International migratory flows have increased worldwide in recent decades. Current estimates suggest that there are 244 million international migrants globally.1 Most people migrate to countries in the Global North A, aiming for job opportunities. However, there is some migration among countries in the Global South,2 called South-South migration. This trend reflects the restrictions imposed by Northern countries on the 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 distinguish between immigrants, refugees and asylum seekers because of different legal definitions and backgrounds. Immigrants, in general, are people who choose 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 refugee status but are still waiting for the outcome of their application. The number of people undergoing forced displacement has increased in recent 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% compared to the data reported in 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 and 2018, there were 3,904 refugees and 11,231 refugees, respectively, in Brazil.8,9 The number of asylum seekers also increased dramatically – from 966 new requests in 2010 to 33,866 in 2017 and 80,057 in 2018. 8,9 By the end of 2018, the majority of refugees in Brazil were from Syria (36%), followed by the Democratic Republic of Congo (DRC) (15%).9 The most common nationality of asylum seekers has been changing every year: in 2010, the majority of asylum seekers were Colombians; in 2013 and 2014, they were Haitians; and in 2017 and 2018, they were Venezuelans.8,9,10 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 severe violation of human rights.11 Any foreigner can apply for refugee status in Brazil. This request is directed to the Brazilian Committee for Refugees (CONARE) to be evaluated. An interview at CONARE is scheduled to evaluate the asylum seeker’s story and determine whether the person will be granted refuge or not. At the moment, this interview takes approximately 2 years to be scheduled. In the meantime, the person is allowed to have a social security number and work permit in Brazil. The majority of refugees and asylum seekers are located in the state of São Paulo.12 As of 2016, there were 2,582 refugees in the state of São Paulo, and 75.6% lived in the city of São Paulo, 13 which is the richest and largest city in Brazil, with many job opportunities and a high level of industrialization.
There are public shelters in the city of São Paulo that are specific for immigrants and refugees, but one cannot stay in most places for more than 3 months. Shelters for the Brazilian homeless population in São Paulo can also be used by immigrants and refugees, also with a limited time of stay. When public shelters are not available (or someone did not adapt to them, or they had to leave), other forms of temporary housing are churches or mosques that allow migrants to sleep in their common areas. It is expected that migrants start working as soon as possible and support themselves integrally. Most jobs have low pay and require a low educational level.
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.14 An uncertain visa status and a prolonged asylum procedure are associated with a higher prevalence of mental disorders and more severe symptoms. 15,16,17
Differences in mental health status between immigrants and refugees have been examined. Some studies support that refugees have higher rates of depressive disorders and post-traumatic stress disorder (PTSD) than non-refugees 18,19,20 and poorer mental health in general.21 Exposure to traumatic events can also be higher for refugees than for immigrants, which is associated with higher rates of PTSD. 22,23
Immigrants usually have lower rates of common mental disorders than locals at arrival; however, over time, their rates become similar to the local population.24 However, for psychotic disorders there is a wide rage of literature describing higher rates among immigrants compared to the local population. Studies are mostly from Global North countries 25, in which locals are mostly White. Ethnicity is taken into account, since minority ethnic groups present higher incidence of psychotic disorders than locals (1.5-3.0 times) 25 and differences are described between different ethnic groups. For instance, in the UK, compared to the local population, psychosis risk is 1.5 times higher for White migrants, while for Pakistani and Bangladeshi people have 2-4 times increased risk and for Black Caribbean and African groups the risk is 10 times higher. 26
Understanding gender differences in migrants’ and refugees’ mental health is an emerging and crucial task. Refugee and asylum-seeking women are more prone to gender-based violence.27 Moreover, higher prevalences of mental disorders, particularly depression and PTSD, are reported in women. 28,29 Additionally, women who are refugees or asylum seekers have higher rates of these disorders than non-refugees. 30,31,32
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.
In Brazil, access to healthcare is universal and free of charge, including for immigrants and refugees.33 In addition to universality of coverage, the principles of the national healthcare system (Sistema Único de Saúde - SUS) include equity and integrality of care, which is meant to be organized by territorial distribution and on primary, secondary and tertiary care facilities. Hence, immigrants and refugees are supposed to access the same general and mental health services offered to the population. However, international migrants face specific barriers for accessing health services, such as language, lack of information and other structural barriers, which justifies directed policies and implementation of specialized secondary and tertiary services. 34
In 1997, an outpatient psychiatric service for immigrants, refugees and asylum seekers was created as part of the Brazilian public health SUS system. 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 developed based on participatory action research through a community – campus 35 partnership between the Institute of Psychiatry of Universidade de Sao Paulo and the Caritas Refugee Reference Center (CRRC), a program linked to Caritas, which is 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 tertiary service specialized in immigrant and refugee psychiatric care in the country.
Given the uniqueness of the ProSol service, we aim to present the profile of all patients who used the service between 2003 and 2018. In fact, quite a few studies describe the profile of immigrants and refugees attending psychiatric specialized care, but the existing literature comes primarily from Global North countries.36,37 Moreover, we aim to discuss the challenges and possibilities of service planning and organization policies for delivering psychiatric care to immigrants and refugees in a highly complex and specialized context. 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 and policies and, ultimately, implementing services specialized in immigrants’ and refugees’ mental healthcare in the Global South.