Mental health of FDM

Generally, FDM present with better overall health compared to host country populations (Rousseau and Frounfelker Reference Rousseau and Frounfelker2019). This ‘healthy migrant effect’ (Kennedy et al. Reference Kennedy, Kidd, McDonald and Biddle2015; Moullan and Jusot Reference Moullan and Jusot2014; Vang et al. Reference Vang, Sigouin, Flenon and Gagnon2015) points to resilience factors that must be considered in health assessments and care planning. The term however generalises amongst a population with diverse and dynamic experiences contributing to psychological distress and coping. Studies show that FDM present with higher rates of mental disorders, particularly stress-related (Rousseau and Frounfelker Reference Rousseau and Frounfelker2019), highly influenced by conditions of living post-migration (Hynie Reference Hynie2018; Porter and Haslam Reference Porter and Haslam2005; WHO 2023). The rates vary, possibly explained by the spectrum of presentations in psychosocial suffering. Or, epistemologically by different labels used to describe populations studied. Regarding this, we collated studies relevant to our topic, citing terms aligned with original papers.

International meta-analyses show high prevalence rates of PTSD, generalised anxiety disorder, and depression in refugees (Blackmore et al. Reference Blackmore, Boyle, Fazel, Ranasinha, Gray, Fitzgerald, Misso and Gibson-Helm2020) compared to non-refugee populations (Henkelmann et al. Reference Henkelmann, de Best, Deckers, Jensen, Shahab, Elzinga and Molendijk2020). There are high prevalances of psychosis amongst migrants, but they may be less likely to use MHS (Patel et al. Reference Patel, Kouvonen, Close, Väänänen, O’Reilly and Donnelly2017) and post-migration factors may play a role (Bourque et al. Reference Bourque, van der Ven and Malla2011). Porter and Haslam (Reference Porter and Haslam2005) found higher rates of mood disorder, psychosis, and PTSD in refugees than non-refugees. In Ireland, comparison studies using culturally adapted tools show lifetime prevalence of PTSD is 7 times higher in IPA compared to native Irish people in Dublin (Wilson et al. Reference Wilson, Hennessy, Dooley, Kelly and Ryan2013). IPA in the west of Ireland are 6 times more likely to report PTSD symptoms (Toar et al. Reference Toar, O’Brien and Fahey2009), possibly mediated by increased levels of social isolation experienced in this part of the country; community belonging is an important resilience factor (Lindert et al. Reference Lindert, Samkange-Zeeb, Jakubauskiene, Bain and Mollica2023; Olcese et al. Reference Olcese, Cardinali, Madera, Camilleri and Migliorini2024).

Horyniak et al. (Reference Horyniak, Melo, Farrell, Ojeda and Strathdee2016) conducted a global systematic review regarding substance use in FDM; finding higher prevalences of harmful alcohol use in camps (17–36%) than communities (4–7%), and little evidence of studies on illicit substance use. Risk factors for substance use in FDM include; male gender, trauma exposure, symptoms of mental illness or distress, low educational level (ibid; Solfrank et al. Reference Solfrank, Nikendei, Zehetmair, Friederich and Nagy2023).

In one primary care study, McMahon et al. (Reference McMahon, Macfarlane and Avalos2007) showed FDM are five times more likely to be diagnosed with mental illness than Irish citizens. These prevalence rates are understood to be higher than in countries of origin, suggesting that the process of migration could be a contributing factor to developing mental illness (Kirmayer et al. Reference Kirmayer, Narasiah, Munoz, Rashid, Ryder, Guzder, Hassan, Rousseau and Pottie2011). Another possibility for this reportedly higher prevalence is clinical pigeon-holing of FDM expressions of distress; occurring when the Western medical lens filters distressed attempts to secure basic security as mental illness (Summerfield Reference Summerfield2001). Such distress can result from lengthy asylum processes and unmet social needs (Ryan et al. Reference Ryan, Benson and Dooley2008), resulting in lack of agency and control. Having opportunities for hope for the future can promote individual resilience better than health systems responses (Lindert et al. Reference Lindert, Samkange-Zeeb, Jakubauskiene, Bain and Mollica2023).

