Amin A. Muhammad Gadit  ( Discipline of Psychiatry, Memorial University of Newfoundland, Canada. )

A refugee is a person who " owing to well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion, is outside the country of his nationality. Due to fear, he is unable or unwilling to avail himself of the protection of that country and not willing to return to his motherland.¹
Developed countries contribute most of the funding to assist refugees; developing countries host the vast majority of the world\'s refugees. In many developing countries, refugees were a large portion of the total population. In Pakistan, the ratio of refugee to total population is 1: 149 (1,088,100 refugees), Canada 1:815 (39, 500 refugees), West Bank and Gaza 1:2 (1,685,800 refugees), United States 1:1,678 (176,700 refugees) and Iran 1:70 (994,000 refugees) etc.²
It is estimated that about 1% of the world\'s population has been displaced either from their home or from their home country.³ In addition to physical problems, these persons are at higher risk for mental disorders because of multiple stressors they experience. Economic, social and cultural conditions before and after displacement influence the mental health of refugees according to a meta-analysis. Existing data indicate over 42 million people can be considered refugees because of war, political violence or related threats.⁴ These refugees are particularly vulnerable to the development of posttraumatic stress disorder (PTSD) and somatization.³
Children, who comprise at least a quarter of asylum seekers, are exposed to numerous risk factors for psychological disturbance, including exposure to violence, forced displacement, and multiple losses.⁵ Few studies have suggested that refugee children incur significant morbidity.⁵ Accessing mental health care pose difficulty for refugee children who are at increased risk for mental health problems.⁶
Statistics Canada reports that each year Canada accepts approximately 225,000 immigrants. Of these, 20,000 are refugees.⁷ Mental health issue is an important priority of the government for this population. A study conducted on a cohort of Sudanese refugees in Canada indicates that qualities of home that Sudanese lack during resettlement points to critical gaps that must be filled by mental health and other service providers to promote positive refugee mental health in countries of resettlement.⁸ A study⁹ conducted on 600 Somali refugees in Minnesota confirmed that almost half of the Somali male patients are under age 30, 80% of whom presented with psychoses, compared with the rate of psychoses (13.7%) in the non-Somali control group of same aged males at the clinic. The older male, and the majority of Somali female patients, show predominantly depressive and PTSD symptomatology.
According to the United Nations High Commissioner for Refugees (UNHCR), half of the world\'s 20 million refugees are children. Majority of refugees in Central Africa are children (57%), service is provided to estimated 7.7 million refugee youth under age of 18 by UNHCR. A large body of research has documented that refugee children exhibit symptoms of PTSD at alarmingly high rates, as high as 75% in a community sample. Refugee children in addition to PTSD, also experience acculturative stress as well as stresses associated with migration and displacement.¹⁰
Pakistan has been the major hub for Afghan refugees for quite some time. An anecdotal report mentions that there are 1.7 million Afghan refugees registered by the Pakistani government. Statements by W.H.O. officials describe high mental health problems among these refugees. They mention about 2 million Afghans as suffering from mental illness. The commonest among these are: depression, anxiety, adjustment disorder and psychosomatic disorder. A fact finding mission to Pakistan found that 30% of Afghan refugees who seek medical care at local facilities are presenting with psychosomatic complaints resulting from psychological illness. Quoting an article published in Journal of American Medical Association, 81% of 160 women studied reported a decline in their mental health status. Depression was found in 97% of these women.¹¹ A local study¹² in Peshawar, Pakistan confirms the high prevalence of PTSD among Afghan refugees. Another study indicates the prevalence of mental issues among refugee children.¹³
A field study conducted in Karachi mentions about somatic symptoms among Afghan refugees as a common way of expressing distress. Most common presentations in the local clinic were medically unexplained aches and pains.¹⁴ There is still a dearth of literature on mental health issue of refugee in Pakistan. None of the very few studies conducted can be generalized based of findings.
It appears that refugees are more vulnerable to the development of mental illness for a number of factors. There is need for effective mental health service for refugees in order to address the still hidden burden of mental illness.
Input from various health organizations and government is highly desirable. Is this too much to ask?

1.United Nations. Convention relating to the Status of Refugees. (Online) (Cited 2010 July 12). Available from URL: http://www2.ohchr.org/english/law/refugees.htm.
2.World Refugee Survey. Ratios of Refugees to Host Country Populations 2006. (Online) (Cited 2010 July 12). Available from URL: http://www.refugees.org/data/wrs/06/docs/ratios_of_refugees_to_host_country_populations.pdf.
3.Ringold S, Burke A, Glass RM. JAMA patient page. Refugee mental health. JAMA 2005; 294: 646.
4.Porter M, Haslam N. Predisplacement and postdisplacement factors associated with mental health of refugees and internally persons - a meta analysis. JAMA 2005; 294: 602-12.
5.Fazel M, Stein A. The mental health of refugee children. Arch Dis Child 2002; 87: 366-70.
6.deAnstiss H, Ziaian T, Procter N, Warland J, Baghurst P. Help-seeking for mental health problems in young refugees: a review of the literature with implications for policy, practice, and research. Transcult Psychiatry 2009; 46: 584-607.
7.Canadian Mental Health Association (CMHA). Immigrant and Refugee Mental Health. (Online) (Cited 2010 July 12). Available from URL: http://www.ontario.cmha.ca/about_mental_health.asp?cID=23054.
8.Simich L, Este D, Hamilton H. Meanings of home and mental well-being among Sudanese refugees in Canada. Ethn Health 2010; 18: 1-14.
9.Kroll J, Yusuf Al, Fujiwara K. Psychoses, PTSD, and depression in Somali refugees in Minnesota. Soc Psychiatry Psychiatr Epidemiol 2010; 31 [Epub ahead of print].
10.Lustig SL, Kia-Keating M, Grant-Knight W, Geltman P, Ellis H, Birman D, Kinzie JD, Keane T, Saxe GN. Review of Child and Adolescent Refugee Mental Health. White Paper. National Child Traumatic Stress Network-Refugee Trauma Task Force 2003; US Department of Health and Human Services (HHS), Boston: 4-5.
11.Park K Eun-Myo. The mental health dimension-Afghan refugees. UN Chronicle 2002.*
12.Naeem F, Mufti KA, Ayub M, Haroon A, Saifi F, Qureshi SM, et al. Psychiatric morbidity among Afghan refugees in Peshawar, Pakistan. J Ayub Med Coll 2005; 17: 23-5.
13.Izutsu T, Tsutsumi A, Sato T, Naqibullah Z, Wakai S, Kunta H. Nutritional and mental status of Afghan refugee children in Peshawar, Pakistan: a descriptive study. Asia Pac J Public Health 2005; 17: 93-8.
14.Kassam A, Nanji A. Mental health of Afghan refugees in Pakistan: a qualitative rapid reconnaissance field study. Intervention 2006; 0: 1-9.