C International Psychogeriatric Association 2016 International Psychogeriatrics (2016), 28:6, 889–896 doi:10.1017/S1041610216000193
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The impact of forced migration on the mental health of the elderly: a scoping review ...........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
Ashwini Virgincar,1 Shannon Doherty2 and Chesmal Siriwardhana2,3 1
King’s College London, Faculty of Life Science & Medicine, London, SE1 1UL, UK Global Public Health, Migration & Ethics Research Group, Faculty of Medical Science, Anglia Ruskin University, Bishop Hall Lane, Chelmsford CM1 1SQ, UK 3 Institute of Psychiatry, Psychology & Neuroscience, King’s College London, 16 De Crespigny Park, London SE5 8AF, UK 2
ABSTRACT
Background: The worldwide elderly population fraction is increasing, with the greatest rise in developing countries. Older adults affected by conflict and forced migration mainly taking place in developing countries may be particularly vulnerable to poor mental health due to other age-specific risk factors. This review aims to explore global evidence on the effect of conflict-induced forced migration on the mental health of older adults. Methods: Seven bibliographic databases were searched. The title and abstract of 797 results were reviewed for qualitative and quantitative studies meeting inclusion and exclusion criteria. Results: Six studies were selected for the in-depth review. Five papers assessed mental health in older adult populations displaced as refugees. One paper assessed mental health of older adults with varying immigration status. Conclusions: This review highlights the dearth of evidence about the impact of forced migration on the mental health of older adults. Further research is needed to explore the risk factors and processes that contribute to adverse mental health outcomes among older adult populations. This is essential to the development of interventions for this vulnerable and at-risk population, particularly in resource-poor settings. Key words: forced migration, mental health, elderly
Introduction Since the mid-2000s, an increasing trend of interstate and societal conflict has been observed worldwide along with conflict-induced forced migration (Centre for Systemic Peace, 2015; IDMC, 2015). According to the Internal Displacement Monitoring Centre (IDMC) figures, internally displaced and refugee population numbered around 57.5 million in 2014, compared to 39 million in 2004 and 33.7 million in 1989 (IDMC, 2015). Conflict-associated trauma significantly contributes to the subsequent development of mental disorders during post-displacement periods (Porter and Haslam, 2005). The development of mental illness among forced migrant populations depends on a number of factors including the nature of Correspondence should be addressed to: Chesmal Siriwardhana, Anglia Ruskin University, Bishop Hall Lane, Chelmsford CM1 1SQ, UK. Phone: +44 (0)1245 68 4199. Email: [email protected]. Received 26 Jul 2015; revision requested 22 Aug 2015; revised version received 22 Dec 2015; accepted 21 Jan 2016. First published online 2 March 2016.
trauma, number of traumatic events experienced, objective/perceived severity of trauma, age and gender (Porter and Haslam, 2005; Roberts and Browne, 2011). Of these, older age (defined as those over the age of 60 by the United Nations) has been reported to be associated with significant mental health issues (World Health Organization, 2015). Impact of forced migration on elderly mental health is important in the context of increasing global older population faction. In 2006, 11% of the world’s population consisted of people over the age of 60 years (Inter-Agency Standing Committee, 2008; United Nations, 2015). By 2050, this is expected to increase to 22% with a simultaneous rise in the proportion of older people living in developing countries (60% to 80%), and the fastest growing subset is the over-80 age group (InterAgency Standing Committee, 2008; Karunakara and Stevenson, 2012). The proportion of older people affected by forced migration only stands to increase due to the rising number of violent conflict situations, especially in the Middle East, Africa,
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and Asia (Inter-Agency Standing Committee, 2008; Karunakara and Stevenson, 2012). A wide range of additional age-specific factors may compound the mental health impact of forced migration among older people (Burton and Breen, 2002; Karunakara and Stevenson, 2012; Loi and Sundram, 2014). Psychological distress induced by forced migration may occur on a background of existing age-related neurological and mental disorders such as dementia, depression, un-recognized alcohol abuse, and general reduction in mental capacity (Inter-Agency Standing Committee, 2008; HelpAge International, 2012; World Health Organization, 2015). Chronic physical illnesses, disability, reduced mobility, and nutritional deficiencies can also compound psychological stress (InterAgency Standing Committee, 2008; Karunakara and Stevenson, 2012; Loi and Sundram, 2014). Such chronic geriatric conditions usually require regular monitoring, medication, and resources (e.g. power supply for respiratory or dialysis machines), and these resources may not be available during enforced migratory episodes, especially in resourcepoor settings (HelpAge International, 2012; Loi and Sundram, 2014). The cumulative effects of existing health impairments may have a significant impact on the mental health of the displaced older adults (Hinton et al., 2005). In addition, having lived through a greater number of adverse events during their lifetime, the displaced older adults are at an increased risk of developing mental illnesses (Chee and Levkoff, 2001). Although positive contributions to society from the older adults are highly valued in many cultures, in situations of forced displacement, they may become a burden on surviving families and communities, as their contribution to survival efforts can be limited (Burton and Breen, 2002; Loi and Sundram, 2014). Inability to play a meaningful role during a time of crisis can result in loss of social/family support/respect, precipitate loss of self-esteem and further contribute to increased psychological distress (Burton and Breen, 2002). Death of close family, such as children, or abandonment by families during displacement may precipitate adverse mental health outcomes (Kirmayer et al., 2010). Furthermore, older forced migrants may have significant issues with acculturation in post-displacement living areas (for example African/Asian/Middle Eastern refugees in Western countries), compounded by cultural, linguistic, and religious barriers impeding their ability to integrate with new social structures (Burton and Breen, 2002; Bhugra et al., 2011). They may also be prevented from making full use of available resources due to a lack of relevant cultural or linguistic knowledge
(Inter-Agency Standing Committee, 2008; Loi and Sundram, 2014). Elderly people may also be reluctant to move from familiar places resulting in increased risk of social isolation (Levkoff et al., 1995). Due to increased pressure to address acute physical health issues in many conflict situations, elderly populations and their psychosocial needs are often overlooked by humanitarian programs (Inter-Agency Standing Committee, 2008). This oversight must be addressed to understand specific risk factors linked to mental disorders among older forced migrants. While there are some existing recommendations and policy guidance on older people in emergencies (World Health Organization, 2006; Inter-Agency Standing Committee, 2008), they lack specific provisions on mental health. Understanding and establishing the current level of knowledge about the impact of forced migration on mental health of older people is essential in the context of the worlds’ aging population and interlinked challenges in providing effective healthcare, especially in resource-poor countries (Mirsky, 2009). However, current and comprehensive evidence-base on issues around forced migration and mental health of older people is not available. In order to address this gap, a scoping review of quantitative and qualitative research on mental health issues of older forced migrants, including refugees, asylum seekers, and internally displaced people (IDP), was conducted.