An Irish longitudinal study on distress levels and predictors in IPA showed high levels of distress; insecure legal status and female gender being contributing factors to psychological distress (Ryan et al. Reference Ryan, Benson and Dooley2008). Women are especially vulnerable to exploitation and gender-based violence (GBV) in the context of forced migration and within European reception systems (Keygnaert et al. Reference Keygnaert, Dias, Degomme, Devillé, Kennedy, Kováts, De Meyer, Vettenburg, Roelens and Temmerman2015; Oliveira et al. Reference Oliveira, Oliveira Martins, Dias and Keygnaert2019); these systems often do not account for GBV support or prevention (Freedman Reference Freedman2016).

This complex nexus of factors makes it challenging to produce definitive epidemiological rates. Indeed, studies with quantitative methodologies can be limited in their validity to accurately conceptualise the experiences of FDM and may risk distorting it into psycho-pathological categories (Summerfield Reference Summerfield2003). A person-centred approach is required to understand and categorise mental health challenges in FDM; contributing factors are multiple and multi-directional (WHO 2023). They are conceptualised into pre-, peri-, and post-migration factors (ibid, Nwachukwu et al. Reference Nwachukwu, Browne and Tobin2009; WHO, Priebe et al. Reference Priebe, Giacco and El-Nagib2016).

Pre-migration factors relate to life in FDM country of origin; exposure to violence and traumatic events, disrupted social networks, loss of home, limited economic opportunities, grief and bereavement. Peri-migration factors include experiences when leaving country of origin and life in transit – making them varied and uncertain, but can include mode of travel (e.g. unsafe vessels and drowning), hardships within refugee camps, lack of stable accomodation, risks of trafficking, sexual abuse and other forms of discrimination.

Post-migration factors are experienced upon arrival to host country, and the resettlement process that ensues. These factors are moderated by demographic factors such as age, language proficiency, time spent in insecure legal status, systems of detention, and ability to access peer networks and familiar culture (WHO 2023; Rousseau and Frounfelker Reference Rousseau and Frounfelker2019). Post-migration stressors include daily socio-economic hardships, barriers in access to health care, change in social role, reduced social integration, and lack of opportunities for agency (Hajak et al. Reference Hajak, Sardana, Verdeli and Grimm2021; WHO 2023). Experiences of discrimination – systemic and interpersonal – and prejudice have impact; these have been growing lately. It has been noted that psychiatric illness rates double if the asylum process extends beyond two years (Laban et al. Reference Laban, Gernaat, Komproe, Schreuders and De Jong2004) and those with precarious legal status are at higher risk of depression and anxiety (Rousseau and Frounfelker Reference Rousseau and Frounfelker2019) and distress (Ryan et al. Reference Ryan, Benson and Dooley2008).

Post-migration factors in the Irish social context

Sparse amounts of Irish research into the impact of the asylum process and living conditions on the mental health of FDM exist (Crumlish and Bracken Reference Crumlish and Bracken2011; Nwachukwu et al. Reference Nwachukwu, Browne and Tobin2009; O’Connell et al. Reference O’Connell, Duffy and Crumlish2016; O’Reilly Reference O’Reilly2018; Ryan et al. Reference Ryan, Benson and Dooley2008). There is no regular population-level monitoring of health status, necessary to inform policy and service planning (Collins et al. Reference Collins, Pericin, Larkin and Diaz2022). This section draws from primary and social care research (Collins et al. Reference Collins, Pericin, Larkin and Diaz2022; Daly and O’Riordan Reference Daly and O’Riordan2024; Moran et al. Reference Moran, Garrity, McGregor and Devaney2019; O’Reilly Reference O’Reilly2018; Pieper et al. Reference Pieper, Clerkin and MacFarlane2011; Ryan et al. Reference Ryan, Benson and Dooley2008), descriptions from other high-income countries (Brandenberger et al. Reference Brandenberger, Tylleskär, Sontag, Peterhans and Ritz2019; Pollard and Howard Reference Pollard and Howard2021), and relevant experiences of Irish health professionals.

