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Original Article

The impact of immigration detention on the mental health of torture survivors is poorly documented – a systematic review

Tania Storm & Marianne Engberg

1. nov. 2013
20 min.

Faktaboks

Fakta

Exposure to torture has enduring mental and physical consequences for survivors [1-4] and has been associated with exceedingly high levels of depression and post-traumatic stress disorder (PTSD) [5]. Subsequent detention possibly exacerbates the mental health problems of torture survivors. Torture exposure is prevailing among asylum seekers and refugees. Many are severely traumatised as a consequence of these or other experiences. The prevalence of torture exposure varies, and estimates are uncertain and difficult to establish [5-7]. This is due, among others, to the secrecy surrounding the practices of torture and a low reliability and validity of the data because of various barriers and methodological problems. According to recommendations from the United Nations’ High Commissioner for Refugees (UNHCR), torture survivors and other vulnerable groups should generally not be detained [8]. It is therefore problematic that torture survivors often are not identified by the systems utilising detention [9, 10]. The impact of immigration detention on asylum seekers has been studied, and results point to adverse effects on their mental health [11-16]. Yet the use of immigration detention is widespread and practiced under various conditions in the recipient countries [17] (the Global Detention project represents an overview at its website). Even though torture survivors constitute an especially vulnerable group among asylum seekers and refugees, the impact of detention on their mental health has not currently been reviewed.

The aim of the present study was to review scientific evidence on the mental health consequences of immigration detention for adult survivors of torture.

METHODS

As the reviewed studies include no experimental intervention, the review follows the PRISMA guidelines [18, 19] to the extent possible. No publication date restriction was applied and we therefore included all peer-reviewed English and Danish publications on adult (18+ years) formerly or currently detained asylum seekers, torture survivors and refugees, examining the mental health consequences of immigration detention. The outcome measures were mental health status, prevalence of psychiatric diagnoses and impact on psychological status/wellbeing. The exclusion criteria were: reviews, editorials, letters, comments, commentaries and “point of views”. PubMed (1999-current), IBSS (1951-current), PsychINFO (1806-current) and PILOTS (1871-current) were searched simultaneously by use of the ProQuest database search tool, and additional sources were found by checking the reference lists of the articles. The last inquiry was made on 20 August 2012 and an update search was made on 7 January 2013. The following search string was applied, search terms were free-text: “All Fields (no full text) ALL”, and limitations: English, Danish, peer-reviewed.

1. ((all(asylum) AND all(seekers)) OR (all(torture) AND all((victims OR survivors)) OR all(refugees)) AND

2. (all(detention) OR all(incarceration) OR all(imprisonment) OR all(prison)) AND

3. (all(mental health) OR all(psychology) OR all(psychiatry) OR all(psychological) OR all(psychiatric))

Firstly, a screening of abstracts and titles was made individually by the two authors (ME and TS) in order to exclude articles according to the exclusion criteria. The authors’ lists of qualified studies were subsequently compared and any disagreement resolved by discussion. Duplicates and records not fulfilling the inclusion criteria were removed. The remaining articles were retrieved in full length for further examination and final selection, and the decision to exclude articles not fulfilling the inclusion criteria was made by both authors in cooperation. A data extraction form was made and a pilot carried out on a random selection of studies before the final form was finished and employed. The data extraction was primarily performed by author TS; however, all data extraction forms were crosschecked with the publications by author ME.

RESULTS

The search identified 241 records from the search string and two from additional sources. A total of 12 records were duplicates which were removed. The abstracts and titles of the remaining 231 records were screened; 194 records were subsequently removed due to the exclusion and inclusion criteria. A total of 37 full-text articles were therefore retrieved. From the 37 full-text articles, 22 were consequently removed. An examination of the full text revealed that they did not address the impact of detention on the mental health status of adult torture survivors or asylum seekers or refugees, or were actually reviews or comments, editorials, etc. One record turned out to cover a complete journal issue comprising 12 records; however, none of the articles of the issue fulfilled the inclusion criteria. It was decided to include two studies even though participant groups exceeded “adults” and comprised the age ranges 0-76 years [20] and 15-52 years [21], respectively. The update searches identified no additional records. Finally, 15 studies were included in the review. See Table 1 for a list of the included studies and Figure 1 for a flow diagram presenting the process.

