Mental Health: Global Challenges Journal
https://mhgcj.org ISSN 2612-2138
What mental illness means in different cultures:
perceptions of mental health among refugees
from various countries of origin
Sarah Moses, David Holmes
University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Department of Family Medicine, 955 Main Street Buffalo, NY,
USA
Address for correspondence:
Sarah Moses, MD, University at Buffalo, Jacobs School of Medicine and Biomedical Sciences,
Department of Family Medicine, 955 Main Street Buffalo, NY 14203.
e-mail: smoses2@buffalo.edu
This work is licensed under a Creative Commons Attribution-Non-Commercial 4.0 International
License (CC BY-NC 4.0).
©Copyright: Moses, Holmes, 2022
Publisher: Sciendo (De Gruyter)
DOI: https://doi.org/10.56508/mhgcj.v5i2.126.
Submitted for publication: 19
October 2021
Revised: 09 April 2022
Accepted for publication: 08
May 2022
Mental Health: Global Challenges Journal
https://mhgcj.org ISSN 2612-2138
Introduction
Mental illness remains a huge problem in the
refugee population despite recent efforts to
combat this unfortunate reality. Blackmore et al.
(2020) conducted a meta-analysis and systematic
review of the prevalence of mental illness in
refugees and asylum seekers. Their review was
conducted across 15 countries, and the
prevalence of posttraumatic stress disorder,
depression, anxiety disorders, and psychosis was
determined. The authors found significantly more
posttraumatic stress disorder and depression in
refugees and asylum seekers than in the general
population (Figure 1). By contrast, they found that
the prevalence of both anxiety disorders and
psychosis in refugees and asylum seekers was
comparable to the prevalence in the general
population (Figure 1). For most of the cases of
posttraumatic stress disorder and depression, the
rates of mental illness among refugees and
asylum seekers were not only high but persisted
for many years after initial resettlement. There
was no difference in prevalence between refugees
displaced fewer than 4 years and those displaced
more than 4 years (Blackmore et al., 2020).
Another systematic review from 2020 found
considerably higher rates of mental health
disorders and biological markers of persistent
stress among refugees than among migrants and
the general population of the host country (Byrow
et al., 2020). As can be gleaned from the study of
15 different countries in the meta-analysis by
Blackmore et al. (2020), mental illness is clearly
prevalent in refugees arriving from many different
countries and is not specific to one country of
origin.
Figure 1. Prevalence of mental illness in
refugees and asylum seekers compared to that in
the general population (Blackmore et al., 2020).
Globally, the stigma surrounding mental illness
remains an important issue due to its high
prevalence and strong impact (Adu et al., 2021).
Often, the stigma from mental illness is defined as
context specific (Major & O'Brien, 2005).
According to a 2021 review article by Adu et al.,
“Mental illness-related stigma is rooted in
culture…it can be societal, familial, perpetuated
by health professionals, or situated within the
individual themselves” (Adu et al., 2021, p. 1).
With stigma playing a large role, there are
numerous barriers to mental health care for
refugees (Koesters et al., 2018). These barriers
are at the patient level, the provider level, and a
systems level. Barriers to mental health care at
the patient level include cultural beliefs about
mental health, linguistic barriers, lack of health
care knowledge, distrust of authority or services,
and financial strain. At the provider level, barriers
involve faulty communication skills and a lack of
cultural competency. At the systems level, there
may be a need for more interpreters and improved
reimbursement systems. Differences between
host countries such as initial restrictions to health
care access can also serve as barriers (Koesters
et al., 2018). Many diverse approaches to
overcoming these barriers have been
implemented and studied in different countries
with different refugee populations (Patel et al.,
2014). Additionally, various types of interventions
have been and continue to be tried and evaluated
in a number of host countries (Giacco & Priebe,
2018). There are certain general principles that
are being emphasized in the efforts to improve
refugees’ mental health care, including
overcoming these barriers to care and promoting
social integration (Giacco & Priebe, 2018).
The systematic review by Byrow et al. (2020)
determined that the most important barriers that
refugees have in seeking mental health care fit
into three categories: cultural, structural, and
refugee-specific factors. Cultural barriers include
mental health stigma, (lack of) knowledge of major
models of mental health, and social concerns. The
review found that research participants in the 24
studies, who were all refugees, talked about
mental illness in a negative way. Unfavorable
cultural perceptions played an important role in
these barriers: “One of the primary barriers to
help-seeking behavior that has been consistently
observed across populations, relates to
perceptions of mental health and mental health
treatment” (Byrow et al., 2020, p. 2). In
consideration of this topic, “perceptions” may be
defined as attitudes, beliefs, or knowledge about
mental health. The review by Byrow et al. (2020)
found that these mental health perceptions impact
refugees’ perceived need for mental health care
and their engagement in mental health care.
