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        Impact of immigration detention and temporary protection on the mental health of refugees
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Abstract

Background

Over the past decade, developed Western countries have supplied increasingly stringent measures to discourage those seeking asylum.

Aims

To investigate the longer-term mental health effects of mandatory detention and subsequent temporary protection on refugees.

Method

Lists of names provided by community leaders were supplemented by snowball sampling to recruit 241 Arabic-speaking Mandaean refugees in Sydney (60% of the total adult Mandaean population). Interviews assessed posttraumatic stress disorder (PTSD), major depressive episodes, and indices of stress related to pasttrauma, detention and temporary protection.

Results

A multilevel model which included age, gender, family clustering, pre-migration trauma and length of residency revealed that past immigration detention and ongoing temporary protection each contributed independently to risk of ongoing PTSD, depression and mental health-related disability. Longer detention was associated with more severe mental disturbance, an effect that persisted for an average of 3 years after release.

Conclusions

Policies of detention and temporary protection appear to be detrimental to the longer-term mental health of refugees.

Footnotes

Declaration of interest

None. Funding detailed in Acknowledgement.

Over the past decade, developed Western countries have applied increasingly stringent measures to discourage those seeking asylum from entering their borders (United Nations High Commissioner for Refugees, 2000). Australian policy has shifted in two fundamental ways. In 1992, mandatory detention for the duration of the asylum determination procedure was introduced for persons arriving by boat or without valid entry visas. In 1999, time limits on residency were instituted by establishing a policy of temporary protection. Holders of temporary protection visas have restricted access to healthcare, education and work, no opportunity for overseas travel and are ineligible for migration to family reunions. Although these policies have led to substantial controversy, countries of the European Union are considering following Australia's lead by adopting similar approaches (Milne & Travis, 2003). The present study applied multilevel modelling (Goldstein, 1995) to test the hypothesis that past detention and ongoing temporary protection visa status each contributes to ongoing post-traumatic stress disorder (PTSD), depression and associated disability in refugees.

METHOD

Participants

The study group comprised Sabaean-Mandaeans (Mandaeans), a small pre-Christian sect of approximately 100 000 people originating mainly from Iran and Iraq (Buckley, 2002). The Mandaeans have suffered long-term discrimination in their home countries, with abuses and persecution escalating prior to and during the Iraq war in 2003 (Kendal, 2004). Mandaean refugees in Sydney fall into two administrative categories based on their visa status (permanent protection visa (PPV) or temporary protection visa (TPV)). Those arriving before 1999 were granted the former; those arriving after 1999 were issued the latter. Only those shown to be genuine refugees according to the 1951 United Nations Convention are eligible for either visa category. Mandaeans who arrived in Australia without entry documents were initially held in detention centres, with the remainder - those arriving with holiday or student visas - being allowed to live in the community while their refugee applications were processed.

Sampling

No census or immigration figures were available for the Mandaean minority in Sydney. Community leaders estimated that there were fewer than 400 Arabic-speaking Mandaean adults living in the city. Sampling of very small and dispersed populations such as the Mandaeans creates formidable methodological challenges (Spring et al, 2003) with random or small-area based probability sampling frames not being feasible. It was important, nevertheless, that the sampling frame adopted had an equal probability of capturing those with permanent and those with temporary protection visas.

Community leaders provided lists of Arabic-speaking Mandaeans and 76 families (172 adults) living in Sydney were identified. To widen the sample beyond those in contact with community groups, snowball or linkage sampling (Patrick et al, 1998) was used, in which primary respondents were asked to provide the names and contact details of other Mandaean families. This procedure identified an additional 38 families (96 adults). The final sample comprised 241 Mandaeans (90% individual response rate for those contacted) living in 104 house-holds (91% household response rate). Based on estimates by community leaders, the sample represented 60% of Arabic-speaking Mandaean adults living in Sydney.

Measures

The study applied two psychometrically tested symptom measures: the Harvard Trauma Questionnaire (HTQ; Mollica et al, 1992), which assesses exposure to refugee-related trauma and associated PTSD symptoms, and the Hopkins Symptom Checklist - 25 (HSCL; Mollica et al, 1987), an instrument that records symptoms of depression and anxiety. The measures yield both continuous scores and diagnostic categories (PTSD and major depressive episode, respectively) based on established DSM-IV-derived algorithms (Mollica et al, 2001). The Medical Outcomes Study - Short Form (SF-12; Gandek et al, 1998) is a widely used international instrument that provides a measure of physical (Physical Component Score; PCS) and mental (Mental Component Score; MCS) health status and disability. We applied the MCS, which is usually scored according to four disability levels: none (50 or above); mild (40-49); moderate (30-39); and severe (below 29) (Sanderson & Andrews, 2003).