Methods Databases and search terms Seven databases (Pubmed, PsycArticles, PsycINFO, Google Scholar, Embase, Medline, and Global Health), expert recommendations, and a manual search were used to explore published and grey literature. The final search terms included a combinations of the following terms as well as related terms: “war” AND “mental health” AND “elderly” AND “older adult” (See the supplementary material). Screening, selection, and assessment The initial search of all databases as well as a manual search and a search of recommended articles produced over 797 results. Of these, 729 articles were rejected following a title and abstract review and as a result of inaccessibility to the full article. Following duplicate review, 15 articles were removed leaving a total of 53 results. Following a full text review, a further 47 articles were rejected. A total of six articles were chosen for a final indepth review (Figure 1). The STROBE checklist
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Stage 1: Search all databases >79 97 articles
Stage 2: T Title and abs stract review 729 rejected based on exclusion criteria and duplication Stage 3: Full text revview
47 rejected based on exclusion criteria and methodological weaknesses Stage 4: Final in-depth review 6 articles
Figure 1. Study selection process.
was used to assess the quality of quantitative studies included (STROBE, 2015). The STROBE checklist lists items that should be included in research articles such as details of the sample population and discussions of potential bias and limitations of the study. There are 22 items, given 1 point each and the total score gives an indication of the strengths and weaknesses found in research studies (STROBE, 2015). Selection criteria included population of conflictaffected migrants over the age of 50 of either gender. Studies on both internal migrants (those displaced within the national borders) and external migrants (those displaced beyond their national borders) were included. Studies with statistically significant mental health outcomes resulting from forced migration were included. The review considered worldwide studies written in the English language. Voluntary migrant populations (for example, those migrating for economic reasons) were excluded. Both qualitative and quantitative research was considered. Demographic variables taken into account in this review include different combinations of age, gender, marital status, living arrangements, education, income, length of residency in host country, age of immigration, and time since traumatic event.
Results Demographic characteristics All included articles except one (Marshall et al., 2005) sampled populations 50 years and older. Marshall et al., (2005) included adults of 35–70 years and was included as it provided valuable
information on mental health of older age groups. Of the six studies included in the final review, three were conducted in the United States of America (USA) (Marshall et al., 2005; Howells Wrobel et al., 2009; Cummings et al., 2011), two studies in Finland (Kuittinen et al., 2014; Mӧlsӓ et al., 2014), and one study in Lebanon (Chaaya et al., 2007). The majority of studies included in the review focused on conflict-affected refugee populations (Marshall et al., 2005; Chaaya et al., 2007; Cummings et al., 2011; Kuittinen et al., 2014; Mӧlsӓ et al., 2014), with one study focusing on a population with varying immigration status (Howells Wrobel et al., 2009). All articles reported mental health findings for both men and women. Five of the included studies sampled populations 50 years and older who had been displaced as adults or older adults (Chaaya et al., 2007; Howells Wrobel et al., 2009; Cummings et al., 2011; Kuittinen et al., 2014; Mӧlsӓ et al., 2014) and one study sampled a population aged 35–75 years (Marshall et al., 2005), who had been displaced as adults. Table 1 summarizes key information of included studies. Mental disorder and psychosocial outcomes Mental disorder and psychosocial outcomes reviewed include post-traumatic stress disorder (PTSD), depression, alcohol use, predictors of depression, expression of mental illnesses, and mental health effects of trauma. A study of resettled Cambodian refugees in the USA found that continued high rates of various psychiatric illnesses indicates long-term consequences of exposure to trauma (Marshall et al., 2005). They reported higher rates of PTSD and major depression but
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Table 1. Summary of selected studies MENTAL HEALTH
STUDY
SAMPLE/
OUTCOME
BACKGROUND/
AND OTHER RELIABILITY
STUDY DESIGN
VALIDITY/
M E A S U R E S ∗ O F M E A S U R E S ∗∗
QUALITY CONCLUSIONS
REPORTED
ASSESSMENT
LIMITATIONS
SCORE
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Continued high rates Cross-sectional design so 16 HTQ, CIDI, All measures 586 resettled of psychiatric illness causality cannot be AUDIT translated and back Cambodian determined, sample translated, modified indicates long-term refugees living in may not be consequences for version of the United States representative, tools exposure to trauma Cambodian HTQ of America (USA)/ not specifically 35–75 years/ validated for the cross-sectional population 17 Depression appears to Small sample size, GDS-15 Arabic version not 740 Palestinian Chaaya be a significant issue cross-sectional design validated but refugees and et al., so causality cannot be in older refugees, correlated with displaced 2007 determined, use of religious practice Arabic validated Lebanese living in non-validated scale may provide an GHQ-12 Lebanon/60+ outlet for social years/crosssolidarity sectional 15 Perception of pressure Recall bias may be 200 Arab–Americans MASI, GDS MASI test–retest Howells present as retrospective to learn English 0.53–0.84, with varying Wrobel assessment, coupled with low Cα=0.73–0.94, immigration et al., English competency cross-sectional design modified to reflect statuses living in 2009 unable to determine appears to predict Arabic cultural the USA/60–92 causality depression in older idioms and years/crossadult immigrants language, GDS sectional split-half reliability=0.88– 0.99, test-retest=0.85, Cα=0.85, translated/back translated into Arabic/English 14 IADL, LSNS, IADL no information Isolation and lack of Statistical power Cummings 70 emigrants from weakened by small social support in on Kurdistan living in MGLQ, et al., sample size, older immigrant validity/reliability, GDS the USA/50+ 2011 populations appears cross-sectional design LSNS internal years/crossunable to determine to increase risk of consistency=0.86, sectional causality depression and reliability α=0.66, highlights the need MGLQ Cα=0.91, for tailored services GDS Cα=0.91 for those affected Kuittinen 128 Somalians living BDI, 14 Matched pair may not Language translations Variance in mental in Finland et al., have controlled for all health expression SCL-R-90 and cultural 2014 factors, instruments needs to be taken appropriateness matched with not validated for the into consideration reviewed by experts Finnish population when tailoring residents/50–85 health services for years/cohort minority groups and diverse populations Instruments not validated 15 Refugee-related Translated but not Mӧlsӓ et al., 128 Somalians living BDI-21, for the population, traumatic back translated, GHQ-12, 2014 in Finland differing data collection experience appears cultural HRQoL matched with methods between to have long-lasting appropriateness Finnish mental health effects groups could have review by experts, residents/50–80 affected results in order adults pilot tested years/cohort
Marshall et al., 2005
∗ HTQ – Harvard Trauma Questionnaire; CIDI – Composite International Diagnostic Interview World Mental Health version; AUDIT – Alcohol Use Disorder Identification Test; GDS-15 – Geriatric Depression Score 15-item; MASI – Multi-dimensional Acculturative Stress Inventory; GDS – Geriatric Depression Scale; IADL – Instrumental Activities of Daily Living and Social Functioning; LSNS – The Lubben Social Network Scale; MGLQ – Migratory Grief and Loss Questionnaire; BDI – Beck Depression Inventory; SCL-R-90 – Symptom Checklist-Revised; BDI-21 – Beck Depression Inventory 21 item version; GHQ-21 – General Health Questionnaire 21 item version; HRQol – Health-Related Quality of Life.
