Refugee status is associated with double the odds of psychological distress in mid-to-late life: Findings from the Canadian Longitudinal Study on Aging

Abstract

Psychological distress is associated with a range of negative outcomes including lower quality of life and an increased risk of premature all-cause mortality. The prevalence of, and factors associated with, psychological distress among middle-aged and older Canadians are understudied. Using the Canadian Longitudinal Study on Aging (CLSA) baseline data, this study examined factors associated with psychological distress among adults between 45 and 85 years, including refugee status and a wide range of sociodemographic, health-related and social support characteristics. Psychological distress was measured by Kessler’s Psychological Distress Scale-K10 scores. Bivariate and multivariable binary logistic regression analyses were conducted. The prevalence of psychological distress was significantly higher among the 244 refugees (23.8%), compared to 23,149 Canadian-born Canadians (12.8%) and 4,765 non-refugee immigrants (12.6%), despite the fact that the average time the refugees had lived in Canada was more than four decades. The results of the binary logistic regression analysis indicated refugees had twice the age-sex adjusted odds of psychological distress (OR = 2.31, 95% CI: 1.74, 3.07). Even after further adjustment for 16 potential risk factors, a significant relationship remained between refugee status and psychological distress (OR = 1.56; 95% CI = 1.12, 2.17). Other significant factors associated with psychological distress included younger age, female gender, visible minority status, lower household income, not having an undergraduate degree, multimorbidities, chronic pain, and lack of social support. Policies and interventions addressing psychological distress among Canadians in mid- to later life should target refugees and other vulnerable groups.

Keywords

Canadian Longitudinal Study on Aging refugees psychological distress mid-age adults older adults immigrants mental health

Introduction

Psychological distress is an important but neglected mental health issue. Psychological distress, a state of emotional suffering, is included as a diagnostic criterion for several psychological disorders (e.g. depressive disorders, anxiety disorders) and as a marker of symptom severity (Phillips, 2009). Between one in five (Caron & Liu, 2011) and one in eight Canadians (Enticott et al., 2018) experience psychological distress and there is a strong negative association between psychological distress and quality of life (Atkins et al., 2013). Psychological distress is more prevalent among those with serious physical health problems including back pain (Power et al., 2001), coronary heart disease (Rasul et al., 2005), myocardial infarction and stroke (Jackson et al., 2018), and Alzheimer’s disease (Wilson et al., 2003). It is also associated with an increased risk of premature all-cause mortality (Batty et al., 2017; Russ et al., 2012).

The prevalence of psychological distress is higher among women (Matud et al., 2015; Stallman et al., 2010) as well as individuals who are unemployed (Reneflot & Evensen, 2014), without a partner (Darghouth et al., 2015), with a lower level of education (Miech et al., 2007) and with low income (Orpana et al., 2009). Some studies indicate that younger adults report a higher level of psychological distress than older adults (Chittleborough et al., 2011), while other research has found that older age is associated with a greater risk of experiencing distress (Atkins et al., 2013; Goulia et al., 2012). Other studies have reported a U-shaped relationship between age and distress, suggesting that the prevalence of mental distress is highest among younger and older age groups (Cairney & Krause, 2005; Schieman et al., 2001).

Among older adults, access to appropriate resources and perceived social support is protective against psychological distress (Sharpley et al., 2015). Greater perceived social support is significantly associated with lower levels of distress among White Americans, but this relationship is not found among African Americans (Morin & Midlarsky, 2016). Women are more likely to pursue emotional support than men (Matud & García, 2019). The positive impact of social support on psychological distress appears to vary among different groups and populations, suggesting additional research is needed.

When compared to the general population, a number of studies reported that immigrants are more likely to experience higher levels of psychological distress (Chen et al., 2017; Honkaniemi et al., 2020; Li & Anderson, 2016; Ryan et al., 2008; Torres & Wallace, 2013). While many studies did not differentiate between refugees and non-refugee immigrants, some studies did suggest that those who are forced to migrate are particularly prone to psychological distress (Ryan et al., 2008; Torres & Wallace, 2013). Recent studies from the USA, New Zealand, Australia, Italy, Germany, and Malaysia indicate that the prevalence rates of psychological distress are high among refugees (Alemi & Stempel, 2018; Guajardo et al., 2016; Ryan et al., 2008; Shaw et al., 2019; Walther et al., 2020). A German study found that more than two in five of the refugees they surveyed had psychological distress (Walther et al., 2020). An Italian study on asylum seekers and refugees found that more than one-third of the participants (36%) showed clinically relevant psychological distress (Nosè et al., 2018). The higher levels of psychological distress among refugees may be a result of pre-migration trauma they experienced in their country of origin (Alemi & Stempel, 2018; Chen et al., 2017; Li & Anderson, 2016). Post-migration resettlement stressors such as long periods of resettlement (Guajardo et al., 2016), the inability to speak a host country’s language (Singh et al., 2015), difficulties in having foreign credentials and work experience recognized, settlement arrangements, employment, and racial, ethnic and/or religious discrimination (Alemi & Stempel, 2018; Honkaniemi et al., 2020; Kim et al., 2018; Shaw et al., 2019) may also negatively impact mental health and wellbeing among refugees.

Only a few studies have investigated psychological distress among specific refugee populations in Canada. One study of Sudanese refugees in seven cities in Ontario reported that economic hardship was associated with greater psychological distress (Simich et al., 2006). A study of Sri Lankan Tamil refugees in Canada showed that the level of psychological distress was associated with pre-migration trauma, the number of children in a family, and daily stressors (George & Jettner, 2016). More work is therefore needed to investigate the unique factors that impact refugees’ mental health and wellbeing.

Grounded in the social determinants of mental health framework (Allen et al., 2014; Hynie, 2018), which suggests that an individual’s mental health culminates from the interplay of various social, economic, and physical environments operating across the lifespan (World Health Organization and the Calouste Gulbenkian Foundation, 2014), the current study aims to explore the relationships between a range of social characteristics and psychological distress among refugees, non-refugee immigrants, and Canadian-born adults in mid-to-later life. The following research questions will be addressed:

(1) Do both refugees and non-refugee immigrants in Canada have a higher prevalence of psychological distress compared to those born in Canada?

(2) Are there demographic, economic, health-related, and social factors that attenuate the association between refugee status and psychological distress?

