https://orcid.org/0000-0003-2480-3652
Abstract
Background
Refugees, and other forcibly displaced people, face mental distress and may be disproportionately affected by risk factors for suicide. Little is known about suicidal behaviour in these highly mobile populations because collecting timely, relevant, and reliable data is challenging.
Methods and findings
A systematic review was performed to identify studies of any design reporting on suicide, suicide attempts, or suicidal ideation among populations of displaced people. A sensitive electronic database search was performed in August 2020, and all retrieved studies were screened for relevance by two authors. Studies were categorised by the population being evaluated: refugees granted asylum, refugees living in temporary camps, asylum seekers, or internally displaced people. We distinguished between whether the sampling procedure in the studies was likely to be representative, or the sample examined a specific non-representative subgroup of displaced people (such as those already diagnosed with mental illness). Data on the rates of suicide or the prevalence of suicide attempts or suicidal ideation were extracted by one reviewer and verified by a second reviewer from each study and converted to common metrics. After screening 4347 articles, 87 reports of 77 unique studies were included. Of these, 53 were studies in representative samples, and 24 were based on samples of specific target populations. Most studies were conducted in high-income countries, and the most studied population subgroup was refugees granted asylum. There was substantial heterogeneity across data sources and measurement instruments utilised. Sample sizes of displaced people ranged from 33 to 196,941 in studies using general samples. Suicide rates varied considerably, from 4 to 290 per 100,000 person-years across studies. Only 8 studies were identified that compared suicide rates with the host population. The prevalence of suicide attempts ranged from 0.14% to 15.1% across all studies and varied according to the prevalence period evaluated. Suicidal ideation prevalence varied from 0.17% to 70.6% across studies. Among refugees granted asylum, there was evidence of a lower risk of suicide compared with the host population in 4 of 5 studies. In contrast, in asylum seekers there was evidence of a higher suicide risk in 2 of 3 studies, and of a higher risk of suicidal ideation among refugees living in camps in 2 of 3 studies compared to host populations.
Conclusion
While multiple studies overall have been published in the literature on this topic, the evidence base is still sparse for refugees in camps, asylum seekers, and internally displaced people. Less than half of the included studies reported on suicide or suicide attempt outcomes, with most reporting on suicidal ideation. International research networks could usefully define criteria, definitions, and study designs to help standardise and facilitate more research in this important area.
Figures
Citation: Cogo E, Murray M, Villanueva G, Hamel C, Garner P, Senior SL, et al. (2022) Suicide rates and suicidal behaviour in displaced people: A systematic review. PLoS ONE 17(3): e0263797. https://doi.org/10.1371/journal.pone.0263797
Editor: Lindsay Stark, Washington University in St. Louis, UNITED STATES
Received: September 20, 2021; Accepted: January 26, 2022; Published: March 10, 2022
Copyright: © 2022 Cogo et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All relevant data are within the manuscript and its Supporting information files.
Funding: The initial scoping study that led to this review was supported by a WHO Agreement for Performance of Work from the WHO Global Service Centre (WHO Registration 2019/891502-0, PO 202208554). This publication was funded by the Research, Evidence and Development Initiative (READ-It). READ-It (project number 300342-104) through UK aid from the UK government; however, the views expressed do not necessarily reflect the UK government’s official policies. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing interests: The authors declare no financial or non-financial competing interests regarding this manuscript.
Introduction
Conflict remains a substantial threat to global population health. The number of people forcibly displaced is higher than ever with record levels of 82.4 million in 2020 (>1% of the world’s population), which is more than double compared to 10 years earlier [1]. Internally displaced people (IDP) make up the largest group of displaced people, at 48.0 million in 2020 [2]. The numbers of refugees and asylum seekers are estimated at 26.4 million and 4.1 million in 2020, respectively [2]. As conflicts become more protracted, the management of non-communicable disease and mental health have resulted in additional challenges [3, 4].
Suicide and suicide attempts have a profound impact on individuals, families, and communities. The World Health Organization (WHO) estimates that approximately 700,000 individuals died by suicide in 2019, with men dying at about twice the rates among women [5]. It is among the leading causes of death worldwide, with more deaths due to suicide than to malaria, breast cancer, war and homicide. The reduction of suicide mortality has been prioritized by the WHO as a global target and included as an indicator in the United Nations Sustainable Development Goals (SDGs) under target 3.4 [6, 7].
Refugees and other forcibly displaced people may be disproportionately affected by suicide risk [8, 9]. Mental health may be adversely impacted by displacement. Refugees face additional stressors during enforced departure from their homeland and on arrival in the host country such as discrimination, detention, language and cultural barriers [8]. ‘Losses’ identified include family and friends, homeland, status, community contact, language, financial assets, income, and financial security [10]. While most suicides are known to occur in low- and middle-income countries (79%) [11], the risks of suicide and suicidal behaviour among forcibly displaced people are unknown.
Previous reviews of suicide in refugee populations found a range of suicide proportions from 3.4% to 34% of recorded deaths [8]. Little is known about populations still in displacement because collecting timely, relevant, and reliable data is challenging in populations that are highly mobile. Suicide is also heavily stigmatized or even illegal in many countries, so suicidal behaviours may go under-reported and people at risk of suicide may be reluctant to seek help [12]. Regular monitoring of suicide across different risk groups is essential for effective national suicide prevention strategies [13]. This provides essential information for understanding the scope of the problem so that interventions can be tailored to meet the needs of specific populations.
This systematic review aims to synthesise what is known about the rates and prevalence of suicide and suicidal behaviour among displaced people from published literature.
Methods
The protocol for this systematic review was registered with PROSPERO (CRD42019137242). In the review protocol it was planned to include studies of people who have been displaced because of natural disasters, but due to the large number of studies, estimates from these populations will now be reported in a separate systematic review. Initially, studies on populations affected by conflict but who have not been displaced were also considered for inclusion. However, the difficulty in defining these populations and the variable level of exposure to conflict, led the author team to decide against including these studies. Studies were also excluded if they reported prevalence estimates for returned asylum seekers or displaced populations (i.e. people not currently displaced), or for economic migrants.
Inclusion criteria
Study designs.
Studies of any design that could provide an estimate of the rate or prevalence of suicide or suicide attempts, or prevalence of suicidal ideation, in populations of displaced people were considered for inclusion. This included observational studies (longitudinal population-based cohort studies, case-control, and cross-sectional surveys) and baseline rates or prevalence in randomised controlled trials of interventions targeted at the populations of interest. Case reports, reviews, and case series were excluded. Publication status was not used to determine eligibility.
Populations.
Studies were included if they reported on populations (of any age) of forcibly displaced people, which we defined as people who have had to leave their homes in the context of an emergency because of a deliberate event such as conflict or war. This includes those who identified as refugees or asylum seekers (i.e. displaced people who cross international borders) as well as internally displaced people (i.e. people who remain in their own country). A list of common definitions for terms used in this review are provided in Box 1.
Outcomes.