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lower risk of possible alcohol use disorder for older participants with women in the sample less likely to have either PTSD or alcohol use disorders (Marshall et al., 2005). One study on older Palestinian refugees living in Lebanon found high rates of depression (Chaaya et al., 2007). They also reported that depression appears to be a significant challenge for all older refugees in their sample and that religious practice may mitigate some of the effects as an outlet for social solidarity (Chaaya et al., 2007). Two other studies conducted in the USA looked at predictors of depression, one among older immigrants with varying immigration status (Howells Wrobel et al., 2009), and another among refugees who had fled conflict (Cummings et al., 2011). The first study with varying immigration status participants found that the risk of depression is predicted by people’s perception of pressure to learn English and low English competency (Howells Wrobel et al., 2009). This study also reported increased levels of depression and acculturative stress amongst those self-identifying as refugees as compared to those identifying as citizens, permanent residents or visa holders of the country providing refuge (Howells Wrobel et al., 2009). The second study in the USA, which sampled refugees from Kurdistan found high rates of depression (Cummings et al., 2011). This study concluded that the risk of developing depression was associated with social isolation and lack of social support (Cummings et al., 2011). A study conducted in Finland compared Somali refugees to Finnish citizens and found that the Somali refugees displayed more somatic-affective symptoms of mental distress (Kuittinen et al., 2014). They concluded that variance in how mental illness is expressed must be taken into account when tailoring health services for minority groups to ensure full spectrum of mental illness is understood (Kuittinen et al., 2014). A second study on the same sample of Somalian refugees living in Finland reported that traumatic experiences can create longlasting mental health effects into older adulthood (Mӧlsӓ et al., 2014). It found clinically significant differences in reported self-related health status, depression symptoms, and general psychological distress (Mӧlsӓ et al., 2014). Methodological issues Table 1 presents summary information on sample and background, study design, mental health outcomes, validity and reliability of measures, study conclusions, and reported limitations. A wide range of mental health measurements were used, including the Harvard Trauma Questionnaire (HTQ), the Composite International Diagnostic
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Interview World Mental Health version (CIDI), the Alcohol Use Disorder Identification Test (AUDIT), Geriatric Depression Score (GDS-15), Multi-dimensional Acculturative Stress Inventory (MASI), Instrumental Activities of Daily Living and Social Functioning (IADL), the Lubben Social Network Scale (LSNS), Migratory Grief and Loss Questionnaire (MGLQ), Beck Depression Inventory (BDI), Symptom Checklist-Revised (SCL-R90), General Health Questionnaire (GHQ-21) and Health Related Quality of Life (HRQoL). The majority of studies were of cross-sectional design. Sample sizes of the studies varied widely (range; 70 to 740). Sample population total from all included studies was 1,724. Reliability and validity of information was provided by some studies, mostly limited to Cronbach’s α figures. In addition, it was not clear in most studies whether the measurements were administered in English, in the native language of the host country (for refugees) or in the native language of participants. The quality assessment scores ranged from 14 to 17 (from a total of 22). Most studies lost points for not stating potential sources of bias, funding sources, and limitations. There was no identifiable pattern of links between quality score and other study attributes such as sample size. Main reported limitations were recall bias, lack of power due to small sample size, and lack of reliability, as instruments were not validated for the population.
Discussion This review explored mental health issues of older forced migrants including refugees, asylum seekers, and IDP. In summary, the findings show an increased level of mental disorders and psychosocial issues among older adults affected by conflict. Most commonly studied and prevalent mental disorders were depression, anxiety, and PTSD. In general, psychosocial well-being of those affected by forced migration was reported as poor, and factors such as experiences during displacement, post-migration acculturation, age at displacement, and gender played a role in poor mental health. Forced migration emerged as a highly significant predictor of negative mental health outcomes among older conflict-affected adults, especially for current anxiety. Overall findings show increased depression, anxiety, and an increased risk of developing PTSD. However, caution must be exercised when interpreting these findings, as the majority of studies had examined populations long after the event of forced migration. Furthermore, factors related to the process of natural aging of participants needs to be considered.
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A key finding to emerge from the review is the lack of epidemiological studies looking at mental health of older adults affected by conflictrelated forced migration in low-and middle-income countries (LAMIC). The studies included in this review were focused on refugee populations living in developed countries such as European Union member states and the United States. Previous research on conflict-affected populations in LAMIC have shown older age to be a specific risk factor for mental disorders (Roberts and Browne, 2011). Despite this, our findings indicate that research with a specific focus on older age groups is scarce in most LAMIC. Studies in the review had focused on refugee populations, neglecting IDP. This is a notable gap in research focus, as the numbers of IDPs from global conflicts have increased exponentially during recent years (IDMC, 2015). As mentioned before, the majority of these IDPs are located in LAMIC, with increasing older population factions. Given the contextual and factual importance, mental health of older adult IDPs should be considered as a research priority. In addition, this review points towards a significant lack of evidence on mental health issues of older adults displaced by recent conflict. The nature, context, and severity of conflicts are fast changing, and it is important to study the mental health impact of forced migration from recent conflicts. Since the World Wars, most conflicts have taken place in developing countries. In this context, understanding mental disorder trajectories of older people affected by conflict and forced migration within the immediate aftermath will be highly useful for the development and delivery of critical psychosocial support to this vulnerable population group. While a number of guidelines have highlighted the importance of providing psychosocial support to older people in emergencies (World Health Organization, 2006; Inter-Agency Standing Committee, 2008; HelpAge International, 2012), lack of research focus on older populations in resource-poor regions hampers such support provision. Most epidemiological studies on mental health of forced migrants focus on a limited number of disorders such as depression, anxiety, and PTSD (De Jong et al., 2003; Siriwardhana et al., 2013). Studies from the current review have similarly focused on these disorders, and only a few examined a wider array of mental disorder outcomes. Prevalence of mental disorders, as evidenced through the reviewed studies, shows a wide variation. This may be explained due to methodological differences such as sample size, measurements, and study quality.
