This is one of the first studies to not only assess levels of distress in asylum seekers, but also to screen for psychiatric disorders, while at the same time addressing possible influences of length of stay, premigration trauma and postmigration factors. To our knowledge, it is the first study to restrict itself to the first two years of the asylum procedure.
The present results show high overall levels of psychiatric morbidity in our samples of asylum seekers, with Major Depression and PTSD being diagnosed most frequently, followed by Pain Disorder and other anxiety disorders. None of the assessed postmigratory factors correlated with psychiatric morbidity; nor did time since arrival in Switzerland. For both samples, the number of trauma types experienced premigration was highly correlated with PTSD and overall psychiatric morbidity.
Results suggest that traumatic events experienced pre- and perimigration strongly influence mental health after arrival in the host country. The social situation seems to neither buffer nor enhance symptoms in this first postmigration period.
The results on mental health in the current sample of asylum seekers are well in line with those of previous studies reporting severe mental distress and high psychiatric morbidity in asylum seekers [3
]. As expected, PTSD rates were lower than in massevacuated victims of war [9
]. We found comparably higher PTSD rates with a longer duration of stay, but this difference did not show in other psychiatric disorders.
The negative influence of postmigratory living problems on mental health found in previous studies looking at longer time spans since arrival [7
] was not found in this study. Instead, traumatic events showed to be associated with psychiatric morbidity. Trauma has been consistently confirmed as a risk factor for refugee mental health [6
], especially in the first period after resettlement.
The main strength of the present study lies in its sampling: we were able to follow the lead of previous studies [7
] by ensuring the assessment of a random sample from the national register of asylum seekers without excluding those who are socially isolated or do not utilize support services. Since the register includes all persons who seek asylum in Switzerland, we were certain of considering the total population of asylum seekers when drawing our samples. Second, we used structured clinical interviews to assess psychiatric morbidity. This approach allowed face-to-face screening of the sixteen most common DSM-IV-TR psychiatric disorders. The use of this instrument reduced the risk of overestimation of symptom prevalence, as has been observed with self-report instruments [23
]. With the assistance of trained interpreters, we were able to resolve any misunderstandings in the questionnaire items. Finally, the demographics of the sample add to the validity of the study: By including asylum seekers of all origins, we ensured that the results were not affected by regional conflict severity or by culture-specific coping styles.
The main limitation of this study lies in its cross-sectional design, which only allows for limited conclusions to be drawn on the course of mental health over time. Comparability of samples was further limited by differences between samples in terms of sociodemographic and postmigration characteristics. Since the presented assessment was conceived as a pilot study for a future large-scale longitudinal study of asylum seekers’ mental health, participants had to be recruited consecutively and could not be matched by age or region of origin. As shown in the analyses, none of the variables with group differences were associated with mental health outcomes, which led us to assume comparability of samples concerning traumatic stress and psychiatric outcomes.
Further limitations relate to the assessment of the participants’ situation in exile. First, our assessment of postmigratory factors was not exhaustive. It included mostly social factors, leaving out factors such as distress caused by immigration office interviews or the ability to cope with postmigration stress. It is therefore unclear whether a more complete set of characteristics of the postmigratory situation may have been shown to interact with mental health on a significant level. Also, we don’t know whether conditions for asylum seekers are more or less supportive in Switzerland relative to other countries. Therefore, we cannot make any inferences regarding the specific impact of the post-migration stress factor in Switzerland. It is possible that conditions in the country of asylum can make a significant difference to the overall impact of post-migration uncertainties about a person’s refugee status. This issue will require further research, using an international, multi-site approach. Second, previous studies show that there are protective factors such as coping mechanisms or security [e.g. [24
]. Due to the extensive screening of psychiatric disorders, we did not have the timely capacity to assess the whole scope of these postmigration factors. We chose to limit ourselves to the assessment of adaption in the host country, knowingly leaving out important items on resources and coping mechanisms. The beneficial effect of employment also could not be examined, because asylum seekers at this stage in the procedure generally do not have a job. Future analyses should include a sample of asylum seekers at a later stage in the procedure, who are more likely to be employed. Third, we did not assess adverse life events after arrival in Switzerland, which a previous study has found to influence mental health [7
]. It can be argued that by leaving out traumatic events about which the respondents had only heard, we did not assess these events exhaustively. We decided to include only events experienced or witnessed by the subjects themselves in order to avoid creating a ceiling effect in positive answers, since the mean number of reported event types would have almost doubled under inclusion of events about which the respondents had only heard (mean of events heard about
Finally, ethical challenges in the questioning of asylum seekers need to be addressed. Having to be considered as a vulnerable group, asylum seekers may feel intimidated or frightened by the interview situation, which may remind them of interviews with Migration Officers or interrogations in their home country. We tried to minimize such associations by employing only trained psychologists to conduct the interviews and by insuring that participants understood at the beginning of the interview that individual data would be anonymized and would not influence the outcome of their asylum request in any way. Where psychiatric morbidity was diagnosed, we informed participants of treatment possibilities, which are unfortunately scarce for asylum seekers and refugees.
To date, empirical studies examining the influence of the postmigratory situation soon after arrival are scarce, making it impossible to clearly determine the local versus global relevance of the present findings. However, Switzerland’s current asylum policies are comparable to those of most other countries implementing mandatory detention. It therefore seems likely that, in countries with similar asylum policies, mental distress in the months after arrival is likewise closely linked to traumatic events experienced prior to migration.
Future research should examine the course of mental health and postmigration characteristics over a longer period of time. Special attention should be given in this respect to the potential mediating effect of postmigratory difficulties on the predictive power of traumatic events on mental health outcomes – specifically, the possibility that individuals traumatized in their home country are more vulnerable to postmigratory stressors. The present study thus highlights the importance of the thorough, large-scale, and longitudinal examination of how postmigratory characteristics impact the mental health of asylum seekers.