As a group, refugees are at greater risk than non-refugees of developing anxiety, depression and post-traumatic stress disorder (PTSD). Although only a small proportion of refugees who settle in developed nations are known to have a mental illness, research indicates that many refugees can benefit from mental health services that are responsive to their shared experiences, such as socio-cultural dislocation.
This HillNote discusses research on the mental health of refugees in Canada and the services available to them. The research applies to the refugees Canada resettles from third countries and to successful refugee claimants in Canada; mental health services are available to all of these refugees.
Refugees and Mental Illness
Discrimination, dislocation and violence are common experiences among refugees. In the 1951 United Nations Convention Relating to the Status of Refugees, refugees are defined as having a “well-founded fear” of being persecuted based on race, religion, nationality, membership in a particular social group or political opinion. Canada’s Immigration and Refugee Protection Act, which incorporates Canada’s international obligations under the Convention into domestic law, also defines the related term “persons in need of protection” as individuals who are in danger of death, torture or cruel and unusual punishment.
Persecution, as well as fear of persecution, come at a cost to mental health – as does fleeing to other countries to escape this persecution. Estimates of the prevalence of mental illness among refugees as a group and in different refugee groups vary. Symptoms of mental illness may also present differently from one culture to another.
As of 2009, empirical studies suggested that, globally, up to one-quarter of refugees or conflict-affected populations have PTSD. More recent quantitative research indicates that, among refugees of war, rates of depression range from 3% to 55%, rates of anxiety range from 24% to 54% and rates of PTSD range from 4% to 61%.
Refugees settled in developed countries appear to have better mental health than refugees in other parts of the world; only a minority of all refugees settled in developed countries experience a mental illness. As reported by Dr. Michaela Hynie, most refugees do not have mental disorders and most recover from the distress of their migratory experiences within one year of resettlement.
According to research conducted in 2005, among refugees settled in seven developed countries, including Canada, 9% have PTSD and 5% have major depression. Nonetheless, these rates of PTSD and depression are still higher than among non-refugees in the same countries. For instance, refugees experience PTSD at a rate of about 10 times that of the age-matched general population of the United States.
Risk Factors for Mental Illness
The prevalence of mental illness in the country of origin of refugees affects how susceptible they are to developing a mental illness. This prevalence also varies over time and according to multiple risk factors experienced before, during and after migration (Figure 1).
Figure 1 – Risk Factors Affecting the Mental Health of Refugees
Source: Figure prepared by the Library of Parliament using data obtained from Laurence J. Kirmayer et al., “Common mental health problems in immigrants and refugees: general approach in primary care,” Canadian Medical Association Journal, Vol. 183, No. 12, 6 September 2011, p. E961.
Among pre-migration risk factors, the experience of potentially traumatic events – and the repetition and severity of such events – is a strong predictor of later mental illness. This is especially true for PTSD and depression. For instance, surveys of refugees and people displaced by mass conflict in which a high number of respondents (40%) reported being tortured found that on average, more than 46% of these respondents experienced PTSD – four times the figure reported in surveys in which the fewest respondents had experienced torture.
More broadly, refugees subjected to prejudice learn to anticipate rejection. This, in turn, leads them to fear, mistrust and avoid others and ultimately self-isolate – a cycle of prejudice and isolation especially felt by refugees with multiple marginalized identities, such as LGBTQ2+ refugees.
A refugee’s greater socio-economic support and higher status in their country of origin comprise a risk factor for later mental ill-health, given how losing these supports after fleeing their country can be devastating. A similar pattern is found among child refugees.
The migration process itself can further increase the chance of mental illness if violence or trauma is inflicted during the journey – especially for those who also experienced such violence or trauma before migrating. As well, the uncertainty and stress of long periods in refugee camps negatively impacts mental health. Child refugees also experience social and educational disruption, and some become separated from parents and relatives.