Three additional measures were developed by the research team: (a) the Post-migration Living Difficulties (PMLD) Checklist, which identifies ongoing stresses that discriminate between refugee and asylum-seeker populations (Silove et al, 1998); (b) the Detention Experiences Checklist, which details 64 common adverse experiences specific to the detention environment and which has been piloted among detained families (Steel et al, 2004); and (c) the Detention Symptom Checklist, a modification of the HTQ (Mollica et al, 1992), which relates symptoms specifically to the detention experience (Steel et al, 2004).

Translation-back-translation

Translation of measures into Arabic was undertaken using established translation and masked back-translation procedures (Bontempo, 1993). The original questionnaires were translated by an Arabic-speaking mental health professional and back-translated by a certified Arabic-speaking healthcare interpreter. Two Arabic-speaking mental health professionals reconciled some minor discrepancies identified by the process.

Procedure

Approval for the study was obtained from the South West Sydney Area Health Service Human Ethics Committee. A research assistant, a nurse practitioner of Mandaean background, made contact with families and individual participants. After consent was obtained, the research assistant visited respondents in their homes and administered the measures.

Data analysis

Preliminary univariate analyses using the Statistical Package for the Social Sciences (SPSS) version 11.5 for Windows were applied to assess for differences across comparison groups in levels of trauma exposure, post-migration stresses, detention experiences and psychiatric morbidity using χ2 analysis for categorical variables and analysis of variance (ANOVA) for numeric variables. Since key predictor variables varied in their frequency across comparison groups and because participants were clustered in family groupings (Goldstein, 1995), we next applied multilevel modelling using MLwiN 1.1 (Rasbash et al, 2001). The purpose of this was to establish whether detention and temporary protection status exerted independent effects on psychiatric symptoms when accounting for family clustering and other predictors and covariates identified by the univariate analysis.

RESULTS

Table 1 presents the major characteristics of the sample and shows that temporary (58%) and permanent protection visas (42%) were each well represented and that more than half of the sample (62%) had been detained. Those with permanent visas had lived in Australia for longer.

Table 1 Characteristics of Mandaean sample (n=241)

Characteristic
Male gender, n (%) 132(54)
Age, years: mean (s.d.) 38(14.2)
Country of origin, n (%)
Iraq 224(94)
Iran 14(6)
Marital status, n (%)
Married 162(67)
Never married 67(28)
Divorced/widowed 11(5)
Detained on arrival, n (%) 150(62)
Families, n (individuals) 1
with one member 31(31)
with two members 40(80)
with three members 15(45)
with four members 10(40)
with five members 3(15)
with six members 5(30)
Residential status, n (%)
Temporary protection 139(58)
Permanent protection 102(42)
Time in Australia, years: mean (s.d.)
Temporary residents 2.8(0.87)
Permanent residents 4.7(3.3) *

* P <0.001.

1. Total number of families=104.

Univariate analyses

Pre-migration trauma

Table 2 shows the extent and nature of pre-migration trauma experiences as measured by the HTQ in holders of temporary and permanent visas. Holders of the former had experienced more traumas than holders of the latter, including death of family and friends, being close to death (i.e. almost dying) and lacking the basic necessities of life. This difference may reflect the increasing persecution of Mandaeans in Iraq leading up to and following the 2003 war.

Table 2 Lifetime exposure to trauma in holders of temporary (n=139) and permanent visa (n=102) (n=241)

Individuals exposed to event, n (%) 1
Trauma event TPV holders PPV holders
Unnatural death of family or friend 110 (79) 63 (62)**
Being close to death 106 (76) 29 (29)***
Murder of family or friend 105 (75) 62 (61)*
Murder of stranger or strangers 68 (49) 32 (32)**
Lack of food or water 65 (46) 23 (23)***
Ill health without access to medical care 53 (38) 16 (16)***
Imprisonment 52 (37) 15 (15)***
Forced separation from family members 36 (26) 11 (11)**
Lack of shelter 26 (19) 11 (11)
Torture 25 (18) 12 (12)
Combat situation 21 (15) 8 (8)
Serious injury 20 (14) 9 (9)*
Forced isolation from others 20 (14) 6 (6)
Brainwashing 18 (13) 6 (6)
Lost or kidnapped 16 (11) 6 (6)

TPV, temporary protection visa; PPV, permanent protection visa.