All studies reporting data on rate or prevalence of suicide, suicide attempts, and suicidal ideation among populations of displaced people were considered for inclusion. For this review we consider suicidal ideation to mean having thoughts or ideas about the possibility of ending one’s life, a suicide attempt to be an attempt to die by suicide that results in survival, and suicide to be intentionally causing one’s death. These outcomes were defined in each study by the authors of the primary studies. We considered suicide estimates measured by death registers, surveillance systems, autopsies (verbal and recorded), and medical records, and estimates of suicidal attempts and ideation measured using validated tools or survey questions.
As the design of the included studies varied, the source and type of data reported for these outcomes also varied. All relevant data for these outcomes was extracted and presented according to data source, host country, and prevalence period (i.e. lifetime prevalence, point prevalence). Where available, data were also extracted on comparative estimates between displaced people and host or general populations.
Search methods.
A broad search strategy informed by experts in this area was developed to maximise sensitivity, combining medical subject headings and free text terms (see S1 Table) to identify relevant studies in the following databases:
- MEDLINE (Pubmed)
- Embase (OVID)
- CINAHL (Cumulative Index to Nursing and Allied Health Literature, EBSCOHost)
- PsycINFO (EBSCOHost)
- Social Science Citation Index (SSCI, Web of Science)
- Scopus (Elsevier)
- Global Index Medicus at http://search.bvsalud.org/ghl/index.php
- Suicide Information and Education Collection (SIEC) database
Searches were conducted in April 2019 and updated in August 2020. Searches were not limited by publication date, geographical location, or language. The reference lists of relevant articles and reviews were screened to identify additional studies.
Selection of studies.
Two reviewers independently screened the abstracts of all studies identified by the search strategy. Following this stage, two reviewers also independently screened full texts of studies appearing to meet the inclusion criteria. Discrepancies were discussed among the reviewers, and where necessary a third reviewer assessed the study under discussion until a consensus was reached.
Data extraction and management.
One reviewer extracted study characteristics and relevant outcome data from all included studies. A second reviewer cross-checked all extracted data and any discrepancies between the two reviewers were discussed. Relevant information extracted from each study included: population characteristics (such as ethnicity, age, religion, trauma exposure, and duration of resettlement), setting, study design, study dates, data collection method and source of data. For each of the three outcomes of interest, the number of participants analysed as well as summary statistics were extracted where available. Host countries/territories (where studies were conducted) were classified into the four World Bank income levels (i.e., low, lower middle, upper middle, high).
Methodological quality.
The search strategy was designed to capture the breadth of the available literature in this population. As a result, a variety of study designs were considered for inclusion in this review. This prevented the use of a single checklist approach to assessing methodological quality and required a more pragmatic approach. The assessment in this review was based on the study design and the source from which data were obtained. Using this pragmatic approach, we judged studies drawing on vital events registration, specific demographic surveillance, and longitudinal population-based cohorts to be of higher quality while studies drawing on data from retrospective cohorts/analysis and cross-sectional surveys were considered low quality.
Data synthesis.
The following common metrics were calculated using the extracted data for each study, when possible, to facilitate comparison across studies, population groups, and settings: suicide rate per 100,000 person-years, prevalence of suicide attempt in percentage, and prevalence of suicidal ideation in percentage with 95% confidence intervals (CIs). Where data were also available comparing the rates or prevalence of the three outcomes in displaced people with the general population of the host country, relative estimates (relative risks or hazard ratios) with 95% CIs were calculated and presented.
We chose not to pool rates of suicide across studies due to the heterogeneity of study designs and used narrative syntheses with tabulated and textual descriptions systematically reporting results for the three aspects of suicidal behaviour. Comparative results with host populations were synthesised using the vote counting based on the direction of effect method [14, 15].
The reporting of studies and results in this review are grouped into two main categories, based on their likely representativeness to the target population or to a target subgroup (for example, adolescents, pregnant women):
- studies using representative or non-selected samples of the target group (that is, evaluating where possible the whole population or whole subgroup, as applicable), referred to below as “general samples”, and
- studies using selected samples of the target group based on their inclusion criteria that may confound the outcomes (for example, known high risk groups within the populations of displaced people, such as those already diagnosed with mental illness), referred to below as “specific samples”.
Furthermore, within each category results are presented separately for the following five population subgroups:
- refugees granted permanent asylum status,
- refugees living in refugee camps or with only temporary protection,
- asylum seekers,
- mixed samples of refugees & asylum seekers, and
- internally displaced people.
Due to possible overlap, if a study reports the population as asylum seekers living in camps, this was categorised under refugees living in camps.
Results
Included studies
A total of 6899 records were identified by the electronic searches. Following removal of duplicates, 4347 abstracts were screened by two reviewers. Of these, 1107 full-text articles were considered potentially relevant. Finally, 87 articles reporting on 77 studies [16–92] plus 10 companion articles [93–102] were included in this review. Reasons for study exclusions are outlined in the PRISMA flow diagram (Fig 1). Five of the included articles were published in languages other than English. These were Danish, Dutch, two in German, and Spanish [50, 79, 83, 90, 99].
Of the 77 included studies, 53 were in general samples and 24 used specific samples. The types of data sources used for each outcome are presented below. Characteristics of the 53 included studies and their populations that used general samples are presented in Table 1, grouped by population subgroup. Additional characteristics are also reported in the corresponding outcome results tables. Study characteristics and results for the specific samples (n = 24 studies) are reported in S2 Table. The various samples evaluated by these studies included people diagnosed/referred for mental health conditions, intoxication-related emergency department admissions, forensic autopsies ordered by attorney’s office, and emergency department admissions that required a forensic exam.
Suicide
Among the studies using general samples, 11 reported on suicide rates [20, 33, 37, 42, 49, 57, 62, 72, 73, 79, 89]. Suicide results, including a visual bar chart display and some characteristics are presented in Table 2. Six of these studies were in refugees granted asylum, one was in refugees living in a refugee camp, three were in asylum seekers, and one was in internally displaced people. Nine studies were conducted in high income level host countries (HIC; as per 2021 World Bank classification), while the study in a refugee camp was in Thailand (an upper middle-income country, UMIC) and the one study on internally displaced people was in Sudan (a low income country, LIC). The sample size of displaced people in these studies ranged from 4164 to 196,941.
All six studies in refugees granted asylum and one of the studies on asylum seekers used vital events registration as the data source. The other studies on asylum seekers used specific monitoring data as the data source or a cross-sectional study design. The study in a refugee camp was a retrospective cohort, and the one on internally displaced people used a cross-sectional study design.
Suicide rates ranged considerably from 4.0 to 290 per 100,000 person-years across the 11 studies in general samples (Table 2). In refugees granted asylum, suicide rates ranged from 4.1 to 25.5 per 100,000 person-years, while in asylum seekers suicide rates ranged from 4.0 to 51.2 per 100,000 person-years. The study in a refugee camp found a suicide rate of 16 per 100,000 person-years, while the study on internally displaced people (in Sudan, a LIC) had the highest suicide rate of 290 per 100,000 person-years.
Only eight studies with general samples also compared suicide rates in displaced people to the host population, including five studies in refugees granted asylum and three conducted in asylum seekers. Seven studies [20, 37, 42, 57, 62, 72, 89] reported data in formats that could be presented visually in forest plots, which were grouped by outcome measure and then sub-grouped by population type (Fig 2).
