The provision of mental health services for asylum seekers and refugees

The Royal Australian and New Zealand College of Psychiatrists (RANZCP) presents this position statement to reflect its standpoint on the provision of mental health services to asylum seekers and refugees, and the governance framework under which care is provided. 

This position statement aims to provide psychiatrists with guidance for providing care to asylum seekers and refugees and outlines some of the important ethical details in this unique field. The position statement also contains recommendations for the construction and operation of immigration systems and processes regarding the provision of health care. 

Key messages

• Access to healthcare is a legal right, including during the immigration process. 
• Health services for asylum seekers and refugees to be provided at an equitable level to the general population.
• Detention can cause acute and ongoing harm; the College does not support the use of detention for immigration processing.
• Children are best served remaining with their primary caregivers unless it is in the best health and developmental interests of the child. 
• Psychiatrists must have the capacity to practice to the highest standards without undue external influence. 
• Asylum seekers and refugees have the same legal entitlements regarding confidentiality of health records

Definition of asylum seekers and refugees

An asylum seeker is a person who has fled their own country and applied for protection as a refugee. A refugee is a person whose claim for asylum has been granted. This is generally on the basis of a person being found to be outside their own country and unable to return due to the fear of  persecution due to their race, religion, nationality, or membership of a particular social group or political opinion.[1,2] Refugee status may also be conferred on those entitled to protection under laws of armed conflict, international humanitarian law, and other international covenants and conventions, including those pertaining to civil and political rights, torture and genocide.[3,4]

Role of the Psychiatrist

Psychiatrists have a leadership role in providing mental health care and support to asylum seekers and refugees. For asylum seekers and refugees, it is crucial that psychiatrists are aware of the requirements of this vulnerable group, provide and advocate for trauma-informed care and conduct themselves to the highest ethical standards. Psychiatrists engaged in providing care for asylum seekers and refugees should familiarise themselves with the details contained within this position statement and be aware of all the legislation and regulations that apply in their jurisdiction.

The role of psychiatrists also includes a requirement to advocate for the best quality mental health care for asylum seekers and refugees in any setting. This includes in advocating for systems and settings to be designed and operated in a way that allows them to practice at the highest standard. 

Introduction

Asylum seekers and refugees have a high prevalence of mental and physical health problems related to their experiences.[8] The provision of appropriate mental health services for asylum seekers and refugees is necessary to ensure positive health outcomes. Child asylum seekers and refugees are particularly vulnerable to the impacts of trauma, negative detention environments and other post-arrival adversities including family separations and exposure to violence.[3,5] The RANZCP recognises the importance of a coordinated approach to healthcare provision, involving government and non-government agencies in the treatment of the physical and mental health of asylum seekers and refugees. 

Mental Health of asylum seekers and refugees

Overview

Asylum seekers and refugees are a vulnerable group with complex health needs. Common mental health disorders are twice as high in refugee populations in comparison with economic migrants. Asylum seekers and refugees are at particular risk of developing a range of comorbid psychological disorders including post-traumatic stress disorder (PTSD), anxiety, depression and psychosomatic disorders. Contributing factors include previous traumatic experiences, including those occurring during the migration process, culture shock, discrepancies between expectations and outcomes, and/or social, cultural and economic exclusion.[6]

Prevalence

Many of the mental health conditions that are most prevalent in asylum seeker and refugee populations (such as PTSD) are complex to treat and often unresponsive to primary interventions. They require specialist therapeutic interventions, resources and independent treatment settings.[7] A systemic review and meta-analysis in 2022 suggested that asylum seekers and refugees were seven times more likely to present with Major Depressive Disorder (MDD), four-to-five times more likely to present with PTSD, and twice as likely to be diagnosed with Bipolar Disorder (BPD) and psychosis than the general population.[8] In an Australian context, one-half of a detained refugee group reported PTSD symptoms and one-third of children, adolescents and adults suffered clinical symptoms requiring tertiary outpatient assessment.[9]

Detention

There is a strong evidence basis showing that immigration detention can cause harm to physical and mental health.[12-21] The ongoing harm of detention has also been shown to create negative health outcomes in detainees.[12-21] Self-harm and suicidal behaviour and ideation by immigration detainees is well-documented.[10,11,14,19, 20]. 

Children are particularly vulnerable in immigration detention settings. Evidence shows that child detainees have a higher risk of developing mental health condition and post-traumatic symptomology, including self-harm, suicidal and self-destructive behaviour.[22,23] Research has shown that children and adolescents in detention are twelve times more likely to self-harm and ten times more likely to attempt suicide than Australian children who are not detained.[24] 

Because of the weight of evidence showing the impacts of detention on mental and physical health, the position of the RANZCP is that detention should not be used for immigration processing. The RANZCP commends the decision of the High Court of Australia in NZYQ v. Minister for Immigration. 

Provision of mental health services to asylum seekers and refugees

The RANZCP position is that asylum seekers and refugees be afforded the same access to health care as the general populations of Australia and Aotearoa New Zealand. This applies whether they are living in the community or held in detention centres either onshore or offshore.

