piloted in four NHS trusts. It could revolutionise mental-health care in the UK, according to its champions, who include Suzanne’s psychiatrist, Russell Razzaque. The North East London Foundation Trust, where he works, has just given the go-ahead for an Open Dialogue-based service for patients referred from anywhere in the country, starting next May.

Open Dialogue is primarily for people who are suffering a mental-health crisis such as suicide or psychosis – 1.8 million of them in the UK last year. They badly need help: a damning report from the Care Quality Commission in June found that the current system is struggling to cope with mental-health crises, with 42 per cent of patients not getting the help they need. A campaign launched last month calls for an increase in funding for mental-health services and parity with physical health.

The Open Dialogue approach was first developed in Finland in the 1980s, which at the time had one of the worst incidences of schizophrenia in Europe. There are now well-established services in Berlin and New York, where state investment in four respite centres that practise Open Dialogue has been doubled to $100m (£66m). Services are also springing up in Italy, Poland and Scandinavia.

What’s most impressive about Open Dialogue is its success with even the most intractable mental illnesses, where current systems of care too often fail, or offer only short-term respite. Results over the past 30 years from Finland sound impressive: 74 per cent of patients experiencing psychosis are back at work within two years, compared with just 9 per cent in the UK. Crucially, relapse rates are far lower than here: after an average of two years’ treatment, most patients don’t need to come back – ever. Here, a mental-health diagnosis can feel like a life sentence.

Open Dialogue’s key principles are: people are seen within 24 hours of becoming unwell; and all meetings with the psychiatric team are held at home, or wherever the patient finds most helpful. Significant others in the patient’s life – family members, or trained peer-support workers – are engaged in meetings from the word go.

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What is the ‘right’ suicide prevention target?

What is the ‘right’ suicide prevention target?

Setting targets has become commonplace as a way of measuring achievement and progress. We have seen this recently as the future ecology of our planet and the complexity of international policy on climate change has been reduced to negotiations around a series of targets.

It is as though the targets give meaning to the goal for change.

So surely we should set targets for suicide prevention, right? How better to concentrate efforts than to set targets for a reduction in the tragic loss of life to suicide? And surely setting targets is a way to communicate and engage with the wider community in results-based suicide prevention?

This has already started. In 2013, the World Health Organisation (WHO) promoted a target of 10% reduction in suicides by 2020 for member countries, of which Australia is one. Then, in 2014, the WHO released its first ever report on suicide documenting the key elements of any national strategy for suicide prevention, drawing on research evidence and expert opinion.

Some countries were ahead of this, such as Scotland which in 2002 set a target for a 20% reduction in suicide deaths by 2013. In fact, Scotland achieved an 18% reduction in this time period. Perhaps setting bold targets matched to an effective national suicide prevention strategy actually works.

Here Suicide Prevention Australia has recommended a target of 50% reduction in suicide deaths in 10 years, as an aspirational statement to galvanise support and action.
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So far, the governments of Australia have declined to accept this recommendation, and it lies as an unresolved matter after more than 12 months of national review of suicide prevention and mental health programs.

The disappointing background to this discussion is that in Australia the number of deaths by suicide each year has not dropped for some time – in fact it has increased by 20% over the past 10 years. Our national suicide rate has stayed stubbornly around the same level of 10 or 11 deaths per 100,000 in population – on par with the annual global age standardised suicide rate. Surely Australia can do better than this.

But target-setting is not without problems on something as complicated and apparently intransigent as suicide. It’s easy to agree that targets should be set; less easy to agree on what the targets should be and on where the accountability for achievement against targets should rest.

One point to consider is the rationale for any target in reduced suicide deaths. If international expertise and evidence through WHO suggests 10% is achievable, is it folly for Australia to adopt a 50% reduction?

Or, does the Scottish experience suggest setting “stretch targets” matched with sound strategy will deliver results? Given there is no calculated rationale for a 50% reduction in Australia, it becomes murky water indeed trying to set the “right’” suicide prevention target.

And there is this inconvenient question – does a target of 50% imply community acceptance that still in Australia 1,300 people will die by suicide each year? Does it suggest an inevitability around some deaths by suicide that is beyond the capability of national strategies, effective services and community action to prevent? Is the prevention of suicide really so difficult as to warrant “easy” targets or is this letting our collective minds, hearts and spirits off the hook a little too easily?

Ethical issues also start to emerge when targets for suicide prevention are raised. Does a focus entirely on reducing deaths diminish our understanding and empathy with the profound despair and pain felt by suicidal persons – whether or not they actually attempt suicide or die?

Perhaps there is a case for setting goals to reduce human suffering with equal attention to the more recognisable and measurable goal of saving lives?

When it comes to poverty reduction, the trend in international aid and development has been to recognise quality of life and wellbeing factors for vulnerable populations instead of simply calculating the prevention of deaths. Indexes on health, wellbeing and opportunity have been established as measures for success in poverty reduction. Programs seek to achieve outcomes that uphold dignity, self-determination and culture for those exposed to poverty, not just abrupt outcomes indicators of life-span and disease based death rates.
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This is not to suggest that the preservation of human life should not be clearly associated with suicide prevention. A death by suicide is, after all, a preventable and tragic loss of life. In Australia, the median age of a person who has died by suicide Is 44.5 years of age. According to the latest Australian Bureau of Statistics results, in the year 2013 suicide accounted for over 85,000 years of life lost, making it the leading cause of premature death in Australia.

We should never discount the value of these lives – real people now sadly missed.

However, the debate about target setting for suicide prevention has some way to go. There are other questions. Should targets be set to reduce suicide attempts – and re-attempts, as indicators of suicidal behavior which is equally worthy of attention as the behaviors that result in actual death? This point has particular relevance along gender lines as more Australian women attempt suicide than die.


Possibly the best target to set is one of zero tolerance – the target should be “zero” deaths and attempts of suicide.

We should not admit to tolerating any loss of life to suicide, nor should we neglect to provide the very best compassion, support and recovery care for those who come to the dark place which suggests death is better than living. All our effort, our programs, our government suicide prevention strategies, our community action should then be measured up against the contribution made towards this target. Our measurement systems then could be associated with celebrating each and every step towards the end result.

Such a stance would reflect the comment from Dr Margaret Chan, director-general of the WHO, when introducing the international report on suicide: “Every single life lost to suicide is one too many.”