Updated: Apr 28, 2021
Concerns over refugee mental health have risen over the years, yet inequities in mental health outcomes persist. In the U.S., there is an excess mental health burden among refugees. The lifetime prevalence of PTSD among refugees is 31.46% , which is approximately 4.5 times the lifetime prevalence of PTSD in the U.S. general population, 6.8%. Similarly, the lifetime prevalence of any depressive disorder among refugees is 31.5% , about 4.4 times the lifetime prevalence in the U.S. general population. The mental health burden does not fall on all refugees equally, with female identifying refugees being reported to face a higher prevalence of mental health issues than male refugees. While refugees often face trauma in their home country and it is logical that trauma leads to mental health challenges, the prevalence and persistence of these mental health issues among refugees in the U.S. raise concerns: what factors may be working to produce and sustain excess the mental health burden among refugees in the U.S. and how can we intervene to address this inequity in mental health status? This essay aims to examine historical approaches of ameliorating the mental health burden experienced by refugees, apply the lenses of intersectionality and colonialism/imperialism in public health to understand how refugee mental health is shaped, and offer practical changes to how we approach developing interventions targeting refugee mental health.
The United Nations High Commissioner on Refugees (UNHCR) defines a refugee as “someone who has been forced to flee his or her country because of persecution, war, or violence [and]. . . has a well-founded fear of persecution”. The U.S. has consistently accepted large numbers of refugees since 1980 and as a participating member of the UN, the U.S. is supposed to follow the 1951 Refugee Convention and 1967 Protocol. Outlined in the 1951 Refugee Convention are the rights accorded to refugees and the responsibilities of the countries providing refugee resettlement. According to Article 23 of the 1951 Convention, “The Contracting States shall accord to refugees lawfully staying in their territory the same treatment with respect to public relief and assistance as is accorded to their nationals”. While there is parity on paper, the persistent excess mental health burden experienced by refugees begs the question, “What factors are producing these inequitable mental health outcomes?”
To begin to understand why refugees are experiencing an excess mental health burden in the U.S., one may benefit from viewing this issue through an ecological lens. In The Ecological Model for Health Promotion introduced by McLeroy et al., they argue that health behavior and outcomes are determined by factors on the intrapersonal, interpersonal, institutional, community, and policy level. Factors operating at each of these levels which affect refugee mental health status include (but are not limited to) individual knowledge of the U.S. mental health care system (intrapersonal), social norms/stigma around mental health care access (interpersonal), cultural competency training in mental health clinics (institutional), geographic accessibility of clinics (community), and provisions of health insurance established by the Affordable Care Act (ACA) (policy).
Traditional and current efforts to address the mental health status of refugees have focused heavily on intrapersonal and interpersonal level factors. For example, when refugees arrive in the U.S. they participate in a “Cultural Orientation” program that is designed to introduce refugees to the culture, health system, laws, and social norms in the U.S. It has historically been argued that acculturation is a driver of poor mental health outcomes, so it can be thought that this measure would play a role in promoting the health of refugees. Efforts at destigmatizing mental health access are also commonly incorporated by refugee resettlement agencies, and refugee-centered therapy groups have also been developed. While there is evidence of the benefits of these individual-oriented programs, and refugees would certainly be worse off without them, we still see high prevalence of mental health issues among refugees, which suggests that interventions may need to be aimed at other levels/factors shaping refugee mental health outcomes.
Female Refugees and an Intersectional Approach to Mental Health
The mental health burden does not fall on all refugees equally, with female refugees facing a higher prevalence of mental health issues than male refugees. Notably this pattern is observed across cultural/ethnic groups. To gain a more nuanced understanding of this phenomenon, it is worth taking an intersectional approach. In “Mapping the Margins: Intersectionality, Identity Politics, and Violence Against Women of Color”, Kimberlé Crenshaw examines the intersection of race and gender and how it influences the way women of color experience violence. Crenshaw explains that traditional feminist and antiracist frameworks have historically focused on single issues, rather than examining the intersection of multiple issues. Crenshaw ultimately advocates that to capture the inequities that black women are facing, we need to stop looking at the dimensions of race and gender separately, and instead look at how the two interact with each other to produce the outcomes we are observing. Likewise, to appreciate why certain subpopulations of refugees are facing a higher mental health burden, it is important to understand how the various identities that refugees occupy shape their health outcomes.
