Causes and Risk Factor of Posttraumatic Stress Disorder in Adult Asylum Seekers and Refugees

Objectives Firstly, to assess the causes and risk factors of PTSD in asylum seekers and refugees. Secondly, to explore whether there are differences of causes and risk factors of PTSD, between male and female refugees and asylum seekers. Study design Systematic review of current literature. Data Sources PubMed, Web of Science, Scopus and Google Scholar up until February 2019 Method A structured systematic search was conducted in the relevant databases. Papers were excluded, if they failed to meet the inclusion and exclusion criteria. Afterwards a qualitative assessment was performed on the selected papers. Results 12 Studies were included for the final analysis. All papers were either case studies, report or cross sectional studies. The most frequently reported pre-migration for PTSD development, in asylum seekers/refugees, is the number of traumatic events they experience. Whilst acculturation stress is the most common post migration stressor. Mixed reports were reported, regarding the causes of PTSD between both genders of refugees/asylum seekers. Conclusion This reviews’ findings, have potential clinical application into helping clinicians, to stratify refugees/asylum seekers for PTSD development and thus to embark on earlier intervention measures. However, more rigorous research similar to this one, is needed for it to be implemented into clinical practice.


Introduction Asylum seekers and refugees
The terms refugees and asylum seekers are too often confused and used interchangeably. Under the 1951 United Nations Convention on the Status of asylum seekers, a refugee is a person seeking protection from other countries because of an established fear or prosecution due to a variety of reasons ranging from religion, race or politics 1 . Where war is by far the leading cause for refugees to move to other countries 1 .Whilst asylum seekers are those who have applied for a sanctuary and international protection but are yet to granted one 2 .The number of refugees is increasing at an alarming and unprecedented rate. As of the end of 2015, the prevalence of refugee forced to leave and flee their homes and countries has reached 66 million 3 A 5 million jump compared to the previous year(2016) . That is nearly 20 people all over the world seeking refugee per minute. Currently, there are 22 million refugees seeking new homes ( a 2 million increase) 4 . Whilst the U.K alone has on average around 40,000 refugees per year 1 5 . On the other hand, there are 1.8 million asylum seeker globally and around 200,000 new ones yearly 2. Today, Syria leads the way in terms of forcibly displaced citizens, currently peaking at around 12 million followed by Columbia( 8 million) , Afghanistan and Iraq (4 million) 6 . To be all this in perspective, Europe in 2016 has seen the greatest surge of refugees since the end of World War 2 6 . Moreover, more than three quarters of those refugees are aged 35 or younger, with most of them having families of their own.

Demography
The general demographic of refugees and asylum seekers across European countries has been slightly in favour of males, with a steady increase from 67% (2013)to 71% (2014) and 73% (2015). Again this difference and slight favouritism towards males is also present within the minor population (defined as under the age of 17), where 20% of asylum seekers are boys whilst approximately 10% are girls 7 .The proportion of unaccompanied minors peaked in 2015 reaching 7%. Afghanistan has seen the largest representation of unaccompanied adolescents (40% of all unaccompanied minors). With most of them making dreaded and torturous trips towards Sweden, Germany and the U.K 8 .Thus, the statistics provided above imply that the epidemic of refugees and asylum seeker is showing no signs of slowing down, therefore making this topic a worthwhile endeavour to dive and delve in.The recent surge of refugees and asylum seekers around the world, has consequently led many countries to revisit their asylum seeking policies and legislations. The U.K for example has passed 6 pieces of legislation over the span of 15 years. The newest of these policies involved restricting and reducing state support for asylum seekers (2015) 8,9 .This pattern of change is also evidential within the policies of other European countries. Traditionally, the EU have always abided by the Dublin 11 system which regulates refugees and asylum seeker's applications. The Dublin's system 'point of first entry' policy -asylum applications are only to be made at the first point of entry to the EU-has been under severe scrutiny by countries mostly affected by it such as Italy and Greece 10 .Thus with the ever reforming refugee policies of hosting countries, the need to address their mental vulnerabilities and underlying causes has become ever so urgent-which this paper endeavours to do.