(3) What factors are significantly associated with psychological distress after accounting for refugee and immigrant status?

Methods

Participants and procedure

The detailed methodology has been previously published (Lin et al., 2020). To summarize, this study used the comprehensive cohort data from the baseline Canadian Longitudinal Study on Aging (CLSA, n.d.), a 2012 population-based study of Canadians aged 45 to 85 years who will be followed for 20 years (Raina et al., 2009). The comprehensive sample consisted of 30,097 respondents. Information was gathered via in-home interviews and physical assessments drawn from dedicated data collection sites. Telephone interviews were conducted 18 months after the initial assessment to maintain contact. This study used data from the In-Home Questionnaire and Data Collection Site Questionnaire and the Maintaining Contact Questionnaire. Those who did not report their mental health status, refugee/immigration status, marital status, multi-morbidities, and or social support availability were excluded (n = 1,939), yielding a final sample size of 28,158. The excluded subjects did not differ significantly from the main group with respect to demographic characteristics. Further details about the study protocol can be found at www.clsa-elcv.ca.

Measures

Outcome variable

Psychological distress was measured using the Kessler Psychological Distress Scale (K10) (Kessler et al., 2002), a 10-item screening questionnaire that yields a global measure of non-specific distress based on questions about anxiety and depressive symptoms experienced in the previous four weeks. The overall K10 score (range: 10–50) was obtained by summing the individual response values that range from “all of the time” (score of 5) to “none of the time” (score of 1) (Andrews & Slade, 2001). A cut-off score of 20 or more (K10 score ⩾ 20) was used to categorize those who had a mild mental disorder (Vasiliadis et al., 2015). K10 has been reported to have good sensitivity (0.80) and specificity (0.81) for any depressive and/or anxiety disorder (Sakurai et al., 2011).

Main independent variable

Refugee/immigrant status was classified into three levels: (1) Canadian-born residents; (2) non-refugee immigrants; and (3) refugees. Because the CLSA did not include specific questions about refugee status, a proxy measure for refugee/immigrant status was created based upon self-reported information of being an immigrant, country of birth, year of arrival in Canada, religion, cultural background and parental ethnic background to match the demographics of historic refugee cohorts (see Table 1). Among refugees (n = 244), the average time since arrival in Canada was 43 years (SD ± 16.2 years). Only 2.5% of refugees (n = 6) had arrived in Canada in the 10 years preceding baseline CLSA data collection and 37.3% (n = 91) had arrived 50 or more years before they were surveyed.

Table 1.

Refugees’ regions of origin and era of immigration (n = 244).

Regions of origin/ethnicity	Weighted (n)
Chinese from China (1940–1989)	45
Hungarians (1956–present)	40
Haiti (1971–present)	31
Jews from Continental Europe (1932–1955)/Middle East and North Africa (1950 & 1970)/Soviet Union (1970–1990)	24
Chileans (1970–1990)	21
Lebanese (1975–present)	17
Baltic origins (1945–1960)	17
Ukrainians (1920–1952)	11
South Asians from Uganda (the 1970s)	10
Vietnamese (1970–1990)	9
Iranians (the 1970s–early 1980s)	5
Afghanistan (1979–present)	<5
Bangladesh (1970–1990)	<5
Yugoslavia (the 1990s)	<5
Cambodians (1970–1990)	<5
Palestinian Arabs from Palestine or Israel (1945–present)	<5
Sum	244

Note. The number of actual records for those four or fewer is suppressed based on Statistics Canada guidelines.Source: Baseline CLSA survey.

Covariates

Besides refugee/immigrant status, other demographic covariates such as age, sex, and marital status were controlled in the core block, because they influence the chances of being exposed to stressful events (Fenta et al., 2004). In addition to the demographic correlates, five different clusters of potential effect modifiers were examined separately to determine the independent contribution of each additional block.

The cluster of socioeconomic factors included annual household income, education level, and subjective report of retirement status.

The cluster of health status and behaviors, consistent with prior operationalization (Davison et al., 2019, 2020), measured multi-morbidities (no condition/one health condition/two health conditions/ three or more health conditions), chronic pain (free of pain/ have pain/no answer), drinking habits in the previous year (non-binge drinker/binge drinker/no answer), and physical activities in the previous seven days (never or seldom/sometimes or often/no answer).

The cluster of social connections captured both social isolation and online social networking. The social isolation index was derived from two indicators measuring social contacts within and outside of the household from the social networking questionnaire (CLSA, n.d.). First, the responses were grouped into three isolation levels according to the time frame of last face-to-face contact with family members (children/siblings/other relatives), friends, and neighbors who live outside of the household, ranging from not isolated (have contacts in the past week or two); mildly isolated (have contacts in the past month but not in the past week or two); to extremely isolated (no contact in the past month). Second, these three isolation categories were divided into six groups stratified by their living arrangements (live alone or not) in the household: (1) not living alone, nor isolated; (2) living alone, but not isolated; (3) not living alone, but mildly isolated; (4) living alone and mildly isolated; (5) not living alone, but extremely isolated; and (6) living alone and extremely isolated. Online social networking was based on the frequency of using social networking sites through the Internet to stay in touch or make plans with family or friends. It was classified into four groups: (1) active use (daily or weekly); (2) moderate use (monthly); (3) mild use (less than monthly); and (4) no answer.

The cluster of social support availability was measured by three binary items modified from the self-administered Medical Outcomes Study (MOS) Social Support Survey (Sherbourne & Stewart, 1991). In the MOS, questions were asked regarding having someone: (1) to advise on a crisis; (2) to confide in or talk to, and (3) who shows love and affection. These three indicators have been identified as key social support indicators for health outcomes in previous studies (Sarason et al., 1997). The response options were dichotomized into two levels: (1) none/a little/some of the time; and (2) most/all of the time.

Race was measured by a binary variable indicating whether the respondent reported he/she was white or visible minority/ Indigenous living in Canada (hereafter called visible minority).