Upon arrival into Ireland, IPA are housed in government subsidised reception centres in a system known as Direct Provision (DP) (IPAS 2025). These centres have arguably failed to meet their original purpose; they are overcrowded, misaligned with needs, and form part of a system that increasingly results in homelessness (Amnesty International Ireland 2024; Nasc Ireland 2023). At a vulnerable time – separated from family, country of origin, adapting to life in a new place – IPA who remain in the DP accommodation system face further insecurity through sudden relocations at short notice. As well as negatively impacting basic social needs and causing distress (Ryan et al. Reference Ryan, Benson and Dooley2008), life in DP contributes to a loss of continuity of medical care (O’Connell et al. Reference O’Connell, Duffy and Crumlish2016), compounded by difficulties registering with GP practices due to national demands. Accessing information on legal procedures and assistance can be challenging (Towers 2013). Waiting times for decisions on applications are long, creating conditions of a ‘liminal life’ (O’Reilly Reference O’Reilly2018); with lack of structure, routine and autonomy. IPA are permitted to work after 6 months in the country but provision of a social security number can be a slow (Irish Refugee Council 2025).

These factors contribute to a heightened state of anxiety and chronic stress. Although in-reach health teams exist, supposedly equipped with psychologists (IPAS 2025), timely access to counselling and therapy can be difficult, especially in rural areas. In primary care, health inequities arise from long wait times, language barriers, financial difficulties, and lack of preparedness amongst therapists to treat FDM. Children have the right to access education, but transport to schools can be a challenge due to lack of options and distance. Ní Raghallaigh (Reference Ní Raghallaigh2014) noted that reasons for mistrust amongst unaccompanied minors stem from pre-migration social context, but are exacerbated by the Irish one.

Moran et al. (Reference Moran, Garrity, McGregor and Devaney2019) have noted that children’s coping and resilience are negatively affected by living in DP. Once protection status is granted, families struggle to finding housing and financially manage another relocation. BoTP arrive to challenging conditions of living with uncertainties regarding location. Legal status is secured more quickly through temporary protection than through international protection applications. It also provides a social security number and the right to work; making it easier to access rented accomodation and integrate. This is an important, albeit uncomfortable, systemic disctinction between IPA and BoTP of which Irish health professionals should be aware; it can affect drivers of distress, presentation, and expectations of services.

For all FDM, integration can be challenging due to language and cultural barriers, but also because reception systems do not easily facilitate local community engagement. Besides increasing susceptibility to mental illness, an accumulation of stressors can also impact cognitive function, affecting psychosocial functioning and ability to engage in the social integration process (Hecker and Neuner Reference Hecker and Neuner2019). Psychosocial support can facilitate integration as well as prevent the development of severe and enduring mental illness (Clare Reference Clare2002). Psychological needs may not relate to experiences of torture or trauma, but rather adjustment and risk of exploitation whilst residing in Ireland. Social needs, such as parenting style, accomodation, or awareness of labour rights, can sometimes be overlooked by the clinician in formulations (Summerfield Reference Summerfield2001).

FDM require an adaptive, culturally competent clinical approach towards their mental distress, that is trauma-informed but not trauma-focused (Whylie et al. Reference Wylie, Van Meyel, Harder, Sukhera, Luc, Ganjavi, Elfakhani and Wardrop2018). Cultural humility is a new discourse within healthcare, inviting MHS to examine existing practices, power dynamics, embrace reciprocal learning and critical self-reflection (Lekas et al. Reference Lekas, Pahl and Fuller Lewis2020; Stubbe Reference Stubbe2020; Trinh et al. Reference Trinh, Jahan and Chen2021). The CHUMS study aims to co-produce a model of cultural humility in MHS, with participatory research principles at the core (Inclusion Health 2025). The impact of social determinants of mental health in the post-migration context (Hynie Reference Hynie2018) indicates a need to engage different disciplines and agencies in the mental healthcare of FDMs (Pieper et al. Reference Pieper, Clerkin and MacFarlane2011; HSE 2023; WHO 2023). There are many complexities to consider in order to provide a appropriate MHS for FDM.

Irish psychiatry: where do we end up and how can we engage?

A number of barriers impact FDM engagement and adherence to follow-up. Irish studies into Psychiatric admission rates in different populations suggest patterns of health seeking behaviours that MHS should consider (Kelly et al. Reference Kelly, Emechebe, Anamdi, Duffy, Murphy and Rock2015). Psychiatrists should consider where our clinical role overlaps with the wider context of quality care; the patient experience, experiences in the specialty, and the broader system of health service delivery.

