Supporting the mental health of refugees: further evidence highlights the need for cultural awareness and competence

Germany is home to 1.2 million refugees and is the fifth largest concentration of refugees in the world (UNHCR, 2020). To put this in context: the UK is hosting 135,000 refugees as of 2019. Germany’s GDP per capita is $ 45,700, compared to $ 40,300 (USD) in the UK. The UK is roughly two-thirds the size of Germany according to World Bank land mass figures for 2020 and 2018, respectively. So why did the UK accept roughly a tenth of the number of refugees that Germany hosts?

Between 2010 and 2014, the UK accepted only 32% of initial asylum applications and two-thirds of appeals were rejected (Sturge, 2019). It has been shown time and again that refugees are at risk of deteriorating mental health (Fazel, Wheeler and Danesh, 2005; Porter and Haslam, 2005), given the widespread xenophobia during Brexit campaigns, the history of discriminatory comments from some members of Parliament and outright racism. that followed the final of Euro 2020, at the forefront of the selective asylum process; The UK can certainly do more to support the mental health of refugees.

This is the first large-scale representative study (to the authors’ knowledge) exploring the prevalence of psychological distress and its potential impact on integration among newly arrived refugees. It focuses on the arrival of refugees in Germany from 2013 to 2016.


The authors aim to analyze the prevalence of psychological distress among refugees and understand whether social and demographic factors can influence levels of distress. Furthermore, this study investigated how the presence of psychological distress affects integration in the host country and post-migration factors once an individual has settled there.

Data from the IAB-BAMF-SOEP Refugee Survey were analyzed. This survey was conducted in 2016 and again in 2017. Participants were selected using sampling probabilities in the German Central Register of Foreigners (AZR). Once selected, the participants were evaluated using the Refugee Health Screening 13 (RHS-13) program, which turned out to have excellent internal reliability. The examiner examined the symptoms of PTSD, anxiety, and depression.

The test population was stratified using the following sociodemographic characteristics: nationality, gender, educational level, and age. Three factors were used after immigration: legal status, family constellation in Germany, and residential status. Inclusion was measured using: Employment, participation in educational programs and integration courses.

The data were analyzed using the weights provided by the SOEP survey. For the main analysis, the overall prevalence of psychological distress among each sociodemographic group was measured using a 95% confidence interval (CI). The risk ratios and parental CIs were then estimated using multivariate Poisson regression models by sex (Chen et al., 2018).


Among the 2,639 participants, the majority were men (63.4%), 25-44 years (65.5%), Syrian (53.4%) and 59.6% had a “low” educational level without education high school. The group also included Afghans (12.6%) and Iraqis (12.1%).

41.2% of the people tested tested positive for the mental disorder, meaning they scored at least 11 points on RHS-13:

7% showed mild psychological distress, which warrants further evaluation.
6% showed moderate psychological distress, which justifies the possible need for treatment.
9% showed severe psychological distress, justifying an urgent need for care.

17.4% of the women showed symptoms of severe psychological stress compared to 8.7% of the men.

Age was found to be positively associated with psychological distress, with 65.2% of subjects aged 25-34 years showing no symptoms of psychological distress, compared to 53.2% of subjects 35-44 years.

Mild distress was roughly the same across nationalities, however, 18.9% and 19.9% ​​of Afghans had moderate and severe psychological distress, respectively. In contrast, 75.2% of Eritreans did not show any symptoms.

Post-migration factors

An increase in psychological distress was found in people with largely uncertain legal status, men without a spouse or children in Germany, and those in refugee accommodation facilities.

Integration factors

Psychological distress was found to be associated with less male employment and less participation in educational programs, especially among women. However, it had little effect on participation in integration courses, no effect on women and little trend on men.


The authors conclude that there is a high prevalence of psychiatric disorders among the general refugee population in Germany. Furthermore, we must recognize that refugees lack heterogeneity, and risk factors and stress differ between subgroups, but also on a personal level. The study indicated that there is a correlation between psychological distress and signs of integration.

The main message of this study is that the mental health of refugees must be treated with greater importance by the host countries.

Strengths and limitations

The authors have successfully used objective assessments of integration and post-migration measures. Furthermore, this is the first large-scale representative study to investigate how psychological distress affects the assimilation process in a larger population. Finally, RHS-13 has already been used with a group of refugees in Germany, making it a reliable and effective tool for detecting psychological distress.

There were limitations as the study included only adults. According to UNHCR, in 2020, 40% (Refugee Council, 2020) of the world’s displaced are children. Furthermore, there was no information on how long the defendant had resided in Germany. As a result, it is not clear whether the presence of psychological distress may be related to integration and post-migration factors. Finally, RHS-13 only detected symptoms associated with depression, anxiety, and PTSD. However, there is insufficient evidence to show that immigrant populations (certainly not refugees) have a higher prevalence of psychotic disorders (Kirmayer et al., 2010), and refugees face a higher risk of psychotic disorders compared to immigrants. not refugees (Holander et al., 2010). al., 2016).

Implications for practice

This study shows that more mental health support needs to be provided to refugees to facilitate their integration. To put this in context, the UK currently offers a pre-entry health assessment for refugees. The protocol document has thirteen pages detailing physical health examinations, but only one paragraph briefly mentions the mental health assessment (Home Office, Public Health England and IOM, 2017).

This is a clear example of cases in which the policy is insufficient; We must not only follow the protocol, but also effectively evaluate the patient. Providing adequate and ongoing support is not always as easy as following a series of steps. It is indisputable that most of us are capable of following directions, but are we willing to do more to better serve the most vulnerable in our society? As shown above, different groups are affected in different ways, for example, Afghans and Eritreans. 75.2% of Eritreans showed no signs of distress, while 38.8% of Afghans showed moderate to severe signs. Following the protocol may be sufficient for a group, but the refugee population is heterogeneous. We harm people by not acknowledging this, we need to be able to challenge and question established procedures for the benefit of the communities we serve. This is why cultural awareness and competence are critical to the quality of care that physicians can provide and the prevention of mental health problems.