Studies on torture survivors

Of the included studies, two [22, 23] were solely on survivors of torture. Both were case studies presenting only three cases in total. Participants were previously and currently detained asylum seekers. Neither of the studies specifies the applied measures, but both find that detention has serious consequences for the mental health of the participants. The first [23] described two cases, one of a former detainee continuously suffering from complex PTSD after release from detention where his symptoms of PTSD, depression and hypertension began. The other is the case of a detainee diagnosed with schizofreniform psychosis after commencing suicidal and agitated behaviour during detention. Underlining the impact of the circumstances of detention, the second study [22] describes the case of a single detainee who experienced panic attacks and startle reactions caused by the sound of banging prison doors during detention. While in detention, he also had flashbacks to imprisonment in Africa along with intrusive memories.

Studies identifying torture survivors among detainees and former detainees

Of the included studies, nine identified previous torture exposure among the participants, but did not treat the torture survivors as a separate, statistically differentiated group. The studies included case studies, descriptive, cross-sectional and cohort studies, some with a mixed methodology. A range of different questionnaires was employed. The Harvard Trauma Questionnaire and Hopkins Symptoms Checklist-25 measuring PTSD, depression and anxiety were most frequently used questionnaires.

A number of studies assessed the mental health of asylum seekers detained [21, 24-26] and previously detained [27-30] in immigration detention centres, and compared their mental health with the mental health of non-detained asylum seekers [24, 27] and former prisoners [24]. Three studies included the dimension of being granted different types of visas in addition to being detained [28-30]. Additionally, one study [9] compared the statistics on deceased asylum seekers [9] to the statistics on the prison population and general population. Overall, the impact of torture exposure was not evaluated, apart from one study [24] which established an interaction between depression scores and the combination of experiences of interpersonal trauma (incl. torture) and detention for longer than one month.

Overall, torture survivors represent a percentage ranging from 12% [29] to 74% [21]. As some studies included many torture survivors [9, 21, 24, 26, 27], the mental health issues assessed may very well be representative of this group. For example, finding that 58% of participants had been subjected to physical torture, one study [26] reported a prevalence of depressive symptoms of 85% and suicidal ideation in 65% of cases. A follow-up study identified a torture exposure rate of 74% [21] and assessed high levels of PTSD (50%), anxiety (77%) and depression (86%) at first assessment, and an increase in severity of these symptoms two months later. Signs of improved mental health were found among participants who had been released at follow-up, though the level of psychological distress remained high. A third study [27] associated detention with the deterioration of mental health in a group of previously detained asylum seekers – 67.3% of whom had been subjected to torture. Consistently, the studies report high levels of psychological distress among the detained and formerly detained populations. Major depressive disorder is identified in 100% of all adult detainees in one study [25], along with suicidal ideation (93%) and PTSD (86%) – overall this is interpreted as a triple escalation of psychiatric disorders if compared to retrospective self-report accounts of the detainees’ mental health when still in their home country. Moreover, the authors found that serious symptoms were directly related to detention. All reported that they were bothered a lot or extremely by “sudden and upsetting memories” from detention, “images of threatening or humiliating events in detention”, “have sudden attacks of anger over small things” and that thinking about detention makes them feel ex- tremely sad and hopeless. Other symptoms include becoming “nervy, sweaty, shaky and/or have rapid heartbeats” when thinking of detention (93%) and having “nightmares about things that happened in detention” (86%). The data are supported by another qualitative study [28] evaluating the detention experience retrospectively. The former detainees described a number of circumstances as having caused “serious” or “very serious” stress in detention. These included fears of deportation, being told by officers to go home, and language difficulties (> 95% of participants). Moreover, separation from family, interviews by immigration officers, inadequate medical treatment, exposure to violence and brutality and witnessing suicide attempts is reported in the same category by more than 90%.