* P<0.05; ** P<0.01; *** P<0.001.

1. Mean number (s.d.) of trauma events for TPV holders=5.3 (2.8) v. 3.1 (3.1) for PPV holders, P<0.001 (range=0-16).

Post-migration living difficulties

Table 3 shows the causes of serious stress in the temporary and permanent visa holders. Holders of temporary visas reported greater stress for the majority of items. Consistent with their status, they continued to live in fear of repatriation, were unable to resolve family separations and struggled more with issues of day-to-day living.

Table 3 Serious or very serious living difficulties reported in the previous 12 months by holders of temporary (n=139) and permanent visas (n=102)

Living difficulty Individuals exposed to difficulty, n (%) 1
TPV holders PPV holders
Unable to return home in an emergency 134 (96) 8 (8)***
Fearful of repatriation 133 (96) 2 (2)***
Concern for family in country of origin 121 (87) 62 (61)***
Unemployment 85 (61) 22 (22)***
Insufficient money to buy food, necessary clothes or pay rent 77 (55) 22 (22)***
Loneliness and boredom 76 (55) 14 (14)***
Communication difficulties 74 (53) 27 (26)***
Separation from family 66 (47) 12 (12)***
Long-term health problems 66 (47) 6 (6)***
Social isolation 65 (47) 11 (11)***
Poor access to treatment for health problems 63 (45) 7 (7)***
Poor access to emergency medical care 58 (42) 8 (8)***
Poor access to long-term healthcare 65 (47) 7 (7)***
Poor access to dental care 47 (34) 5 (5)***
Poor access to counselling 41 (29) 5 (5)***
Bad work conditions 18 (13) 6 (6)
Discrimination 17 (12) 3 (3)*
Difficulties obtaining help from charities 15 (11) 1 (1)**
Conflict with other ethnic groups in Australia 8 (6) 2 (2)
Difficulties obtaining government help with welfare 8 (6) 2 (2)
Conflict with immigration officials 4 (3) 0 (0)
Interviews with immigration officials 3 (2) 1 (1)

TPV, temporary protection visa; PPV, permanent protection visa.

* P<0.05; ** P<0.01; *** P<0.001.

1. Mean number (s.d.) of living difficulties for TPV holders=9.2 (3.8) v. 2.3 (2.4) for PPV holders, P<0.001 (range=0-23).

Immigration detention experiences

The majority of temporary visa holders (124 out of 139, 90%) and 30% of permanent-visa holders (30 out of 102) had been held in immigration detention centres on arrival in Australia. Table 4 includes all those held in detention and details the 20 highest-ranking adverse experiences that caused serious or very serious stress while confined. The results are stratified in terms of short detention (0-5 months) and long detention (≥6 months) based on the median time spent in detention (6 months). Although groups with short- and long-term detention both reported substantial stress, the latter group scored higher on almost all items (total score=21.3, s.d.=10.4 v. 9.8, s.d.=10.1).

Table 4 Twenty most frequently reported negative detention experiences causing serious/very serious stress, stratified by duration of detention

Factor Individuals reporting experience, n (%) 1
0- to 5-month detainees (n=57) ≥6-month detainees (n=93)
Application process
Fears of being sent home 33 (59) 88 (96)***
Separation from family 32 (56) 52 (57)
Worries about family back home 33 (59) 80 (87)***
Delays in processing refugee application 18 (32) 77 (85)***
Not being informed about progress of refugee application 11 (19) 75 (81)***
Conditions
Boredom 20 (35) 76 (83)***
Isolation 13 (23) 73 (79)***
Overcrowding in rooms 9 (16) 44 (48)***
Woken during the night/head counts or other disturbances 9 (16) 43 (46)***
Poor-quality food 15 (26) 41 (45)*
Interpersonal stress
Racist comments by other detainees 28 (49) 76 (82)***
Being sworn at by other detainees 26 (46) 75 (81)***
Being intentionally humiliated by other detainees 25 (44) 72 (77)***
Seeing people making suicide attempts 17 (30) 63 (68)***
Seeing people engage in self-harm 12 (21) 60 (65)***
Witnessing physical assault 17 (30) 57 (61)***
Healthcare
Poor access to dental care 16 (29) 53 (57)**
Not getting treatment for health problems 12 (21) 44 (48)**
Poor access to emergency medical care 14 (25) 44 (48)**
Poor access to long-term medical care 10 (18) 42 (45)**

* P <0.05; ** P<0.01; *** P<0.001.