There is a notable lack of focus on older agespecific physical or mental health outcomes in reviewed studies. The impact of trauma caused by forced migration on an older individual can be compounded by age-specific, pre-existing conditions such as chronic physical illnesses, Parkinson’s disease, dementia, geriatric depression, and unrecognized alcohol abuse. Prevalence of these conditions are generally increased among the elderly and present difficulties to differentiate psychological distress induced by forced migration from distress due to prevailing age-related health issues. Pre-existing conditions can act as strong predictors or mediators between traumatic experience of forced migration and subsequent mental ill health among older adults. The review findings identify the need for research that explores associations between age-related health issues and consequences of forced migration trauma. In addition, routine inclusion of specific measurements for age-related mental/neurological disorders in health surveys among conflict-affected older adults is recommended. Among older refugees or IDPs, being forced to abandon their homes, villages, and countries where they have lived for most of their life may instill strong feelings of loss (Burton and Breen, 2002). Sense of attachment to their ancestral land is likely to be increased among older forced migrants than their younger counterparts. Acculturation process in new and unfamiliar cultural or linguistic settings may be slower among older forced migrants. They may find it more difficult to re-establish fragmented social support systems and networks, compounded by losing close family or friends during the forced migration process. Some studies included in our review show that older refugees with low social support and low English proficiency (or the language of the recipient country) can increase the risk of depression (Howells Wrobel et al., 2009; Cummings et al., 2011). Forced migration of older adults needs to be conceptualized in a framework that emphasizes the importance of social support as well as comprehensive care, which includes both medical and psychosocial components. Our review has identified several methodological issues among mental health research of older forced migrants. Most research studies are of cross-sectional design, limiting the understanding of temporality and clear causal pathways between forced migration and development of mental disorders. Given the complex nature of health issues faced by older forced migrants, longitudinal studies are encouraged. We identified a paucity of qualitative studies exploring mental health issues around forced migration of older people. Older forced migrants may have diverse, rich, and
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in-depth lived experiences that could allow researchers to gain a deeper understanding of trauma and mental health trajectories, and the lack of qualitative exploration prevents use of such valuable insight for specific intervention development. The current review also highlights the lack of clear information or agreement about the instruments used to measure mental health outcomes. Most studies have not provided adequate information about translation/adaptation process of measurements (if required by the setting/population) or information on reliability and validity of instruments. Importance of validity and reliability of psychiatric measurements is firmly established, and given the contextual complexities in mental health research among older forced migrant populations, more attention should be given to measurement issues. As mentioned before, a number of studies in the review have issues regarding recall and information bias, and care must be taken to avoid such biases where possible. Our review has several limitations. The scarcity of studies we discovered in this review should be considered a limitation itself, as the low number of studies limits a wider discussion. Although a large volume of current work on conflict-affected displacement and mental health include older population fractions, this review only included studies with a primary focus on older adults. We also acknowledge that there are other potential approaches to this topic (for example, after careful consideration, studies looking at long-term mental health of those displaced as children due to conflict were excluded). The heterogeneity of studies prevented a systematic review (meta-analytic) being conducted. The heterogeneity of methodology, samples, measurements, and statistical analysis prevented us from providing a pooled data analysis. We may not have captured other important studies published in languages other than English and some grey literature. Studies that did not have a primary focus on mental health, conflict or displacement were not included; therefore, a substantial subset of literature on older people in emergencies such as disasters has not been included. In addition, the keywords used may have caused the omission of some relevant literature (for example, using broader “mental health” term might exclude specific disorder-focused studies). In conclusion, as the older adult population fraction increases worldwide along with severe conflict, it is crucial to establish the extent of current evidence-base on the effect of forced migration on mental health of these populations. The design and implementation of effective mental health interventions should be informed by research
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that reflects the changing global realities such as population and conflict dynamics, especially in resource-poor LMIC (Mirsky, 2009). According to our review findings, the current body of mental health research on older forced migrants does not seem to reflect the changing realities in the world, and highlights the need for a strategic re-think from academics, health professionals, and other stakeholders on a global scale.
Supplementary Materials To view supplementary material for this article, please visit http://dx.doi.org/10.1017/ S1041610216000193.
Conflict of interest None.
Description of authors’ roles CS conceptualized the paper. AV conducted the literature search. AV and SD reviewed articles and wrote the first draft. CS reviewed and edited the manuscript. All authors agreed on the final version.