Therefore, mental health perceptions can provide
additional knowledge concerning behavioral
differences in the utilization of services in different
populations (Andrade et al., 2014; Byrow et al.,
2020). Overcoming refugees’ barriers to mental
health care is even more challenging because of
the immense heterogeneity across different
populations of refugees, host countries, and
contexts (Koesters et al., 2018). Mental health
perceptions differ between different cultures, with
diverse explanations and beliefs behind them
(Byrow et al., 2020).
0
20
40
60
PTSD Depression Anxiety
Disorders
Psychosis
Prevalence (%)
Refugees and Asylum Seekers
General Population
Mental Health: Global Challenges Journal
https://mhgcj.org ISSN 2612-2138
Purpose
This article distinguishes the perceptions of
mental health of refugees according to their
country of origin, because knowing these cultural
differences has the potential to improve refugee
mental health care. If the culture-specific
perceptions of refugees from various countries of
origin can be better understood, taken into
consideration, and utilized for treatment purposes,
then the barriers to care will be reduced.
Furthermore, this information could provide insight
into better approaches to refugee mental health
treatment that are more specialized,
individualized, and therefore more effective for
certain populations.
Methodology
Study design
This study was a comprehensive review. The
following electronic databases were searched for
original research and review articles that
assessed perceptions of mental health among
refugees from different countries of origin:
American Psychiatric Association (APA) PsycInfo
database, Global Health database, MEDLINE via
Ovid, and CINAHL Plus with Full Text. This
search included two groupings of terms
(keywords): (i) refugees, asylum seekers,
displaced, and migrants; (ii) perceptions of mental
illness, perceptions of mental health, and stigma
of mental illness.
Inclusion and exclusion criteria
Only relevant peer-reviewed articles published
from the year 2000 to September 2021 were
reviewed. Only articles that included the name of
a specific group of refugees (from one specific
country of origin) in the title were selected. Finally,
only those articles that focused on refugees’
perceptions, ideas, thoughts, or feelings about
mental health were selected. Articles not
published in English were excluded. Duplicate
articles were excluded.
This search produced 4,405 results. Of these,
only articles that included the name of any specific
group of refugees (from one specific country of
origin) in the title were selected. Of these, only
those that focused on refugees’ perceptions,
ideas, thoughts, or feelings about mental health
were selected. Sixty articles met the inclusion
criteria. In addition, to find more information on
specific topics, the references from some of the
articles found were explored and utilized, and an
additional search was completed on Google
Scholar with the search term “refugee perceptions
of mental illness.” Of the 60 articles, only those
that focused on one of four themes (causes of
mental illness, symptoms and behavior associated
with mental illness, mental health treatment, and
mental health stigma) were ultimately included
(Table 1). The search resulted in the review of
eight articles. All eight are primary research
articles. Six of these were from the reference
search and two were found on Google Scholar.
Data collection and analysis
Perceptions within the following four themes
were identified in the reviewed studies: causes of
mental illness, symptoms and behavior associated
with mental illness, mental health treatment, and
mental health stigma (Table 1).
Results
The perceptions of mental illness and mental
health care among refugees from various
countries of origin were categorized into the four
themes described above. Overall, there were both
similarities and distinctions among the five main
refugee populations studied, which are outlined
below.
Somali refugees
The Somali and Somali Bantu are the largest
groups of foreign-born Africans in the United
States and make up 45% of the African refugee
population (Carroll et al., 2007; Johnson et al.,
2009). A substantial proportion of Somali
refugees, between 14% and 31.5% of the
population, suffer from mental illness (Boynton et
al., 2010). A pilot study by Bettmann et al. (2015)
extensively examined the perceptions of mental
health and mental health treatment in Somali and
Somali Bantu refugees in the United States. The
study found that this population mostly described
mental illness in terms of observable behaviors.
Of the 20 participants interviewed, seven of them
believed that just hearing an individual’s verbal
expressions can determine whether someone is
mentally ill. Overall, this population utilized the
terms “worried,” “crazy,” and “stressed” as almost
synonymous with various types of mental illness.
There were several physical symptoms that the
Somali refugees associated with mental illness
(see Table 1). In terms of the stigma of mental
illness, the authors explained that the refugees’
perceptions of stigma were variable from one
individual to the next (Bettmann et al., 2015).