1. Mean number of problems (s.d.) for those detained for 0-5 months=9.8 (10.1) v. 21.3 (10.4) for those detained ≥6 months, P <0.0001 (range=0-64).

Immigration detention symptoms

Table 5 shows the traumatic stress symptoms associated with negative detention experiences. Even though the mean time since release from detention was nearly 3 years (35.5 months), the group detained for ≥6 months reported more severe distress for all nine symptoms.

Table 5 Traumatic stress symptoms experienced in previous week related to past detention

Traumatic stress symptom Individuals reporting experience, n (%) 1
0-to 5-month detainees (n=57) ≥ 6-month detainees (n=93)
Feeling extremely sad and hopeless when thinking about detention 15 (26) 69 (74)***
Sudden and upsetting memories of time in detention 14 (25) 68 (73)***
Images of the threatening or humiliating events in detention 10 (18) 58 (62)***
Avoiding talking about detention because causes distress 10 (18) 54 (58)***
Sudden attacks of anger over small things since being in detention 8 (14) 53 (57)***
Becoming nervy, sweaty, shaky and/or having rapid heart beat when thinking about detention 10 (18) 52 (56)***
Nightmares about things that happened in detention 6 (11) 38 (41)***
Avoiding interaction with other people since being in detention 3 (5) 26 (28)**
Feeling numb since being in detention 4 (7) 24 (26)**

** P <0.01; *** P <0.001.

1. Mean number of symptoms causing distress (s.d.) for those detained for 0-5 months=1.4 (2.3) v. 4.8 (3.0) for those detained ≥6 months, P <0.0001 (range=0-9).

Psychiatric status and disability

Figures 1 and 2 display the univariate results for depression, PTSD and mental health-related disability according to residency status and length of detention respectively. The HTQ and HSCL were analysed according to the standard algorithms to yield diagnoses of PTSD and major depressive episode respectively. The standard cut-off on the MCS was applied for moderate-to-severe mental health-related (MCS) disability. Holders of temporary protection visas had higher rates of depression, PTSD and disability than those with permanent visas. Those who had experienced long-term detention also continued to experience greater rates of depression, PTSD and MCS disability.

Fig. 1 Prevalence of depression, post-traumatic stress disorder (PTSD) and mental health-related disability in permanent (n=102) and temporary (n=139) residents.

▪, Permanent residents; □, temporary residents.

Fig. 2 Prevalence of depression, post-traumatic stress disorder (PTSD) and mental health-related disability in those not detained (n=91), those detained for 1-5 months (n=57) and those detained for ≥6 months (n=93).

░, Depression; ▒, PTSD; □, disability.

Multilevel modelling

Calculation of intraclass correlation coefficients indicated substantial family clustering for PTSD (0.42), depression (0.40) and MCS disability (0.27). To ascertain the independent effects of detention and temporary protection status, we applied multilevel modelling, an analysis which included the impact of family clustering and other predictor variables identified in the univariate analyses.

Prediction of psychiatric status and disability

Three multilevel models were calculated using continuous scores for PTSD, depression and MCS disability respectively. Level one predictor variables were age, gender, number of traumas prior to arrival, months in detention (0 for those not detained), residency status (temporary or permanent visa) and months living in the community (i.e. post-detention or post-immigration length of stay in Australia). The level two variable was family clustering.

Variables excluded on the basis of preliminary analyses were number of detention experiences (Table 4) and detention-specific symptoms (Table 5), since these correlated highly (r=0.72 and r=0.70 respectively) with the duration of detention. Similarly, indices of post-migration living difficulties were strongly related to temporary protection status and hence made no additional contribution as predictors.

