INTRODUCTION
The last few decades have witnessed an alarming increase in the number of ethnic conflicts, civil disorders, natural disasters, insurgencies, terrorist attacks and low intensity wars throughout the world. These conflicts have led to forced displacement, internal migration, loss of livelihood; break up of families and communities. It is worth noting that the majority of the victims of these conflicts are those who are not involved in actual “fighting” i.e., civilian population including women, children, elderly and disabled. The civilian population is the most vulnerable and the impact of these conflicts is very complex and far-reaching on the overall functioning and well being of the population affected. The migrants can be the direct victims of the violence or disasters or may have actually witnessed it. Exposure to trauma and disruption can result in lasting mental health and psychosocial problems for these individuals. The psychosocial health of the population affected by violence, natural disasters, terrorism and subsequent forced migration is an area of key concern and needs great deal of attention in current times.
Migration and its effect on mental health
“Migration” is defined as the process of social change resulting in an individual moving from one cultural setting to another for the purposes of settling down either permanently or for a prolonged period. Such a move can be for any number of reasons; commonly economic, political or educational betterment. The process is inevitably stressful and stress can lead to mental illness and other psychosocial problems1. The migrants may be “refugees”, who are described as the people who have fled from and are unable to return to their own country because of persecution and violence, and the “internally displaced”, who are the people who have been uprooted because of persecution and violence but who remain in their own countries2. In recent times conflicts, civil disorders and terrorist attacks have produced a large number of immigrants and refugees. These immigrants are first influenced by pre-migration disruptions like war and torture, and then they go through the actual process of migration, then the resettlement stress in a different area and eventually having problems of assimilation, acculturation and social isolation, increasing their overall vulnerability to both physical and mental health problems. Migrant experiences typically involve multiple traumatic events and sometimes torture. Trauma often continues during and after migration. The regimes from which migrants flee may perpetrate violence, killings, rape, assaults, disappearances, deliberate food shortages, prohibition of traditional practices and other human rights violations3, 4. Migrants may also experience extreme isolation, humiliation, and immense losses, some of which are existential, including loss of loved ones, the homeland, culture, identity, hope, trust, meaning in life and faith in a just world5. Psychological effects of these experiences may include feelings of helplessness, grief, anxiety, depression, somatisation, shame, anger, shattered assumptions, sensitivity to injustice and survivor guilt6. The most important mental health consequences are mainly stress related disorders like acute stress disorder, post-traumatic stress disorder(PTSD), anxiety disorders, depressive disorders, bereavement problems, adjustment disorders, exacerbation of pre-existing mental health problem, acute and transient psychotic episodes and illicit drug and alcohol use. The increased mental health challenges within immigrants and refugee populations may also develop due to matters of strained adjustment. Also, cultural factors can greatly affect the conception, manifestation, diagnosis, subjective experience, prognosis, family and community responses, and help-seeking patterns towards professionals7.
Interventions to address psychological concerns
The psychosocial concerns have led to the rapid growth of a multidisciplinary body of research on the mental health and psychosocial wellbeing of migrants, mostly concerned with the negative impact of migrant experiences. Various psychological approaches like debriefing, psycho-education, trauma counselling, emotional ventilation, cognitive behavioural therapy (CBT), group work and EMDR have been tried in the affected individuals, but the evidence base is limited. It is important to identify the psycho-social needs, and support the affected individuals, which in turn can promote resilience and return to normality. Early work on the use of drugs such as beta-adrenergic blockers to block the action of stress hormones in the consolidation of traumatic memories has shown promising results8, but further studies are necessary.