Palmer’s (2006) study in London revealed a
greater emphasis on stigma in certain Somali
refugee communities: “For the overwhelming
majority of Somalis, mental illness carries a
certain taboo and has associations with madness”
(Palmer, 2006, p. 51).
The study by Bettmann et al. (2015) examined
the refugees’ ideas of the causes of mental illness
in detail. The Somali refugees attributed the
causes of mental illness to many factors. Some of
their descriptions seemed very situational and
revolved almost exclusively around important
events in an individual’s life.
Mental Health: Global Challenges Journal
https://mhgcj.org ISSN 2612-2138
Table 1. Comparison of refugee mental health
perceptions according to country of origin
Theme
Somali Refugees
(Bettmann et al., 2015)
(Palmer, 2006)
Burmese Refugees
(Kim et al., 2021)
(Fellmeth et al., 2015)
Syrian Refugees
(Al Laham et al., 2020)
(Kerbage et al., 2020)
Bhutanese Refugees
(MacDowell et al., 2020)
(Maleku et al., 2021)
Causes of Mental
Illness
Worry, stress,
wanting something
unattainable,
traumatic events,
significant loss
50%: God causes
illness
15%: Possession by
evil spirits
Kim et al. (2021):
Number one cause is
past traumatic
experiences
Post-resettlement
challenges:
expectations unmet,
difficult adjustment,
loss of social support
Possession by evil
spirits
Sinning in past life
Fellmeth et al. (2015):
Current economic,
family, and domestic
challenges
Excessive worry
External stress
including adverse
living conditions
Believed distress was
a normal shared
reaction to adversity
Environmental/struct
ural stressors: lack of
fulfillment of basic
needs
Psychosocial
stressors: loss of
social or occupational
role (including loss
of social networks)
Socio-cultural norms
Possession by evil
spirits
Emphasis on mind-body-
spirit connection
Symptoms and
Behavior Associated
with Mental Illness
Associated many physical
symptoms with mental
illness: “sensations of heat
coming out of the head,
dizziness, poor vision,
feeling that one’s head is
upside down, the inability
to see letters, the inability
to repeat what others say,
feeling nauseous, and lack
of appetite” (Bettmann et
al., 2015, p. 744).
Fellmeth et al. (2015):
Loss of control over
emotions
Inappropriate or
abnormal social
behavior
Excessive worry
Physical symptoms
Mental and physical
symptoms (metaphors of
external tension causing
buildup of pressure and of
being strangled)
Majority described people
with mental health
problems as unpredictable
Mental Health
Treatment
Medical: “the
majority” of
participants believed
in medical treatments
Nonmedical: caring
acts by the family or
community
(including informal
talking)
Religious: “the
majority” of
participants read the
Quran, talking to the
Imam
Kim et al. (2021):
Alternative
treatments such as
praying and
meditation
Advocated for
community-level
solutions: education,
training
Fellmeth et al. (2015):
Most commonly
mentioned and first
line: social and
emotional support
(talking with family
and friends)
Seen as more
extreme: medication,
hospitalization
Neither study indicated
counseling as primary
treatment option
Initial treatment:
seeing religious
healers
Advocated for
community-level
interventions with
increased social
engagement
Only real solution is
resettlement in new
country
Majority believed
there was no cure for
mental illness
Coping mechanism:
support-seeking
behavior (talking
with family, friends,
community members)
Coping mechanism:
physical, mental, and
spiritual practices
including yoga and
walking
Traditional religious
rituals and customs
Mental Health Stigma
U.S. article: context
and treatment
dependent, variable
London article:
mental illness =
taboo = associated
with madness
Kim et al. (2021):
Built into Burmese
cultures
Mental illness is
possession by evil
spirits or due to sins
Mental illness is
taboo, brings shame
to the individual and
family
Mentally ill are
mentally unfit to be
around others
Talking about mental
health openly
jeopardizes role in
community
Mental illness is
associated with
shame and fear
Mental illness is an
internal dysfunction
or “craziness” within
Mental illness is
possession by evil
spirits
57.7%: the term
“mental illness”
causes them to feel
embarrassed
52.2%: it brings
shame to attend
counseling, is seen as
a sign of weakness
>71%: those who
seek counseling are
viewed in an
unfavorable manner
Mental health is
taboo
Mentally ill are seen
as incapable
Mental Health: Global Challenges Journal
https://mhgcj.org ISSN 2612-2138
Half of the refugees studied believed that God
was the cause of mental illnesses. As one woman
explained, “Everything is because of God. You get
better because of God and you get sick because
of God” (Bettmann et al., 2015, p. 746). In terms
of managing mental illness, “the majority” of the
Somali refugee participants did believe in medical
treatments, including medicine, going to the
hospital, and seeing a doctor (Bettmann et al.,
2015, p. 747). However, they felt that talking to
doctors was a form of assessment but not a form
of treatment. If talking were to be utilized to
manage mental illness, it was informal and with a
family member or friend (Bettmann et al., 2015).