Table 6 displays the key characteristics of the multilevel regression analysis, with each model emerging as statistically significant. The R 2 estimates indicate that the overall models account for a substantial proportion of the variance for each dependent variable, although more so for PTSD and depression than for MCS disability. Intraclass correlation coefficients show the level of family clustering for each dependent variable, with the family variance partition coefficient indicating that nearly 30% of the symptom measures and 20% of the disability measures were accounted for by family clustering. Calculation of standardised regression weights (β) allowed for direct comparison of the magnitude of the effect of each predictor variable. After including the effects of age, gender, previous trauma exposure, family composition and length of residency, time in detention and temporary protection status made an equal and substantial contribution to psychiatric morbidity and disability.

Table 6 Multilevel regression models assessing predictors of post-traumatic stress disorder (PTSD), depression and mental health-related disability (from the Mental Component Score (MCS) of the SF-12) (n=241) 1

PTSD symptoms Depressive symptoms MCS disability score
Intraclass correlation for families 0.42 0.40 0.27
Family variance partition component, % 2 30.1 29.0 19.5
R 2 estimate 0.44 0.45 0.29
Model significance χ2=131.4, d.f.=6, P <0.001 χ2=135.4, d.f.=5, P <0.001 χ2=96.48, d.f.=5, P <0.001
Level one predictor variables, B (β) 3
Gender 0.34 (0.23) 0.43 (0.27) 2.93 (0.14)
Age 0.014 (0.26) 0.013 (0.24) 0.16 (0.21)
Previous trauma 0.041 (0.18) 0.036 (0.14) 0.77 (0.23)
Months in detention 0.023 (0.14) 0.032 (0.18) 0.36 (0.16)
Residency status 0.33 (0.22) 0.50 (0.31) 3.84 (0.18)
Length of residency in Australia −0.003 (−0.15) NS NS

NS, not significant, B, regression weight; β, standardised regression weight; SF-12, Medical Outcomes Study - Short Form.

1. All reported parameters are significant at 0.05 or greater unless marked NS.

2. Percentage of explained variance due to family.

3. Standardised regression weight used to determine the relative effect of each parameter.

A subsidiary analysis showed that those who had no family in Australia (a proxy measure for family isolation) were at greater risk for depression and PTSD than those living in families of three or more persons. Families consisting of two available members fell into an intermediate risk category (F 2,238=3.82, P<0.05 for depression and F 2.237=4.09, P<0.05 for PTSD).

DISCUSSION

Developed Western countries have implemented increasingly stringent policies to deter those seeking asylum (Silove et al, 2000). Australia has adopted particularly restrictive policies, including the detention of people seeking asylum but arriving without entry visas and, more recently, limiting those found to be refugees to temporary protection visas only. European countries and North America are considering the adoption of similar policies (Crisp, 2003). It is timely, therefore, to consider the impact of such policies on the mental health of refugees.

The present study suggests that both prolonged detention and temporary protection contribute substantially to the risk of ongoing depression, PTSD and mental health-related disability in refugees. The independent influence of these two risk factors remained robust after controlling for other variables previously identified as risk factors (de Jong et al, 2001), including female gender, greater age, extent of past traumas, length of residency and family separation.

Limitations of the study design

Before interpreting the results in greater detail, limitations of the study design require consideration. A population-wide probabilistic sampling method was not feasible because of the minority status and dispersal of the target group. It is possible that community members with the most severe mental disturbances were more likely to respond, although previous research suggests that greater community contact is a protective factor against emotional distress (Steel et al, 1999). It is also noteworthy that the rates of PTSD and depression fall within the limits of prevalence data in other groups of asylum seekers and refugees studied in Australia and other resettlement countries (Hobbs et al, 2002; Silove et al, 2002). Furthermore, Goodman (1961) argued that snowball sampling, although not ideal for establishing absolute prevalence rates, is appropriate for comparing subgroups within samples, the key focus of the present study.

Transcultural measurement issues must be considered as a potential source of error. We applied a standard translation and masked back-translation method, reconciling minor semantic and linguistic differences with the assistance of two Arabic-speaking mental health professionals. The relationships yielded between key variables provided indirect support for the validity of the measures. For example, we replicated the well-established dose-response relationship between trauma exposure and mental disorder, a finding that is robust across the majority of published studies (e.g. Hauff & Vaglum, 1994; Mollica et al, 1998).