Data analysis

All analyses were completed using SPSS Version 22 (IBM). The weights provided by CLSA were normalized to produce population-representative estimates corrected for the sample size. Bivariate analyses based on Chi-square tests using weighted means were conducted to describe the sample. Adjusted odds ratios (aOR) were calculated using binary logistic regression analyses to examine associations between refugee/immigration status and psychological distress while adjusting for the covariates. A series of binary logistic regression analyses were conducted. The first and all subsequent binary logistic regression analyses included refugee/immigrant status, age, sex and marital status (Model 1). In model 2, socioeconomic factors were included. In Model 3, health status and health behaviors were added to model 1. Subsequent clusters included social isolation and online social networking (Model 4), social support (Model 5), and racial minority status (Model 6), respectively. The final model was adjusted for all of the aforementioned variables (Model 7).

Ethics approval

The study protocol of the CLSA has been approved by 13 research ethics boards across Canada. This secondary analysis of CLSA data was approved by the University of Toronto’s Health Sciences Research Ethics Board (Protocol number: 34065).

Results

Description of sample

Table 2 presents the descriptive characteristics of the total sample by level of psychological distress and refugee status. The prevalence of mild to severe psychological distress was higher among younger respondents, women, visible minority members, those who were not married, those with low income and without a high school diploma. People with three or more health conditions, who reported that they were experiencing chronic pain, and who did fewer physical activities, had a higher prevalence of psychological distress. However, people who were less socially isolated and did more frequent online networking, and those with a higher frequency of social support, had a lower rate of psychological distress.

Table 2.

Description of overall sample (n = 28,158) according to distress status and immigrant/refugee status.

Variables	Total	By distress status (% wt)		By immigrant/refugee status (% wt)
	Unweighted n = 28,158	Distress n = 3,242	Chi-square (df), p-value	Born in Canada n = 23,149	Non-refugee immigrant n = 4,765	Refugee n = 244	Chi-square (df), p-value
Demographics
Refugee status
Born in Canada	23,149	12.77%	29.62 (2), <.001	—	—	—	—
Non-refugee immigrant	4,765	12.63%		—	—	—
Refugee	244	23.81%		—	—	—
Age groups (years)
45 to 55	7,137	14.52%	62.01 (3), <.001	42.71%	39.15%	44.69%	145.79 (6), <.001
56 to 65	9,324	12.42%		30.85%	26.04%	23.81%
66 to 75	6,943	10.40%		16.30%	21.69%	20.15%
76 to 85	4,754	11.47%		10.13%	13.11%	11.36%
Sex
Male	13,804	10.94%	91.03 (1), <.001	48.92%	52.92%	55.68%	29.00 (2), <.001
Female	14,354	14.74%	91.03 (1), <.001	51.08%	47.08%	44.32%	29.00 (2), <.001
Race
White	26,991	12.54%	45.54 (1) <.01	98.65%	80.22%	43.07%	4,390.81 (2), <.001
Visible minorities	1,167	18.74%	45.54 (1) <.01	1.35%	19.78%	56.93%	4,390.81 (2), <.001
Marital status
Single/never married	2,438	20.57%	262.57 (3), <.001	8.82%	5.17%	4.74%	94.24 (6), <.001
Married/with partner	19,572	11.19%		75.67%	80.48%	81.02%
Divorced/separated	3,617	18.70%		10.33%	8.60%	9.12%
Widowed	2,531	13.86%		5.18%	5.75%	5.11%
Socioeconomic factors
Household income
<$20,000	1,326	33.78%	484.41 (2), <.001	4.14%	3.15%	8.03%	33.11 (4), <.001
$20,000+	25,064	11.74%		90.63%	90.33%	86.86%
No answer	1,768	16.06%		5.23%	6.52%	5.11%
Education
<Secondary school	1,438	23.59%	167.74 (3), <.001	5.05%	2.45%	2.20%	126.65 (6), <.001
High school graduate	4,678	14.35%		16.01%	12.58%	11.72%
Post-secondary degree	21,999	11.92%		78.84%	84.65%	86.08%
No answer	43	28.95%		0.09%	0.32%	—
Retirement status
Completely retired	12,408	12.43%	22.12 (3), <.001	33.04%	33.23%	28.83%	11.33 (6), <.079
Partly retired	3,129	10.60%		9.63%	9.28%	10.58%
Not retired	12,527	13.44%		57.02%	56.91%	60.58%
No answer	94	19.19%		0.31%	0.57%	—
Health-related factors
Multi-morbidities
No condition	5,055	6.01%	958.22 (3), <.001	19.85%	22.14%	22.71%	27.06 (6), <.001
One health condition	7,301	8.64%		27.30%	28.57%	30.04%
Two health conditions	6,506	12.37%		22.68%	21.84%	18.32%
Three or more health conditions	9,296	21.79%		30.17%	27.44%	28.94%
Chronic pain
Free of pain	22,132	9.87%	874.92 (2), <.001	79.66%	79.75%	75.82%	22.37 (4), <.001
Have pain	5,923	24.57%		20.17%	19.76%	23.44%
No answer	103	18.75%		0.17%	0.49%	0.73%
Binge drinking
Non-binge drinker	17,783	13.43%	27.56 (2), <.001	57.46%	64.91%	72.99%	339.75 (4), <.001
Binge drinker	9,728	11.74%		40.94%	30.86%	19.71%
No answer	647	17.32%		1.60%	4.24%	7.30%
Physical activities
Never/seldom	25,145	13.07%	10.38 (2), .006	89.86%	89.35%	90.84%	3.78 (4), .44
Sometimes/often	3,005	10.95%		10.12%	10.58%	9.16%
No answer	8	12.50%		0.02%	0.06%	—
Social connections
Social isolation
Not alone nor isolated	21,176	11.76%	141.86 (5), <.001	81.07%	82.11%	83.21%	111.52 (10), <.001
Alone/not isolated	6,044	17.58%		15.42%	12.46%	8.03%
Not alone/mildly isolated	546	15.83%		2.25%	3.41%	5.11%
Alone/mildly isolated	111	24.71%		0.33%	0.17%	0.36%
Not alone/very isolated	219	18.70%		0.75%	1.66%	2.92%
Alone/very isolated	62	27.45%		0.18%	0.19%	0.36%
Online networking
Use yearly/never	14,272	12.73%	5.44 (2), .07	45.89%	46.97%	49.08%	11.95 (4), .02
Use monthly	6,968	13.52%		29.52%	27.17%	27.11%
Use weekly/daily	6,918	12.29%		24.60%	25.87%	23.81%
Social support (Medical outcomes study or MOS)
MOS: Confide
None/a little/some	4,955	23.17%	517.04 (1), <.001	15.65%	18.22%	26.28%	39.78 (2), <.001
Most/all of the time	23,203	10.86%	517.04 (1), <.001	84.35%	81.78%	73.72%	39.78 (2), <.001
MOS: Advise crisis
None/a little/some	4,765	21.50%	353.99 (1), <.001	15.39%	17.29%	28.57%	44.12 (2), <.001
Most/all of the time	23,393	11.22%	353.99 (1), <.001	84.61%	82.71%	71.43%	44.12 (2), <.001
MOS: Show love
None/ a little/some	2,492	28.78%	513.38 (1), <.001	7.33%	7.49%	17.58%	41.15 (2), <.001
Most/all of the time	25,666	11.57%	513.38 (1), <.001	92.67%	92.51%	82.42%	41.15 (2), <.001