Post-Traumatic Stress Disorder
According to the NHS, Post Traumatic stress Disorder is defined as a 'severe anxiety disorder due to either very stressful, frightening or distressing events' 11 .This can be either a single event or a consequence of continuous exposure such as in childhood rape. The 4 main PTSD symptoms are re-experiencing the traumatic event, avoidance or numbing behaviour, hyper arousal and negative alterations 12 . These symptoms need to have lasted for more than a month, in order diagnose PTSD. The diagnostic criteria for PTSD is provided by the diagnostic and statistical manual of mental disorders (DSM 5) 13 . PTSD sufferers are more likely to self-neglect, indulge in suicidal thoughts and are at a higher risk of co morbidities such as chronic depression and anxiety 14 .PTSD is most notoriously and classically known to affect war veterans. However, recent events of hardship and war-especially in Middle Eastern countries-has seen a large number of people flee their homeland ,and consequently rates of PTSD has significantly increased among those vulnerable groups. Asylum seekers and refugees are 10 times more prone to suffer from mental health conditions compared to the general population 14 . PTSD currently leads the way against other psychological issues such as depression, suicide and excessive substance abuse. Moreover, it has been estimated that the overall average prevalence of PTSD among asylum seekers is between 28%-30% with some studies reporting it to be as high 66% followed by depression and anxiety (26%-29%) 15 .Accurate and definite percentages were difficult to concluded because of the varying designs and structure adopted by researchers in order to collect PTSD prevalence rates among refugees. Furthermore, inconsistent diagnostic criteria's and language barriers may have hindered accurate articulation of PTSD symptoms and hence explain the high variability of PTSD prevalence rates between different studies 15 .Most of the epidemiological and interventional studies published in relation to refugees , focus mainly on PTSD as opposed to other mental health such depression or anxiety 11 . Therefore building on this background, PTSD is the ideal mental condition for further exploration in terms of causes and risk factors 15 .
Why is the study needed?

Media (150)
'Illegal immigrants', 'Living off our taxes' and 'Unwanted invaders'. These are just a few of the headlines from the printed media. As the number of refugees and asylum seekers continues to grow globally, an opposing right-winged counterparty has emerged in parallel. Hatred, marginalisation and 'we and them' were at the heart of many newspaper -as concluded by a report conducted on the perception and representation of asylum seekers and refugees the Australian Newspapers. 16 This negative portrayal of refugees is also present across the European mainstream media. 17 However, a second, more sympathetic group has also emerged-namingly the Swedish press. Which takes a more inclusive and positive approach to incoming asylum seekers. 18 This bipolar split across various newspapers and media outlets is what initially sparked the interest into refugees and asylum seekers

Others papers/previous research
Surprisingly, as more and more media attention is being turned to asylum seekers, there were relatively few systematic reviews explicitly dealing with the causes and risk factors of PTSD in refugees and asylum seekers. A quick research scope using the Mesch terms 'Causes' OR 'Risk factors' AND 'PTSD' 'Asylum seekers OR Refugees' with an inclusion criteria of 'systematic review' in PubMed, identified 16 studies concerning PTSD, asylum seekers and refugees.Most studies focused and compared the efficacy of different psychological treatment of PTSD in asylum seeker and refugees such as in the Nosè M, Ballette F, study 19 Whilst other studies looked at the epidemiology and prevalence of PTSD among refugees ( Reavell J, Fazil Q.) . 20 The Michele Hyne study was the closest to what we are achieving however, her study focused on the social determinant and post migration causes, whist this study takes a more general looks at the causes behind PTSD in refugees. 21 Thus this study was made with the intention of filling this gap in research.Jurist Henry De Bracton (d. 1268) a 17 th century Englishmen cleric once famously said 'Prevention is better than cure' with this in mind, the exploration of PTSD causes within the refugee community will hopefully in the future, make the prevention, diagnoses and treatment of PTSD a lot simpler.

Aim of study
Primary aim-to explore and compare the causes and risk factors of PTSD within the adult refugee and asylum seeker population.
Secondary aim -To evaluate if causes/risk factors of PTSD differ between male and female adult refugees and asylum seekers.