Health screening

The RANZCP has endorsed the Royal Australian College of Physicians’ position statement on Refugee and Asylum Seeker Health and supports health screening for asylum seekers and refugees on arrival. Health screening allows early health intervention targeted to individual needs. Screening should be adequate, appropriate and health led. Information from these screenings needs to be readily available to healthcare providers and immigration administrators (following best practice guidelines for confidentiality of health records).[25] 

Access to healthcare and support services

The RANZCP’s position is that asylum seekers and refugees be given access to healthcare equitable to the general populations of Australia and Aotearoa New Zealand. Information on how to access health care services, and what asylum seekers and refugees are entitled to, must be easily accessible and relevant to the relevant to the current immigration process in culturally and linguistically appropriate forms, including via interpreters. If a person is granted refugee status information about access to community services and basic details on the operation of the Australian or Aotearoa New Zealand health system should be provided. 

Specific considerations for child asylum seekers and refugees

Child asylum seekers and refugees are particularly vulnerable to negative mental and physical health outcomes during the immigration process. The nature of the immigration process, exacerbated when children are separated from their families or caregivers, reduces developmental, educational and socio-cultural facilities and supports which evidence shows can cause developmental compromise.[15-18] Ensuring that child and adolescent asylum seekers and refugees are not separated from their families and caregivers and are provided with adequate developmental supports can help reduce these effects. 

When treating child and adolescent asylum seekers and refugees, specialist services may be required to combat physical and mental developmental hurdles. Psychiatrists should collaborate and operate within a multidisciplinary care team as required, including child and adolescent psychiatrists, paediatricians and behavioural and developmental specialists. 

Role and ethics of psychiatrists

Psychiatrists are bound by the RANZCP Code of Ethics (2017) in all clinical settings. Five key ethical considerations for psychiatrists working with asylum seekers and refugees have been identified. 

Proper use of knowledge and skills

Psychiatrists must not use their knowledge and skills for purposes other than providing the best quality health care. This includes the use or misuse of documentation or clinical records. 

Responsibility to the patient

Psychiatrists maintain their primary responsibility to act in the best interests of their patient. This responsibility is the priority if and when there are conflicts with other duties or obligations, such as those to employers. 

Clinical independence

Clinicians involved in providing care within the immigration system need the opportunity to practice their speciality at the highest level of excellence. This includes having the capacity to implement best practice guidelines and clinical wisdom, undertake independent assessment and institute effective treatment.[26] The RANZCP position is that the ability to practice high-quality care includes the ability to discuss their work in external clinical supervision and peer review, and other independent supports as appropriate.

Advocacy

Where the needs of the patient cannot be met in the current setting and/or the setting is contributing to the patient’s mental deterioration, clinicians should advocate for changes to their patient’s situation according to their professional expertise. Channels allowing for the documentation and progression of this advocacy must be readily available in immigration processes and procedures. 

Confidentiality

Any person receiving assessment or treatment needs to be advised about the purpose of, and any implications stemming from, the assessment or treatment.[26] The rules of confidentiality and third-party non-disclosure are the same for asylum seekers and refugees as for the general population, even in immigration settings. 

Recommendations

The RANZCP recommends that:

• Detention of asylum seekers and refugees does not occur. 
• Immigration systems are reviewed to ensure decisions regarding separation and processing of child and adolescent asylum seekers and refugees are made with their best physical and mental health and developmental interests as a priority.
• Immigration systems that do not provide for equitable access to health care and support services according to consumer needs are reviewed and reformed.
• Health screening for both physical and mental health conditions is critical at the beginning of the immigration process to identify any health care needs.
• Psychiatrists treating asylum seekers and refugees work collaboratively within a multidisciplinary team where required.
• Clear and concise information regarding assessment, treatment and support services is made available to asylum seekers and refugees in culturally and linguistically appropriate forms.
• Immigration systems are constructed and operated in a way that allows clinicians to provide the best quality care, including allowing clinicians to advocate for changes to the consumer’s setting and to maintain clinical independence and cooperation.
• Psychiatrists’ ethical requirement for confidentiality regarding patient records is upheld and supported in all immigration processes.

Additional resources

• Royal Australasian College of Physicians, Refugee and Asylum Seeker Health Position Statement
• Royal College of Psychiatrists, United Kingdom Mental health of Refugees and Asylum Seekers
• World Psychiatric Association Madrid Declaration on Ethical Standards for Psychiatric Practice