Norredam 2013 [62] adjusted for age and income; Amin 2021 [20] adjusted for socio-demographic, labour market marginalisation and morbidity factors (i.e. sex, age, educational level, family situation and type of residential area, days with full-time unemployment, net days with sickness absence, granted disability pension, history of suicide attempt; history of inpatient or specialised outpatient healthcare); Hollander 2020 [42] adjusted for attained age, gender, and disposable income; Goosen 2011 [37] standardised for age; Westman 2006 [89] adjusted for age, marital status, socioeconomic status, and hospitalization for psychiatric disorders or substance abuse; Saunders 2019 [73] and Mittendorfer-Rutz 2020 [57] were unadjusted.
Among the studies in refugees granted asylum, there was evidence of a lower risk of suicide compared with the host population in four studies [20, 42, 62, 72]. The final study on refugees granted asylum [89] reported lower, higher, and inconclusive risk compared with the host population depending on gender of the refugees and their birth region. In contrast, among the studies in asylum seekers there was evidence of a higher suicide risk compared with the host population in two studies [50, 57], including one study that reported age-standardised mortality ratios (SMR) of 2.8 [95% CI 1.5, 4.1] in males, and 1.5 [95% CI 0.0, 3.6] in females [50]. The third asylum seekers study was inconclusive about whether the risk was higher or lower, as it varied based on gender [37].
An additional study [31] on asylum seekers in detention in the UK estimated 211 suicides per 100,000, however, a rate estimate could not be calculated as total person-year was not reported.
Only two studies using specific samples were identified that reported on suicide rates; one study described forensic autopsies of deceased refugees [36], and the other study only reported on the proportion of suicides amongst causes of death in refugees [41] (S3 Table).
Suicide attempt
Among the studies using general samples, 15 [17, 18, 20, 30, 39, 47–49, 54, 55, 77, 79, 83, 85, 88] reported on the prevalence of suicide attempts (Table 3). The results are ordered by timeframe for the prevalence estimates and then sub-grouped by population type. Six of these studies were in refugees granted asylum, three were in refugees living in refugee camps, one was in mixed refugees & asylum seekers, two were in asylum seekers, and three were in internally displaced people. Ten studies were from high income countries, and the other five were conducted in India (a lower middle-income country, LMIC), Jordan (UMIC), Sudan (LIC), and two in Colombia (UMIC). The sample sizes of displaced people ranged from 53 to 196,941.
Two of the 15 studies had a prospective cohort design, one used specific monitoring data as the data source, one used national statistics, while 11 studies had a cross-sectional design. The prevalence timeframe of the studies (i.e. either how far back participants were asked about the occurrence of a suicide attempt or the follow-up time) ranged from 1 week to 9 years.
The prevalence of suicide attempts ranged from 0.14% to 15.1% across the studies in general samples (Table 3). In refugees granted asylum, the prevalence of suicide attempt ranged from 0.14% to 15.1%, and in the refugees living in camps it ranged from 0.18% to 7.3%. In the studies on asylum seekers the prevalence was 1.0% and 2.9%, and in internally displaced people it ranged from 2.2% to 9.1%. The study in mixed refugees & asylum seekers found a suicide attempt prevalence of 0.78%. The one study in a LIC (Sudan) did not find a higher prevalence than average.
Six studies in general samples compared the prevalence of suicide attempts in displaced people to the host population. Only five of these studies [20, 30, 54, 77, 81] reported data in formats that could be presented visually in forest plots (Fig 3). Two of these studies were in refugees granted asylum, one was in mixed refugees & asylum seekers, one was in internally displaced people, and one was a pooled report of mixed refugee populations across 21 countries [81].
Choi 2020 [30] adjusted for interview year; Stein 2010 [81] adjusted for person-year, country, demographic factors (age, sex, time-varying education, time-varying marriage), interactions between life course and demographic variables, parent psychopathology, and childhood adversities; Amin 2021 [20] adjusted for socio-demographic, labour market marginalisation and morbidity factors (i.e. sex, age, educational level, family situation and type of residential area, days with full-time unemployment, net days with sickness absence, granted disability pension, history of suicide attempt; history of inpatient or specialised outpatient healthcare); Sohn 2019 [77] age- and gender-matched; Marroquin-Rivera 2020 [54] unadjusted.
In the two studies on refugees granted asylum, one reported a lower risk of suicide attempt than in the host population [20] while the other reported a higher risk [30]. The study of mixed refugee types [81] reported an odds ratio of 1.00 [95% CI 0.60, 1.67] indicating little to no difference between the refugees and the host populations. In one study [77] on mixed refugees & asylum seekers, they found a higher risk of suicide attempts. One study [54] on internally displaced people found a 4-fold greater risk of suicide attempt compared to the host population, RR 4.43 [95% CI 2.18, 9.00]. In addition, one study [79] found asylum seekers had a 3.4 times higher rate of suicide attempts compared to the host population (unadjusted).
One study [87] reported a composite outcome of self-harm or suicide. Refugees granted asylum were evaluated over a one-year timeframe and prevalence was reported as 0.10%, the rate was 101.2 per 100,000 person-years, and the comparative result was RR 0.80 [95% CI 0.58, 1.08] (unadjusted) for self-harm or suicide compared to the host population.
An additional three studies reported only a composite outcome of self-harm or suicide attempt. One [72] was conducted in refugees granted asylum, and the study timeframe ranged from 5–14 years. Prevalence was 0.68%, and the rate was 8.09 per 100,000 person-years [95% CI 7.31, 8.93]. The comparative result was found to be RR 0.85 [95% CI 0.77, 0.94] (unadjusted) for this composite outcome. In contrast, one of two studies [37] was conducted in asylum seekers, and the study timeframe was not reported. The rate was 119.2 per 100,000 person-years in males, and 188.2 per 100,000 person-years in females. Compared to the host population for self-harm or suicide attempt, asylum seekers had age-standardised RR 1.42 [95% CI 1.20, 1.66] in males, and RR 1.00 [95% CI 0.84, 1.18] in females. The other study [80] in asylum seekers assessed 10 detained families and found the prevalence of self-harm or suicide attempt was 29.4%.
Nine studies using specific samples of the target populations reported on suicide attempts (S4 Table).
Suicidal ideation
Among the studies with general samples, 37 [16–18, 21, 25, 30, 32, 35, 44, 45, 47–49, 52, 54, 55, 60, 61, 64, 66, 70, 71, 75, 77–80, 82–84, 86, 88, 90] reported on the prevalence of suicidal ideation (Table 4). The findings were ordered by prevalence timeframe and sub-grouped by population type. 11 studies were in refugees granted asylum, 11 were in refugees living in refugee camps, eight were in asylum seekers, three were in mixed refugees & asylum seekers, and four were in internally displaced people. 22 studies were from high income countries, and 15 were conducted in: India (LMIC), Lebanon (UMIC), Malaysia (UMIC), Nigeria (LMIC), Occupied Palestinian Territory (LMIC), Pakistan (LMIC), Syria (LIC), Thailand (UMIC), Uganda (LIC), and two each in Colombia (UMIC), Jordan (UMIC), and Sudan (LIC).