An intersectional approach can help shed light on why female refugees are facing a disproportionate mental health burden. For example, looking at the social location of Afghan female refugees in the U.S. along the axes of race, gender, and immigration status, one starts to see the vulnerable position they occupy with regards to mental health. Regarding gender (and cultural gender norms), Afghan culture is traditionally more patriarchal and women often assume caregiving roles within the home. If they continue to subscribe to those roles post-migration, female refugees who are mothers find much of their time restricted to the home, as they look after children. Being restricted to the home makes it harder for refugee women to acquire English language skills, learn to navigate the community and integrate with others, so there is a greater potential for social isolation. What is more, a 2018 publication regarding refugee mental health revealed that “social isolation is a particularly salient determinant of mental health among older adults in the general population, especially among women” , which illustrates how the gender identity of refugees and their cultural gender norms can work to produce inequitable mental health outcomes.
Along the axis of race, Afghan refugees’ racial/ethnic minority status is another contributor to the disproportionate mental health burden they face. Anti-immigrant policies (such as the “Muslim Ban” and lowering of the refugee admissions cap), portrayals of refugees as a security threat, and media-fueled Islamophobia have “racialize[d] and construct[ed] immigrants as undesirable others and a threat to the nation”. Consequently, refugees from the Middle East and associated regions often face racial/ethnic discrimination, which is associated with profound health consequences. For example, a 2009 meta-analysis indicated that “increased levels of perceived discrimination are associated with more negative mental and physical health” and contribute to a heightened stress response.
Finally, immigration status can also play a critical role in shaping a person’s mental health outcomes. Already mentioned is the anti-immigrant sentiment that refugees must cope with. On a policy level, immigration status is often a dimension considered when developing social programs and refugees may face disproportionate exclusion from public benefits. Policies related to mental health care access are no exception. Refugees who qualify under the Immigration and Naturalization Act and arrive in the United States are initially eligible for Refugee Medical Assistance (RMA) - limited medical insurance which lasts for eight months post-arrival. Subsequently, refugees may see if they qualify for Medicaid, private insurance, or employer-based insurance. Real and perceived gaps in coverage when transitioning from RMA to Medicaid, private, or employer-based insurance create an economic burden on this population and encourage refugees to delay seeking care. Furthermore, inadequate primary language access - influenced by health policy - was frequently noted as a significant barrier to accessing mental health care. Taken together, it is evident that female refugees from Afghanistan occupy a more “subordinate” position in the gender, race, and immigration hierarchies that place them at risk for associated exposures (i.e., social isolation, perceived racism and anti-immigrant sentiment, inadequate access to insurance and interpretation services) which are correlated with worse mental health outcomes. Consequently, if we are to appropriately intervene on refugee mental health, it is critical to take an intersectional approach and examine the various identities refugees hold, and to design interventions that address the multitude of factors that reproduce inequitable mental health outcomes (e.g., sexism, racism, anti-immigrant sentiment, etc.).
In terms of designing future public health interventions to address the disproportionate mental health burden refugees face in the U.S., a multi-pronged approach is needed. While it may be attractive, at first glance, to say the U.S. should take the most upstream approach to addressing refugee mental health by ending its pursuit of foreign policy which drives forced migration, I am reminded of the words of Paul Farmer and colleagues. They state, “Those who argue that focusing solely on economic development will in time wipe out tuberculosis may be correct, but en route toward this utopia the body count will remain high if care is not taken to diagnose and treat the sick. The same holds true for other diseases of poverty”. That being said, in the short term, there is still a need to continue with individual-level interventions to meet the immediate mental health needs of refugees. Teaching refugees how to schedule interpreters, navigate the U.S. mental health and insurance system, and practice mindfulness are important steps to take to allow refugees to take full advantage of the existing systems/resources. However, application of an intersectional lens reveals ways in which the systems (e.g., health, economic, political) in the U.S. are broken. In addition to the individual-level interventions, we need to mobilize for systemic change. It will be important to include refugees in feminist movements, anti-racist practice, social movements, and policy solutions. For example, in the fight for Medicare for All, it is imperative that refugees are included so that they too may enjoy the promise of equitable access to health/mental health care. Finally, when considering the role of colonialism and imperialism in refugee mental health, if we want to address refugee mental health, we need to address foreign policy choices that create trauma and fuel forced migration.