Palmer’s (2006) study indicated that Somali
refugees in London viewed many available
psychiatric treatments with mistrust. The Somali
refugees in the U.S. study discussed many
nonmedical treatments for mental illness. Reading
the Quran, as reported by “the majority of
participants,” was a treatment method for all
illnesses, and mental illness was no exception
(Bettmann et al., 2015, p. 749). The Somali
refugees explained that Imams, who are Islamic
religious leaders, served important roles in the
treatment of mental illness by visiting patients and
reading the Quran for the family. Moreover,
almost half of the participants stated that
individuals with mental illness were kept at home
while they were ill (Bettmann et al., 2015).
Burmese refugees
Burmese refugees are among the largest of
the refugee groups in the United States; between
2002 and 2019, around 178,000 refugees
resettled in the United States from Burma,
otherwise known as Myanmar (Admissions and
arrivals, 2019). A study by Kim et al. (2021) on the
perceptions and barriers to mental health services
in refugees from Burma discussed three themes:
sources of mental illnesses, barriers to service
use, and working toward community solutions.
These Burmese refugees believed that the
number one source of mental illness was past
traumatic experiences and that memories of these
experiences persisted for decades. The other
major source reported was post-resettlement
challenges. In terms of barriers to mental health
service use, there was a glaring lack of
understanding of mental health: “Mental health is
a new concept to most refugees from Burma”
(Kim et al., 2021, p. 967). Most of these
individuals had never lived where mental health
services were available. This lack of knowledge
led to an inability to recognize mental health
problems and to access treatment. Language
difficulty was frequently cited as a barrier,
especially because of the lack of an appropriate
translation of the term “mental health” (and other
mental health terminology) in these refugees’
languages. Another major barrier to care was
cultural stigma: mental health stigma is ingrained
in Burmese cultures. A common faith-based belief
is that mental illness occurs in someone who has
sinned in a past life. When discussing mental
health management, these refugees emphasized
the need for community-level solutions, including
widescale education and training programs for all
individuals in the community (Kim et al., 2021).
In addition, another study exclusively looked at
pregnant refugee and migrant women from
Myanmar who were currently living on the Thai-
Myanmar border (Fellmeth et al., 2015). This
population was studied because of the high
prevalence of mental illness during a woman’s
childbearing years (Stewart et al., 2003).
Specifically, the rates of mental illness are up to
three times higher during the perinatal period than
at other times in a woman’s life (Gavin et al.,
2005). When questioned about the causes of
mental illness, these women emphasized current
challenges in addition to excessive worry
(Fellmeth et al., 2015). In contrast to the study by
Kim et al. (2021) previously discussed, only one of
the 92 pregnant participants believed that trauma
can contribute to mental illness. This article
provided possible explanations for these
contrasting results, including the methods used to
elicit information and this specific population’s
protective factors. A minority of participants
believed that spirits caused mental illness. When
suicide was discussed, these female refugees
described suicide almost exclusively in terms of
shame. As an example of shame leading to
suicide, the study quoted one of the participants,
“One girl I knew killed herself because she lost
some expensive jewelry and felt ashamed when
her family was angry with her” (Fellmeth et al.,
2015, p. 6). Additionally, these refugees believed
suicide was not necessarily caused by mental
illness and described suicide as a separate
condition. In terms of managing mental illness, the
most commonly mentioned first line of treatment
was social and emotional support from talking with
family and friends. These refugees from Myanmar
thought both medication and hospitalization could
be utilized as management strategies, but these
were frequently seen as extreme measures
(Fellmeth et al., 2015).
Syrian refugees
Since the beginning of the Syrian civil war,
over one million Syrians have fled to Lebanon
(Syria regional refugee response, 2019). A study
in Lebanon looked at the mental health
perceptions and experiences of Syrian refugees in
mental health treatment and of Lebanese mental
health professionals (Kerbage et al., 2020).
Similarly to the refugees from Burma, Syrian
refugees associated mental illness with stigma,
shame, and fear (Al Laham et al., 2020). The
Syrian refugee participants, who were in mental
health treatment, believed the greatest causes of
their emotional distress were environmental and
psychosocial stressors (Kerbage et al., 2020).
