International migratory flows have increased worldwide in the last decades. Current estimates suggest that there are 244 million international migrants globally.1 Most people migrate to countries from the Global North A aiming for job opportunities. However, there is an extent of migration among countries from the Global South,2 called South-South migration. This trend reflects the restrictions imposed by Northern countries on entrance and permanence of immigrants in their territories and economic issues. In 2015, there were 90·2 million South-born immigrants living in another Southern country, while in the Global North, there were 85·3 million South-born immigrants.3
In migratory studies it is important to make the distinction between immigrants, refugees and asylum seekers, because of different legal definitions and background. Immigrants, in general, are people who chose to migrate, usually for economic reasons. Refugees, on the other hand, fall under the category of forced displacement, since they leave their countries because of persecution and life threatening situations. Asylum seekers are people who have applied for the refugee status but are still waiting for the outcome of their application. Forced displacement reached high marks in the last years. According to the United Nations High Commissioner for Refugees (UNHCR), 70·8 million people were displaced by the end of 2018. Of these, 13·6 million people became displaced just during 2018.4
As part of the South-South migration trend, immigration has also increased in Brazil. According to the 2010 national Census, the number of immigrants increased 53% when compared to the 2000 Census.5 The number of new entrances has also increased there were 59,442 new registrations in 2010 6 and 117,745 in 2015.7
The number of refugees and asylum seekers in Brazil is also on the rise. In 2010, there were 3,904 refugees and 10,145 in 2017 in Brazil.8 The number of asylum seekers also increased dramatically: from 966 new requests in 2010 to 33,866 in 2017. Today, the majority of refugees in Brazil are from Syria (39%), followed by people from the Democratic Republic of Congo (DRC) (13%).8,9 When considering asylum seekers, main nationalities have been changing every year: in 2010 the majority of asylum seekers were from Colombians, in 2013 and 2014, were Haitians; and in 2017, Venezuelans.8,10 In Brazil, a person is considered a refugee when they are being persecuted due to their religion, nationality, ethnicity, political opinion, membership to a particular social group, or due to severe violation of human rights.11 Any foreigner can apply for refugee status in Brazil, but application outcomes usually take a few years to be made.9 It is noteworthy that refugees and asylum seekers are allowed to have a social security number and work permit in Brazil.
The main destinations for immigrants arriving in Brazil are the Southern and Southeastern states. A higher level of industrialization and job opportunities might help explain the preference for Southern instead of Northern states in Brazil. Refugees and asylum seekers are concentrated mainly in the state of São Paulo9. Being the richest city in Brazil, Sao Paulo has more job opportunities and better infrastructure than other Brazilian cities.
Immigrants and refugees are a vulnerable group. Many stressors can be identified in different stages of migration. Once in a new country, they can be confronted with differences such as language and culture. They also have to deal with losses of significant relationships and social support networks. Some immigrants also face difficulties with documents and paper work, and experience discrimination and social exclusion.12
This population is exposed to situations of high psychological distress, which can be related to the development of mental illnesses. Refugees who have been exposed to violence, for instance, often have higher rates of mental disorders. Immigrants usually have lower rates of common mental disorders than locals at arrival. Nevertheless, over time, their rates become similar to the local population.13
Though widely discussed in Europe and North America, immigrant and refugee health is a field of very recent development in Brazil, with few publications and expertise. So far, there are no official programs or estabilished training for mental health professionals focusing on these issues.
In Brazil, the access to healthcare is universal and free of charge, also for immigrants and refugees14. However, international migrants face specific barriers for accessing care, such as language, lack of information and structural barriers15, which justifies directed policies and implementation of specialized services.
In 1997, an outpatient psychiatric service for immigrants, refugees and asylum seekers was created as part of a service of the universal health system (Sistema Único de Saúde – SUS). The aim of the service was to facilitate access to mental health care and provide long-term care for immigrants, refugees, and asylum seekers in Sao Paulo. The service called Programa de Psiquiatria Social e Cultural (ProSol) was created through a partnership between Institute of Psychiatry of Universidade de Sao Paulo (IPq-HCFMUSP) with the Caritas Refugee Reference Center (CRRC), a program linked to Caritas, an international Catholic non-governmental organization (NGO) of humanitarian help. The CRRC provides legal, documentational and social aid, orientations, referrals and psychological support for immigrants, refugees, and asylum seekers. The São Paulo State Secretary of Health supported the creation of the project. To date, ProSol is the only service specialized in immigrant and refugees mental health in the country.
In this study, we aim to present the profile of all patients attended between 2003 and 2018 in the ProSol. There are very few studies regarding the profile of immigrants and refugees attending psychiatric specialized care, and the existing literature comes primarily from Global North countries.16,17 Moreover, we will discuss the challenges and possibilities of service planning and organization. As ProSol is the only psychiatric reference center for refugees and immigrants in Brazil, the characterization of this specific population can be useful for planning future research, polices and, ultimately, implementing services specialized on immigrants and refugees’ mental healthcare.