Methodology Search Methods
3 Databases -PubMed, Scopus and Web of Science were the primary search engines used .In addition, Google scholar was the secondary source. We followed the PRISMA (preferred reporting items for systematic reviews and Meta -analyses) checklist for carrying out a systematic review and metaanalysis 22 .
The search methodology and process used is broken up into two stages. The initial/first stage encompasses applying relevant search terms into the databases mentioned above and identifying the most appropriate papers. The second stage can be described as a 'filter' stage which involves selecting the most applicable studies from stage one, through the aid of the quality assessment PRISMA checklist.
The search was conducted at the end of February 2019. A quick research scope using the Mesch terms 'Causes' OR 'Risk factors' AND 'Post Traumatic Stress Disorder 'AND 'Asylum seekers' OR 'Refugees' looking at just the abstract, title and author name in PubMed In addition, a more focused search was carried out in order to scope out the most relevant papers. Which included the MESCH terms '((cause* OR risk factor*))) AND ((post-traumatic stress disorder) AND ('refugee*' OR 'Asylum seeker*).Moreover the terms= (cause*) OR risk factor*) AND (post-traumatic stress disorders) AND ('asylum seeker*' OR refugee*) NOT (Children) NOT (Adolescent) NOT (Teens) NOT (treatment) NOT (intervention) were applied. Furthermore, the inclusion and exclusion criteria mentioned below were then applied, this yielded less papers.
. Most of those papers excluded, focussed on treatment and intervention efficacies of PTSD within the refugee population as opposed to the causes and risk factors for developing PTSD.
Similar search methodology and terms were implemented, in Web of Science and Scopus Advance Search= = (cause*)

OR risk factor*) AND (posttraumatic stress disorders) AND ('asylum seeker*' OR refugee*) NOT (Children) NOT (Adolescent) NOT (Teens) NOT (treatment) NOT (intervention)
Filters: Inclusion and exclusion criteria and PRISMA quality checklist applied

Inclusion exclusion criteria
Various inclusion and exclusion criteria were applied in order to extract the most fitting and suitable papers and studies to this research. The papers had to meet certain criteria to be included. The inclusion criteria is as follows the articles had to be in English, full text was available, had to be a primary research/study , and it should have focussed on adults. On the other hand, articles and papers were omitted if they were not in English, full text was unavailable, was a systematic review as opposed to a clinical trial and focused on adolescent and children. These criteria were applied throughout the search process.

Quality assessment
The evaluation tool for qualitative studies 22 , recommended by the Cochrane handbook for systematic reviews, was used to critically appraise the quality of the 12 included studies. This assessment tool, focussed on 6 domains, study overview, study setting, ethical approval, data collection and analysis, potential sources of bias, practical transferability of results and number of references used.

Search Results
A final literature search was lead on the 2 nd of February 2019. This was conducted on 3 different databases (PubMed, Scopus and Web of Science) and other external sources, such as reading the references of papers and google scholar. The initial scope search, yielded 126 papers from the databases and 3 additional papers from other sources. This then stemmed down to 120 papers after removal of duplicates. Of those 120 papers, 80 were excluded after applying the relevant inclusion and exclusion criteria. From the 40 articles retrieved, 28 were excluded after the full paper was read and. Most of the papers excluded focused on prevalence rates and intervention efficacies of refugees with PTSD. Thus, 12 articles were selected for this systematic.

Main causes of PTSD in asylum seekers and refugees: Primary aim
The leading cause of pre-migration stressor is the total number of traumatic events experienced i.e. near death encounters as concluded from the literature. In regards to post migration risk factors, the ability to adapt to the new surrounding is the strongest cause linked to PTSD. Some notable causes, were reported in the Hinton et al 29,31 ,which found that nightmares(dreaming of the dead) interpreted within a cultural/spiritual context was associated with PTSD.

Comparison of risk factors between male and female refugees: Secondary aim
2 studies found, that men are more likely to experience traumatic events compared to women (Men=2.85 events Women=2.28 events) 27,33 . Oren et al found, women with a strong ideological stance and who were involuntarily evacuated from the Gaza settlement, had a higher odds of developing PTSD(OR=2.24 CL 95% 1. 12-4.47). Gerritsen et al found higher prevalence rates of PTSD in females in comparision to males.(OR=3.45 CL 1.53-7.780)

Summary of findings
This systematic review was conducted, with the aim of searching the existing literature, for studies investigating the causes and risk factors of PTSD in asylum seekers and refugees. The intensity and frequency of traumatic events encountered by refugees/asylum seekers, is by far the most widely reported risk factor for PTSD development. Moreover, it was found that asylum seekers were more likely to develop PTSD,this in part, because of the addition stressor such as lack of work permission and uncertainty surrounding their legal status, placed upon them , Conflicting conclusion were drawn between the studies, as to whether gender itself, is a risk factor for PTSD. Furthermore, there were mixed results concerning age, marital status and socioeconomic background as being causes of PTSD.
Overall, a cloud of uncertainty surround these findings, due to the non-randomisation nature of these studies-only 3 studies reported the use of randomisation when sampling refugees/asylum seekers.