Sociocultural norms, which were inevitable in
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many cases, also appeared to be intimately
connected to mental health for some individuals
(Al Laham et al., 2020). Additionally, they felt that
their emotional distress was a normal shared
reaction to adversity that everyone in their
community was feeling (Kerbage et al., 2020). In
terms of their specific symptoms of emotional
distress, these Syrian refugees in treatment
believed that all displaced Syrians were
experiencing these same symptoms. Interestingly,
it was common for the Syrian refugees to describe
their mental distress as a buildup of pressure.
They saw mental illness as an internal dysfunction
or “craziness” within an individual and therefore
did not attribute how they were feeling to mental
illness. At the same time, their practitioners and
policymakers (professionals) viewed the distress
of these individuals as symptoms of mental illness
(Kerbage et al., 2020).
Another study on Syrian refugees in Wadi
Khaled, a specific community within Lebanon,
revealed that mental illness was associated with
religious beliefs and the supernatural, including
the idea of possession by evil spirits (Al Laham et
al., 2020). Syrian refugees advocated for
community-level solutions (Kerbage et al., 2020).
Whereas the professionals were recommending
short-term interventions for these refugees, the
refugees believed that the only real solution to
their social and mental health problems was
resettlement in a new country (Kerbage et al.,
2020).
Bhutanese refugees
Bhutanese refugees are another major
population of refugees who have resettled in the
United States (MacDowell et al., 2020). A study by
MacDowell et al. (2020) on these refugees
revealed that this group generally exhibited
negative perceptions of mental illness and mental
health treatment.
Cambodian refugees
Lastly, Wong et al. (2006) studied barriers to
mental health services in Cambodian refugees
from the largest Cambodian refugee community in
the United States. A majority of the barriers
reported were structural, including the high cost of
mental health services, linguistic difficulties, and
transportation issues. Interestingly, Cambodian
refugees reported cultural barriers much less
frequently. Less than 6% of Cambodian refugees
endorsed any mental health concerns related to
stigma, disapproval from family, lack of
confidence in Western medicine, or a higher level
of confidence in indigenous treatments (Wong et
al., 2006). Aside from this information, the data on
Cambodian refugees were limited.
Summary of similarities between different
refugee groups
• Causes of mental illness:
o Traumatic events (Somali, Burmese)
o Possession by evil spirits (Somali,
Burmese, Syrian)
• Physical symptoms associated with
mental illness (Somali, Burmese, Syrian)
• Mental health treatment:
o Informal talking with family and/or friends
(Somali, Burmese, Bhutanese)
o Religious (Somali, Syrian, Bhutanese)
o Community-level solutions (Burmese,
Syrian)
• Mental health stigma:
o Mental health/illness is taboo (Somali,
Burmese, Bhutanese)
o Possession by evil spirits (Burmese,
Syrian)
o Associated with shame (Burmese, Syrian,
Bhutanese)
o Mentally ill are mentally unfit/internally
dysfunctional/incapable (Burmese, Syrian,
Bhutanese)
Discussion
The results indicate that there are many
differences and many similarities in the
perceptions of mental health among refugees
from different countries of origin. The cultures of
refugees greatly influence how they think and feel
about mental health. The commonly reported
causes of mental illness included traumatic events
and possession by evil spirits, and physical rather
than psychological symptoms were often
emphasized. The frequently stated mental health
treatment options included religious methods and
informal conversations. Overall, the mental health
stigma was very prevalent, with multiple refugee
groups regarding mental illness as taboo or
shameful.
This review is novel in its inclusion and
comparison of refugees from numerous countries
of origin. To date, most of the research has
focused on a specific population of refugees from
one cultural background. The study of refugees’
perceptions of mental health has the potential to
aid the refugee mental health crisis. The article by
Kim et al. (2021) on Burmese refugees
emphasizes the importance of addressing the
mental health problems of refugees:
“Unrecognized and untreated mental health
issues may interfere with or even prevent
refugees from successful integration into the host
society” (Kim et al., 2021, p. 966). To give
refugees a fair chance of integrating into their new
society, mental health problems must be tackled.
Furthermore, awareness of cultural perceptions of
mental health can offer valuable information to
service providers and policymakers (Andrade et
al., 2014). When studying Syrian refugees and
professionals, Kerbage et al. (2020) reported that,
“Among professionals, 56 of the 60 repeatedly
highlighted Syrian culture as the main challenge
to working with Syrian refugees. They considered
it an obstacle to the efficient provision of mental
health care” (Kerbage et al., 2020, p. 5). However,
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the culture of one population of refugees can differ
immensely from that of another refugee
population; therefore, studying one culture in
isolation is not sufficient. In their research on
Burmese refugees, the authors determined, “a
one-size-fits-all approach will not work with
refugee communities because of their inherent
ethnocultural and linguistic heterogeneity,” further
reiterating the need for culturally specific mental
health care (Kim et al., 2021, p. 970).