Additionally, the distribution of most of the main variables and covariates were similar between the total sample and the three refugee/immigrant subgroups (Canadian-born residents, non-refugee immigrants, and refugees) except for sex, race, and multi-morbidities. Both non-refugee immigrants and refugees had a higher percentage of women than men (non-refugee immigrant women = 53%, refugee women = 56%). There were also more visible minorities in the refugee group than Whites (visible minority refugees = 57%; Visible minority non-refugee immigrants = 19.8%; visible minority born in Canada = 1.4%). Moreover, non-refugee immigrants and refugees showed a slightly lower prevalence of having two or more health conditions (non-refugee immigrants = 49%, refugees = 47%) than Canadian-born residents (53%).

Multivariable analysis

Objective 1: Do both refugees and non-refugee immigrants in Canada have a higher prevalence of psychological distress compared to those born in Canada?

The results of the bivariate analysis showed that the prevalence of psychological distress was significantly higher among the 244 refugees (23.8%), compared to 23,149 Canadian-born Canadians (12.8%) and 4765 non-refugee immigrants (12.6%) (See Table 2). Results from the binary logistic regression models (see Table 3) further indicated that the odds of experiencing psychological distress were consistently higher for refugees compared to the Canadian-born (aORs from 2.31 (model 1 to 1.56 fully adjusted model). However, the odds of psychological distress among non-refugee immigrants hovered around 1.00, and in all but one analysis, were not statistically significant (non-refugee immigrants: aOR=0.97 to 1.11).

Table 3.

Adjusted odds ratios for psychological distress based on binary logistic regression.

Nagelkerke R²	Model 1	Model 2	Model 3	Model 4	Model 5	Model 6	Model 7
	Demographic	Socioeconomic	Health status	Social connection	Social support	Minority status	Full adjusted
	R² = 0.03	R² = 0.05	R² = 0.12	R² = 0.03	R² = 0.07	R² = 0.03	R² = 0.15
Refugee status (ref. born in Canada)
Non-refugee immigrant	1.06 (0.97, 1.17)	1.11 (1.01, 1.22)	1.10 (1.00, 1.21)	1.06 (0.96, 1.16)	1.02 (0.93, 1.13)	0.97 (0.88, 1.08)	1.02 (0.91, 1.13)
Refugee	2.31 (1.74, 3.07)	2.30 (1.72, 3.07)	2.31 (1.71, 3.12)	2.26 (1.70, 3.01)	1.88 (1.40, 2.53)	1.80 (1.33, 2.43)	1.56 (1.12, 2.17)
Age groups (76–85)
45–55	1.43 (1.25, 1.63)	1.92 (1.63, 2.27)	2.02 (1.76, 2.32)	1.49 (1.29, 1.71)	1.65 (1.44, 1.89)	1.40 (1.22, 1.60)	2.39 (2.00, 2.85)
56–65	1.17 (1.02, 1.34)	1.45 (1.25, 1.69)	1.41 (1.22, 1.62)	1.20 (1.05, 1.38)	1.27 (1.11, 1.46)	1.15 (1.00, 1.32)	1.62 (1.38, 1.89)
66–75	0.93 (0.80, 1.08)	1.02 (0.87, 1.19)	1.00 (0.86, 1.16)	0.94 (0.81, 1.10)	0.99 (0.85, 1.15)	0.93 (0.80, 1.08)	1.09 (0.94, 1.28)
Female (ref. male)	1.37 (1.27, 1.47)	1.33 (1.24, 1.43)	1.18 (1.09, 1.27)	1.40 (1.30, 1.50)	1.51 (1.41, 1.63)	1.37 (1.27, 1.47)	1.3 (1.21, 1.41)
Visible minorities (ref. white)						1.53 (1.30, 1.79)	1.47 (1.24, 1.75)
Marriage (ref. married/with partner)
Single/never married	2.00 (1.79, 2.23)	1.61 (1.43, 1.81)	1.87 (1.67, 2.10)	1.85 (1.61, 2.13)	1.47 (1.31, 1.66)	1.99 (1.79, 2.23)	1.30 (1.12, 1.52)
Divorced/separated	1.79 (1.62, 1.99)	1.51 (1.35, 1.68)	1.60 (1.44, 1.79)	1.71 (1.51, 1.94)	1.45 (1.30, 1.62)	1.80 (1.62, 2.00)	1.24 (1.08, 1.43)
Widowed	1.39 (1.18, 1.64)	1.11 (0.94, 1.32)	1.30 (1.09, 1.54)	1.31 (1.08, 1.57)	1.17 (0.99, 1.39)	1.39 (1.18, 1.64)	1.03 (0.85, 1.26)
Household income (ref. ³$20,000)
<$20,000		2.66 (2.30, 3.07)					1.89 (1.61, 2.20)
No answer		1.37 (1.19, 1.59)					1.24 (1.07, 1.45)
Education (ref. post-secondary degree)
<secondary school education		2.08 (1.80, 2.41)					1.84 (1.58, 2.14)
High school graduate		1.22 (1.11, 1.34)					1.16 (1.04, 1.28)
no answer		2.60 (1.23, 5.47)					2.08 (0.93, 4.66)
Retirement (ref. not retired)
Completely retired		1.16 (1.04, 1.30)					1.01 (0.90, 1.13)
Partly retired		0.95 (0.82, 1.09)					0.86 (0.74, 1.00)
No answer		1.31 (0.78, 2.20)					0.90 (0.52, 1.55)
Multi-morbidities (ref. no condition)
One health condition			1.45 (1.26, 1.66)				1.47 (1.28, 1.69)
Two health conditions			2.13 (1.86, 2.44)				2.09 (1.82, 2.40)
Three or more health conditions			3.76 (3.31, 4.27)				3.60 (3.16, 4.10)
Chronic pain (ref. free of pain)
Have pain, activities prevented			2.23 (2.06, 2.42)				2.10 (1.94, 2.28)
No answer			1.84 (0.96, 3.50)				1.33 (0.68, 2.64)
Binge drinking (ref. non-binge drinker)
Regular binge drinker			0.91 (0.84, 0.98)				0.97 (0.89, 1.05)
No answer			1.36 (1.08, 1.71)				1.10 (0.86, 1.40)
Physical activities (ref. sometimes/often)
Never/seldom			1.27 (1.11, 1.44)				1.21 (1.06, 1.38)
No answer			0.44 (0.05, 4.11)				0.35 (0.04, 3.45)
Social isolation (ref. not live alone nor isolated)
Live alone/not isolated				1.09 (0.96, 1.25)			0.93 (0.81, 1.07)
Not live alone/mildly isolated				1.36 (1.10, 1.68)			1.34 (1.07, 1.67)
Live alone/mildly isolated				1.65 (1.00, 2.74)			1.18 (0.68, 2.03)
Not live alone/extremely isolated				1.68 (1.22, 2.31)			1.34 (0.95, 1.88)
Live alone/extremely isolated				1.85 (0.98, 3.48)			0.83 (0.41, 1.70)
Online networking (ref. weekly/daily)
Use yearly/never				1.15 (1.05, 1.26)			1.11 (1.00, 1.21)
Use monthly				1.13 (1.03, 1.24)			1.11 (1.00, 1.23)
MOS: confide none (ref. mostly)					1.78 (1.61, 1.97)		1.67 (1.50, 1.86)
MOS: advise crisis none (ref. mostly)					1.47 (1.33, 1.63)		1.30 (1.17, 1.45)
MOS: show love none (ref. mostly)					1.82 (1.62, 2.05)		1.67 (1.48, 1.90)