Two of the 37 studies used specific monitoring data as the data source, two used national statistics, and 33 had a cross-sectional design. The timeframe of the evaluation ranged from the ‘current state’ to 1 year. Sample sizes of displaced people ranged from 33 to 8526.
Prevalence of suicidal ideation ranged from 0.17% to 70.6% across the studies in general samples (Table 4). In refugees granted asylum, the prevalence of suicidal ideation ranged from 0.24% to 35.0%, and in refugees living in camps it ranged from 1.2% to 32.3%. In asylum seekers the prevalence ranged from 0.17% to 70.6%, and in internally displaced people from 0.48% to 19.8%. The mixed refugees & asylum seekers studies reported prevalences of 3.1%, 23.8% and 33.9%. There was not a pattern of generally higher prevalence in low income countries across the 4 LIC studies.
Only nine studies [16, 30, 45, 54, 71, 75, 77, 81] in general samples compared suicidal ideation in displaced people to the host population as displayed in Fig 4. Two of these studies were in refugees granted asylum, four were in refugees living in refugee camps with only temporary protection, one was in mixed refugees & asylum seekers, one was in internally displaced people, and one was a pooled report of mixed refugees across 21 countries [81].
Choi 2020 [30] adjusted for interview year; Stein 2010 [81] adjusted for person-year, country, demographic factors (age, sex, time-varying education, time-varying marriage), interactions between life course and demographic variables, parent psychopathology, and childhood adversities; Sohn 2019 [77] age- and gender-matched; Akinyemi 2012 [16], Itani 2017 [45], Slodnjak 2002 [75], Marroquin-Rivera 2020 [54], and Salama 2020 [71] were unadjusted.
Among refugees living in refugee camps, there was evidence of a higher risk of suicidal ideation compared with the host population from three studies [16, 45], while one study reported a lower risk [75]. There was evidence of a higher risk of suicidal ideation among refugees granted asylum in two studies [30, 71]. Individual studies reported higher risk of suicidal ideation in mixed refugee and asylum seeker populations [77], and internally displaced people [54]. The report [81] of mixed refugees across 21 countries reported little to no difference in risk of suicidal ideation compared with the host population (OR 1.00 [95% CI 0.80, 1.25]).
An additional two studies in general samples reported a composite outcome of suicidal ideation or suicide attempt. One study [26] evaluated mixed refugees & asylum seekers, and the study timeframe was 1 month. Prevalence was 9.1% [95% CI 4.9, 15] for suicidal ideation or suicide attempt. The other [29] was conducted in asylum seekers, and the prevalence was 55.6% for this composite outcome. This study’s timeframe was not reported.
Three studies only reported continuous outcome data on suicidal ideation. One [76] was conducted in refugees granted asylum but the study’s timeframe was not reported. Mean score using the Suicidal Ideation Scale was 20.34 (SD 7.39). A study [91] in refugees with only temporary protection reported mean scores using the Personality Assessment Index’s Suicide Ideation subscale were 49.5 (SD 10.9) in males and 53.8 (SD 17.0) in females (timeframe was not reported). The other [38] assessed asylum seekers, and the timeframe was 2 weeks. Mean score using the PHQ-9 symptom severity Item 9 for suicidal ideation was 0.98 (SD 1.11).
Sixteen studies using specific samples reported on suicidal ideation (S5 Table).
Discussion
This systematic review identified 77 studies that reported on suicide, suicide attempts, or suicidal ideation in displaced people. Estimates of suicide rates from the studies which are more representative of refugee and asylum seeker populations (i.e. general samples) ranged widely and appeared to differ based on the source of the data and the population subgroup being assessed. Estimates of the prevalence of suicide attempts or suicidal ideation also ranged widely and were inconsistently reported across studies, making comparisons across groups challenging.
While numerous studies have been published on this topic, the evidence base is still sparse for the differing contexts of refugees in refugee camps, asylum seekers, and internally displaced people. Additionally, fewer than half of the studies reported on suicides or suicide attempts and almost one third of the studies were not representative samples of the target population. This systematic review has provided an overview of the populations, contexts, and study designs that have been used for research on suicide and suicidal behaviours in these populations, but further research is warranted to fill the gaps in knowledge around these specific populations.
The heterogeneity in study populations, designs, analytical approaches, and results mean that it is not possible to draw firm conclusions on the comparative rate of suicide in refugees and host populations. The results from different studies are inconclusive, with several studies suggesting that rates of suicide may be lower in refugees granted asylum than in the host populations [20, 42, 72, 89]. These results should be interpreted with caution because the variability of the available data may be due to effect estimates being mediated by a range of mechanisms. These factors might include the local context (such as rates or prevalence of suicidal behaviour in the host population, as well as possible confounders such as poverty and deprivation), as well as possible mechanisms of action, such as the extent of physical injury, loss of housing, financial distress, and the level of social support that is provided. The length of stay in a host country has also been suggested as a potential mediator, with refugees having a lower risk once they have lived in a host country for longer than 10 years [42].
The strengths of this systematic review included developing a sensitive search strategy and screening all results in duplicate, as well as careful evaluation and reporting of the data according to study design and population. However, there are some limitations to this review, particularly around the sparse international evidence base which prevents us from drawing firm conclusions. The wide variety of study designs and approaches to reporting risks prevented meta-analysis of the results. This variety in study designs also means that we were only able to do a relatively high-level assessment of methodological quality based on the source of data for the studies included in this review. Further data on mediators or risk factors for suicidal behaviour in these populations could add to the evidence base and strengthen the development of prevention or management interventions. In addition, there is potential for overlap in the five population subgroups used in this review. It is often difficult to distinguish which of these subgroups a study population belongs to without access to further population characteristics from the primary studies.
Despite the sparsity of studies, there is evidence of a high risk of suicide and suicidal behaviour among refugees in camps and asylum seekers, which suggests that these groups require additional support and monitoring. Strengthening the evidence base around the risk of suicidal behaviour in these vulnerable groups is needed to further develop understanding of the factors that influence them. Many factors have been suggested to influence the risk of suicide and suicidal ideation in these populations, including a combination of socioeconomic disadvantage [93], exposure to potentially traumatic events [103], increased depression and anxiety [104], or a lack of appropriate and accessible care [39, 105]. Improvements in understanding the suicide risk in these populations can be made by better routine data collection to enable consistent surveillance across countries. Countries hosting people affected by conflict, including refugees and asylum seekers, should ensure that these groups are identifiable in routine data [12, 104]. Agreed methods for analysing and presenting data would support comparisons between exposed populations in different countries and settings and would aid in quantitative synthesis of the risk of suicidal behaviours.
Finally, a better understanding of mediating factors may also help to inform policy responses and potential interventions for refugees or displaced people. A recent review found only a limited number of suicide prevention or response programs were implemented for refugee or displaced populations [4]. The review recommended programs that were multi-tiered, focussing on multiple levels of suicide prevention. A comprehensive approach to suicide prevention should include adequate surveillance, identify risk and protective factors, and ensure evaluation of programs following implementation. Studies on prevalence are well placed to identify risk and protective factors that might explain some of the variability across populations and contexts. For example, studies should consider including measures of local context as well as potential mediators such as experience of physical injury, loss of housing, financial hardship, levels of social support, legal context, and access to mental health services [106, 107].