Bettmann, et al. were solely focused on Somali
refugees when they stated, “In order to effectively
approach and treat mental health issues in a
population, it is imperative to first understand
some of the population’s basic beliefs surrounding
mental health” (Bettmann et al., 2015, p. 741).
Nevertheless, some of their findings about the
mental health perceptions of this population were
similar to the perceptions found in other refugee
populations from different cultures. Therefore,
some of their recommendations could prove
useful in these other refugee groups. The studies
on the Somali refugees, Syrian refugees, and the
pregnant Burmese refugees all found that physical
symptoms were frequently reported when
discussing mental health issues (Bettmann et al.,
2015; Fellmeth et al., 2015; Kerbage et al., 2020).
Western-trained physicians often carry a dualistic
body-versus-mind perspective (Kirmayer et al.,
2011). It would be helpful for all medical doctors
treating these populations of refugees to learn
more about the ways in which common mental
illnesses may manifest in physical symptoms in
order to more efficiently and effectively determine
the etiology of these symptoms (Bettmann et al.,
2015). Similarly, in the specified cultures,
symptoms of mental illness were described more
in physical terms, such as the widespread Somali
description of a buildup of pressure, which may
initially seem to be a physical symptom (Bettmann
et al., 2015). Therefore, it would be beneficial for
doctors working with refugees to learn about
some of these common physical descriptions and
to consider that seemingly physical descriptions
may reflect their cultural interpretation of their
mental health symptoms.
In these three groups of refugees, substantial
benefit can come when mental health
professionals work closely with medical doctors to
treat mental illness in a more holistic manner. The
potential of this type of strategy is exemplified in a
community health center in Boston where both
medical doctors and mental health professionals
work, which has led to increased referrals to
mental health care (Bettmann et al., 2015). One
potential solution could be to implement mobile
health clinics that treat both physical and mental
health issues. These clinics could even provide
social needs such as housing and transportation
as an additional component. Im et al. (2021)
applied a multitier mental health and psychosocial
support services (MHPSS) model to provide
mental health care to refugees in a holistic
manner. Their approach was built on existing
MHPSS models, which are used in some refugee
communities, and emphasizes trauma- and
culture-informed care. Refugees have
multilayered mental health needs that can benefit
from the coordinated systems of care and the
holistic framework proposed by Im at al. (2021).
The use of more integrative models for mental
health care in refugee communities could provide
many advantages for refugee mental health.
Because the cultural stigma surrounding
mental health is widespread, the suggestions by
Kim et al. (2021) for Burmese refugees would
likely be helpful for other refugee populations as
well. Mental health stigma is so entrenched in
Burmese culture that even speaking about mental
health openly jeopardizes one’s role in this
community; thus, Burmese refugees need indirect
approaches to mental health. Primary care
doctors for these refugees need to provide
encouragement and referrals. This is because
primary care physicians are “the most effective
way of getting [Burmese] people to use mental
health services… ‘they won’t go on their own
voluntarily’” but “would follow through with their
physician’s recommendations” because they are
viewed as trusted professionals and authority
figures (Kim et al., 2021, p. 969). Because of the
power of primary care physicians in the eyes of
many refugees, there should be routine refugee
mental health screening in primary care settings.
In addition, the importance of cultural competency
must be emphasized to primary care doctors and
mental health professionals working with any
refugee populations in order to effectively interact
with patients and their families (Kim et al., 2021).
Practices that treat even a small number of
refugees should require training in culturally
sensitive care (Byrow et al., 2020). Mental health
practitioners would benefit from learning and
utilizing the DSM-5’s cultural formulation interview
guide as a tool to provide culturally sensitive and
individualized treatment while also enhancing the
therapeutic alliance (Byrow et al., 2020).
