The aim of this study was to estimate the differences in prevalence of mental illness between asylum seekers and refugees, including both quota and other refugees. We found quota and other refugees to be at 40% lower risk of mental health illness compared to asylum seekers, confirming our hypothesis. We also assessed whether gender, age, gross national income per capita in the country of origin, or by probability of being granted asylum could explain the differences in mental health among the groups. Our hypothesis was not fully confirmed. Although these variables partly influenced the prevalence of mental illness, they did not explain the prevalence in a consistent way.
Our results depict that asylum seekers have a specifically high likelihood of mental illness compared to other refugees such as quota and those coming under other prerequisites. Previous studies have shown that asylum seekers are at increased risk of developing mental illnesses, but these studies have often compared with migrants who have been in the country for a longer period, and as a result, potentially made the comparison possibly biased [2, 11, 26]. The increased risk for asylum seekers found in our study could be partly explained by their uncertain residence status and uncertainty regarding their asylum application [27–30]. Asylum seekers are confronted with more unfavorable circumstances when it comes to, for instance, housing opportunities, health care education and working conditions, compared to those who have been granted residence permit. Legal status has shown to be a significant predictor of poor mental health, even when controlling for pre-and post-migration factors such as traumatic events, post migration resources and social desirability [11, 30]. Remarkably, severe levels of mental illness were more commonly reported than mild and moderate levels of mental illness, for both groups, 52,9% and 35,7% respectively, indicating higher intensity of symptoms.
Our finding also corroborates previous literature on the differences in risk of mental illness by country or region of origin. Regional differences in both reported mental illness, experienced traumatic events and use of psychiatric care have been found [10, 31–33]. A recent Finish study found asylum seekers from Africa (excluding North Africa) reported traumatic events more frequently than asylum seekers from other regions [31]. Moreover, refugees from Syria, Iraq, and Afghanistan were most likely to exhibit a positive screening for mental health symptoms compared to refugees from other countries such as Somalia, Myanmar and D.R. Congo [32]. Various hypotheses have been postulated to explain this, including socioeconomic factors, cultural differences, differences in social support and coping style, discrimination, and varying vulnerabilities among different subgroups [15, 32, 34].
Our study expands on prior research examining differences by gender and age, with women reporting higher odds for mental illness, compared to men. Both female gender and older age have been linked with poorer psychological health in refugees, though there are some studies that demonstrate no effect of gender on outcomes [8, 32, 34–36]. It has been suggested that the gender differences in mental health are linked to roles and social positions, where women are limited in their role and lack of choice. Literature has been devoted to explaining the gender gap as a result of exposure to trauma and lack of self-control. Indeed, the broader social determinants of health associated with restricted economic opportunities, insecure housing, location of residence and migration status can have a profound influence on one’s sense of control [34, 36, 37]. It could also be that women may be at higher risk due to increased sexual victimization and domestic violence. Considering age, our results are consistent with past work, inciting greater vulnerability in older people. This could be due to greater accommodation of traumas over time [15, 32] for older people, or younger refugees being less affected by the enduring stresses of displacement.
Determination of illness severity could have important clinical implications when it comes to, for example treatment strategies or prioritizing care when resources are scares. Considering this aspect may be useful in planning public health interventions targeting this vulnerable group. Furthermore, our findings could be applicable to individuals without legal document/status (former asylum seekers who have been rejected asylum/or others without legal status) as these individuals are often confronted with similar challenges and have same health care entitlements as asylum seekers.
Limitations And Strengths
The study has many strengths: first, data is generated through a validated screening instrument specifically developed for refugee populations. Although the study was conducted only in one region in Sweden, it was conducted in two primary healthcare centers that together executes a high number of HE in Stockholm, in addition to including both asylum seekers and other refugees, leading to increasing the generalizability of the findings. Both asylum seekers and other refugees are represented in our study, giving the study a good representation in terms of migrants. Data was collected with the help of health care professionals working in the centers and there was no need for outreach methods, which minimizes the risk of bias or misunderstanding of the data.
While this study provides important information on differences in mental illness by legal status there are several limitations. We had no information on risk and resilience factors related to participants’ mental health such as trauma experiences, length of stay in Sweden, educational level and other known determinants of mental health. Another limitation is possible selection bias as the RHS-13 screening was part of a voluntary HE and those opting out of HE might have different mental health profiles. In addition, we do not have information about the few who took part in an HE but declined screening with the RHS-13. It could be that their mental health profiles too were different from those that accepted screening.