Psychological distress among refugees in Germany: a cross-sectional analysis of individual and contextual risk factors and potential consequences for integration using a nationally representative survey

Abstract

ObjectivesResponding to the mental health needs of refugees remains a pressing challenge worldwide. We estimated the prevalence of psychological distress in a large refugee population in Germany and assessed its association with host country factors amenable to policy intervention and integration indicators.DesignA cross-sectional and population-based secondary analysis of the 2017 wave of the IAB-BAMF-SOEP refugee survey.SettingGermany.Participants2639 adult refugees who arrived in Germany between 2013 and 2016.Main outcome measuresPsychological distress involving symptoms of depression, anxiety and post-traumatic stress disorder was measured using the Refugee Health Screener-13.ResultsAlmost half of the population surveyed (41.2% (95% CI: 37.9% to 44.6%)) was affected by mild, moderate or severe levels of psychological distress. 10.9% (8.4% to 13.5%) of the population screened positive for severe distress indicative of an urgent need for care. Prevalence of distress was particularly high for females (53.0% (47.2% to 58.8%)), older refugees (aged ≥55, 70.4% (58.5% to 82.2%)) and Afghans (61.5% (53.5% to 69.5%)). Individuals under threat of deportation were at a greater risk of distress than protection status holder (risk ratio: 1.55 (95% CI: 1.14 to 2.10)), single males at a greater risk than males with nuclear families living in Germany (1.34 (1.04 to 1.74)) and those in refugee housing facilities at a greater risk than those in private housing (1.21 (1.02 to 1.43)). Distressed males had a lower likelihood of employment (0.67 (0.52 to 0.86)) and reduced participation in integration courses (0.90 (0.81 to 0.99)). A trend of reduced participation in educational programmes was observed in affected females (0.42 (0.17 to 1.01)).ConclusionThe finding that a substantial minority of refugees in Germany exhibits symptoms of distress calls for an expansion of mental health services for this population. Service providers and policy-makers should consider the increased prevalence among female, older and Afghan refugees, as well as among single males, residents in housing facilities and those under threat of deportation. The associations between mental health and integration processes such as labour market, educational programme and integration course participation also warrant consideration.

A Systematic Review of Factors Affecting Mental Health and Well-Being of Asylum Seekers and Refugees in Germany

“…The uncertain legal status of a subsidiary protection or a temporary suspension from deportation, both residence permits for 1 year, was significantly associated with report of psychological distress compared to participants with a granted residence status, with males reporting greater psychological distress (58,59). Compared to a subsidiary protection, a temporary suspension from deportation was also associated with lower mental HrQoL (56).…”

“…El Khoury (52) used the 18-item version of the Mental Health Inventory [MHI; (67)] to evaluate the psychological experiences of participants within the past 4 weeks. On the depression subscale of the MHI-18, where higher scores from a total score of 0 to 100 indicate better mental health, females showed a depression mean score of 14.47 (SD = 4.84) (59). In the study by Walther et al (58), participants reported a mean value of 3.14 on the Patient Health Questionnaire for Depression and Anxiety [PHQ-4; (79)], indicating mild psychological distress on average in the past 2 weeks which was higher than the mean score of 1.76 previously determined as the rate for the general German population (80).…”

“…Seventeen different instruments were used in these studies. In six studies, questionnaires were completed by participants (self-report) (50,52,53,55,61,62), while the studies by Comtesse and Rosner (54) and Kaltenbach et al (60) used semi-structured clinical interviews, and five studies conducted computer-assisted face-to-face interviews (51,(56)(57)(58)(59). All instruments used in the studies and their validity are presented in Supplementary Table A3.…”

“…Similarly, prevalence rates of mental health symptoms might have been underestimated. The sampling procedure in the IAB-BAMF-SOEP survey, whose data was used in three studies, might have resulted in a high risk of selection bias in favor of participants with higher levels of mental health and well-being, as is generally expected in population-based surveys (57)(58)(59). In two studies, subjects with more severe mental health symptoms were even completely excluded from study participation (50,60).…”

“…In addition, the results might have been biased by an unequal distribution of a variable within the study sample, such as a larger number of study participants residing in refugee establishments (52). All studies identified confounding factors such as gender, age or country of origin, but only five stated strategies to deal with these (52,(57)(58)(59)61) and thus confounding biases could affect the results of the remaining eight studies. In general, all studies used validated instruments to assess psychological symptoms and appropriate statistical methods to determine outcomes.…”