Lastly, another factor that can negatively affect the mental health of refugees, especially children, in the post-migration period is the fact that some refugee claimants are detained while they await hearings to decide their refugee status. Refugees who have resettled or who receive refugee protection often report greater initial happiness. Memories of traumatic experiences also can fade over time. At the same time, stresses of racism and other discrimination, a lack of social connection and a low employment rate contribute to the likelihood that they will experience anxiety, depression and PTSD. New experiences of violence and discrimination can trigger memories of previous traumas.
Factors Promoting Mental Health
In the settlement country, a refugee’s socio-economic status, the availability and quality of supports, and their overall stability improve their mental health and resiliency. Mental health is the product of overlapping factors: individual well-being, socio-economic connection, and rights and values (Figure 2). According to the Mental Health Commission of Canada, fundamental factors that promote mental health include “the way groups are welcomed into a country; where they live; whether they can work; if they are considered residents; and their access to education, training, and initiatives fostering social inclusion.” Practical issues, such as employment and housing, can also affect the mental health of refugees.
Figure 2 – Elements that Promote Mental Health Resilience
Source: Figure prepared by the Library of Parliament using data obtained from Branka Agic et al., Supporting the Mental Health of Refugees to Canada, Mental Health Commission of Canada, January 2016, p. 6.
Treatment Available in Canada
Resettled refugees and successful refugee claimants, like other newcomers to Canada, have access to mental health support though settlement services and community or peer support groups, and they have access to primary physician care.
Settlement services, including mental health supports or referrals, are offered by more than 550 organizations to help newcomers adjust to life in Canada. The federal government provides a list of the mental health resources and supports available to newcomers, including refugees. In April 2022, the federal government invested $3,775,000 in these supports, including $2 million for the Centre for Addiction and Mental Health (CAMH) and $1,775,000 distributed among 13 distress centres. For the CAMH, this investment will be put toward the development of “curated resources to assist in meeting the diverse needs of priority populations during and beyond the COVID-19 pandemic,” including refugees. Distress centres will use the investment to meet the increased demand for crisis services, such as crisis line supports for immigrant populations.
The House of Commons Standing Committee on Citizenship and Immigration often hears testimony about how important it is for refugees to have access to communities and tailored supports. For example, private refugee sponsors help LGBTQ2+ refugees “navigate Canadian systems and programs and provide a support network into the LGBTQ+ community.” Organizations that provide settlement services in Canada have noticed significant challenges and barriers for newcomers with mental health issues – particularly those who do not benefit from peer or community support – such as linguistic barriers, in accessing mental health supports. Mental health supports for newcomers tend to be most successful when they are sensitive to the culture of these newcomers.
As a distinct group among newcomer populations, refugees have unique mental health challenges. For instance, in times of low resources or higher arrivals of refugees, institutions may struggle to deliver psychotherapy to large numbers of refugees with PTSD. As a displaced population, refugees are particularly vulnerable to violence that affects whole families, as well as to the harmful effects of separation from family members. Refugees also have poorer mental health than other newcomers, even as both groups are equally unlikely to seek mental health services compared to Canadian-born citizens.
Overall, despite programs and services already in place, experts and parliamentary studies have called for more mental health supports for refugees and more services that are specifically responsive to refugees’ experiences.
Béchard, Julie and Robert Mason. Refugee Protection in Canada. Publication No. 2020-50-E, Library of Parliament, 30 July 2020.
Coleman, Lara. “LGBTQ2* Refugees in Canada.” HillNotes, Library of Parliament, 10 June 2020.
Coleman, Lara. Resettling Refugees: Canada’s Humanitarian Commitments. Publication No. 2020-74-E, Library of Parliament, 26 November 2020.
Guruge, Sepali and Hissan Butt. “A scoping review of mental health issues and concerns among immigrant and refugee youth in Canada: Looking back, moving forward.” Canadian Journal of Public Health, Vol. 106, No. 2, 2015.
Schouler-Ocak, Meryam. “Refugees and Asylum Seekers.” In Mental Health and Illness of Women, Prabha S. Chandra et al., eds. Springer, 2020.
By Madalina Chesoi and Martin McCallum, Library of Parliament
Categories: Current Issues in Mental Health in Canada, Health and safety, Law, justice and rights