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Hinton, L., Franz, C. E., Yeo, G. and Levkoff, S. E. (2005). Conceptions of dementia in a multi-ethnic sample of family caregivers. Journal of the American Geriatrics Society, 53, 1405–1410. doi:10.1111/j.1532-5415.2005.53409.x. Howells Wrobel, N., Farrag, M. F. and Hymes, R. W. (2009). Acculturative stress and depression in an elderly Arabic sample. Journal of Cross Cultural Gerontology, 24, 273–290. doi:10.1007/s10823-009-9096-8. Inter-Agency Standing Committee (IASC) Working Group. (2008). Humanitarian action and older persons: an essential brief for humanitarian actors. IASC, 2–7. Internal Displacement Monitoring Centre (IDMC). (2015). Global overview 2015: people internally displaced by conflict and violence. IDMC, 1–99. Karunakara, U. and Stevenson, F. (2012). Ending neglect of older people in the response to humanitarian emergencies. PLOS Medicine, 9, 1–3. doi:10.1371/journal/pmed.1001357. Kirmayer, L. J. et al., (2010). Common mental health problems in immigrants and refugees: general approach in primary care. Canadian Medical Association Journal, 183, E959–E967. Kuittinen, S. et al., (2014). Depressive symptoms and their psychological correlates among older Somali refugees and native Finns. Journal of Cross-Cultural Psychology, 45, 1434–1452. doi: 10.1177/0022022114543519. Levkoff, S. E., Macarthur, I. W. and Bucknall, J. (1995). Elderly mental health in the developing world. Social Science & Medicine, 41, 983–1003. Loi, S. and Sundram, S. (2014). To fell, or not to flee, that is the question for older asylum seekers. International Psychogeriatrics, 26, 1403–1406. doi: 10.1017/S1041610214001057. Marshall, G. N., Schell, T. L., Elliott, M. N., Berthold, S. M. and Chun, C. (2005). Mental health of Cambodian refugees 2 decades after resettlement in the United States. JAMA, 294, 571–579. Mirsky, J. (2009). Mental health implications of migration: a review of mental health community studies on
Russian-speaking immigrants in Israel. Social Psychiatry Psychiatric Epidemiology, 44, 179–187. Mölsä, M. et al., (2014). Mental and somatic health and preand post-migration factors among older Somali refugees in Finland. Transcultural Psychiatry, 51, 499–525. doi: 10.1177/1363461514526630. Porter, M. and Haslam, N. (2005). Predisplacement and postdisplacement factors associated with mental health of refugees and internally displaced persons. Journal of the American Medical Association, 294, 602– 612. Roberts, B. and Browne, J. (2011). A systematic review of factors influencing the psychological health of conflict-affected populations in low-and middle-income countries. Global Public Health, 6, 814– 829. Siriwardhana, C. et al., (2013). Prolonged internal displacement and common mental disorders in Sri Lanka: the COMRAID study. PLOS One, 8, 1–9. doi:10.1371/journal.pone.0064742. STROBE. (2007). STROBE checklist for cohort, case-control, and cross-sectional studies (combined) Strengthening the Reporting of Observational studies in Epidemiology. Available at: http://www.strobestatement.org/fileadmin/Strobe/uploads/checklists/ STROBE_checklist_v4_combined.pdf; last accessed 2 March, 2015. United Nations, Department of Economic and Social Affairs, Population Division. (2015). World population prospects: the 2015 revision, key findings and advance tables. Working Paper No. ESA/P/WP.241. World Health Organization (WHO). (2006). Older persons in emergencies: WHO Draft Fact Sheet, 1–2. Available at: http://www.who.int/mediacentre/factsheets/fs404/en/; last accessed 19 October, 2015. World Health Organization (WHO). (2015). Definition of an older or elderly person: Proposed working definition of an older person in Africa for the MDS project. Available at: http://www/who.int/healthinfo/survey/ageingdefnolder/ en/index/html; last accessed 12 May, 2015.
REVIEW
The impact of forced migration on the mental health of the elderly: a scoping review ...........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
Ashwini Virgincar,1 Shannon Doherty2 and Chesmal Siriwardhana2,3 1
King’s College London, Faculty of Life Science & Medicine, London, SE1 1UL, UK Global Public Health, Migration & Ethics Research Group, Faculty of Medical Science, Anglia Ruskin University, Bishop Hall Lane, Chelmsford CM1 1SQ, UK 3 Institute of Psychiatry, Psychology & Neuroscience, King’s College London, 16 De Crespigny Park, London SE5 8AF, UK 2
ABSTRACT
Background: The worldwide elderly population fraction is increasing, with the greatest rise in developing countries. Older adults affected by conflict and forced migration mainly taking place in developing countries may be particularly vulnerable to poor mental health due to other age-specific risk factors. This review aims to explore global evidence on the effect of conflict-induced forced migration on the mental health of older adults. Methods: Seven bibliographic databases were searched. The title and abstract of 797 results were reviewed for qualitative and quantitative studies meeting inclusion and exclusion criteria. Results: Six studies were selected for the in-depth review. Five papers assessed mental health in older adult populations displaced as refugees. One paper assessed mental health of older adults with varying immigration status. Conclusions: This review highlights the dearth of evidence about the impact of forced migration on the mental health of older adults. Further research is needed to explore the risk factors and processes that contribute to adverse mental health outcomes among older adult populations. This is essential to the development of interventions for this vulnerable and at-risk population, particularly in resource-poor settings. Key words: forced migration, mental health, elderly
Introduction Since the mid-2000s, an increasing trend of interstate and societal conflict has been observed worldwide along with conflict-induced forced migration (Centre for Systemic Peace, 2015; IDMC, 2015). According to the Internal Displacement Monitoring Centre (IDMC) figures, internally displaced and refugee population numbered around 57.5 million in 2014, compared to 39 million in 2004 and 33.7 million in 1989 (IDMC, 2015). Conflict-associated trauma significantly contributes to the subsequent development of mental disorders during post-displacement periods (Porter and Haslam, 2005). The development of mental illness among forced migrant populations depends on a number of factors including the nature of Correspondence should be addressed to: Chesmal Siriwardhana, Anglia Ruskin University, Bishop Hall Lane, Chelmsford CM1 1SQ, UK. Phone: +44 (0)1245 68 4199. Email: [email protected]. Received 26 Jul 2015; revision requested 22 Aug 2015; revised version received 22 Dec 2015; accepted 21 Jan 2016. First published online 2 March 2016.
trauma, number of traumatic events experienced, objective/perceived severity of trauma, age and gender (Porter and Haslam, 2005; Roberts and Browne, 2011). Of these, older age (defined as those over the age of 60 by the United Nations) has been reported to be associated with significant mental health issues (World Health Organization, 2015). Impact of forced migration on elderly mental health is important in the context of increasing global older population faction. In 2006, 11% of the world’s population consisted of people over the age of 60 years (Inter-Agency Standing Committee, 2008; United Nations, 2015). By 2050, this is expected to increase to 22% with a simultaneous rise in the proportion of older people living in developing countries (60% to 80%), and the fastest growing subset is the over-80 age group (InterAgency Standing Committee, 2008; Karunakara and Stevenson, 2012). The proportion of older people affected by forced migration only stands to increase due to the rising number of violent conflict situations, especially in the Middle East, Africa,