Other experiences identified to have caused “serious” or “very serious” stress include; “being handcuffed during transport” (71%); “being woken during the night for head counts” (85%); assaults by officers (81%); “solitary confinement” (60%) and “being forced to use unhygienic toilets” (81%). Also addressing detention stressors, a third study [29] associated length of detention with higher levels of psychological distress including PTSD and depression. Studies comparing the mental health status of detained and previously detained asylum seekers to the mental health status of non-detained asylum seekers [24, 27-30] all reported higher levels of psychological distress including PTSD and depression among the former groups. Three of these [28-30] further assessed that more psychological problems were to be found among asylum seekers being granted temporary protection visa as opposed to a permanent protection visa. Another study focused on cases of suicide among asylum seekers [9]. As concluded in the study, the lack of data on the deceased asylum seekers is striking. The data are characterized by an imprecision of suicide rates and inadequate suicide risk assessment including information on mental health status, self-harm incidents, and trauma- and torture history. In 46% of cases, prior exposure to torture was not registered; yet, despite the low inquiry rate, four out of nine of the deceased detainees were known survivors of torture.

Studies not identifying torture survivors among detainees and former detainees

The remaining four studies comprised cross sectional and follow-up studies that did not report proportions of torture survivors among the detained [20, 31] and previously detained [32, 33] asylum seekers. All studies reported high levels of psychological problems associated with detention. One study [20] established an association between length of detention and an increase in new mental health problems. When measured as the percentage of people with any sort of new mental health problem – diagnosis, symptoms and complaints, the proportion ranged from 3% (detention < 3 months) to 44.6% (detention > 24 months). The study comprised both asylum seekers and a sample of all detainees confined in Australian immigration detention centres during 2005-2006. The study found that rates of new mental health problems as well as physical injuries due to self-harm were higher for asylum seekers in this period. Improvement of asylum seekers’ mental health following release (assessed at a mean 6.75 months after release) including a marked reduction in suicidal ideation was established by a second study [33], and psychiatric illness found in 14 out of 16 detained adults in a third [31] – with 87% of the 16 detainees suffering from major depression. By use of retrospective qualitative interviews, the fourth study [32] finds an overall evaluation of the detention period as very negative, and participants referring to it as traumatizing. More than half the participants reported symptoms including nightmares about detention, flashbacks from the detention period and sensitivity to detention reminders. The study also included a quantitative mental health assessment revealing significant levels of depression, anxiety and PTSD.

DISCUSSION

Among the 15 included studies, merely two examined a population consisting exclusively of torture survivors; both were case studies and the total number of cases amounts to three. The limited data are not sufficient to ascertain the impact that detention may have on the mental health of survivors of torture. The three cases, however, did present serious mental health issues and symptoms related directly to the experience of detention. Detention is the context in which much torture is executed; a strong reaction to similar surroundings at a later point in time is evidently very likely. The data are supported by the fact that several of the included studies find high levels of psychological problems among participants of whom torture survivors and other traumatized refugees make up a large percentage. Whether there are any differences between torture survivors and other severely traumatized refugees remains unknown due to the lack of studies on this topic. Once again, it is important to note that the prevalence of torture exposure in populations of asylum seekers and refugees is an insecure estimate, and that the data are characterized by problems with reliability and validity, among others. When deciding on confinement, a systematic screening with a view to identifying torture survivors is often not performed. This constitutes a lack of compliance with the recommendations outlined in the UNCHR detention guidelines which state that, generally, survivors of torture should not be detained [8]. Consequently, special attention is neither paid to torture survivors nor to other severely traumatized detainees.

It can be deduced from the included studies that serious mental health issues are to be found among detainees and former detainees. PTSD [21-25, 27-29, 31, 32], depression [21-26, 28-32] and anxiety [21, 22, 24, 27-30, 32] are frequently identified disorders, and suicidal ideation [21, 23, 25, 26, 33] and psychotic symptoms [23, 25,26, 31] are not uncommon. The qualitative evaluations of the experience of detention reveal a range of stressors directly related to detention [28, 29]. Moreover, detention as such is presented as the originator of trauma symptoms among current [25] and former detainees [32]. The stressful nature of detention and the uncertainties surrounding the situation obviously produce a strong reaction in people who already fled war and/or prosecution [16, 34].