Studies of the perceptions of mental illness in
the Somali, Syrian, and Bhutanese refugees
revealed that these groups share a strong focus
on religion (Al Laham et al., 2020; Bettmann et al.,
2015; Maleku et al., 2021). The study on Syrian
refugees in the rural area of Wadi Khaled in
Lebanon described that, in this community,
religious healers are culturally acceptable and
less stigmatizing to go to for mental health
problems than mental health professionals (Al
Laham et al., 2020). This article even described
working with religious healers as the “key to
identifying [mental health] symptoms and creating
referral pathways to [mental health] professionals”
(Al Laham et al., 2020, p. 875). Similarly, the
article by Bettmann et al. (2015) discussed how
refugees’ spiritual explanations and treatments of
Mental Health: Global Challenges Journal
https://mhgcj.org ISSN 2612-2138
mental illness cannot be disregarded. Instead,
mental health practitioners should directly address
these spiritual aspects and attempt to use these
strongly held beliefs to help them understand a
patient’s symptoms and trajectory (Bettmann et
al., 2015). It is imperative that mental health
professionals working with all three of these
refugee groups collaborate not only with religious
healers and other religious leaders but also with
any additional community leaders. Mental health
and public health professionals could spend time
teaching religious leaders about mental health
problems and the benefits of medical treatment,
counseling, and group therapy. These
professionals could then encourage the leaders to
share this education with their followers, such as
by talking about mental health issues in sermons,
classes, seminars, newsletters, or social media. In
addition, the professionals could ask these
leaders to encourage their followers to seek help
for mental health problems and not suffer in
silence. It would be very beneficial for religious
leaders to inform their followers that suffering from
mental health problems does not mean that the
sufferer has sinned, that he or she does not have
enough spiritual faith, or that this is God’s
punishment. On the contrary, mental illness is a
disease, similar to high blood pressure or any
other physical condition, and should be treated
this way. Understanding this and hearing it from
one’s religious or community leader could
decrease the guilt and shame that so many feel
when they are having mental health problems.
Because the religious, traditional, and familial
practices are deeply valued in the Somali, Syrian,
and Bhutanese cultures, these practices need to
be considered and likely incorporated into any
mental health treatment plan. Working with family
was commonly seen as an initial step in mental
health treatment in the refugee populations
reviewed; thus, the involvement of family and
community members in assessment and
treatment may provide more effective care. The
incorporation of family members would be
especially beneficial for certain refugees from
Myanmar, because the pregnant refugees’ most
commonly used treatment was emotional and
social support from family and close friends
(Fellmeth et al., 2015). The involvement of family
would also benefit Bhutanese refugees, who
discussed seeking social support in order to cope
(Maleku et al., 2021).
Although there were several distinctions
between the mental health perceptions of
refugees from different cultures, there were also
many similarities. Therefore, it is crucial to include
some general recommendations for refugee
mental health care. Providing community-level
solutions is essential. This would include
education and training for community leaders in
addition to education for all individuals within
refugee communities (Kim et al., 2021). In all
refugee groups, there is a need for increased
mental health literacy pertaining to overall mental
health, mental illness, and treatment for
individuals struggling with mental health problems.
The study on pregnant refugees from Myanmar
emphasized the importance of psychoeducation,
particularly because only one participant believed
that trauma could cause mental illness (Fellmeth
et al., 2015). In reality, the trauma that so many
refugees experience contributes to the
development of mental health problems (Johnson
& Thompson, 2008). Because “translation
difficulties, in combination with a lack of
understanding about mental health, aggravate
cultural stigma,” increased mental health literacy
could help to reduce stigma (Kim et al., 2021, p.
970).
In addition to psychoeducation’s potential to
decrease stigma, refugee communities could also
incorporate public stigma interventions that focus
on changing culture-specific negative perceptions
of mental illness (Byrow et al., 2020). Even just
altering the language used when discussing
mental health could have an impact. For example,
Kerbage et al. (2020) noted that Syrian refugees
thought of the MHPSS as a source of support and
felt it was helpful and provided them with a safe
environment to talk about their problems.
However, they did not consider MHPSS to be a
specialized clinic, the idea of which may have
turned many refugees away (Kerbage et al.,
2020). Psychoeducation and improved mental
health literacy would not only impact the initiation
of care but also help with treatment adherence
and maintenance when individuals have a better
understanding of the science of mental illness.
Another potential approach to break the barrier
of mental health stigma is to use telehealth and
mental health apps. Refugees could use their
phones or any other electronic device for
psychiatry visits, counseling sessions, or self-help
interventions. This approach might encourage
refugees who fear the stigma of treatment to seek
mental health care. This is because telehealth
visits and mental health apps can be used in the
privacy of one’s own home, out of view of anyone
who patients might worry would look down on
them for getting mental health treatment.
Telehealth and apps could also help refugees
start mental health treatment and then act as a
bridge to in-person visits with mental health
professionals if needed. In addition to acting as a
bridging aid, these approaches may be used to
augment or complement other types of mental
health treatment. Therefore, both telehealth and
mental health apps could “lower the threshold for
refugees to seek help” (Golchert et al., 2019, p.