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and Asia (Inter-Agency Standing Committee, 2008; Karunakara and Stevenson, 2012). A wide range of additional age-specific factors may compound the mental health impact of forced migration among older people (Burton and Breen, 2002; Karunakara and Stevenson, 2012; Loi and Sundram, 2014). Psychological distress induced by forced migration may occur on a background of existing age-related neurological and mental disorders such as dementia, depression, un-recognized alcohol abuse, and general reduction in mental capacity (Inter-Agency Standing Committee, 2008; HelpAge International, 2012; World Health Organization, 2015). Chronic physical illnesses, disability, reduced mobility, and nutritional deficiencies can also compound psychological stress (InterAgency Standing Committee, 2008; Karunakara and Stevenson, 2012; Loi and Sundram, 2014). Such chronic geriatric conditions usually require regular monitoring, medication, and resources (e.g. power supply for respiratory or dialysis machines), and these resources may not be available during enforced migratory episodes, especially in resourcepoor settings (HelpAge International, 2012; Loi and Sundram, 2014). The cumulative effects of existing health impairments may have a significant impact on the mental health of the displaced older adults (Hinton et al., 2005). In addition, having lived through a greater number of adverse events during their lifetime, the displaced older adults are at an increased risk of developing mental illnesses (Chee and Levkoff, 2001). Although positive contributions to society from the older adults are highly valued in many cultures, in situations of forced displacement, they may become a burden on surviving families and communities, as their contribution to survival efforts can be limited (Burton and Breen, 2002; Loi and Sundram, 2014). Inability to play a meaningful role during a time of crisis can result in loss of social/family support/respect, precipitate loss of self-esteem and further contribute to increased psychological distress (Burton and Breen, 2002). Death of close family, such as children, or abandonment by families during displacement may precipitate adverse mental health outcomes (Kirmayer et al., 2010). Furthermore, older forced migrants may have significant issues with acculturation in post-displacement living areas (for example African/Asian/Middle Eastern refugees in Western countries), compounded by cultural, linguistic, and religious barriers impeding their ability to integrate with new social structures (Burton and Breen, 2002; Bhugra et al., 2011). They may also be prevented from making full use of available resources due to a lack of relevant cultural or linguistic knowledge
(Inter-Agency Standing Committee, 2008; Loi and Sundram, 2014). Elderly people may also be reluctant to move from familiar places resulting in increased risk of social isolation (Levkoff et al., 1995). Due to increased pressure to address acute physical health issues in many conflict situations, elderly populations and their psychosocial needs are often overlooked by humanitarian programs (Inter-Agency Standing Committee, 2008). This oversight must be addressed to understand specific risk factors linked to mental disorders among older forced migrants. While there are some existing recommendations and policy guidance on older people in emergencies (World Health Organization, 2006; Inter-Agency Standing Committee, 2008), they lack specific provisions on mental health. Understanding and establishing the current level of knowledge about the impact of forced migration on mental health of older people is essential in the context of the worlds’ aging population and interlinked challenges in providing effective healthcare, especially in resource-poor countries (Mirsky, 2009). However, current and comprehensive evidence-base on issues around forced migration and mental health of older people is not available. In order to address this gap, a scoping review of quantitative and qualitative research on mental health issues of older forced migrants, including refugees, asylum seekers, and internally displaced people (IDP), was conducted.
Methods Databases and search terms Seven databases (Pubmed, PsycArticles, PsycINFO, Google Scholar, Embase, Medline, and Global Health), expert recommendations, and a manual search were used to explore published and grey literature. The final search terms included a combinations of the following terms as well as related terms: “war” AND “mental health” AND “elderly” AND “older adult” (See the supplementary material). Screening, selection, and assessment The initial search of all databases as well as a manual search and a search of recommended articles produced over 797 results. Of these, 729 articles were rejected following a title and abstract review and as a result of inaccessibility to the full article. Following duplicate review, 15 articles were removed leaving a total of 53 results. Following a full text review, a further 47 articles were rejected. A total of six articles were chosen for a final indepth review (Figure 1). The STROBE checklist
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Stage 1: Search all databases >79 97 articles
Stage 2: T Title and abs stract review 729 rejected based on exclusion criteria and duplication Stage 3: Full text revview
47 rejected based on exclusion criteria and methodological weaknesses Stage 4: Final in-depth review 6 articles
Figure 1. Study selection process.
was used to assess the quality of quantitative studies included (STROBE, 2015). The STROBE checklist lists items that should be included in research articles such as details of the sample population and discussions of potential bias and limitations of the study. There are 22 items, given 1 point each and the total score gives an indication of the strengths and weaknesses found in research studies (STROBE, 2015). Selection criteria included population of conflictaffected migrants over the age of 50 of either gender. Studies on both internal migrants (those displaced within the national borders) and external migrants (those displaced beyond their national borders) were included. Studies with statistically significant mental health outcomes resulting from forced migration were included. The review considered worldwide studies written in the English language. Voluntary migrant populations (for example, those migrating for economic reasons) were excluded. Both qualitative and quantitative research was considered. Demographic variables taken into account in this review include different combinations of age, gender, marital status, living arrangements, education, income, length of residency in host country, age of immigration, and time since traumatic event.
Results Demographic characteristics All included articles except one (Marshall et al., 2005) sampled populations 50 years and older. Marshall et al., (2005) included adults of 35–70 years and was included as it provided valuable
information on mental health of older age groups. Of the six studies included in the final review, three were conducted in the United States of America (USA) (Marshall et al., 2005; Howells Wrobel et al., 2009; Cummings et al., 2011), two studies in Finland (Kuittinen et al., 2014; Mӧlsӓ et al., 2014), and one study in Lebanon (Chaaya et al., 2007). The majority of studies included in the review focused on conflict-affected refugee populations (Marshall et al., 2005; Chaaya et al., 2007; Cummings et al., 2011; Kuittinen et al., 2014; Mӧlsӓ et al., 2014), with one study focusing on a population with varying immigration status (Howells Wrobel et al., 2009). All articles reported mental health findings for both men and women. Five of the included studies sampled populations 50 years and older who had been displaced as adults or older adults (Chaaya et al., 2007; Howells Wrobel et al., 2009; Cummings et al., 2011; Kuittinen et al., 2014; Mӧlsӓ et al., 2014) and one study sampled a population aged 35–75 years (Marshall et al., 2005), who had been displaced as adults. Table 1 summarizes key information of included studies. Mental disorder and psychosocial outcomes Mental disorder and psychosocial outcomes reviewed include post-traumatic stress disorder (PTSD), depression, alcohol use, predictors of depression, expression of mental illnesses, and mental health effects of trauma. A study of resettled Cambodian refugees in the USA found that continued high rates of various psychiatric illnesses indicates long-term consequences of exposure to trauma (Marshall et al., 2005). They reported higher rates of PTSD and major depression but
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Table 1. Summary of selected studies MENTAL HEALTH
STUDY
SAMPLE/
OUTCOME
BACKGROUND/
AND OTHER RELIABILITY
STUDY DESIGN
VALIDITY/
M E A S U R E S ∗ O F M E A S U R E S ∗∗
QUALITY CONCLUSIONS
REPORTED
ASSESSMENT
LIMITATIONS
SCORE
.........................................................................................................................................................................................................................................................................................................................
