- Refugees in Germany have high rates of mental health issues like PTSD, depression, and anxiety due to pre-migration trauma, difficulties during migration, and post-migration stressors. However, there is limited access to adequate mental health care for refugees in Germany due to language barriers, bureaucratic hurdles, and insecure legal status. - The refuKey project aims to improve mental health care for refugees in Lower Saxony through establishing counselling centers, training staff in transcultural competence, providing interpreters, and evaluating outcomes. Results found significant improvements in refugees' mental wellbeing after receiving treatment through refuKey. - Guidance from organizations like the EPA emphasizes the need for culturally-sensitive care

1. Reflecting on the EPA’s guidance on mental health
care of migrants and refugees in Germany
Iris Tatjana Graef-Calliess
Supporting refugees’ mental health
Helsinki, 11–12 December 2019

2. Refugees in Germany
Number of refugees 2019
 1.300.000 people under protection
 274.600 in asylum procedures
 191.100 rejected & tolerated
https://mediendienst-integration.de/migration/flucht-
asyl/zahl-der-fluechtlinge.html
2018: 27.3% refugee recognition rate, 50.2% rate of protection
(www.unhcr.org/de)

3. Mental health of migrants
 Substantial cultural variations
 in expression (cultural syndromes, idioms of distress, culturally influenced
symptom patterns),
 perception of mental disorders (explanations/ attributions) and
 response to psychological distress as well as acceptance of certain treatments
(Kirmayer & Ryder, 2006)
 Diagnoses of migrant patients in psychiatric routine care in Germany (Koch et al.,
2008)
 36% schizophrenic disorders (psychotic disorders, e.g. paranoid schizophrenia)
 30% addiction disorders
 12% affective disorders
 7% reaction to severe stress & adjustment disorders

4. Mental health of refugees
 Refugees and asylum seekers most affected and vulnerable population
 High psychiatric morbidity for PTSD, depression, anxiety & schizophrenic
disorders (Bogic et al., 2015, Georgiadou et al., 2018; Giacco et al., 2018):
 ca. 30% (Steel et al., 2009)
 PTSD 10x as high in refugees as in local population (Fazel et al., 2005)
 common mental disorders twice as high in refugees as in migrants (Bhugra
et al., 2014), schizophrenia 6x as high (Hollander et al., 2016)
 Mental health of refugees in Germany
 very few robust data available in Germany
 50% with psychiatric diagnosis in a German reception center (Nesterko et
al., 2019)
 74,6% with a psychiatric disorder in reception centers in Berlin (Winkler et
al., 2018)

5. Impact factors on mental health of refugees
 Pre-migratory stressors: individual predisposition & vulnerability, traumatic
events, e.g., physical and sexual abuse, war, death of relatives
 Traumatic experiences during migration
 Post-migration stressors:
 socioeconomic difficulties,
 lengthy asylum-seeking process & complicated immigration policies
perceived discrimination & racism experiences,
 social isolation & exclusion
 Post-migration stressors & traumatic experiences affect long-term mental
health in refugees (Laban et al., 2004; Bourque et al., 2011; Li et al. 2016;
Giacco et al., 2018): e.g., association between lack of refugee status and
symptom severity of PTSD and depression (Knipscheer et al., 2015)

6. Psychiatric routine care of refugees in Germany I
 Lack of access to adequate mental health care worldwide (Ansar et al.,
2017; Bhugra et al., 2014; Giacco et al., 2018;):
 restricted access to health care in Germany (Altunoz et al., 2016;
Bozorgmehr & Razum, 2015; Schröder et al., 2018)
 late access to mental health care (Koch et al., 2008)
 Underrepresentation in psychotherapeutic care and day clinic treatment &
overrepresentation in intensive inpatient and forensic care in Germany
(Koch et al., 2008)
 Large differences in degree of intercultural opening in psychiatric clinics in
Germany (Graef-Calliess et al., 2019; Trilesnik et al., 2019)
 Lack of systematic and sufficient data documentation of refugees and
migrants in psychiatric routine care (Koch et al., 2008; Trilesnik et al., 2019)