Importantly, FDM patient experiences in MHS have not been published in Ireland (Cronin et al. Reference Cronin, Hannigan, Ibrahim, Seidler, Owoeye, Gasmalla, Moyles and MacFarlane2024). The heterogenous nature of this group and their experiences, combined with poor uptake of services, has led some researchers to suggest that the systems of assessment in Global North countries are lacking when it comes to the relationship between culture and health (Bäärnhielm and Schouler-Ocak Reference Bäärnhielm and Schouler-Ocak2022; Napier et al. Reference Napier, Ancarno, Butler, Calabrese, Chater, Chatterjee, Guesnet, Horne, Jacyna, Jadhav, Macdonald, Neuendorf, Parkhurst, Reynolds, Scambler, Shamdasani, Smith, Stougaard-Nielsen, Thomson, Tyler, Volkmann, Walker, Watson, Williams, Willott, Wilson and Woolf2014; WHO 2023; Satinsky et al. Reference Satinsky, Fuhr, Woodward, Sondorp and Roberts2019). Transcultural lenses suggest methods should account for “culture [shaping] the experience and expression of emotional distress” (p145, Kirmayer et al. Reference Kirmayer, Groleau, Guzder, Blake and Jarvis2003).

While understanding and appropriately categorising presentations relies on the Psychiatrists’ interpretation, it is underpinned by Western societal concepts of mental illness (Whylie et al. Reference Wylie, Van Meyel, Harder, Sukhera, Luc, Ganjavi, Elfakhani and Wardrop2018). The assumption that this model of diagnostics and formulation is globally applicable can be misguided (Summerfield Reference Summerfield2000). For example, the labelling of a potential mood or trauma disorder as a somatic disorder, when it is common for certain cultures to express psychological distress as physical, chronic pain (Collins et al. Reference Collins, Pericin, Larkin and Diaz2022). Another scenario is the difficulty in distinguishing between PTSD and secondary psychosis (Nygaard et al. Reference Nygaard, Sonne and Carlsson2017). Many Psychiatrists helpfully draw on their own experience to compensate, but it would be logical to consider cultural competence in training (O’Connell et al. Reference O’Connell, Duffy and Crumlish2016). Understanding outlooks, belief systems, religion and other cultural habits are important to formulation, some professionals are uncomfortable with these questions (Whylie et al. Reference Wylie, Van Meyel, Harder, Sukhera, Luc, Ganjavi, Elfakhani and Wardrop2018). Without standardised tools or implementable frameworks, inconsistencies can arise in the application of a transcultural approach (ibid).

Brandenberger et al. (Reference Brandenberger, Tylleskär, Sontag, Peterhans and Ritz2019) developed a patient-centred “3C model” to support clinicians in their daily practice; the themes were communication, continuity of care, and confidence. Communication is an interesting theme, as it was noted to be a bi-directional challenge between professionals and patients. Interpreter access is key to support communication, but is not limited to availability; the quality and accuracy of interpretation, flexibility of a system for adequate time, and the role of trust all have impact. Some FDM prefer interpretation through family or friends, which healthcare providers can be reluctant towards (Ballard-Kang Reference Ballard-Kang2021; Brisset et al. Reference Brisset, Leanza, Rosenberg, Vissandjée, Kirmayer, Muckle, Xenocostas and Laforce2014).

In Ireland, access to interpreters is a significant issue. Efforts to offer a national pathway in health services have faced challenges. University of Limerick and Dublin City University offer courses to interpreters to help this practice, but training is not mandatory. Equally, there is no routine training for mental health professionals on working with interpreters. These standards are recommended by The World Psychiatric Association-Lancet commission (Bhugra et al. Reference Bhugra, Tasman, Pathare, Priebe, Smith, Torous, Arbuckle, Langford, Alarcón, Chiu and First2017).