The excess mental health burden among refugees in the U.S. is a pressing social justice issue. Traditional solutions have focused on individual-level interventions shaped around individuals’ “refugee identity”. Consequently, a lack of intersectionality in solution-making has forced refugees to continue to face barriers to achieving equitable mental health outcomes. Female refugees continue to face a higher mental health burden than males and refugees have a higher prevalence of mental health diagnoses compared to the U.S. general population. Therefore, to ensure refugees do not continue to face a disproportionate mental health burden, we need not only to equip refugees with the skills to navigate the complex health system but also to make policy choices that do not perpetuate trauma and fuel forced migration, that include refugees in social movements, and address the systemic barriers that prevent refugees from achieving quality mental health.
Allison Miyashiro is a student at the University of California, Berkeley who is studying to receive her Master’s in Public Health and Master’s in Social Welfare. Prior to graduate school, she worked as an intensive case manager at the International Rescue Committee in Sacramento, CA. She is interested in pursuing a career that improves access to mental health services for refugees.
Notes:  Rebecca Blackmore et al., “The Prevalence of Mental Illness in Refugees and Asylum Seekers: A Systematic Review and Meta-Analysis,” PLOS Medicine 17, no. 9 (September 21, 2020): e1003337, https://doi.org/10.1371/journal.pmed.1003337.  Ronald C. Kessler et al., “Lifetime Prevalence and Age-of-Onset Distributions of DSM-IV Disorders in the National Comorbidity Survey Replication,” Archives of General Psychiatry 62, no. 6 (June 1, 2005): 593, https://doi.org/10.1001/archpsyc.62.6.593.  Blackmore et al., “The Prevalence of Mental Illness in Refugees and Asylum Seekers.”  National Institute of Mental Health, “NIMH » Major Depression,” February 2019, https://www.nimh.nih.gov/health/statistics/major-depression.shtml.  Rita Chi-Ying Chung and Fred Bemak, “Revisiting the California Southeast Asian Mental Health Needs Assessment Data: An Examination of Refugee Ethnic and Gender Differences,” Journal of Counseling & Development 80, no. 1 (January 2002): 111–19, https://doi.org/10.1002/j.1556-6678.2002.tb00173.x; R. Srinivasa Murthy and Rashimi Lakshminaryana, “Mental Health Consequences of War: A Brief Review of Research Findings,” World Psychiatry 5, no. 1 (February 2006): 25–30; Eboni Taylor et al., “Physical and Mental Health Status of Iraqi Refugees Resettled in the United States,” Journal of Immigrant and Minority Health / Center for Minority Public Health 16, no. 6 (December 2014): 1130–37, https://doi.org/10.1007/s10903-013-9893-6.  UNHCR, “What Is a Refugee? Definition and Meaning | USA for UNHCR,” 2020, https://www.unrefugees.org/refugee-facts/what-is-a-refugee/.  U.S. Department of State, “Refugee Admissions,” United States Department of State (blog), 2020, https://www.state.gov/refugee-admissions/.  United Nations High Commissioner for Refugees, “Convention and Protocol Relating to the Status of Refugees,” UNHCR, 1951, https://www.unhcr.org/protection/basic/3b66c2aa10/convention-protocol-relating-status-refugees.html.  Kenneth R. McLeroy et al., “An Ecological Perspective on Health Promotion Programs,” Health Education Quarterly 15, no. 4 (December 1988): 351–77, https://doi.org/10.1177/109019818801500401.  Chung and Bemak, “Revisiting the California Southeast Asian Mental Health Needs Assessment Data”; Murthy and Lakshminaryana, “Mental Health Consequences of War”; Taylor et al., “Physical and Mental Health Status of Iraqi Refugees Resettled in the United States.”  