Significant values (p<0.05) are in bold.

Objective 2: Are there demographic, economic, health-related, and social factors which attenuate the association between refugee status and psychological distress?

As shown in Table 3, in the baseline model 1, the odds of experiencing psychological distress was more than twice as high for refugees as they were for those born in Canada (aOR = 2.31, 95% CI: 1.74–3.07) when only age, sex, and marital status were taken into account. After adjusting for a wide range of known risk factors for distress in the final model (Model 7), the odds of experiencing psychological distress were slightly decreased but still significant (aOR = 1.56, 95% CI: 1.12–2.17).

Objective 3: What factors are significantly associated with psychological distress after refugee and immigrant status were taken into account?

The results outlined in Table 3 show that the odds of experiencing psychological distress was higher for people who were 45–65 years of age when compared to those who were 66 years of age and older (45–55 years: aOR = 2.39, 95% CI: 2.00–2.85; 56–65 years: aOR = 1.62, 95% CI: 1.38–1.89). Females (aOR = 1.30, 95% CI: 1.21–1.41) and visible minorities (aOR = 1.47, 95% CI: 1.24–1.75) had higher odds of psychological distress than males and Whites. When compared to people who were married or with a partner, those who were single/never married (aOR = 1.30, 95% CI: 1.12–1.52) or divorced/separated (aOR = 1.24, 95% CI: 1.08–1.43) had higher odds of experiencing psychological distress. Lower household income (aOR = 1.89, 95% CI: 1.61–2.20) and lower educational attainment (secondary school or under: aOR = 1.84, 95% CI: 1.58–2.14) were also associated with higher odds of psychological distress when compared to people who had higher income and a post-secondary degree. People who were semi-retired were less likely to experience psychological distress (aOR = 0.86, 95% CI: 0.74–1.00).

In terms of health status, we observed a graded association between the number of health conditions and psychological distress. Specifically, the odds of psychological distress were more than three times higher for people with three or more health conditions compared to those with no health conditions (aOR = 3.60, 95% CI: 3.16–4.10). Similarly, those who reported having chronic pain were more likely to experience psychological distress (aOR = 2.10, 95% CI: 1.94–2.28) compared to those without chronic pain. Those who seldom or never participated in physical activities in the previous seven days were also at higher risk of experiencing psychological distress compared to those who did physical activities sometimes or often (aOR = 1.21, 95% CI: 1.06–1.38).

In comparison to those who lived with others and were not socially isolated, those who lived with others but were either mildly social isolated from others outside the household had higher odds of psychological distress (aOR = 1.34, 95% CI = 1.07–1.67). These results suggest that people without someone to confide in (aOR = 1.67, 95% CI: 1.50–1.86), to advise them if they have a crisis (aOR = 1.30, 95% CI:1.17–1.45), or to show love and affection to (aOR = 1.67, 95% CI: 1.48–1.90) have higher odds of psychological distress when compared to people who have these social supports most of or all of the time.

Discussion

Psychological distress is an under-recognized and undertreated mental health issue (Drapeau et al., 2012). This study found that refugee status is associated with almost twice the prevalence of psychological distress compared to those who are Canadian-born. This strong association remained statistically significant even when demographic, economic, health and social factors were taken into account. The observed high prevalence of psychological distress is in keeping with studies of refugees in many OECD countries. When compared to the general population, studies from different countries including USA, Canada, Australia, Ireland, Sweden, all reported that refugees and immigrants are more likely to experience higher levels of psychological distress despite that the fact that the levels vary by measures and contexts (Chen et al., 2017; Honkaniemi et al., 2020; Li & Anderson, 2016; Ryan et al., 2008; Torres & Wallace, 2013). For example, a Swedish study found that nearly one quarter of non-OECD migrants and one-fifth of OECD migrants reported having psychological distress. These levels are much higher than the one-eighth of Swedish-born participants who were in distress (Honkaniemi et al., 2020). The higher levels of psychological distress among refugees may possibly be due to traumatic experiences that motivated them to leave their country of origin in the first place. Non-refugee immigrants did not have elevated odds of psychological distress in this study. Resettling in a new country presents challenges including trying to adapt relatively quickly to a new social, cultural, and geographic environment, experiencing discrimination and poverty, having limited or no social networks and social support, and experiencing social isolation (Hynie, 2018; Stewart, 2014). These factors, however, should have been equally relevant for immigrants as well as refugees. Therefore, we hypothesize that the psychological distress experienced by refugees may be largely a function of the pre-migration trauma which may have resulted in their need to seek refugee status and leave their country of origin (Chen et al., 2017; Jurado et al., 2017; Li & Anderson, 2016). Refugees often experience pre-migration political or religious oppression, war, genocide, forced displacement, human trafficking, sexual assault, famine, loss of family members, and various forms of abuse (Chen et al., 2017; George & Jettner, 2016; Li & Anderson, 2016). The cumulative effect of premigration trauma and distress can persist long after resettlement (Makwarimba et al., 2013; Singh et al., 2015).