2). These mental health interventions would also
allow for greatly increased flexibility in terms of
both treatment time and location. One example of
mobile mental health is Step-by-Step (SbS), a
culturally adaptive e-mental health intervention
Mental Health: Global Challenges Journal
https://mhgcj.org ISSN 2612-2138
developed by the World Health Organization for
depression (Burchert et al., 2019). In a study on
the usage of SbS among Syrian refugees,
Burchert et al. (2019) found that “The majority of
the respondents reacted positively to the
presented app prototypes, stressing the potential
health impact of the intervention (n = 28; 78%), its
flexibility and customizability (n = 9; 53%) as well
as the easy learnability of the app (n = 12; 33%)”
(p. 1).
In addition, enhancing the sense of community
felt by refugees could have a major effect on
refugee mental health (Kim et al., 2021). This
could be accomplished by facilitating social
engagement to establish better ties to their
community. For most refugees, community and
social connections are lost when they come to a
new country (Kim et al., 2021). In contrast to
these general recommendations that apply to
most of the refugee groups reviewed, it would be
more appropriate to suggest approaches to
improve the structural aspects of mental health
care in Cambodian refugees, because this
population did not report culturally based mental
health barriers and had less concern about stigma
(Wong et al., 2006).
Limitations of the study
There are some limitations to this review.
There was heterogeneity among the studies in
terms of the methods, protocol, and measures
used. These studies were also conducted in
different host countries, which have variable
income levels and barriers to care. Although the
reviewed studies on Syrian refugees and refugees
from Myanmar took place in Lebanon and the
Thai-Myanmar border, respectively, the rest of the
reviewed studies occurred in the United States or
the United Kingdom (London) (Al Laham et al.,
2020; Fellmeth et al., 2015; Kerbage et al., 2020).
As Byrow et al. (2020) emphasized regarding their
review, “Given that most studies included
individuals living in a high-income resettlement
country, these findings may not be generalizable
to individuals in other countries,” especially
considering that the majority of refugees are
located in developing countries (Byrow et al.,
2020, p. 18). Because the study designs were
generally not longitudinal in nature, there is no
way to know how perceptions may have changed
over time. Byrow et al. (2020) felt that the duration
of resettlement and associated variables could
greatly impact a refugee’s knowledge about
mental health and the best treatment strategies.
Future directions
There are many possible future directions. It
would be helpful to examine different refugee
cultures in a more standardized manner. This
could be accomplished with a study that looks at
more than one population of refugees, which
would enable standardization of not only the major
themes assessed but also the methods and
measures utilized. A study that looks at multiple
populations of refugees in a single host country
would achieve even greater uniformity. It would
also be interesting to use longitudinal research
designs to determine if and how the mental health
perceptions in the populations studied change
over time. Longitudinal studies would also enable
researchers to determine if there are key time
points when certain mental health treatment
interventions or programs are most effective
(Byrow et al., 2020). In addition, it would be useful
to determine whether there are associations
between mental health perceptions and specific
mental health treatments that are efficacious.
Research that utilizes culture-specific mental
health perceptions to create interventions for
different refugee groups would enable us to see
how specialized mental health services make a
difference in the mental health outcomes of
refugees.
Conclusions
This review studied the perceptions of mental
health, mental illness, and mental health
treatment among refugees from various countries
of origin, unlike previous studies that focused on
one group of refugees. From this review, it is clear
that refugees’ thoughts and feelings about mental
health are impacted by their specific cultural
group. Refugee groups varied in terms of their
opinions about the causes of mental illness and
the treatment options emphasized by them.
However, mental health was similarly stigmatized
as taboo and perceived as a shameful
dysfunction, and treatment options frequently
revolved around religion and informal family
assistance. Furthermore, physical symptoms of
mental illness were often highlighted, and mental
illness was commonly thought to result from
traumatic events and possession by evil spirits.
Interventions to address the refugee mental health
crisis should take cultural background, including
cultural perceptions of mental illness, into
account. Specifically, refugee mental health care
could be improved with more integrative treatment
methods, greater involvement of primary care
practitioners, psychoeducation of community
leaders, telehealth, and more culturally oriented
approaches.
Funding Sources
This project was partially funded from a grant
from the University at Buffalo Foundation/John E.
Brewer Global Medicine Endowment Account
problems associated with psychoactive substance
abuse (Cabinet of Ministers of Ukraine, 2017).
Mental Health: Global Challenges Journal
https://mhgcj.org ISSN 2612-2138
Conflict of interest
The authors declare that they have no conflicts
of interest.
Acknowledgements
We thank Nell Aronoff and Karen Dietz, PhD
for assistance in writing, reviewing, and editing
this manuscript. This work was supported by the
University at Buffalo Foundation/John E. Brewer
Global Medicine Endowment Account
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