Given the high risk of suicide in refugees in camps and asylum seekers, host countries should increase efforts to prevent suicide in asylum seekers, with actions that may span from speeding up asylum processes and improving social conditions of asylum seekers to offering better mental health prevention and management interventions. Given that prevalence of mental disorders is high in displaced people and that that these conditions appear associated with suicide attempts, there is a need to invest in prevention and care of mental disorders in this vulnerable group.
Supporting information
S1 Table. PubMed search strategy to identify studies on suicide in displaces people.
https://doi.org/10.1371/journal.pone.0263797.s001
(PDF)
S2 Table. Characteristics of included studies using specific samples, grouped by population type.
https://doi.org/10.1371/journal.pone.0263797.s002
(PDF)
S3 Table. Suicide rates per 100,000 person-years using specific samples.
https://doi.org/10.1371/journal.pone.0263797.s003
(PDF)
S4 Table. Suicide attempt prevalence percentage using specific samples, ordered by population type (and then by author).
https://doi.org/10.1371/journal.pone.0263797.s004
(PDF)
S5 Table. Suicidal ideation prevalence percentage using specific samples, ordered by population type (and then by author).
https://doi.org/10.1371/journal.pone.0263797.s005
(PDF)
Acknowledgments
The authors would like to acknowledge Alexandra Fleischmann, Mark van Ommeren and the WHO advisory group (Corrado Barbui, Fiona Charlson, Pim Cuijpers, David Gunnell, GJ Melendez-Torres, Wietse Tol, and Pieter Ventevogel) for advice on the protocol and review of the WHO-commissioned background paper.
The authors would also like to acknowledge additional members of the Cochrane Response team, Hanna Bergman, Jennifer Petkovic, Katrin Probyn, and Yanina Sguassero, for their assistance in extracting and checking data.
References
- 1.
United Nations Office for the Coordination of Humanitarian Affairs (OCHA). Global Humanitarian Overview 2022. New York: OCHA; 2021. https://gho.unocha.org/trends/forced-displacement-record-levels-covid-19-hampers-durable-solutions
- 2.
United Nations High Commissioner for Refugees (UNHCR). Global Trends Forced Displacement in 2020. UNHCR; 2021. https://www.unhcr.org/60b638e37/unhcr-global-trends-2020
- 3. Spiegel PB, Checchi F, Colombo S, Paik E. Health-care needs of people affected by conflict: future trends and changing frameworks. The Lancet. 2010;375(9711):341–5. pmid:20109961
- 4.
Haroz EE, Decker, E., Lee, C. Evidence for suicide prevention and response programs with refugees: a systematic review and recommendations. Geneva: United Nations High Commissioner for Refugees (UNHCR); 2018. https://www.unhcr.org/5e15d3d84.pdf
- 5.
World Health Organization. World health statistics 2021: monitoring health for the SDGs, sustainable development goals. Geneva: World Health Organization; 2021.
- 6.
World Health Organization. Suicide in the world: Global health estimates. Geneva: World Health Organization; 2019.
- 7.
United Nations General Assembly. Transforming our world: the 2030 Agenda for Sustainable Development: UN General Assembly; 2015. https://www.refworld.org/docid/57b6e3e44.html
- 8. Vijayakumar L, Jotheeswaran A. Suicide in refugees and asylum seekers. Mental health of refugees and asylum seekers. 2010:195–210.
- 9. Charlson F, van Ommeren M, Flaxman A, Cornett J, Whiteford H, Saxena S. New WHO prevalence estimates of mental disorders in conflict settings: a systematic review and meta-analysis. The Lancet. 2019. pmid:31200992
- 10. Carta MG, Bernal M, Hardoy MC, Haro-Abad JM, Report on the Mental Health in Europe Working G. Migration and mental health in Europe (the state of the mental health in Europe working group: appendix 1). Clin Pract Epidemiol Ment Health. 2005;1:13. pmid:16135246
- 11.
World Health Organization. Suicide in the world: Global health estimates. Geneva; 2019.
- 12. Vijayakumar L. Suicide Among Refugees—A Mockery of Humanity. Crisis. 2016;37(1):1–4. pmid:27033678
- 13.
World Health Organization. Preventing Suicide: a global imperative. Geneva: World Health Organization; 2014.
- 14.
McKenzie JE, Brennan SE. Synthesizing and presenting findings using other methods. In: Higgins JPT, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, et al., editors. Cochrane handbook for systematic reviews of interventions. Version 62 (updated February 2021). London, UK: Cochrane; 2021. pp. 321–47.
- 15. Campbell M, McKenzie JE, Sowden A, Katikireddi SV, Brennan SE, Ellis S, et al. Synthesis without meta-analysis (SWiM) in systematic reviews: reporting guideline. BMJ. 2020;368. pmid:31948937
- 16. Akinyemi OO, Owoaje ET, Ige OK, Popoola OA. Comparative study of mental health and quality of life in long term refugees and host populations in Oru-Ijebu, Southwest Nigeria. BMC research notes. 2012;5(1):1–9. pmid:22846111
- 17. Al-Modallal H. Patterns of coping with partner violence: Experiences of refugee women in Jordan. Public Health Nursing. 2012;29(5):403–11. pmid:22924563
- 18. Alley JC. Life-threatening indicators among the Indochinese refugees. Suicide & life-threatening behavior. 1982;12(1):46–51. pmid:7112635
- 19. Allodi F, Cowgill G. Ethical and psychiatric aspects of torture: A Canadian study. The Canadian Journal of Psychiatry / La Revue canadienne de psychiatrie. 1982;27(2):98–102. pmid:7066853
- 20. Amin R, Helgesson M, Runeson B, Tinghög P, Mehlum L, Qin P, et al. Suicide attempt and suicide in refugees in Sweden–a nationwide population-based cohort study. Psychological medicine. 2021;51(2):254–63. pmid:31858922
- 21. Ao T, Shetty S, Sivilli T, Blanton C, Ellis H, Geltman PL, et al. Suicidal ideation and mental health of Bhutanese refugees in the United States. Journal of immigrant and minority health. 2016;18(4):828–35. pmid:26711245
- 22. Aronsson B, Wiberg C, Sandstedt P, Hjern A. Asylum-seeking children with severe loss of activities of daily living: clinical signs and course during rehabilitation. Acta paediatrica (Oslo, Norway: 1992). 2009;98(12):1977–81. pmid:19814751
- 23. Belz M, Belz M, Özkan I, Graef-Calliess IT. Posttraumatic stress disorder and comorbid depression among refugees: assessment of a sample from a German refugee reception center. Transcultural Psychiatry. 2017;54(5–6):595–610. pmid:29226790
- 24. Betancourt TS, Newnham EA, Birman D, Lee R, Ellis BH, Layne CM. Comparing trauma exposure, mental health needs, and service utilization across clinical samples of refugee, immigrant, and US-origin children. Journal of traumatic stress. 2017;30(3):209–18. pmid:28585740
- 25. Bhui K, Abdi A, Abdi M, Pereira S, Dualeh M, Robertson D, et al. Traumatic events, migration characteristics and psychiatric symptoms among Somali refugees—preliminary communication. Social psychiatry and psychiatric epidemiology. 2003;38(1):35–43. pmid:12563557
- 26. Bhui K, Craig T, Mohamud S, Warfa N, Stansfeld SA, Thornicroft G, et al. Mental disorders among Somali refugees: developing culturally appropriate measures and assessing socio-cultural risk factors. Social psychiatry and psychiatric epidemiology. 2006;41(5):400–8. pmid:16520881
- 27. Bolton P, Lee C, Haroz EE, Murray L, Dorsey S, Robinson C, et al. A Transdiagnostic Community-Based Mental Health Treatment for Comorbid Disorders: Development and Outcomes of a Randomized Controlled Trial among Burmese Refugees in Thailand. PLoS Medicine. 2014;11(11). pmid:25386945
- 28. Brown AD, Müller M, Hirschi T, Henssler JF, Rönz K, Exadaktylos AK, et al. Acute and mixed alcohol intoxications in asylum seekers presenting to an urban emergency department in Switzerland. BMC public health. 2019;19(1):1–8.