Limitations of study
This review has limitations. Firstly, there was a limited number of studies (12) to review, coupled with the non-randomisation sampling process adopted by 9/12 studies, makes a definitive conclusion difficult. Secondly, most studies equated symptoms of PTSD to diagnoses without adopting formal diagnostic algorithm, which may overestimated PTSD diagnoses and skew causality of PTSD. Thirdly, the language barrier and word count are intrinsic limitations of this review. Fourthly, all studies relied on self-reporting which enhances recall bias. Fifthly, all studies were either case studies/report or cross sectional studies, and because of their retrospective nature, making a definitive causality link between cause and disease not possible. Sixthly, the Rasmussen et al 27 , is the only study that satisfies a margin of error of less than 5% 36 , as they used a sample size greater than 500.Therefore, a small sample size of the studies included, is another limitation of this review. Seventhly, asylum seekers/refugees may have tailored their responses, in hope of receiving financial benefits or advances on their asylum status. Eighthly, no study except one 30 , used a specifically designed sampling instrument for their selected population.

What this study adds/ comparison with other studies
This study adds to the current literature, as it derived the most common cause/risk factors of PTSD in asylum seekers and refugees. Where the magnitude and number of traumatic experiences by any one refugees/asylum seeker emerged as the strongest predictor of PTSD development. Another important finding to add to the literature, is the role of cultural connotations and interpretation of events, as a potential risk factor for pre-disposing displaced persons to develop PTSD, as concluded by the Hinton et al 29,31 and Oren et al 30 studies. Most research concerning PTSD and refugees/asylum seekers focussed on the efficacy of various psychological interventions, such as cognitive behavioural therapy and neuroemotional therapy. However, some reviews are in line with this one, such as the Hameed and colleagues study 36 , which looked at risk-factors concerning PTSD, depression and anxiety disorder manifestations. Furthermore, a Susan et al study 37 , which explored the relationship between postmigration stressors and PTSD in the asylum seekers/refugee populations, came to similar conclusions. But, the slight difference is that this systematic review, looked at the wider causes of PTSD.

Practical application of findings
Our findings, have potential practical applications to clinical practice. Knowing that the number of traumatic events and their intensity is heavily linked to PTSD, provides clinicians with a strong evidence base, to identify high risk patients and initiate earlier intervention and possible better prognosis. Furthermore, in light of the finding, that lack of cultural preservations and traditions of refugees/asylum seekers, may further pre-dispose them to PTSD. Helps guide the addition of, social integration and adaptation in these vulnerable population, as part of the treatment options provided to them by psychologists. However, as there is a very limited number of systematic reviews of the same elk to this one, more is needed for our findings to be translated to a clinical setting.

Future research
1-The need for more randomised studies investigating the causes/risk factors of PTSD in the asylum seekers/refugees, to reduce recall bias.
2-The use of questionnaire/sampling instrument that is specifically designed for the chosen population, in order to increase confidence in the results

3-
The need for more studies, comparing the risk factors of non-immigrants with PTSD and asylum seekers/refugees. 4-Adoption of a validated diagnostic algorithm, when assessing potential PTSD diagnosis.
5-Research into the exact mechanism and pathway of how relevant causes of PTSD manifest. Which could further advance intervention options.
6-A larger sample size, preferably more than 500 participants, when examining displaced persons for PTSD causes/risk factors. 7-More research/studies is needed that has similar objectives to this review. To further enhance confidence in our findings.

Conclusion
The magnitude and number of traumatic events coupled with acculturation stress, are the most commonly reported pre and post migration causes of PTSD in asylum seekers/refugee respectfully. Moreover, there are conflicting conclusions in the current literature, in regards to the causes/risk factors of PTSD in refugees and asylum seekers between both genders. The results of this systematic review, have possible clinical implications into the advances of PTSD treatment in this jeopardised group. However, more robust research similar to this review, examining the relationship of PTSD and its causality in the asylum seekers/ refugee population is needed, for it to be incorporated into day to day clinical practice.