7.  Main impediments to high-quality mental health care for refugees in
Germany (Trilesnik et al., 2019):
bureaucratic workload,
language barriers,
e.g., 45% of personnel report difficulties in (differential) diagnostics or
misdiagnosis & difficulties in therapy due to language & cultural
understanding (Koch et al., 2008)
insecure legal status (no residence permit),
limited resources (trained personnel, time,…)
 Consequence: huge treatment gap!
 Need of culturally and geographically appropriate and accessible
psychiatric service (Bhugra et al., 2014)
Psychiatric routine care of refugees in Germany II

8. EPA Guidance mental health care of migrants
Bhugra et al., 2014

9. EPA Guidance mental health care of migrants
1. Transcultural competence training of service
providers
2. Qualified interpreters, cultural mediators
3. Documentation & diagnostic with specific
instruments (National Migration Questionnaire,
Cultural Formulation Interview (CFI) etc.)
4. Culturally and need adapted treatment
5. Reduction of structural access barriers through
unrestricted access to health care, service maps
and information about the health care system in
different languages
Bhugra et al., 2014; Kirmayer & Ryder, 2016; Trilesnik et al., 2019)

10. Approaches to mental health care of refugees in Germany
I. Specialized health care provision
 Few specialized outpatient departments (e.g., ZIPP Charité, Berlin)
 Psychosocial centers for torture victims
 Rehabilitation clinics (e.g., Segeberger Clinics (Turkish), Dr. Ebel Vogelsberg-
Clinic (Russian))
II. Intercultural opening of routine mental health care
 General outpatient departments of psychiatric clinics (e.g. St. Hedwig Clinic,
Berlin)
 Center for Transcultural Psychiatry & Psychotherapy, Wahrendorff Clinic
Hanover, Germany (inpatient, day clinic, outpatient)
 MEHIRA study
 RefuKey project

11. Center for Transcultural Psychiatry & Psychotherapy,
Wahrendorff Clinic Hanover, Germany
day clinic
Turkish & Farsi
(20 patients)
Inpatient treatment
(25 patients)
day clinic
Russian & Polish
(20 patients)
Outpatient treatment
(approx. 550 patients quarterly)
Setting 50/50
low threshold
access

12. What is refuKey about?
stepped-care approach
 setup of psychosocial counselling
centers (PCC) next to 5 state
reception centers
 linking PCCs with psychiatric
routine care clinics as co-operating
competence centers
 provision of interpreters & refuKey
staff as „midwives“
 In-house training (asylum law, work
with interpreters, transcultural
psychiatry etc.)
Aim
Improvement of mental health
care for refugees in the state of
Lower Saxony, Germany
 reduction of access barriers
 transcultural competence of
treatment teams
 need-adapted treatment:
prevention, adequate access to
care & follow-up => reduction
of re-hospitalization rate
 scientific evaluation of the
project
REFUGEES
funded by:
refuKey project

13. ♦ Sample: refugee patients in refuKey open counselling hours and treatment:
• N = 454
• 59% PCC, 41% psychiatric clinics
• 54% males
• 16 - 67 y.o. (M=31.5, SD=10.4)
• ≤ 4 years in Germany
• > 60% no residence permit
• from 30 different countries of origin:
Afghanistan (15.4%), Iran (14.2%), Syria
(8.0%) and Iraq (6.8%), Kosovo, Lebanon,
Turkey and Sudan (3.1% each)
stepped-care approach beneficial to deliver need-adapted treatment
according to symptom severity (Frank et al., 2017)
no
answer
0 1 2 3 4 5 6 7 8 9 10
no very light light moderate strong extreme
12.6 .6 1.1 0 1.1 1.1 3.4 5.2 7.5 14.4 18.4 34.5
♦ Reported estimation of burden severity at admission in % (n=100)
refugee patients are severely burdened
♦ Similar levels of severity of psychiatric symptoms between refugee patients in
psychiatric clinics and PCC before the treatment
refuKey study (Trilesnik, Altunoz,…, Graef-Calliess, 2019)

