Most migrants do not experience mental health problems. However, refugees and asylum seekers can be at increased risk, particularly if they have experienced violence and trauma, including exploitation, torture or sexual and gender-based violence.
Issues can range from low to moderate levels of anxiety and depression through to more severe mental disorders. The mental health section of the Migrant Health Guide provides further information and links to resources, including patient information in other languages.
People from different cultural backgrounds can have different conceptions and experiences of mental illness. For example, patients may complain about non-specific pain or frequent headaches and stomach-aches rather than emotional distress.
In such cases, you should sensitively investigate their history as well as current circumstances to establish whether such complaints may be an expression of mental health or other social issues. This approach can help to minimise unnecessary referrals for investigations and prescribing of medication.
It can be extremely helpful to consider dialect, culture, gender and sexual orientation when selecting a language interpreter. It may also be helpful to link patients with support organisations with expertise in supporting refugees and asylum seekers.
Caring for patients with trauma
Providing care for people who have experienced violence or persecution can be challenging. They may be unable to discuss their health problems openly or be fearful of examination. They may also have difficulty trusting people in positions of authority, including doctors.
Experiences of torture and other violence can cause deep-rooted feelings of shame, humiliation and guilt, and many patients may be reluctant to disclose to a relative stranger. You should respond compassionately and sensitively, and be aware that building a relationship of trust and support to facilitate disclosure can take some time.
If patients are willing to talk about what happened to them, the situation described can be disturbing for you as well as for the patient (see box 2).
Box 2: Burnout and vicarious trauma
Healthcare professionals and other staff who are exposed to disturbing patient accounts can be emotionally affected. This can include burnout as well as vicarious trauma.
Awareness and self-care along with access to education and training, regular debriefing and peer support can help you look after your own wellbeing when caring for patients who have experienced severe violence and cruelty.
If you are professionally isolated, the migrant.health forum can connect you with a community of other UK practitioners working with vulnerable migrants.
The BMA also provides 24/7 access to our wellbeing support services, which offer peer support and professional telephone counselling, including with trauma specialists. The service is open to all UK doctors and medical students.
Victims of human trafficking and modern slavery
Refugees and asylum seekers are at risk of exploitation, trafficking and modern slavery. This can often involve experiences of mental, physical and sexual violence.
As a healthcare provider, you may be well-placed to identify people who have been trafficked and help them to access specialist support.
Further information on common health conditions affecting people who have been trafficked and what signs to look for is available in the human trafficking section of the Migrant Health Guide. DHSC (Department of Health and Social Care) has also produced guidance and a quick two-page guide for health professionals.
The UK operates a national referral mechanism for adults and children. Adults must consent to be referred in this way. The Salvation Army can also assist with referrals.
Victims of torture and other forms of violence
Recent estimates suggest that on average 44% of asylum seekers have experienced torture, although this can vary significantly by country.
If you have patients who are refugees and asylum seekers, you should be alert to and able to identify health problems which may be physical and mental consequences of torture. However, it is important that you recognise the limits of your own competence and refer to a specialist service when appropriate.
Depending on the nature of your patient’s experiences, the most appropriate specialist service may be secondary mental health, sexual health, or support for victims of domestic or sexual abuse, or human trafficking.
The assessment and documentation of the sequelae of torture should be undertaken by experienced health professionals. The main UK centres where patients can receive specialist psychological therapy and expert assessment for medical reports to support asylum application are:
- Freedom from Torture (formerly the Medical Foundation for the Care of Victims of Torture)
- The Helen Bamber Foundation
More information on these organisations can be found in 'useful resources and organisations'.
It is of vital importance that asylum seekers who report experiences of torture, FGM, exploitation or sexual and gender-based violence are referred on to a specialist service without delay. Proper evaluation and medical reports concerning these experiences can have a significant impact on a patient’s asylum application or appeal.