Long-term mental health of war-refugees: a systematic literature review.
BACKGROUND
There are several million war-refugees worldwide, majority of whom stay in the recipient countries for years. However, little is known about their long-term mental health. This review aimed to assess prevalence of mental disorders and to identify their correlates among long-settled war-refugees.


METHODS
We conducted a systematic review of studies that assessed current prevalence and/or factors associated with depression and anxiety disorders in adult war-refugees 5 years or longer after displacement. We searched Medline, Embase, CINAHL, PsycINFO, and PILOTS from their inception to October 2014, searched reference lists, and contacted experts. Because of a high heterogeneity between studies, overall estimates of mental disorders were not discussed. Instead, prevalence rates were reviewed narratively and possible sources of heterogeneity between studies were investigated both by subgroup analysis and narratively. A descriptive analysis examined pre-migration and post-migration factors associated with mental disorders in this population.


RESULTS
The review identified 29 studies on long-term mental health with a total of 16,010 war-affected refugees. There was significant between-study heterogeneity in prevalence rates of depression (range 2.3-80%), PTSD (4.4-86%), and unspecified anxiety disorder (20.3-88%), although prevalence estimates were typically in the range of 20% and above. Both clinical and methodological factors contributed substantially to the observed heterogeneity. Studies of higher methodological quality generally reported lower prevalence rates. Prevalence rates were also related to both which country the refugees came from and in which country they resettled. Refugees from former Yugoslavia and Cambodia tended to report the highest rates of mental disorders, as well as refugees residing in the USA. Descriptive synthesis suggested that greater exposure to pre-migration traumatic experiences and post-migration stress were the most consistent factors associated with all three disorders, whilst a poor post-migration socio-economic status was particularly associated with depression.


CONCLUSIONS
There is a need for more methodologically consistent and rigorous research on the mental health of long-settled war refugees. Existing evidence suggests that mental disorders tend to be highly prevalent in war refugees many years after resettlement. This increased risk may not only be a consequence of exposure to wartime trauma but may also be influenced by post-migration socio-economic factors.
Unit for Social and Community Psychiatry, WHO Collaborating Centre for Mental Health Services Development, Queen Mary University of London, E13 8SP, London, UK. m.bogic@qmul.ac.uk.
Marija
M
Bogic
Fredericton OSI Clinic, NB, Canada. dr.anthony.njoku@horizonnb.ca.
Anthony
A
Njoku
Unit for Social and Community Psychiatry, WHO Collaborating Centre for Mental Health Services Development, Queen Mary University of London, E13 8SP, London, UK. s.priebe@qmul.ac.uk.
Stefan
S
Priebe
D000328:Adult; D001008:Anxiety Disorders / Q000523:psychology; D000068337:Armed Conflicts / Q000523:psychology*; D003863:Depression / Q000523:psychology; D006801:Humans; D038622:Internationality; D008603:Mental Health; D012036:Refugees / Q000523:psychology*; D012307:Risk Factors; D012923:Social Class; D013315:Stress, Psychological; D013997:Time Factors; D000067453:War Exposure