Murthy and Lakshminaryana, “Mental Health Consequences of War.”  Kimberle Crenshaw, “Mapping the Margins: Intersectionality, Identity Politics, and Violence against Women of Color,” Stanford Law Review 43, no. 6 (July 1991): 1241, https://doi.org/10.2307/1229039.  Culture Atlas, “Afghan Culture - Family,” Cultural Atlas, 2020, http://culturalatlas.sbs.com.au/afghan-culture/afghan-culture-family.  Michaela Hynie, “The Social Determinants of Refugee Mental Health in the Post-Migration Context: A Critical Review,” Canadian Journal of Psychiatry. Revue Canadienne de Psychiatrie 63, no. 5 (May 2018): 297–303, https://doi.org/10.1177/0706743717746666.  Edna A. Viruell-Fuentes, Patricia Y. Miranda, and Sawsan Abdulrahim, “More than Culture: Structural Racism, Intersectionality Theory, and Immigrant Health,” Social Science & Medicine 75, no. 12 (December 2012): 2099–2106, https://doi.org/10.1016/j.socscimed.2011.12.037.  Elizabeth A. Pascoe and Laura Smart Richman, “Perceived Discrimination and Health: A Meta-Analytic Review,” Psychological Bulletin 135, no. 4 (July 2009): 531–54, https://doi.org/10.1037/a0016059.  DHCS, “MEDI-CAL ELIGIBILITY PROCEDURES MANUAL LETTER NO.: 285. DHCS” (Department of Health Care Services, October 14, 2003), https://www.dhcs.ca.gov/services/medi-cal/eligibility/Documents/c285.pdf.  Hamutal Bernstein et al., “Amid Confusion over the Public Charge Rule, Immigrant Families Continued Avoiding Public Benefits in 2019,” May 2020, https://www.urban.org/sites/default/files/publication/102221/amid-confusion-over-the-public-charge-rule-immigrant-families-continued-avoiding-public-benefits-in-2019_3.pdf; Holly Straut-Eppsteiner, “Documenting Harm Caused by the Department of Homeland Security’s Public Charge Rule,” National Immigration Law Center (blog), February 2019, https://www.nilc.org/issues/economic-support/documenting-harm-caused-by-the-department-of-homeland-securitys-public-charge-rule/.  Taylor et al., “Physical and Mental Health Status of Iraqi Refugees Resettled in the United States”; Eunice C. Wong et al., “Barriers to Mental Health Care Utilization for U.S. Cambodian Refugees.,” Journal of Consulting and Clinical Psychology 74, no. 6 (2006): 1116–20, https://doi.org/10.1037/0022-006X.74.6.1116.  Paul E Farmer et al., “Structural Violence and Clinical Medicine,” PLoS Medicine 3, no. 10 (October 24, 2006): e449, https://doi.org/10.1371/journal.pmed.0030449.
Bernstein, Hamutal, Dulce Gonzalez, Michael Karpman, and Stephen Zuckerman. “Amid Confusion over the Public Charge Rule, Immigrant Families Continued Avoiding Public Benefits in 2019,” May 2020. https://www.urban.org/sites/default/files/publication/102221/amid-confusion-over-the-public-charge-rule-immigrant-families-continued-avoiding-public-benefits-in-2019_3.pdf.
Blackmore, Rebecca, Jacqueline A. Boyle, Mina Fazel, Sanjeeva Ranasinha, Kylie M. Gray, Grace Fitzgerald, Marie Misso, and Melanie Gibson-Helm. “The Prevalence of Mental Illness in Refugees and Asylum Seekers: A Systematic Review and Meta-Analysis.” PLOS Medicine 17, no. 9 (September 21, 2020): e1003337. https://doi.org/10.1371/journal.pmed.1003337.
Chung, Rita Chi-Ying, and Fred Bemak. “Revisiting the California Southeast Asian Mental Health Needs Assessment Data: An Examination of Refugee Ethnic and Gender Differences.” Journal of Counseling & Development 80, no. 1 (January 2002): 111–19. https://doi.org/10.1002/j.1556-6678.2002.tb00173.x.
Crenshaw, Kimberle. “Mapping the Margins: Intersectionality, Identity Politics, and Violence against Women of Color.” Stanford Law Review 43, no. 6 (July 1991): 1241. https://doi.org/10.2307/1229039.
Culture Atlas. “Afghan Culture - Family.” Cultural Atlas, 2020. http://culturalatlas.sbs.com.au/afghan-culture/afghan-culture-family.