Recall bias is always a potential confounding variable, particularly when reporting past traumatic events. An important recent study (Herlihy et al, 2002) has shown that refugees remain consistent in reporting major traumatic events such as those we recorded, with more variability occurring in recall of minor historical details. The higher levels of trauma reported by holders of temporary protection visas who have arrived more recently in Australia was consistent with a history of escalating violence and persecution directed at the Mandaean group in Iraq in the lead-up to the 2003 war.

At the same time it may be argued that holders of temporary visas are prone to exaggerating their plight, a potentially self-serving bias motivated by the hope of advancing future claims for extension of their visas. Although this cannot be ruled out entirely, the anonymous nature of the study meant that there was no direct personal gain resulting from participation. Holders of temporary visas were not currently applying for extensions visa, so that further documentation at the time of the study was not directly useful. Furthermore, the criteria used by immigration officials in judging the need for further protection focus principally on risk of future persecution, not on past history or ongoing living difficulties, the subject of our study.

Although the shared cultural, historical and political experiences of the permanent and temporary visa holders strengthened the comparisons, the focus on a single refugee population potentially limits the generalisability of the findings, making it important for future studies to replicate our results in other cultural groups.

Longer-term mental health impact of detention

Our study suggests that prolonged detention exerts a long-term impact on the psychological well-being of refugees. Refugees recording adverse conditions in detention centres also reported persistent sadness, hopelessness, intrusive memories, attacks of anger and physiological reactivity, which were related to the length of detention. Previous studies examining the effects of detention concur with our findings (Steel & Silove, 2001; Sultan & O'Sullivan, 2001; Keller et al, 2003), although our study is the first to show that such mental health effects persist for a prolonged period after detention. These effects were independent of other established predictors of psychiatric morbidity in refugees, such as past exposure to trauma and recency of arrival (Steel et al, 2002). The present findings provide systematic support for the observations of successive commissions of inquiry undertaken in Australia (Human Rights and Equal Opportunity Commission, 1998; Office of the High Commissioner for Human Rights, 2002) that have raised repeated concerns about the mental health effects of prolonged detention.

Temporary protection

The present study is the first to investigate the specific effects of temporary protection on the mental health of refugees. In the past refugee settlement countries such as Australia have offered permanent residency to refugees according to the 1951 United Nations Convention and Australia continues to administer a separate programme of permanent resettlement for a quota of refugees screened in other countries. Permanent protection means that previously traumatised refugees are given certainty about their futures, allowing them to plan their lives with a substantial level of security. A recent epidemiological study undertaken among Vietnamese refugees in Australia (Steel et al, 2002) has provided evidence that permanent residency is associated with improvement in the mental status of previously traumatised individuals.

In contrast, the present study adds to evidence (Silove et al, 2000) that insecure residency and associated fears of repatriation contribute to the persistence of psychiatric symptoms and associated disabilities in refugees. Temporary protection status was strongly associated with daily stresses related to financial and work difficulties, and problems in accessing healthcare, language classes and other educational opportunities. Countries considering the adoption of temporary protection regimes therefore need to consider how such provisions may undermine the sense of security that seems to be essential for refugees to recover from trauma-related psychiatric symptoms.

Family factors

The multilevel modelling analysis indicated that there was a concentration of mental distress within family groups. Risk of mental illness was lower in larger family units, whereas those refugees who were isolated from other family members were more likely to experience severe psychiatric symptoms. Temporary protection status in Australia specifically denies refugees the right to family reunion and prevents holders from re-entering Australia if they travel overseas, making direct contact with families in other countries effectively impossible. The common consequence is prolonged separations that compound the disruptive effects on families of past persecution (Silove et al, 2000). Our findings therefore highlight the need to consider carefully the impact of refugee policy changes on family unity and the potential risk that enforced family separations may result in prolonged mental disorder in isolated refugees.

Clinical Implications and Limitations

CLINICAL IMPLICATIONS

  1. To prevent further psychological harm to previously traumatised refugees, it is necessary to minimise detention and ensure that conditions in detention are humane.

  2. Certainty of residency to persons recognised as refugees seems to be essential for recovery from trauma-related psychiatric symptoms.

  3. Families and social groups that are not kept together or reunited may be at greater risk of prolonged mental disorder.

LIMITATIONS

  1. The study used non-random sampling.

  2. The study was limited to one refugee group, the Mandaeans.

  3. There was potential for exaggeration bias in reporting.

Acknowledgement

This study was supported by an Australian National Health and Medical Research Council programme grant (3000403).

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