- 29. Cheney MK, Gowin MJ, Taylor EL, Frey M, Dunnington J, Alshuwaiyer G, et al. Living outside the gender box in Mexico: testimony of transgender Mexican asylum seekers. American journal of public health. 2017;107(10):1646–52. pmid:28817317
- 30. Choi S, Kim K. We Don’t Belong Here: Adolescents of North Korean Refugee Families and Their Suicidal Behaviors. International Migration. 2020;58(6):232–46.
- 31. Cohen J. Safe in our hands?: a study of suicide and self-harm in asylum seekers. Journal of forensic and legal medicine. 2008;15(4):235–44. pmid:18423357
- 32. Falb KL, McCormick MC, Hemenway D, Anfinson K, Silverman JG. Suicide ideation and victimization among refugee women along the Thai-Burma border. Journal of traumatic stress. 2013;26(5):631–5. pmid:24038637
- 33. Fellmeth G, Paw MK, Wiladphaingern J, Charunwatthana P, Nosten FH, McGready R. Maternal suicide risk among refugees and migrants. International journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics. 2016;134(2):223–4. pmid:27177519
- 34. Ferrada-Noli M, Sundbom E. Cultural bias in suicidal behaviour among refugees with post-traumatic stress disorder. Nordic Journal of Psychiatry. 1996;50(3):185–91.
- 35. Fuhrer A, Eichner F, Stang A. Morbidity of asylum seekers in a medium-sized German city. European journal of epidemiology. 2016;31(7):703–6. pmid:27068422
- 36. Gleich S, Domingo O, Ackermann N, Schwerer M, Graw M, Schöpfer J. A post-mortem study of the cause of death and concomitant diseases of refugees in Munich (2014–2015). Rechtsmedizin. 2018;28(1):25–32.
- 37. Goosen S, Kunst AE, Stronks K, van Oostrum IE, Uitenbroek DG, Kerkhof AJ. Suicide death and hospital-treated suicidal behaviour in asylum seekers in the Netherlands: a national registry-based study. BMC public health. 2011;11:484. pmid:21693002
- 38. Grupp F, Piskernik B, Mewes R. Is depression comparable between asylum seekers and native Germans? An investigation of measurement invariance of the PHQ-9. J Affect Disord. 2020;262:451–8. pmid:31744740
- 39. Hermans MPJ, Kooistra J, Cannegieter SC, Rosendaal FR, Mook-Kanamori DO, Nemeth B. Healthcare and disease burden among refugees in long-stay refugee camps at Lesbos, Greece. European journal of epidemiology. 2017;32(9):851–4. pmid:28597126
- 40. Hocking D, Sundram S. Demoralisation syndrome does not explain the psychological profile of community-based asylum-seekers. Comprehensive Psychiatry. 2015;63:55–64. pmid:26555492
- 41. Hollander A-C. Social inequalities in mental health and mortality among refugees and other immigrants to Sweden–epidemiological studies of register data. Global health action. 2013;6(1):21059. pmid:23810108
- 42. Hollander A-C, Pitman A, Sjöqvist H, Lewis G, Magnusson C, Kirkbride JB, et al. Suicide risk among refugees compared with non-refugee migrants and the Swedish-born majority population. The British Journal of Psychiatry. 2020;217(6):686–92. pmid:31608849
- 43. Hougen HP. Physical and psychological sequelae to torture. A controlled clinical study of exiled asylum applicants. Forensic science international. 1988;39(1):5–11. pmid:3209147
- 44. Huemer J, Karnik N, Voelkl-Kernstock S, Granditsch E, Plattner B, Friedrich M, et al. Psychopathology in African unaccompanied refugee minors in Austria. Child Psychiatry & Human Development. 2011;42(3):307–19.
- 45. Itani T, Jacobsen KH, Kraemer A. Suicidal ideation and planning among Palestinian middle school students living in Gaza Strip, West Bank, and United Nations Relief and Works Agency (UNRWA) camps. International journal of pediatrics & adolescent medicine. 2017;4(2):54–60.
- 46. Jahangir F, ur Rehman H, Jan T. Degree of religiosity and vulnerability to suicidal attempt/plans in depressive patients among Afghan refugees. The International Journal for the Psychology of Religion. 1998;8(4):265–9.
- 47. Jankovic J, Bremner S, Bogic M, Lecic-Tosevski D, Ajdukovic D, Franciskovic T, et al. Trauma and suicidality in war affected communities. European psychiatry: the journal of the Association of European Psychiatrists. 2013;28(8):514–20. pmid:22986125
- 48. Keller AS, Rosenfeld B, Trinh-Shevrin C, Meserve C, Sachs E, Leviss JA, et al. Mental health of detained asylum seekers. The Lancet. 2003;362(9397):1721–3. pmid:14643122
- 49. Kim G, Torbay R, Lawry L. Basic health, women’s health, and mental health among internally displaced persons in Nyala Province, South Darfur, Sudan. American journal of public health. 2007;97(2):353–61. pmid:17138925
- 50. Koppenaal H, Bos CA, Broer J. [High mortality due to infectious diseases and unnatural causes of death among asylum seekers in the Netherlands, 1998–1999]. Nederlands tijdschrift voor geneeskunde. 2003;147(9):391–5. Dutch. pmid:12661458
- 51. Lama S, Francois K, Marwan Z, Sami R. Impact of the Syrian Crisis on the Hospitalization of Syrians in a Psychiatric Setting. Community mental health journal. 2016;52(1):84–93. pmid:25982832
- 52. Leiler A, Hollifield M, Wasteson E, Bjärtå A. Suicidal ideation and severity of distress among refugees residing in asylum accommodations in Sweden. International journal of environmental research and public health. 2019;16(15):2751. pmid:31374949
- 53. Lerner E, Bonanno GA, Keatley E, Joscelyne A, Keller AS. Predictors of suicidal ideation in treatment-seeking survivors of torture. Psychological trauma: theory, research, practice and policy. 2016;8(1):17–24. pmid:25915645
- 54. Marroquín Rivera A, Rincón Rodríguez CJ, Padilla-Muñoz A, Gómez-Restrepo C. Mental health in adolescents displaced by the armed conflict: findings from the Colombian national mental health survey. Child and adolescent psychiatry and mental health. 2020;14:1–8.