Refugees’ higher psychological distress levels may also be attributed to the lack of cultural sensitivity and tolerance in Canadian refugee policies (Rousseau et al., 2002). Many policies are highly Eurocentric and are not applicable to the diverse cultural, social, and political experiences of refugees (George, 2010). However, refugees are still viewed positively in Canada. Eighty percent of Canadians say refugees are “made to feel very or somewhat welcome by the local population” (Smith, 2019). Programs are in place to help refugees gain English language skills, retrain and locate jobs, access health care and to help their children integrate into the Canadian education system (Government of Canada, n.d.). Future research is therefore needed to address how elements of pre-migration trauma, refugee status, and post-migration challenges influence psychological distress.

The findings also indicate those who were visible minority members had significantly higher adjusted odds of psychological distress compared to those who were not people of color. This is possibly due to the fact that visible minority members may experience higher levels of discrimination and unfair treatment (De Maio & Kemp, 2010; Montazer, 2019), greater difficulty affording appropriate housing (Murdie, 2003), and challenges associated with accessing culturally appropriate mental health services (Reitmanova & Gustafson, 2009).

Consistent with the findings from other research, the results of this study reported that the odds of psychological distress were higher among women (Matud et al., 2015; Stallman et al., 2010), as well as those who were single, divorced or widowed (Darghouth et al., 2015), who had lower household income (Orpana et al., 2009) and lower levels of education (Miech et al., 2007), who had more comorbid health conditions, experienced chronic pain (Rice et al., 2016), and reported lower levels of physical activity (Perales et al., 2014). The results of this study indicated that middle-aged adults (45–65 years) had a higher level of psychological distress than older adults (75 years+), while previous research findings have not reported consistent associations between age and psychological distress (Cairney& Krause, 2005; Chittleborough et al., 2011; Goulia et al., 2012; Schieman et al., 2001). Additional research is needed to understand what mechanisms underlie the observed associations.

Previous studies have indicated that social support is protective against psychological distress (Bøen et al., 2012). The findings of the present study also indicate that those who reported having someone to confide in, provide advice to in a crisis, and having someone to show love to are less likely to experience psychological distress. However, the association between greater online social network use and lower psychological distress was only modest. Future research should continue to investigate these relationships because online social networking is growing in importance, even among older adults. Most research to date has focused on younger generations (Chen & Lee, 2013; Marino et al., 2018). Internet use may be a tool to reduce social isolation and increase social connectedness and interactions (Chen & Schulz, 2016; Cotten et al., 2011) and reduce the probability of depression among older adults (Chopik, 2016; Cotten et al., 2014). This may have particular relevance to social distancing measures that are instituted to control the spread of communicable diseases such as COVID-19.

Limitations of the study and implications

Findings of this research need to be considered in the context of the following limitations: First, the causal relationship between psychological distress and the various social determinants cannot be inferred as the data was cross-sectional. Second, refugee status was conceptualized based on year of arrival in Canada and country of origin. CLSA did not include questions on formal refugee status nor type of sponsorship. Therefore, a number of refugees in the analysis may have been missed. Third, although race and ethnicity may influence levels of psychological distress (Bratter & Eschbach, 2005; Park et al., 2018), the small sample of refugees in the current research prohibited a more nuanced analysis.

The findings of the study are based on the CLSA data which was collected in 2012 and all respondents had to speak English or French. Thus, these findings exclude refugees who could not speak either of Canada’s official languages and cannot be generalized to that group. Since the data were collected, there has been a surge of refugees resettled in Canada. Between 2015 and 2018, more than 58,000 Syrians arrived (Government of Canada, 2018). In 2018, Canada accepted 28,000 refugees, which was the largest number of any country in the world (Government of Canada, 2018). Syrian refugees are younger and have a higher percentage of families consisting of a couple with children when compared to refugees from other countries. Syrian refugees are less likely to speak English or French and had lower educational attainment, which suggests that they might at risk of socioeconomic vulnerability (Houle, 2019). More studies should be conducted examining the mental health of these newly arrived refugees.

Despite these limitations, the fact that almost one-quarter of refugees in this sample were in distress, even decades after settlement in Canada, suggests the need for creative public policy to address mental health problems as soon as possible after arrival. In light of the strong link observed in the current study between a lack of social support and distress, programs that improve social connectedness are worth considering. One particularly promising Canadian strategy for refugee resettlement, which may be worth adopting in other countries, is the privately sponsored refugees (PSRs) program. In this program, networks of volunteers from churches, mosques or other social groups provide refugee families with financial assistance for the first year after arrival, in addition to very extensive assistance locating health care, accommodation, furnishing and clothing, language training, suitable jobs, and help with registering children for school. The emotional support these groups provide can be very helpful and may mitigate subsequent distress. Syrian refugees who arrived under the PSR scheme are more likely to report they are employed and that they have help with daily errands. They are also less likely to report unmet needs in comparison to refugees who were resettled in Canada under the traditional government sponsored program (Hanley et al., 2018; Immigration, Refugees and Citizenship Canada, 2016; Kaida et al., 2020). To improve resilience and decrease mental illness among refugees, an additional strategy is to provide trauma-informed care to vulnerable refugees. Aspects of trauma-informed care for refugees include regularly screening for trauma and related distress, adoption of a strength-based focus, provision of health and mental health care by culturally and linguistically similar providers, and provision of multigenerational care (Miller et al., 2019). Trauma-focused cognitive behavioural treatment is a very promising intervention for refugees with mental health challenges (Miller et al., 2019).