Experiences of mental health professionals are important in discussions around service development and delivery. Studies in Europe (Peñuela-O’Brien et al. Reference Peñuela-O’Brien, Wan, Edge and Berry2023; Sandhu et al. Reference Sandhu, Bjerre, Dauvrin, Dias, Gaddini, Greacen, Ioannidis, Kluge, Jensen, Lamkaddem and Puigpinós i Riera2013) describe significant challenges with care provision, for example diagnostically with language barriers, belief systems, cultural expectations, and complex traumatic experiences (Sandhu et al. Reference Sandhu, Bjerre, Dauvrin, Dias, Gaddini, Greacen, Ioannidis, Kluge, Jensen, Lamkaddem and Puigpinós i Riera2013). Some professionals believe it important to identify trauma, but expressed reluctance to work with refugees due to lack of confidence or uncertainty about the stability of their socioeconomic conditions (Peñuela-O’Brien et al. Reference Peñuela-O’Brien, Wan, Edge and Berry2023). Indeed, it can be psychologically harmful to do so. These dynamics are further complicated pressurise that FDM may feel to produce a good ‘PTSD story’ for the clinician, who is often seen as a gatekeeper of needed social resources (Summerfield Reference Summerfield2001). In the humanitarian setting, Psychological First Aid has been developed as a technique to stabilise early traumatic experiences where resources are lacking (WHO 2024).

Advocacy and activism are listed reactions of professionals working with refugees (Peñuela-O’Brien et al. Reference Peñuela-O’Brien, Wan, Edge and Berry2023), as well as feelings of admiration and warmth (Century et al. Reference Century, Leavey and Payne2007). Other responses pertain to negative feelings such as mistrust or feeling manipulated for secondary gain (Holmqvist and Andersen Reference Holmqvist and Andersen2003; Hultsjö and Hjelm Reference Hultsjö and Hjelm2005). Feelings of hopelessness and the risk of vicarious trauma are also raised as important experiences. These experiences and the possible ensuing counter-transference, highlight the need for strong supervision, and support for mental health professionals.

Inter-agency collaboration should be considered in the broader context of MHS delivery in Ireland. In the proposed HSE Model and existing structures, primary care teams and NGOs address the bulk of FDM screening, assessment and initial treatment. Accordingly, cases referred to specialist MHS will be complex; a vulnerable cohort experiencing multi-faceted challenges and subject to an under-resourced system. As in any population, there are a certain proportion of people with genetic predisposition to mental illness who require secondary care. With this in mind, do Psychiatrists have a role in supporting primary care? How? There are different agencies involved in FDM support in Ireland, for example Spirasi – a Dublin-based charity who provide rehabilitation and psychosocial support for survivors of torture thoughout Ireland (Spirasi 2025). Can we facilitate reciprocal knowledge sharing? How do we engage with those more immersed in the provision of care?

Adopting a collaborative approach will improve care provision and expand knowledge bases. One example; a training workshop for GP trainees, delivered as a collaboration between a GP from Spirasi, a Psychologist from the Cultural Competence Hub and a Psychiatry trainnee from the Migrant Mental Health Working Group of the College of Psychiatrists. Another regular meetings between the MHS and Primary Care teams in a Dublin Primary Care Centre who host a large reception centre in their catchment. Collaboration can also reduce risk in fragmented health systems; Finglas Community Mental Health Team and an IPA Reception Centre collaborated to create a document to note mental health assessment, formulation and treatment for people in DP, resulting in a useful record for the service user and accounting for realities of their post-migration factors (Lam et al. Reference Lam, Wong, Legris, Meaney, Byrne, David, Keogh, McKeon, Lavin, Moriarty, Sheane and Belay2024). The CHUMS study exemplifies collaborative service improvement between mental and public health and people with lived experience.

Recommendations

• • Given that unmet basic psychosocial needs, challenging post-migration factors, and a lengthy legal process can impact mental health and result in presentations to MHS, we must acknowledge the need for an improvement to the legal processes and conditions that FDM face in Ireland.

• • Access to interpreters must be straightforward in all healthcare settings. Training should be offered and expected of interpreters and to those utilising them in consultations.

• • All stakeholders should work in close collaboration – primary care, mental health teams, local DP centres and NGOs – for assessments and care planning, as well as to ensure co-ordination of services (WHO, Priebe et al. Reference Priebe, Giacco and El-Nagib2016). An updated inter-sectoral service map could be included as part of this.

• • FDM experiences should be integrated into the curricula of mental health professionals; through learning opportunities, cultural competency training, and protected time for supervision.

• • The inclusion of people with lived experience in research and service development is recommended (Inclusion Health 2025; WHO 2023). This could be extended to clinical supervision setting and/or through the development of peer support programmes.

• • Surveying the current status of Irish health professionals’ knowledge, readiness, and experiences of care provision – in primary and secondary care – is recommended for service improvement.