- 55. Meyerhoff J, Rohan KJ. The desire to be dead among Bhutanese refugees resettled in the United States: Assessing risk. American journal of orthopsychiatry. 2020;90(2):236. pmid:31545623
- 56. Mezey AG. Psychiatric Illness in Hungarian Refugees. Journal of Mental Science. 1960;106(443):628–37.
- 57. Mittendorfer-Rutz EH, A; Hollander A. High suicide rates among unaccompanied minors/youth seeking asylum in Sweden. Crisis. 2020;41(4):314–7. pmid:31859565
- 58. Neuner F, Kurreck S, Ruf M, Odenwald M, Elbert T, Schauer M. Can asylum-seekers with posttraumatic stress disorder be successfully treated? A randomized controlled pilot study. Cognitive behaviour therapy. 2010;39(2):81–91. pmid:19816834
- 59. Nguyen SD. Mental health services for refugees and immigrants. Psychiatric Journal of the University of Ottawa. 1984;9(2):85–91. pmid:6379723
- 60. Nickerson A, Byrow Y, O’Donnell M, Mau V, McMahon T, Pajak R, et al. The association between visa insecurity and mental health, disability and social engagement in refugees living in Australia. European journal of psychotraumatology. 2019;10(1):1688129. pmid:32002133
- 61. Noh JW, Park H, Kwon YD, Kim IH, Lee YH, Kim YJ, et al. Gender Differences in Suicidal Ideation and Related Factors among North Korean Refugees in South Korea. Psychiatry investigation. 2017;14(6):762–9. pmid:29209379
- 62. Norredam M, Olsbjerg M, Petersen JH, Laursen B, Krasnik A. Are there differences in injury mortality among refugees and immigrants compared with native-born? Injury prevention: journal of the International Society for Child and Adolescent Injury Prevention. 2013;19(2):100–5. pmid:22627779
- 63. Olema DK, Catani C, Ertl V, Saile R, Neuner F. The hidden effects of child maltreatment in a war region: correlates of psychopathology in two generations living in Northern Uganda. Journal of traumatic stress. 2014;27(1):35–41. pmid:24478246
- 64. Park S, Rim SJ, Jun JY. Related Factors of Suicidal Ideation among North Korean Refugee Youth in South Korea. International journal of environmental research and public health. 2018;15(8). pmid:30096867
- 65. Premand N, Baeriswyl-Cottin R, Gex-Fabry M, Hiller N, Framorando D, Eytan A, et al. Determinants of Suicidality and of Treatment Modalities in a Community Psychiatry Sample of Asylum Seekers. The Journal of nervous and mental disease. 2018;206(1):27–32. pmid:28118267
- 66. Rahman A, Hafeez A. Suicidal feelings run high among mothers in refugee camps: a cross-sectional survey. Acta psychiatrica Scandinavica. 2003;108(5):392–3. pmid:14531761
- 67. Ramel B, Taljemark J, Lindgren A, Johansson BA. Overrepresentation of unaccompanied refugee minors in inpatient psychiatric care. SpringerPlus. 2015;4:131. pmid:25825687
- 68. Reko A, Bech P, Wohlert C, Noerregaard C, Csillag C. Usage of psychiatric emergency services by asylum seekers: Clinical implications based on a descriptive study in Denmark. Nord J Psychiatry. 2015;69(8):587–93. pmid:25765437
- 69. Richter K, Peter L, Lehfeld H, Zäske H, Brar-Reissinger S, Niklewski G. Prevalence of psychiatric diagnoses in asylum seekers with follow-up. BMC Psychiatry. 2018;18(1):1–7.
- 70. Salah TT, Abdelrahman A, Lien L, Eide AH, Martinez P, Hauff E. The mental health of internally displaced persons: an epidemiological study of adults in two settlements in Central Sudan. The International journal of social psychiatry. 2013;59(8):782–8. pmid:22982816
- 71. Salama E, Castaneda AE, Suvisaari J, Rask S, Laatikainen T, Niemelä S. Substance use, affective symptoms, and suicidal ideation among Russian, Somali, and Kurdish migrants in Finland. Transcultural psychiatry. 2020:1363461520906028.
- 72. Saunders NR, Lebenbaum M, Stukel TA, Lu H, Urquia ML, Kurdyak P, et al. Suicide and self-harm trends in recent immigrant youth in Ontario, 1996–2012: a population-based longitudinal cohort study. BMJ open. 2017;7(9):e014863. pmid:28864687
- 73. Saunders NR, Chiu M, Lebenbaum M, Chen S, Kurdyak P, Guttmann A, et al. Suicide and self-harm in recent immigrants in Ontario, Canada: a population-based study. The Canadian Journal of Psychiatry. 2019;64(11):777–88. pmid:31234643
- 74. Schoretsanitis G, Eisenhardt S, Ricklin ME, Srivastava DS, Walther S, Exadaktylos A. Psychiatric emergencies of asylum seekers; descriptive analysis and comparison with immigrants of warranted residence. International journal of environmental research and public health. 2018;15(7):1300.
- 75. Slodnjak V, Kos A, Yule W. Depression and parasuicide in refugee and Slovenian adolescents. Crisis. 2002;23(3):127–32. pmid:12542111
- 76. Sobhanian F, Boyle GJ, Bahr M, Fallo T. Psychological status of former refugee detainees from the Woomera Detention Centre now living in the Australian community. Psychiatry, Psychology and Law. 2006;13(2):151–9.
- 77. Sohn JH, Lim J, Lee JS, Kim K, Lim S, Byeon N, et al. Prevalence of possible depression and post-traumatic stress disorder among community dwelling adult refugees and refugee applicants in South Korea. Journal of Korean medical science. 2019;34(11). pmid:30914907
- 78. Ssenyonga J, Kani D, Owens V. Posttraumatic stress disorder, suicide, domestic violence and social support among refugees. Int J Psychol. 2012;47:777-.
- 79. Staehr MA, Munk-Andersen E. [Suicide and suicidal behavior among asylum seekers in Denmark during the period 2001–2003. A retrospective study]. Ugeskrift for laeger. 2006;168(17):1650–3. Danish. pmid:16674877
- 80. Steel Z, Momartin S, Bateman C, Hafshejani A, Silove DM, Everson N, et al. Psychiatric status of asylum seeker families held for a protracted period in a remote detention centre in Australia. Australian and New Zealand journal of public health. 2004;28(6):527–36. pmid:15707201
- 81. Stein DJ, Chiu WT, Hwang I, Kessler RC, Sampson N, Alonso J, et al. Cross-national analysis of the associations between traumatic events and suicidal behavior: Findings from the who world mental health surveys. PLoS ONE. 2010;5 (5) (no pagination)(e10574). pmid:20485530
- 82. Sultan A, O’sullivan K. Psychological disturbances in asylum seekers held in long term detention: A participant–observer account. Medical Journal of Australia. 2001;175(11–12):593–6. pmid:11837854
- 83. Tamayo Martinez N, Rincon Rodriguez CJ, de Santacruz C, Bautista Bautista N, Collazos J, Gomez-Restrepo C. [Mental Problems, Mood and Anxiety Disorders in The Population Displaced by Violence in Colombia; Results of The National Mental Health Survey 2015]. Revista colombiana de psiquiatria. 2016;45 Suppl 1:113–8. Spanish.