Continued high rates Cross-sectional design so 16 HTQ, CIDI, All measures 586 resettled of psychiatric illness causality cannot be AUDIT translated and back Cambodian determined, sample translated, modified indicates long-term refugees living in may not be consequences for version of the United States representative, tools exposure to trauma Cambodian HTQ of America (USA)/ not specifically 35–75 years/ validated for the cross-sectional population 17 Depression appears to Small sample size, GDS-15 Arabic version not 740 Palestinian Chaaya be a significant issue cross-sectional design validated but refugees and et al., so causality cannot be in older refugees, correlated with displaced 2007 determined, use of religious practice Arabic validated Lebanese living in non-validated scale may provide an GHQ-12 Lebanon/60+ outlet for social years/crosssolidarity sectional 15 Perception of pressure Recall bias may be 200 Arab–Americans MASI, GDS MASI test–retest Howells present as retrospective to learn English 0.53–0.84, with varying Wrobel assessment, coupled with low Cα=0.73–0.94, immigration et al., English competency cross-sectional design modified to reflect statuses living in 2009 unable to determine appears to predict Arabic cultural the USA/60–92 causality depression in older idioms and years/crossadult immigrants language, GDS sectional split-half reliability=0.88– 0.99, test-retest=0.85, Cα=0.85, translated/back translated into Arabic/English 14 IADL, LSNS, IADL no information Isolation and lack of Statistical power Cummings 70 emigrants from weakened by small social support in on Kurdistan living in MGLQ, et al., sample size, older immigrant validity/reliability, GDS the USA/50+ 2011 populations appears cross-sectional design LSNS internal years/crossunable to determine to increase risk of consistency=0.86, sectional causality depression and reliability α=0.66, highlights the need MGLQ Cα=0.91, for tailored services GDS Cα=0.91 for those affected Kuittinen 128 Somalians living BDI, 14 Matched pair may not Language translations Variance in mental in Finland et al., have controlled for all health expression SCL-R-90 and cultural 2014 factors, instruments needs to be taken appropriateness matched with not validated for the into consideration reviewed by experts Finnish population when tailoring residents/50–85 health services for years/cohort minority groups and diverse populations Instruments not validated 15 Refugee-related Translated but not Mӧlsӓ et al., 128 Somalians living BDI-21, for the population, traumatic back translated, GHQ-12, 2014 in Finland differing data collection experience appears cultural HRQoL matched with methods between to have long-lasting appropriateness Finnish mental health effects groups could have review by experts, residents/50–80 affected results in order adults pilot tested years/cohort
Marshall et al., 2005
∗ HTQ – Harvard Trauma Questionnaire; CIDI – Composite International Diagnostic Interview World Mental Health version; AUDIT – Alcohol Use Disorder Identification Test; GDS-15 – Geriatric Depression Score 15-item; MASI – Multi-dimensional Acculturative Stress Inventory; GDS – Geriatric Depression Scale; IADL – Instrumental Activities of Daily Living and Social Functioning; LSNS – The Lubben Social Network Scale; MGLQ – Migratory Grief and Loss Questionnaire; BDI – Beck Depression Inventory; SCL-R-90 – Symptom Checklist-Revised; BDI-21 – Beck Depression Inventory 21 item version; GHQ-21 – General Health Questionnaire 21 item version; HRQol – Health-Related Quality of Life.
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lower risk of possible alcohol use disorder for older participants with women in the sample less likely to have either PTSD or alcohol use disorders (Marshall et al., 2005). One study on older Palestinian refugees living in Lebanon found high rates of depression (Chaaya et al., 2007). They also reported that depression appears to be a significant challenge for all older refugees in their sample and that religious practice may mitigate some of the effects as an outlet for social solidarity (Chaaya et al., 2007). Two other studies conducted in the USA looked at predictors of depression, one among older immigrants with varying immigration status (Howells Wrobel et al., 2009), and another among refugees who had fled conflict (Cummings et al., 2011). The first study with varying immigration status participants found that the risk of depression is predicted by people’s perception of pressure to learn English and low English competency (Howells Wrobel et al., 2009). This study also reported increased levels of depression and acculturative stress amongst those self-identifying as refugees as compared to those identifying as citizens, permanent residents or visa holders of the country providing refuge (Howells Wrobel et al., 2009). The second study in the USA, which sampled refugees from Kurdistan found high rates of depression (Cummings et al., 2011). This study concluded that the risk of developing depression was associated with social isolation and lack of social support (Cummings et al., 2011). A study conducted in Finland compared Somali refugees to Finnish citizens and found that the Somali refugees displayed more somatic-affective symptoms of mental distress (Kuittinen et al., 2014). They concluded that variance in how mental illness is expressed must be taken into account when tailoring health services for minority groups to ensure full spectrum of mental illness is understood (Kuittinen et al., 2014). A second study on the same sample of Somalian refugees living in Finland reported that traumatic experiences can create longlasting mental health effects into older adulthood (Mӧlsӓ et al., 2014). It found clinically significant differences in reported self-related health status, depression symptoms, and general psychological distress (Mӧlsӓ et al., 2014). Methodological issues Table 1 presents summary information on sample and background, study design, mental health outcomes, validity and reliability of measures, study conclusions, and reported limitations. A wide range of mental health measurements were used, including the Harvard Trauma Questionnaire (HTQ), the Composite International Diagnostic
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Interview World Mental Health version (CIDI), the Alcohol Use Disorder Identification Test (AUDIT), Geriatric Depression Score (GDS-15), Multi-dimensional Acculturative Stress Inventory (MASI), Instrumental Activities of Daily Living and Social Functioning (IADL), the Lubben Social Network Scale (LSNS), Migratory Grief and Loss Questionnaire (MGLQ), Beck Depression Inventory (BDI), Symptom Checklist-Revised (SCL-R90), General Health Questionnaire (GHQ-21) and Health Related Quality of Life (HRQoL). The majority of studies were of cross-sectional design. Sample sizes of the studies varied widely (range; 70 to 740). Sample population total from all included studies was 1,724. Reliability and validity of information was provided by some studies, mostly limited to Cronbach’s α figures. In addition, it was not clear in most studies whether the measurements were administered in English, in the native language of the host country (for refugees) or in the native language of participants. The quality assessment scores ranged from 14 to 17 (from a total of 22). Most studies lost points for not stating potential sources of bias, funding sources, and limitations. There was no identifiable pattern of links between quality score and other study attributes such as sample size. Main reported limitations were recall bias, lack of power due to small sample size, and lack of reliability, as instruments were not validated for the population.
Discussion This review explored mental health issues of older forced migrants including refugees, asylum seekers, and IDP. In summary, the findings show an increased level of mental disorders and psychosocial issues among older adults affected by conflict. Most commonly studied and prevalent mental disorders were depression, anxiety, and PTSD. In general, psychosocial well-being of those affected by forced migration was reported as poor, and factors such as experiences during displacement, post-migration acculturation, age at displacement, and gender played a role in poor mental health. Forced migration emerged as a highly significant predictor of negative mental health outcomes among older conflict-affected adults, especially for current anxiety. Overall findings show increased depression, anxiety, and an increased risk of developing PTSD. However, caution must be exercised when interpreting these findings, as the majority of studies had examined populations long after the event of forced migration. Furthermore, factors related to the process of natural aging of participants needs to be considered.