DHCS. “MEDI-CAL ELIGIBILITY PROCEDURES MANUAL LETTER NO.: 285. DHCS.” Department of Health Care Services, October 14, 2003. https://www.dhcs.ca.gov/services/medi-cal/eligibility/Documents/c285.pdf.
Farmer, Paul E, Bruce Nizeye, Sara Stulac, and Salmaan Keshavjee. “Structural Violence and Clinical Medicine.” PLoS Medicine 3, no. 10 (October 24, 2006): e449. https://doi.org/10.1371/journal.pmed.0030449.
Hynie, Michaela. “The Social Determinants of Refugee Mental Health in the Post-Migration Context: A Critical Review.” Canadian Journal of Psychiatry. Revue Canadienne de Psychiatrie 63, no. 5 (May 2018): 297–303. https://doi.org/10.1177/0706743717746666.
Kessler, Ronald C., Patricia Berglund, Olga Demler, Robert Jin, Kathleen R. Merikangas, and Ellen E. Walters. “Lifetime Prevalence and Age-of-Onset Distributions of DSM-IV Disorders in the National Comorbidity Survey Replication.” Archives of General Psychiatry 62, no. 6 (June 1, 2005): 593. https://doi.org/10.1001/archpsyc.62.6.593.
McLeroy, Kenneth R., Daniel Bibeau, Allan Steckler, and Karen Glanz. “An Ecological Perspective on Health Promotion Programs.” Health Education Quarterly 15, no. 4 (December 1988): 351–77. https://doi.org/10.1177/109019818801500401.
Murthy, R. Srinivasa, and Rashimi Lakshminaryana. “Mental Health Consequences of War: A Brief Review of Research Findings.” World Psychiatry 5, no. 1 (February 2006): 25–30.
National Institute of Mental Health. “NIMH » Major Depression,” February 2019. https://www.nimh.nih.gov/health/statistics/major-depression.shtml.
Pascoe, Elizabeth A., and Laura Smart Richman. “Perceived Discrimination and Health: A Meta-Analytic Review.” Psychological Bulletin 135, no. 4 (July 2009): 531–54. https://doi.org/10.1037/a0016059.
Straut-Eppsteiner, Holly. “Documenting Harm Caused by the Department of Homeland Security’s Public Charge Rule.” National Immigration Law Center (blog), February 2019. https://www.nilc.org/issues/economic-support/documenting-harm-caused-by-the-department-of-homeland-securitys-public-charge-rule/.
Taylor, Eboni, Emad Yanni, Michael Guterbock, Clelia Pezzi, Erin Rothney, Elizabeth Harton, Jessica Montour, Collin Elias, and Heather Burke. “Physical and Mental Health Status of Iraqi Refugees Resettled in the United States.” Journal of Immigrant and Minority Health / Center for Minority Public Health 16, no. 6 (December 2014): 1130–37. https://doi.org/10.1007/s10903-013-9893-6.
UNHCR. “What Is a Refugee? Definition and Meaning | USA for UNHCR,” 2020. https://www.unrefugees.org/refugee-facts/what-is-a-refugee/.
United Nations High Commissioner for Refugees. “Convention and Protocol Relating to the Status of Refugees.” UNHCR, 1951. https://www.unhcr.org/protection/basic/3b66c2aa10/convention-protocol-relating-status-refugees.html.
U.S. Department of State. “Refugee Admissions.” United States Department of State (blog), 2020. https://www.state.gov/refugee-admissions/.
Viruell-Fuentes, Edna A., Patricia Y. Miranda, and Sawsan Abdulrahim. “More than Culture: Structural Racism, Intersectionality Theory, and Immigrant Health.” Social Science & Medicine 75, no. 12 (December 2012): 2099–2106. https://doi.org/10.1016/j.socscimed.2011.12.037.
Wong, Eunice C., Grant N. Marshall, Terry L. Schell, Marc N. Elliott, Katrin Hambarsoomians, Chi-Ah Chun, and S. Megan Berthold. “Barriers to Mental Health Care Utilization for U.S. Cambodian Refugees.” Journal of Consulting and Clinical Psychology 74, no. 6 (2006): 1116–20. https://doi.org/10.1037/0022-006X.74.6.1116.