- 84. Tay AK, Rees S, Miah MAA, Khan S, Badrudduza M, Morgan K, et al. Functional impairment as a proxy measure indicating high rates of trauma exposure, post-migration living difficulties, common mental disorders, and poor health amongst Rohingya refugees in Malaysia. Translational psychiatry. 2019;9(1):1–9.
- 85. Tousignant M, Habimana E, Biron C, Malo C, Sidoli-LeBlanc E, Bendris N. The Quebec Adolescent Refugee Project: psychopathology and family variables in a sample from 35 nations. Journal of the American Academy of Child and Adolescent Psychiatry. 1999;38(11):1426–32. pmid:10560230
- 86. Um MY, Rice E, Lee JO, Kim HJ, Palinkas LA. Suicidal ideation among North Korean refugees in South Korea: Exploring the influence of social network characteristics by gender. Transcultural psychiatry. 2020:1363461520935314. pmid:32691690
- 87. Vigod SN, Arora S, Urquia ML, Dennis CL, Fung K, Grigoriadis S, et al. Postpartum self-inflicted injury, suicide, assault and homicide in relation to immigrant status in Ontario: a retrospective population-based cohort study. CMAJ open. 2019;7(2):E227–e35. pmid:30979727
- 88. Vijayakumar L, Mohanraj R, Kumar S, Jeyaseelan V, Sriram S, Shanmugam M. CASP—An intervention by community volunteers to reduce suicidal behaviour among refugees. The International journal of social psychiatry. 2017;63(7):589–97. pmid:28776476
- 89. Westman J, Sundquist J, Johansson LM, Johansson S-E, Sundquist K. Country of birth and suicide: a follow-up study of a national cohort in Sweden. Archives of Suicide Research. 2006;10(3):239–48. pmid:16717040
- 90. Winkler JG, Brandl EJ, Bretz HJ, Heinz A, Schouler-Ocak M. Psychische Symptombelastung bei Asylsuchenden in Abhängigkeit vom Aufenthaltsstatus. Psychiatrische Praxis. 2019;46(04):191–9. German.
- 91. Yu SE, Jeon WT. Mental health of north korean refugees in protective facilities in china. Psychiatry investigation. 2008;5(2):70–7. pmid:20046348
- 92. Yüzbaşıoğlu Y, Işık GÇ. Retrospective analysis of forensic cases in refugees admitted to emergency department. The American journal of emergency medicine. 2019;37(9):1691–3. pmid:30577984
- 93. Akinyemi OO, Atilola O, Soyannwo T. Suicidal ideation: Are refugees more at risk compared to host population? Findings from a preliminary assessment in a refugee community in Nigeria. Asian journal of psychiatry. 2015;18:81–5. pmid:26412050
- 94. Betancourt TS, Newnham EA, Layne CM, Kim S, Steinberg AM, Ellis H, et al. Trauma history and psychopathology in war-affected refugee children referred for trauma-related mental health services in the United States. Journal of traumatic stress. 2012;25(6):682–90. pmid:23225034
- 95. Björkenstam E, Helgesson M, Amin R, Lange T, Mittendorfer-Rutz E. Mental disorders and suicidal behavior in refugees and Swedish-born individuals: is the association affected by work disability? Social psychiatry and psychiatric epidemiology. 2020;55(8):1061–71. pmid:31897579
- 96. Björkenstam E, Helgesson M, Amin R, Mittendorfer-Rutz E. Mental disorders, suicide attempt and suicide: differences in the association in refugees compared with Swedish-born individuals. The British Journal of Psychiatry. 2020;217(6):679–85. pmid:31608856
- 97. Cochran J, Geltman PL, Ellis H, Brown C, Anderton S, Montour J, et al. Suicide and suicidal ideation among Bhutanese refugees—United States, 2009–2012. MMWR Morbidity and mortality weekly report. 2013;62(26):533. pmid:23820966
- 98. Ellis BH, Lankau EW, Ao T, Benson MA, Miller AB, Shetty S, et al. Understanding Bhutanese refugee suicide through the interpersonal-psychological theory of suicidal behavior. The American journal of orthopsychiatry. 2015;85(1):43–55. pmid:25642653
- 99. Richter K, Lehfeld H, Niklewski G. [Waiting for Asylum: Psychiatric Diagnosis in Bavarian Admission Center]. Gesundheitswesen (Bundesverband der Arzte des Offentlichen Gesundheitsdienstes (Germany)). 2015;77(11):834–8. German. pmid:26406770
- 100. Um MY, Rice E, Palinkas LA, Kim HJ. Migration-Related Stressors and Suicidal Ideation in North Korean Refugee Women: The Moderating Effects of Network Composition. Journal of traumatic stress. 2020;33(6):939–49. pmid:32529676
- 101. Van Oostrum IE, Goosen S, Uitenbroek DG, Koppenaal H, Stronks K. Mortality and causes of death among asylum seekers in the Netherlands, 2002–2005. Journal of Epidemiology & Community Health. 2011;65(4):376–83. pmid:20515894
- 102. Vonnahme LA, Lankau EW, Ao T, Shetty S, Cardozo BL. Factors Associated with Symptoms of Depression Among Bhutanese Refugees in the United States. Journal of immigrant and minority health. 2015;17(6):1705–14. pmid:25348425
- 103. Steel Z, Chey T, Silove D, Marnane C, Bryant RA, Van Ommeren M. Association of torture and other potentially traumatic events with mental health outcomes among populations exposed to mass conflict and displacement: a systematic review and meta-analysis. Jama. 2009;302(5):537–49. pmid:19654388
- 104. Lindert J, von Ehrenstein OS, Priebe S, Mielck A, Brähler E. Depression and anxiety in labor migrants and refugees–a systematic review and meta-analysis. Social science & medicine. 2009;69(2):246–57.
- 105. Wong EC, Marshall GN, Schell TL, Elliott MN, Hambarsoomians K, Chun C-A, et al. Barriers to mental health care utilization for US Cambodian refugees. Journal of consulting and clinical psychology. 2006;74(6):1116. pmid:17154740
- 106. Ventevogel P, Ryan G, Kahi V, Kane J. Capturing the essential: Revising the mental health categories in UNHCR’s Refugee Health Information System. Intervention-Journal of Mental Health and Psychosocial Support in Conflict Affected Areas. 2019;17(1):13-.
- 107. Procter NG, Kenny MA, Eaton H, Grech C. Lethal hopelessness: Understanding and responding to asylum seeker distress and mental deterioration. International Journal of Mental Health Nursing. 2018;27(1):448–54. pmid:28322492
