Prevalence of psychiatric diagnoses in asylum seekers with follow-up

Asylum seekers are among the most vulnerable, marginalized and powerless groups in society with a high risk for psychiatric disturbances. They have most likely only recently fled difficult living conditions [1‐8] and now live in constant fear of deportation and under permanent strain in admission centers, which contributes to their psychological distress.

Germany was the country with the highest number of applications for asylum (65,000) within the European Union in the Year 2012, recording an increase of 41% in application numbers as compared to 2011 [9].

This study was conducted in one of Bavaria’s biggest admission centers, the Admission Center for Asylum Seekers (ZAE) – Zirndorf. The goals were to examine asylum seekers’ psychiatric diagnoses in the first weeks after their arrival in the country, to verify the diagnoses a few months after their discharge from the center and to examine whether mentally ill asylum seekers had received appropriate psychiatric and psychological treatment after discharge.

Most studies on mental disorders in asylum seekers focus on posttraumatic stress disorder (PTSD), reporting a range of prevalence rates between 32 and 46% [4, 10‐16]. Others report numbers as high as 74% [17] or as low as 14% [18]. Affective and anxiety disorders were found to be the most frequent comorbidities with PTSD [19‐21].

A review of published studies on the prevalence of mental disorders in asylum seekers shows a fundamental problem which makes a comparison of results difficult: the sampling methods used are very heterogeneous and led to samples that range from a randomly selected group of subjects to an examination of a rigidly selected group such as the population using counselling or other services [22].

Trying to build on and extend the reviewed research, we formulated the following questions: What are the prevalence rates of mental illness in groups of randomly selected and help-seeking asylum seekers? Which sociodemographic groups will be represented in these two groups? How will psychiatric diagnoses develop over time? And finally, in what ways will mentally ill asylum seekers receive treatment in the German public health system?

Within the project “Psychiatric Examination of Asylum Seekers” supported by the Bavarian Ministry of Labour, Social Affairs, Family and Women [23], a psychiatric center was installed in an admission center in southern Germany. Here, two samples of asylum seekers underwent examination for mental disorders in a preliminary study (t1) between 01/2011 and 05/2012. The first sample consisted of help-seekers, i.e. individuals who had contacted the center of their own impetus. Information regarding psychiatric services was freely available to the residents of the admission center in the form of flyers which had been translated into ten different languages. As a result of close working relationships with local services, medical practitioners, and volunteer services, the project coordinators were able to widely disseminate information about the psychiatric services offered. The random sample consisted of randomly selected residents of the center. As part of the randomization process, a cross-check procedure was used to ensure that no participants from the help seeking group were invited to the random group. All of the invited individuals agreed to participate in the initial screening and all participants provided their consent in written form. Following written agreement from the Ethical Committee, participants were interviewed within the first six weeks of their residence in the center. The most common countries of origin in both samples were Iran (30.4%), Afghanistan (20.1%), Russia (19.4%), Iraq (14.5%), and Azerbaijan (5.7%). Islam (66.5%) and Christianity (13.9%) were the most common religious denominations.

Participants were interviewed by trained bilingual specialists who administered questionnaires to assess the frequency of mental disorders in the 12 months before the interview. Where possible, patients’ preferences with regard to the examiner’s gender were accommodated. Diagnoses were made in accordance with the International Classification of Diseases, 10th revision (ICD 10; [24]) using the Mini-International Neuropsychiatric Interview (MINI; [25]). We assessed psychiatric symptoms by use of the Brief Symptom Inventory (BSI), a culturally sensitive 53-item self-report symptom checklist. Based on BSI results, nine primary symptom dimensions can be computed: somatic symptoms, obsessive-compulsive symptoms, feelings of personal inadequacy, depression, clinical anxiety, anger and hostility, phobic anxiety, paranoid ideation, and social alienation [26]. To measure suicidal thoughts, item 10 of the Montgomery Asberg Depression Rating Scale (MADRS) was used, explicitly asking on a seven point scale for the feeling that life is not worth living, death would be welcome, suicidal thoughts are present or that a suicidal act is being prepared [27]. PTSD symptoms were measured using the Essen Trauma Inventory (ETI), a screening inventory consisting of 35 items for a broad range of traumatic events and 23 symptom based items for posttraumatic stress symptoms on four subscales: intrusion, avoidance, hyperarousal, and peritraumatic dissociation [28]. To assess sleep disturbances, we used the Pittsburg Sleep Quality Index (PSQI), concentrating on the first three of its seven subscores, i.e. subjective sleep quality, sleep latency, and sleep duration [29]. In addition, the interview included questions about the asylum seekers’ use of health services, as well as on social, economic and cultural factors since the migration.