In addition to the almost nonexistent data on survivors of torture, the potential limitations of the current review need to be considered. Isolating the net effect of detention is challenging. The studies included faced methodological difficulties and several reported problems with access to detention facilities or inadequate data on detainees. The studies employ a variety of qualitative and quantitative methods, but experimental randomised designs employing control groups to examine the direct impact of detention have obviously not been conducted as they would be unethical. The studies included in this paper face a number of challenges, e.g., small numbers, selection and recall bias and language barriers. In the studies that do not include participation rates, estimating the consequences of the stated requirements is difficult. Recall bias is a possibility as several studies make use of retrospective self-report measures. Moreover, language is an understandable barrier as well as a potential source of exclusion or misinterpretation. The studies vary in the degree to which efforts have been made to validate translations of questionnaires. Overall, the varying approaches and methods add to the total picture that a range of mental health problems are found. The questionnaires often engage measures on PTSD, depression and anxiety which could be one reason why these disorders are most commonly found. Other instruments like Schedules for Clinical Assessment in Neuropsychiatry (SCAN) or Structured Clinical Interviews for DSM Disorders (SCID) are infrequently used. The participants vary much in terms of demography and in regard to a range of factors that could influence their mental health status, e.g. detention duration and prior trauma. Nevertheless, the studies consistently find high levels of mental health problems among detainees. The majority of the studies (10/15) were carried out in the context of the Australian immigration detention system. Publications from a broader selection of countries would be favourable, including more studies from continents receiving great numbers of refugees like Europe and the USA. Despite the fact that the circumstances of detention vary from country to country and between facilities, the key element remains that people are deprived of their liberty and not permitted to leave (cf. the definition set forth by UNHCR [8]). Traumatized populations from all over the world may very well endure similar psychological sufferings when faced with long-term deprivation of liberty. Finally, we recognise that a search strategy employing different terms might have generated a different outcome; but also that finding more studies on torture survivors is unlikely.

What is consistently recognised in the literature is the unfulfilled need for mental health care, the inadequate assessment and lack of treatment of detainees [16, 34-36]. Torture survivors and other traumatised individuals are among the most vulnerable in the groups of asylum seekers. The poor mental health found among detainees and former detainees may well be related to, and exacerbated by, detainees’ experiences of prior trauma. Screening for torture exposure and its sequelae prior to detention is of outmost importance. Likewise mental health assessment and adequate treatment are crucial for the wellbeing of detainees.

CONCLUSION

The impact of detention on the mental health of survivors of torture is very poorly documented. Only two case studies, representing three cases, address this issue directly. The data do not provide a sufficient basis for the analysis and establishment of the specific effects of detention on the mental health of survivors of torture. There is a serious need for research on this issue. The two case studies do, however, report severe effects of detention on the detainees’ mental health and identify specific symptoms developed during detention. Moreover, studies focusing on asylum seekers as a general group – but comprising subgroups of torture survivors and other traumatised refugees – add valuable data on the mental health consequences of immigration detention. All included studies find a wide range of serious mental health problems among current and former detainees associating detention with a deterioration of mental health. To prevent human suffering, inhuman treatment and the potential risk of self-harm and self-inflicted death, it is crucial to perform systematic screening within the systems utilising detention, identifying torture survivors and assessing and monitoring mental health issues. Before deciding upon confinement, the impact detention may have on the mental health and wellbeing of each individual should be carefully considered.

Correspondence: Marianne Engberg, DIGNITY – Danish Institute Against Torture, Borgergade 13, PO Box 2107, 1014 Copenhagen K, Denmark. E-mail: me@dadlnet.dk

Accepted: 9 September 2013

Conflicts of interest:Disclosure forms provided by the authors are available with the full text of this article at www.danmedj.dk

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