14. ♦ Mental health of refugee patients before and after treatment within refuKey
(n=28; Paired t-test)
N
Pre-
treatment
Post-
treatment t df p
Cohen’s
d
M SD M SD
General well-being 28 38.5 15.2 45.1 14.6 -2.644 27 .05* .499
Depressivity 27 41.7 9.0 34.2 11.5 3.902 26 .001 .613
Anxiety 28 27.2 6.8 22.8 7.9 3.245 27 .01 .751
Psychoticism 27 21.1 11.6 9.2 8.7 4.945 26 .001 .952
Somatization 28 24.9 14.7 12.8 12.9 4.807 27 .001 .908
Traumatization 27 79.1 20.7 69.2 19.5 2.529 26 .05* .487
Quality of Life 25 67.9 18.8 74.3 23.9 -1.816 24 ns -
Post-Migration
Living Difficulties
28 58.8 12.9 56.0 15.1 .919 27 ns -
* not significant after
Bonferroni correction for
multiple testing
Significant improvement of mental health
refuKey study (Trilesnik, Altunoz,…, Graef-Calliess, 2019)

15. ♦ The prevalence of clinically relevant symptoms & their severity before and after
treatment within refuKey (n=28)
92.6% -> 72.4%
85.7% -> 75.9%
96.6% -> 63%
79.3% -> 42.9%
69% -> 64.3%
Pre-treatment measurement (%) Post-treatment measurement (%)
N
< Cut
off
Cut
off +
1 SD
Cut
off +
2 SD
Cut
off +
3 SD
Cut
off +
4 SD
N
< Cut
off
Cut
off +
1 SD
Cut
off +
2 SD
Cut
off +
3 SD
Cut
off +
4 SD
Depression (HSCL-25-D) 27 7.4 11.1 37.0 37.0 7.4 29 27.6 31.0 31.0 10.3 0
Anxiety (HSCL-25-A) 28 14.3 10.7 35.7 35.7 3.6 29 24.1 31.0 31.0 13.8 0
Psychoticism (SCL-90-P) 29 3.4 37.9 24.1 24.1 10.3 27 37.0 37.0 14.8 11.1 0
Somatization (SCL-90-S) 29 20.7 31.0 24.1 20.7 3.4 28 57.1 17.9 14.3 10.7 0
Traumatization (HTQ) 29 31.0 34.5 24.1 6.9 3.4 28 35.7 53.6 10.7 0 0
rates of very
severe symptoms -> 0
rates of clinically relevant symptoms
decrease over the course of treatment
refuKey study (Trilesnik, Altunoz,…, Graef-Calliess, 2019)
depressivity
anxiety
psychoticism
somatization
traumatization

16. General
well-being
Depressivity Anxiety Psychoticism Somatization Traumatization
Quality of
life
-.250** .415** .341** .367** .401** .457** -.537**
♦ Correlation between mental health and Post-Migration Living Difficulties Scale
(Pearsons Correlation Analysis; n=134)
strong links between post-migration factors and mental health
(Laban et al., 2004; Bourque et al., 2011)
♦ Post-Migration Living Difficulties: refugee status determination process; health,
welfare and asylum problems; family concerns; general adaptation stressors; social
and cultural isolation
refuKey study (Trilesnik, Altunoz,…, Graef-Calliess, 2019)

17. “Universal and equitable access to health services and to all
determinants of the highest attainable standard of health
within the scope of universal health coverage
needs to be provided by governments to migrant populations,
regardless of age, gender, or legal status.”
(Lancet Commission on Migration and Health, 2018)
Mental health care of migrants and refugees

18. Thank you!