The examinations were performed over a 3-h period during which a psychiatric history was taken by a psychiatry specialist and psychometric testing was carried out by a psychologist. The psychologist/psychiatrist provided detailed information to the participants on the background of the study and the examination procedure. In all cases, the psychiatric-psychological examination was carried out fully after the person selected for examination had given their written consent.

One week after the first interview, subjects that had received a psychiatric diagnosis were asked to return for a second interview (see fig. 1). In this second consultation, therapeutic recommendations for future treatment were made after a discussion of the results and the diagnosis with the patient. Persons without a psychiatric diagnosis were not invited to the second interview.

Four to ten months later, after the asylum seekers had been discharged from the admission center to steadier accommodations, a follow-up examination (t2) was carried out. Our aim was to interview subsamples of both initially examined groups in their new homes. At t2, most individuals in the sample were either of Iranian (44.1%), Afghan (26.5%), or Russian (11.8%) nationality.

Statistical Analyses were performed using the program SPSS 20. Chi-square tests and variance analysis methods were used for interference statistical comparisons of the two subsamples in addition to the descriptive presentation of results by frequency charts and mean values. Missing data was excluded from the statistical analysis.

Our results show a high prevalence of psychiatric disorders in asylum seekers with a significantly higher prevalence in the help-seeking group of patients as opposed to the random group. The most frequent primary diagnosis in both groups was PTSD (F43.1). Compared to the research provided by Wittchen and colleagues [30], the prevalence is clearly higher in our random sample than in the European population (17.6% vs. 2.9%). This might be explained by the potentially traumatic circumstances that may have led this population to seek asylum in the first place, in combination with post migration stress [31‐33]. The second most frequent diagnosis found was a depressive episode (light to severe) followed by insomnia. When we combine the prevalence of stress-related and affective disorders, the results are similar to those shown in the research on refugees by Lindert and colleagues [5] (37.6% vs. 40%). In total, the prevalence rates in our random sample falls into the mid-range of values reported in literature on this topic [4, 12, 14‐16].

From the collected data we conclude that asylum seekers tend to be more vulnerable to psychiatric illness. This reflects the assumption by Lindert and colleagues [5] that within the heterogeneous group of migrants there is a higher prevalence of depression and anxiety in asylum seekers than in other groups, such as labor migrants.

From t1 to t2, the prevalence of PTSD increased without evident additional traumatic events. According to the diagnostic criteria for PTSD in ICD 10 [24], there is a time latency of several weeks or months for the manifestation of the main symptoms. These results suggest that asylum seekers’ psychiatric diagnoses soon after arrival should be recorded carefully and that examination should be repeated after six months. Otherwise, PTSD symptoms might remain undiscovered and grow even more severe. Considering the diagnoses of depression, the disease receded in 11 of 13 cases. We assume that the improvement of social circumstances and living conditions after leaving the crowded admission center might be contributing to this, as only five subjects in the follow-up sample had received some sort of psychotherapy or counselling. The authors conclude that the psychological and psychiatric treatment of mentally ill asylum seekers after discharge from the admission center is insufficient.

The typical subjects in the help-seeking group were Russian women of Christian denomination with previous migration experience. In the random group, there was a higher proportion of male asylum seekers of Muslim denomination coming mainly from Iraq and Iran, of which 45% fulfilled the criteria for a psychiatric diagnosis. They, however, were not seeking help. The cause for this appears to be due to gender as well as cultural, ethnic and religious differences in how psychiatric symptoms are understood and ultimately expressed. Moreover, they could be a starting point for the targeted treatment of risk groups. In order for public health systems to cope with this problem, the authors suggest psychoeducation and information for asylum seekers with the aim to relieve stigmatization from mental illness.

On the basis of current research, we recommend the establishment of outpatient psychiatric-psychological services for those who need treatment as well as short psychiatric screenings for all asylum seekers immediately upon their arrival in the host country. Screening and supportive consultation should be available as part of the first wave of medical screening/treatment with an option for pharmacotherapy if appropriate and necessary. Psychotherapeutic treatments could be offered as a second step in a hierarchy of treatment model. With regard to post migration stress, a helpful step would be to reduce the temporal duration of the application procedure for asylum status - this should also include limiting the time spent in an admission center.