A challenge to health care systems
Global concern about the mental health and wellbeing of migrants and displaced population has increased in recent years. This is largely because of the growing view that mental health is a priority once basic material needs are met9. While mental disorders affect the cross-section of the society, the migrant population and refugees are disproportionately affected. In the countries of their destination, migrants have generally poor access to health services than the natives. Provision and access to mental health services for refugees and displaced migrants has significantly improved in European and American countries but unfortunately it is still a matter of significant concern in third world countries. Attending to the mental health needs of this population in the the third world countries is not a priority due to lack of resources. In the context of large scale migrations health care systems face a number of challenges in meeting the mental health needs of this population. There has been a significant increase in the migration of the people from different conflict zones like Afghanistan, North West Frontier Province in Pakistan (NWFP), Iraq etc., to neighbouring regions or to other countries. The recent conflict in Pakistan has displaced approximately 3 million Pakistani citizens from the provinces of Swat, Buner and Lower Dir. This forced migration is the largest movement of civilians in the region since 1947, when the partition of India created Pakistan10. These migrants apart from suffering the effects of migration also may have been the victims of actual violence or torture. This group of people is at a very high risk of developing the stress related psychosocial problems, children and women being more vulnerable than the other population.
There are questions which need to be answered and looked into. Are psychosocial approaches developed and researched in Europe and US applicable universally? What would constitute a proper psychosocial package for these individuals and will this package be cost effective especially in third world countries? Can these interventions be delivered to large populations? How can changes or improvements be measured reliably? The number of displaced population from NWFP (North-West Frontier Province) to rest of Pakistan is phenomenal. Millions of people will be stressed and prone to have higher rates of mental illness. This presents a particularly serious challenge to health services in Pakistan.
In current circumstances there is a strong need to re-evaluate the overall mental health services and related policies in response to migration which will ensure equitable access to mental health services for all the people including immigrants and refugees. Social policies in relation to migration also require reconsideration as they can impact on the psychological stresses and social disadvantages experienced by migrant groups. Mental health professionals can make a major contribution to this process by providing high-quality and evidence- based mental health care. Cost-effective measures like increasing the awareness of mental illness by offering community education among migrants, and to provide appropriate training to mental health workers, to provide effective needs-based interventions for specific migrant communities may prove beneficial. International psychiatric and humanitarian organisations also have a crucial role in advocating improved psychiatric care and working conditions for all mental health workers. Provision of humanitarian aid can mitigate the development of adverse mental health problems in immigrants. There is a significant need to put mental health as a priority on the agenda of the government and international organizations. There is a need for comprehensive research, especially in third world countries to better understand the mental health needs of this population. While specific events are unpredictable, it seems that there will be a continued rise in migration due to conflicts and wars for the coming times, suggesting a global burden on mental health services.
REFERENCES
1. Bhugra D, Jones P. Migration and mental illness. Adv Psychiatric Treat 1991; 7: 216–23.
2. Burnett A, Thompson K. Enhancing the psychosocial wellbeing of asylum seekers and refugees. In: Barrett KH, George WH, editors. Race, culture, psychology, and law. Thousand Oaks, CA: Sage; 2005. p. 205-24
3. Ehntholt K A, Yule W. Practitioner review: Assessment and treatment of refugee children and adolescents who have experienced war-related trauma. J Child Psychol Psychiatry 2006; 47: 1197–210.
4. Ingleby D. Editor’s introduction. In: Ingleby D, editor. Forced migration and mental health: Rethinking the care of refugees and displaced persons. New York: Springer; 2005. p. 1-28.
5. Jayshree B. Pakistan’s Humanitarian Crisis. [Online]2009[Cited on 2009, 10th November]. Available from URL:http://www.cfr.org/publication/19407/pakistans_humanitarian_crisis.html.
6. Last M.Healing the social wounds of war. Med Confl Surviv 2000;16: 370–82.
7. Loescher G. Forced Migration in the post-Cold War Era: The Need for a Comprehensive Approach. In: Ghosh B, editor. Managing Migration: Time for a New International Regime? Oxford: University Press; 2000.
8. Minas H, Silove D. Transcultural and refugee psychiatry. In: Bloch S, Singh BS, editors. Foundations of clinical psychiatry. 2nd edition. Melbourne: Melbourne University Press; 2001. p. 475-90.
9. Pitman RK, Sanders KM, Zusman RM, Healy AR, Cheema F, Lasko NB, et al. Pilot study of secondary prevention of posttraumatic stress disorder with propranolol. Biol Psychiatry 2002; 51:189–92.
10. Victorian Foundation for Survivors of Torture. Rebuilding shattered lives. Melbourne: Victorian Foundation for Survivors of Torture;1998.
Culled: http://www.jpps.com.pk/