The findings have substantial policy and practice implications for improved screening, outreach, and service provision to refugees and other vulnerable groups. By targeting modifiable variables such as education, income, social capital, and lifestyle factors that contribute to chronic diseases, the wellbeing of refugees and all mid-life and older Canadians can be better supported.

Footnotes

Acknowledgements

This research was made possible using the data collected by the Canadian Longitudinal Study on Aging (CLSA). Funding for the Canadian Longitudinal Study on Aging (CLSA) is provided by the Government of Canada through the Canadian Institutes of Health Research (CIHR) under grant reference: LSA 94473 and the Canada Foundation for Innovation. This research has been conducted using the CLSA Baseline Comprehensive Dataset version 4.0, under Application ID 170605. The CLSA is led by Drs. Parminder Raina, Christina Wolfson and Susan Kirkland.

Author’s contributions

EFT, KMD, KK, HT, and LS developed the analysis plan. KMD and LS conducted the analysis with the direction of EFT. HT, LS, and YL wrote the first and subsequent manuscript drafts; all team members provided feedback. HT, YL, SA and EFT made the final revisions. EFT supervised all components of the project.

Disclaimer

The opinions expressed in this manuscript are the authors’ own and do not reflect the views of the CLSA administrators.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Part of this study was funded through EFT’s Sandra Rotman endowed chair funds and KMD’s Fulbright Canada scholarship.

ORCID iDs

Hongmei Tong

Yu Lung

Shen (Lamson) Lin

Senyo Agbeyaka

Esme Fuller-Thomson

References

Alemi

Stempel

(2018). Discrimination and distress among Afghan refugees in northern California: The moderating role of pre-and post-migration factors. PLoS ONE, 13(5), e0196822.

Allen

Balfour

Bell

Marmot

(2014). Social determinants of mental health. International Review of Psychiatry, 26(4), 392–407.

Andrews

Slade

(2001). Interpreting scores on the Kessler Psychological Distress Scale (K10). Australian and New Zealand Journal of Public Health, 25(6), 494–497.

Atkins

Naismith

S. L.

Luscombe

G. M.

Hickie

I. B.

(2013). Psychological distress and quality of life in older persons: Relative contributions of fixed and modifiable risk factors. BMC Psychiatry, 13, Article 249.

Batty

G. D.

Russ

T. C.

Stamatakis

Kivimaki

(2017). Psychological distress in relation to site specific cancer mortality: Pooling of unpublished data from 16 prospective cohort studies. BMJ, 356, j108. doi:10.1136/bmj.j108

Bøen

Dalgard

O. S.

Bjertness

(2012). The importance of social support in the associations between psychological distress and somatic health problems and socio-economic factors among older adults living at home: a cross sectional study. BMC Geriatrics, 12(1), 27.

Bratter

J. L.

Eschbach

(2005). Race/ethnic differences in nonspecific psychological distress: Evidence from the National Health Interview Survey. Social Science Quarterly, 86(3), 620–644.

Cairney

Krause

(2005). The social distribution of psychological distress and depression in older adults. Journal of Aging and Health, 17(6), 807–835. doi:10.1177/0898264305280985

Canadian Longitudinal Study on Aging, Social Networks Questionnaire (Baseline) Adapted from the General Social Survey, Statistics Canada. https://www150.statcan.gc.ca/n1/en/catalogue/89F0115X; consulted on: July 23, 2018.

10.

Caron

Liu

(2011). Factors associated with psychological distress in the Canadian population: A comparison of low-income and non low-income sub-groups. Community Mental Health Journal, 47(3), 318–330.

11.

Chen

Hall

B. J.

Ling

Renzaho

A. M.

(2017). Pre-migration and post-migration factors associated with mental health in humanitarian migrants in Australia and the moderation effect of post-migration stressors: Findings from the first wave data of the BNLA cohort study. Lancet Psychiatry, 4(3), 218–229. doi:10.1016/S2215-0366(17)30032-9

12.

Chen

Lee

K. H.

(2013). Sharing, liking, commenting, and distressed? The pathway between Facebook interaction and psychological distress. Cyberpsychology, Behavior, and Social Networking, 16(10), 728–734.

13.

Chen

Y. R. R.

Schulz

P. J.

(2016). The effect of information communication technology interventions on reducing social isolation in the elderly: A systematic review. Journal of Medical Internet Research, 18(1), e18.

14.

Chittleborough

C. R.

Winefield

Gill

T. K.

Koster

Taylor

A. W.

(2011). Age differences in associations between psychological distress and chronic conditions. International Journal of Public Health, 56(1), 71–80. doi:10.1007/s00038-010-0197-5

15.

Chopik

W. J.

(2016). The benefits of social technology use among older adults are mediated by reduced loneliness. Cyberpsychology, Behavior, and Social Networking, 19(9), 551–556.

16.

Cotten

S. R.

Ford

Hale

T. M.

(2014). Internet use and depression among retired older adults in the United States: A longitudinal analysis. The Journals of Gerontology, Series B: Psychological Sciences and Social Sciences, 69(5), 763–771.

17.

Cotten

S. R.

Goldner

Hale

T. M.

Drentea

(2011). The importance of type, amount, and timing of internet use for understanding psychological distress. Social Science Quarterly, 92(1), 119–139.

18.

Darghouth

Brody

Alegría

(2015). Does marriage matter? Marital status, family processes, and psychological distress among Latino men and women. Hispanic Journal of Behavioral Sciences, 37(4), 482–502.

19.

Davison

K. M.

Lung

Lin

S. L.

Tong

Kobayashi

K. M.

Fuller-Thomson

(2019). Depression in middle and older adulthood: The role of immigration, nutrition, and other determinants of health in the Canadian Longitudinal Study on Aging. BMC Psychiatry, 19(1), 329.

20.

Davison

K. M.

Lung

Lin

S. L.

Tong

Kobayashi

K. M.

Fuller-Thomson

(2020). Psychological distress in older adults linked to immigrant status, dietary intake, and physical health conditions in the Canadian Longitudinal Study on Aging (CLSA). Journal of Affective Disorders, 265, 526–537.

21.

De Maio

F. G.

Kemp

. (2010). The deterioration of health status among immigrants to Canada. Global Public Health, 5(5), 462–478.

22.

Drapeau

Marchand

Beaulieu-Prévost

(2012). Epidemiology of psychological distress. Mental Illnesses-Understanding, Prediction and Control, 69, 105–106.