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A key finding to emerge from the review is the lack of epidemiological studies looking at mental health of older adults affected by conflictrelated forced migration in low-and middle-income countries (LAMIC). The studies included in this review were focused on refugee populations living in developed countries such as European Union member states and the United States. Previous research on conflict-affected populations in LAMIC have shown older age to be a specific risk factor for mental disorders (Roberts and Browne, 2011). Despite this, our findings indicate that research with a specific focus on older age groups is scarce in most LAMIC. Studies in the review had focused on refugee populations, neglecting IDP. This is a notable gap in research focus, as the numbers of IDPs from global conflicts have increased exponentially during recent years (IDMC, 2015). As mentioned before, the majority of these IDPs are located in LAMIC, with increasing older population factions. Given the contextual and factual importance, mental health of older adult IDPs should be considered as a research priority. In addition, this review points towards a significant lack of evidence on mental health issues of older adults displaced by recent conflict. The nature, context, and severity of conflicts are fast changing, and it is important to study the mental health impact of forced migration from recent conflicts. Since the World Wars, most conflicts have taken place in developing countries. In this context, understanding mental disorder trajectories of older people affected by conflict and forced migration within the immediate aftermath will be highly useful for the development and delivery of critical psychosocial support to this vulnerable population group. While a number of guidelines have highlighted the importance of providing psychosocial support to older people in emergencies (World Health Organization, 2006; Inter-Agency Standing Committee, 2008; HelpAge International, 2012), lack of research focus on older populations in resource-poor regions hampers such support provision. Most epidemiological studies on mental health of forced migrants focus on a limited number of disorders such as depression, anxiety, and PTSD (De Jong et al., 2003; Siriwardhana et al., 2013). Studies from the current review have similarly focused on these disorders, and only a few examined a wider array of mental disorder outcomes. Prevalence of mental disorders, as evidenced through the reviewed studies, shows a wide variation. This may be explained due to methodological differences such as sample size, measurements, and study quality.
There is a notable lack of focus on older agespecific physical or mental health outcomes in reviewed studies. The impact of trauma caused by forced migration on an older individual can be compounded by age-specific, pre-existing conditions such as chronic physical illnesses, Parkinson’s disease, dementia, geriatric depression, and unrecognized alcohol abuse. Prevalence of these conditions are generally increased among the elderly and present difficulties to differentiate psychological distress induced by forced migration from distress due to prevailing age-related health issues. Pre-existing conditions can act as strong predictors or mediators between traumatic experience of forced migration and subsequent mental ill health among older adults. The review findings identify the need for research that explores associations between age-related health issues and consequences of forced migration trauma. In addition, routine inclusion of specific measurements for age-related mental/neurological disorders in health surveys among conflict-affected older adults is recommended. Among older refugees or IDPs, being forced to abandon their homes, villages, and countries where they have lived for most of their life may instill strong feelings of loss (Burton and Breen, 2002). Sense of attachment to their ancestral land is likely to be increased among older forced migrants than their younger counterparts. Acculturation process in new and unfamiliar cultural or linguistic settings may be slower among older forced migrants. They may find it more difficult to re-establish fragmented social support systems and networks, compounded by losing close family or friends during the forced migration process. Some studies included in our review show that older refugees with low social support and low English proficiency (or the language of the recipient country) can increase the risk of depression (Howells Wrobel et al., 2009; Cummings et al., 2011). Forced migration of older adults needs to be conceptualized in a framework that emphasizes the importance of social support as well as comprehensive care, which includes both medical and psychosocial components. Our review has identified several methodological issues among mental health research of older forced migrants. Most research studies are of cross-sectional design, limiting the understanding of temporality and clear causal pathways between forced migration and development of mental disorders. Given the complex nature of health issues faced by older forced migrants, longitudinal studies are encouraged. We identified a paucity of qualitative studies exploring mental health issues around forced migration of older people. Older forced migrants may have diverse, rich, and
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in-depth lived experiences that could allow researchers to gain a deeper understanding of trauma and mental health trajectories, and the lack of qualitative exploration prevents use of such valuable insight for specific intervention development. The current review also highlights the lack of clear information or agreement about the instruments used to measure mental health outcomes. Most studies have not provided adequate information about translation/adaptation process of measurements (if required by the setting/population) or information on reliability and validity of instruments. Importance of validity and reliability of psychiatric measurements is firmly established, and given the contextual complexities in mental health research among older forced migrant populations, more attention should be given to measurement issues. As mentioned before, a number of studies in the review have issues regarding recall and information bias, and care must be taken to avoid such biases where possible. Our review has several limitations. The scarcity of studies we discovered in this review should be considered a limitation itself, as the low number of studies limits a wider discussion. Although a large volume of current work on conflict-affected displacement and mental health include older population fractions, this review only included studies with a primary focus on older adults. We also acknowledge that there are other potential approaches to this topic (for example, after careful consideration, studies looking at long-term mental health of those displaced as children due to conflict were excluded). The heterogeneity of studies prevented a systematic review (meta-analytic) being conducted. The heterogeneity of methodology, samples, measurements, and statistical analysis prevented us from providing a pooled data analysis. We may not have captured other important studies published in languages other than English and some grey literature. Studies that did not have a primary focus on mental health, conflict or displacement were not included; therefore, a substantial subset of literature on older people in emergencies such as disasters has not been included. In addition, the keywords used may have caused the omission of some relevant literature (for example, using broader “mental health” term might exclude specific disorder-focused studies). In conclusion, as the older adult population fraction increases worldwide along with severe conflict, it is crucial to establish the extent of current evidence-base on the effect of forced migration on mental health of these populations. The design and implementation of effective mental health interventions should be informed by research
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that reflects the changing global realities such as population and conflict dynamics, especially in resource-poor LMIC (Mirsky, 2009). According to our review findings, the current body of mental health research on older forced migrants does not seem to reflect the changing realities in the world, and highlights the need for a strategic re-think from academics, health professionals, and other stakeholders on a global scale.
Supplementary Materials To view supplementary material for this article, please visit http://dx.doi.org/10.1017/ S1041610216000193.
Conflict of interest None.
Description of authors’ roles CS conceptualized the paper. AV conducted the literature search. AV and SD reviewed articles and wrote the first draft. CS reviewed and edited the manuscript. All authors agreed on the final version.
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