References

1. United Nations General Assembly (1951) Convention relating to the status of refugees. Treaty series vol. 189. Available at https://www.refworld.org/docid/3be01b964.html (accessed 22 July 2023)
2. United Nations General Assembly (1967) Protocol relating to the status of refugees. Treaty series vol. 606. Available at https://www.refworld.org/docid/3ae6b3ae4.html (accessed 22 July 2023)
3. Maley W What is a refugee? Melbourne: Scribe; 2016
4. McAdam J, Chong F. Refugees: Why Seeking Asylum is Legal and Australia’s Policies Are Not Sydney: UNSW Press; 2014 
5. Fazel M, Reed R, Panter-Brick C, Stein A. Mental health of displaced and refugee children resettled in high-income countries: risk and protective factors. The Lancet 2012; 379(9812): 266–82.
6. Bhugra D, Gupta S, Bhui K, Craig T, Dogra N, Ingleby J, Kirkbride J, Moussaoui D, Nazroo J, Qureshi A, Stompe T, Tribe R. WPA guidance on mental health and mental health care in migrants. World Psychiatry 2011; 10(2): 2–10.
7. Ashcroft R. Standing up for the medical rights of asylum seekers. Journal of Medical Ethics 2005; 31: 125–6. 
8. Patanè M, Ghane S, Karyotaki E, Cuijpers P, Schoonmade L, Tarsitani L, Sijbrandij M. Prevalence of mental disorders in refugees and asylum seekers: a systemic review and meta-analysis Global Mental Health 2022; 9: 250-263
9. Young P, Gordon MS. Mental health screening in immigration detention: A fresh look at Australian government data. Australasian Psychiatry 2016; 24(1): 19–22.
10. Médecins Sans Frontières, Indefinite Despair: The tragic mental health consequences of offshore processing on Nauru 2018 available at https://msf.org.au/article/statements-opinion/indefinite-despair-mental-health-consequences-nauru (accessed 27 July 2023)
11. United Nations Committee Against Torture (2022) Concluding observations on Australia’s sixth period review  CAT/C/AUS/CO/6 available at: tbinternet.ohchr.org/_layouts/15/treatybodyexternal/SessionDetails1.aspx?SessionID=2587&Lang=en (accessed 27 July 2023)
12. Méndez J (2015) Report of the Special Rapporteur on torture and other cruel, inhuman or degrading treatment or punishment. United Nations General Assembly. Human Rights Council twenty-eighth session.
13. Amnesty International (2016) Amnesty International Report 2015/16. London: Amnesty International Ltd.
14. Australian Human Rights Commission (2013) Asylum seekers, refugees and human rights: Snapshot report. Sydney, Australia: AHRC.
15. Australian Human Rights Commission (2014a) The Forgotten Children: National inquiry into children in immigration detention. Sydney, Australia: AHRC.
16. Australian Human Rights Commission (2014b). The Forgotten Children: National inquiry into children in immigration detention. Transcripts from Third Public Hearing, 31 July 2014.
17. Australian Human Rights Commission (2014c). National inquiry into children in immigration detention (Forgotten Children). Transcripts from Fourth Public Hearing, Melbourne, 2 July 2014.
18. Australian Human Rights Commission (2014d). National inquiry into children in immigration detention (Forgotten Children). Transcripts from Fourth Public Hearing, 22 August 2014.
19. Australian Human Rights Commission (2015) ‘Use of force in immigration detention facilities.’ Available at: www.humanrights.gov.au/sites/default/files/document/publication/Factsheet-on-use-of-force-in-immigration-detention-facilities.pdf (accessed 25 August 2016).
20. United Nations Committee Against Torture (2014) Concluding observations on the combined fourth and fifth periodic reports of Australia. United Nations Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment, CAT/C/AUS/CO4-5.
21. Filges T, Montgomery E, Kastrup M, Jørgensen AMK (2015) The Impact of Detention on the Health of Asylum Seekers: A Systematic Review. Available at: www.campbellcollaboration.org/library/the-impact-of-detention-on-the-health-of-asylum-seekers-a-systematic-review.html (accessed 6 October 2016).
22. Mares S (2016) Fifteen years of detaining children who seek asylum in Australia – evidence and consequences. Australasian Psychiatry 24(1): 11–4.
23. Human Rights and Equal Opportunity Commission (2004) A Last Resort? Report of the National Inquiry into Children in Immigration Detention. Sydney, Australia.
24. Steel Z, Momartin S, Bateman C, Hafshejani A, Silove D, Everson N, Salehi J K, Roy K, Dudley M, Newman L, Blick B, Mares S, Raman S, Everett (2004) 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 28(6): 427–36.
25. Steel Z, Liddell BJ, Bateman-Steel CR, Zwi A (2011) Global protection and the health impact of migration interception. PLoS Medicine 8(6): e1001038. doi:10.1371/journal.pmed.1001038
26. Royal Australasian College of Physicians (2015) Refugee and Asylum Seeker Health Position Statement available at https://www.racp.edu.au/advocacy/policy-and-advocacy-priorities/refugee-and-asylum-seeker-health (accessed 18 August 2023)
27. World Psychiatric Association (2011) Madrid Declaration on Ethical Standards for Psychiatric Practice.

Disclaimer:This information is intended to provide general guidance to practitioners, and should not be relied on as a substitute for proper assessment with respect to the merits of each case and the needs of the patient. The RANZCP endeavours to ensure that information is accurate and current at the time of preparation, but takes no responsibility for matters arising from changed circumstances, information or material that may have become subsequently available.