Mental health implications of detaining asylum seekers: systematic review

Authors:
ROBJANT Katy, HASSAN Rita, KATONA Cornelius
Journal article citation:
British Journal of Psychiatry, 194(4), April 2009, pp.306-312.
Publisher:
Cambridge University Press

The number of asylum seekers, refugees and internally displaced people worldwide is rising. Western countries are using increasingly restrictive policies, including the detention of asylum seekers, and there is concern that this is harmful. In order to investigate mental health outcomes among adult, child and adolescent immigration detainees a systematic review was conducted through a systematic search of databases and a supplementary manual search of references. Ten studies were identified. All reported high levels of mental health problems in detainees. Anxiety, depression and post-traumatic stress disorder were commonly reported, as were self-harm and suicidal ideation. Time in detention was positively associated with severity of distress. There is evidence for an initial improvement in mental health occurring subsequent to release, although longitudinal results have shown that the negative impact of detention persists. This area of research is in its infancy and studies are limited by methodological constraints. Findings consistently report high levels of mental health problems among detainees. There is some evidence to suggest an independent adverse effect of detention on mental health.

Extended abstract:
Author

ROBJANT Katy; HASSAN Rita; KATONA Cornelius;

Mental health implications of detaining asylum seekers: systematic review.

Journal citation/publication details

British Journal of Psychiatry, 194(4), April 2009, pp.306-312.

Summary

The ten Australian, UK and US studies reviewed are of mixed, and generally rather poor, methodological quality. However, they deliver a consistent picture of high levels of mental distress among detainees and their families, with problems increasing in severity with the length of time spent in detention. Although there may be an initial improvement on release, this may not persist, especially if immigration status remains uncertain.

Context

The number of asylum seekers has been rising, and Western countries have increasingly attempted to reduce the numbers seeking residency through ‘policies of deterrence’ that include detaining them while their claims are processed, and providing time-limited protection. Asylum seekers, who have often experienced traumatic events in their own countries, are thus likely to be at heightened risk of mental health problems. The aim of this review is to explore whether there is an association between detention and the increased prevalence and severity of mental health problems.

Methods

What sources were used?

The following databases were searched to April 2007: PILOTS (An Electronic Index to the Traumatic Stress Literature); PsycINFO; PubCentral; and PubMed. The reference lists of relevant studies were also checked.

 

What search terms/strategies were used?

The search terms were: asylum; detention; depression; anxiety; PTSD.

 

What criteria were used to decide on which studies to include?

Eligible studies used qualitative or quantitative methods to examined mental health in children, adolescents or adults who were detained, or had been detained, in immigration detention ort removal centres in Australia, the UK or USA. ‘Qualitative studies that described consecutive case series of more than two cases were included.’ Single case studies, commentaries, letters, studies conducted in other countries, and reviews were excluded although relevant references cited by these publications were included.

 

Who decided on their relevance and quality?

The searches were carried out by the lead author and yielded 49 studies that met the inclusion criteria. Screening was carried out by more than one author, with disagreements resolved by discussion, but whether the process was conducted independently by the individuals is not reported.

 

How many studies were included and where were they from?

Ten studies were reviewed, with summary details of study design, measures, results and findings given in an online data supplement available to subscribers to the British Journal of Psychiatry. Six were conducted in Australia, three in the UK and one in the USA.

 

How were the study findings combined?

The review is descriptive, with case series and quantitative studies considered separately.

Findings of the review

Case series

Two UK and one Australian study provide case series evidence. The UK studies, carried out 15 years apart, ‘both describe manifest psychological or psychiatric difficulties experienced by detainees with whom the authors had worked.’ The first was conducted with victims of torture and the second with 56 consecutive patients who were either in detention or recently released. A participant-observer study in an Australian immigration centre (in which one of the authors, an Iraqi doctor, was a detainee) also reported high levels of mental health problems, and suggest that these increase through stages ‘triggered by negative outcomes or asylum decisions’.

 

Although these studies provide clear documentary evidence, the participants may not be representative of the detainee population as a whole and the association between poor mental health and detention ‘is confounded by high rates of previous trauma exposure’. However, the high rates of disorder compared with those reported in the general refugee literature, and the fact that symptoms appear to get worse with increasing time in detention, do suggest ‘an independent or confounding role for the detention process.’

 

Systematic studies

Two quantitative studies based in Australia reported univariate and multivariate analyses of data collected using measures specifically developed for use with detainees, as well as others that have been widely employed in refugee research. The findings indicate that ‘the combination of the detention experience and continued immigration status uncertainty following release is particularly harmful to mental health.’

 

A UK longitudinal study examined rates of depression, anxiety and post traumatic stress disorder (PTSD) in detained asylum seekers, and compared them with rates about 100 days later, by which time some had been released. As in the Australian studies, time in detention was directly related to symptom severity, and clinically significant rates of depression, anxiety and PTSD were found in 86%, 77% and 50% of the sample respectively. A second UK study, the first to examine the impact of detention, used focus groups and in-depth interviews with 15 former detainees. It identified various specific difficulties associated with the detention system, including the fact that it does not allow the use of normal coping skills and ‘constitutes a meaningless environment’ in which boredom, frustration and hopelessness are widespread. Sixty percent of this sample were diagnosed with depression and 27% with PTSD.

 

Impact on children, adolescents and families

Three Australian studies looked at children and families. One identified a range of problems including separation anxiety, disruptive conduct, bed-wetting, sleep disturbances, impaired cognitive development and, in some cases, severe reactions such as mutism and refusal to eat or drink. However, the reliability of the data in this study are described as severely limited.

 

A second study looked at ten consecutive family referrals from a detention centre to a child and adolescent mental health service. All children had at least one parent with a mental health problem (with self-harm occurring in nearly a third) although only two adults reported difficulties prior to arrival. Developmental delays, emotional and behavioural problems, and attachment problems were ‘common’ in children under five, and there were ‘extensive’ mental health problems among the ten older children and adolescents (for example, all met the clinical criteria for PTSD, and eight had self-harmed). After treatment, the five families that remained in detention had not improved, and the five that had been released had not maintained initial improvements experienced on release. Again the data are of limited reliability.

 

The final study was based on the administration of semi-structured interviews via the telephone and was thus of better methodological quality. However, the data collected through interviews were compared with self-reports of how things had been prior to detention, and these could have been subject to recall bias. The study covered ten families from a single ethnic group who had been detained for at least two years. All adults had experienced traumatic events prior to leaving their home countries, and the prevalence of psychiatric problems had increased markedly since detention: all adults had major depressive disorder; 86% had PTSD; and 93% experienced persistent suicidal ideation. A tenfold increase in psychiatric difficulties was found among children.

Authors' conclusions

‘Findings from these studies consistently support an association between the experience of immigration detention practices and poor mental health.’ High levels of emotional distress and, among children, developmental delays and behavioural problems, were common. The findings relate in part to pre-detention trauma experiences, but detention itself appears to exercise an independent effect. Research in this field is difficult for a range of methodological and ethical reasons, and because of linguistic, cultural and literacy barriers to communication with asylum seekers. However, the severity of mental health problems suggested by the reviewed studies means that further research is imperative.

Implications for policy or practice

None are discussed beyond the general observation that research into this area must not be hampered by ‘concerns over political implications’.

Subject terms:
mental health problems, asylum seekers, anxiety, custodial institutions, depression;
Content type:
systematic review
Location(s):
Australia, United Kingdom, United States
Links:
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Journal home page
ISSN online:
1472-1465
ISSN print:
0007-1250

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