7 May 2018

Out of the shadows: refugees’ invisible burden

Sophia writes:*

When Merkel declared her famous phrase: “Wir schaffen das!”[We can do it!] in the summer of 2015, the year that the arrival of asylum seekers hit an all-time historical high at 890,000 [pdf], she might have underestimated the barriers that refugees’ mental health issues pose to successful integration.

Over the past three years around 1.5 million asylum seekers have arrived in Germany. The German Federal Chamber of Psychotherapists estimates that half of those refugees suffer from psychological problems. Most common are post-traumatic stress disorders (PTSD), depression, anxiety disorders and suicidal tendencies. Due to the recurrent exposure to high-risk stressors, mental health issues are overrepresented in the refugee population with refugees being 10 times more likely to suffer from PTSD compared to the general population [pdf]. Pre-flight [pdf] refugees often experience traumatic events involving high levels of violence (war, sexual abuse, torture) and chronic stressors as losses of loved-ones and belonging. During flight refugees face high emotional and physical stress due to travels, separation from family and friends and uncertainty about the future. Lastly, the arrival and adaption in a host-country involves uncertainty about asylum status, economic hardship, cultural loss and adaption and social exclusion.

So far, the German government has failed to adequately address the refugees’ and asylum seekers’ mental health burden. The German Federal Chamber of Psychotherapists estimates that in 2015 only 4 % of arriving refugees received psychotherapy. Despite, EU guidelines [pdf] requiring the identification of vulnerable groups, Germany has no adequate screening procedure for mental health problems. The already overstrained mental health care system was unprepared to deal with the large influx of refugees and lacked mental health professionals, particularly therapists trained to treat PTSD. This resulted in long waitlists and only emergencies getting treated. While in bigger cities like Berlin there exists at least some basic infrastructure, the issue is all the more acute in rural areas. Even if a refugee has access to mental health services, language barriers still pose significant challenges to the therapy and require the presence of a translator, which is often not covered by the health insurance. Moreover, therapists are often not trained for cultural specific modes of expressions, increasing the risk of misdiagnosis. Both language and cultural barriers make it difficult to establish trust between the patient and therapist. Refugees’ low utilization of existing mental health services is also due to a lack of communication about entitlements, unfamiliarity with health care system, cultural norms and stigmatization.

However, addressing refugees’ psychological issues is essential, as the mental health burden does not only rest on the shoulders of individual suffers but affects the well-being of the whole society. Untreated mental health issues can be detrimental to successful integration. Acquiring language proficiency and participating in the labor market requires high-functioning physical, cognitive and interpersonal skills; however, refugees suffering from mental illnesses are often severely distressed and unable to function in daily life  [pdf]. If a PTSD sufferer wakes up three times every night tormented with flashbacks, he or she will have limited energy to participate in language school or job training the next morning. So while the German government offers integration and language courses [pdf], their effectiveness is undermined by the lack of treatment for psychological problems as shown by high-drop out rates of German language courses [pdf]. Difficulties to form trusting relationships and frequent retreat to social isolation further impair integration efforts. The Leopoldina academy of science report [pdf] also argues that the frequent witnessing of violence can lead to normalization and increase violent tendencies and antisocial behavior, particularly in children. Mental health issues are highly prevalent among children with one in five suffering from PTDS. As children experience extreme stressors during sensitive development stages [pdf] the long-term consequences of trauma are severe with potential language deficiencies and increased self-harm and suicide risk. Impaired learning capacities can also negatively influence school performance and pose a barrier to social mobility.
Drawing by a young traumatized Syrian
Early detection and treatment of refugees’ mental health issues is also cost-effective in an economic sense, as failure to treat will increase Germany’s future economic burden. Studies have demonstrated the high economic cost of mental illness and the potential economic benefits of effective treatment. If mental health issues are left untreated is it likely that they will become chronic. Moreover, mental disorder increase the risk for other costly chronic diseases [pdf], e.g. cancer, cardiovascular diseases, obesity, diabetes etc. Undiagnosed mental health issues also manifest in somatic symptoms increasing doctor visits without appropriate treatment. Therefore, refugees’ untreated psychological problems increase public health expenditures in the long run. At the same time, indirect costs occur due to lost productivity. Psychological problems [pdf] can lead to unemployment, absenteeism, under-performance at work, early retirement or premature mortality. Refugees suffering from mental health problems face difficulties to both integrate and participate in the labor market. Besides the lost productivity, the failure to integrate in the job market results in increased welfare payments.

On the bright side, The World Health Organization argues that the improvements in labor force participation and productivity due to investment into mental health treatments outweigh the costs. As affordable and effective treatment methods exist, there is the possibility to minimize long-term consequences with early treatment. NGOs have started to propose low-level interventions to address the inadequate mental health care provision for refugees in Germany. Interventions with refugees as peer-counselors, sharing language and cultural backgrounds, have shown promising results. The trained peer-counselor works under close supervision of a therapist, who can treat more severe cases, and provides self-help programs and group therapy, which might also show refugees that they are not alone with their problems.

Bottom line: Hundreds of thousand asylum seekers and refugees arriving in Germany over the past years suffer from psychological problems, which are often invisible to the eye. Refugees’ mental health is usually not considered a priority by the German government as shown by the great shortage of adequate mental health services. However, untreated mental health problems pose great barriers to refugees’ integration in society and labor market. Furthermore, by failing to address mental health issues immediately Germany accepts the long-term economic burden of increased future health-care costs, productivity loss and increased welfare payments. To minimize potential long-term harms to integration and economic efficiency the government needs to pick up the pace and start addressing refugees’ inadequate mental health support.

* Please help my growth and development economics students by commenting on unclear analysis, other perspectives, data sources, etc. (Or you can just say something nice :)