23.

Enticott

J. C.

Lin

Shawyer

Russell

Inder

Patten

Meadows

(2018). Prevalence of psychological distress: How do Australia and Canada compare? Australian & New Zealand Journal of Psychiatry, 52(3), 227–238.

24.

Fenta

Hyman

Noh

(2004). Determinants of depression among Ethiopian immigrants and refugees in Toronto. The Journal of Nervous and Mental Disease, 192(5), 363–372.

25.

George

(2010). A theoretical understanding of refugee trauma. Clinical Social Work Journal, 38(4), 379–387.

26.

George

Jettner

(2016). Migration stressors, psychological distress, and family—A Sri Lankan tamil refugee analysis. Journal of International Migration and Integration, 17(2), 341–353.

27.

Government of Canada. (2018). Canada - admissions of Syrian refugees* by immigration category and family composition, November 4, 2015 - September 5, 2018. https://open.canada.ca/data/en/dataset/ca243c40-a6d3-4a46-a578-b4fad4369df0

28.

Government of Canada. (n.d.). Find refugee services in Canada. https://www.canada.ca/en/immigration-refugees-citizenship/services/refugees/help-within-canada.html

29.

Goulia

Papadimitriou

Machado

M. O.

Mantas

Pappa

Tsianos

Pavlidis

Drosos

A. A.

Carvalho

A. F.

Hyphantis

(2012). Does psychological distress vary between younger and older adults in health and disease? Journal of Psychosomatic Research, 72(2), 120–128.

30.

Guajardo

M. G. U.

Slewa-Younan

Smith

Eagar

Stone

(2016). Psychological distress is influenced by length of stay in resettled Iraqi refugees in Australia. International Journal of Mental Health Systems, 10, Article 4.

31.

Hanley

Al Mhamied

Cleveland

Hajjar

Hassan

Ives

Khyar

Hynie

(2018). The social networks, social support and social capital of Syrian refugees privately sponsored to settle in Montreal: Indications for employment and housing during their early experiences of integration. Canadian Ethnic Studies, 50(2), 123–148.

32.

Honkaniemi

Juárez

S. P.

Katikireddi

S. V.

Rostila

(2020). Psychological distress by age at migration and duration of residence in Sweden. Social Science & Medicine, 250, Article 112869.

33.

Houle

(2019). Results from the 2016 Census: Syrian refugees who resettled in Canada in 2015 and 2016. Insights on Canadian Society. February Statistics Canada Catalogue no. 75-006-X.

34.

Hynie

(2018). The social determinants of refugee mental health in the post-migration context: A critical review. The Canadian Journal of Psychiatry, 63(5), 297–303.

35.

Immigration, Refugees and Citizenship Canada. (2016). Rapid impact evaluation of the Syrian refugee initiative: Research and evaluation (Reference no. E1-2016). Author.

36.

Jackson

C. A.

Sudlow

C. L.

Mishra

G. D.

(2018). Psychological distress and risk of myocardial infarction and stroke in the 45 and up study: A prospective cohort study. Circulation: Cardiovascular Quality and Outcomes, 11(9), e004500.

37.

Jurado

Alarcón

R. D.

Martínez-Ortega

J. M.

Mendieta-Marichal

Gutiérrez-Rojas

Gurpegui

(2017). Factors associated with psychological distress or common mental disorders in migrant populations across the world. Revista de Psiquiatría y Salud Mental (English Edition), 10(1), 45–58.

38.

Kaida

Hou

Stick

(2020). The long-term economic integration of resettled refugees in Canada: A comparison of Privately Sponsored Refugees and Government-Assisted Refugees. Journal of Ethnic and Migration Studies, 46(9), 1687–1708.

39.

Kessler

R. C.

Andrews

Colpe

L. J.

Hiripi

Mroczek

D. K.

Normand

S. L.

Walters

E. E.

Zaslavsky

A. M.

(2002). Short screening scales to monitor population prevalences and trends in non-specific psychological distress. Psychological Medicine, 32(6), 959–976.

40.

Kim

Keovisai

Kim

Richards-Desai

Yalim

A. C.

(2018). Trauma, discrimination, and psychological distress across Vietnamese refugees and immigrants: A life course perspective. Community Mental Health Journal, 55(3), 385–393. doi:10.1007/s10597-018-0268-2

41.

Anderson

J. G.

(2016). Pre-migration trauma exposure and psychological distress for Asian American immigrants: Linking the pre- and post-migration contexts. Journal of Immigrant and Minority Health, 18(4), 728–739. doi:10.1007/s10903-015-0257-2

42.

Lin

S. L.

Kobayashi

Tong

Davison

K. M.

Arora

S. R.

Fuller-Thomson

(2020). Close relations matter: The association between depression and refugee status in the Canadian Longitudinal Study on Aging (CLSA). Journal of Immigrant and Minority Health, 22, 946–956. doi:10.1007/s10903-020-00980-0

43.

Makwarimba

Stewart

Simich

Makumbe

Shizha

Anderson

(2013). Sudanese and Somali refugees in Canada: Social support needs and preferences. International Migration, 51(5), 106–119.

44.

Marino

Gini

Vieno

Spada

M. M.

(2018). The associations between problematic Facebook use, psychological distress and well-being among adolescents and young adults: A systematic review and meta-analysis. Journal of Affective Disorders, 226, 274–281.

45.

Matud

M. P.

Bethencourt

J. M.

Ibáñez

. (2015). Gender differences in psychological distress in Spain. International Journal of Social Psychiatry, 61(6), 560–568.

46.

Matud

M. P.

García

M. C.

(2019). Psychological distress and social functioning in elderly Spanish people: A gender analysis. International Journal of Environmental Research and Public Health, 16(3), 341.

47.

Miller

K. K.

Brown

C. R.

Shramko

Svetaz

M. V.

(2019). Applying trauma-informed practices to the care of refugee and immigrant youth: 10 clinical pearls. Children, 6(8), 94.

48.

Miech

Power

Eaton

W. W.

(2007). Disparities in psychological distress across education and sex: a longitudinal analysis of their persistence within a cohort over 19 years. Annals of Epidemiology, 17(4), 289–295.

49.

Montazer

(2019). Immigration, visible-minority status, gender, and depression. Society and Mental Health, 10(3), 218–236.

50.

Morin

R. T.

Midlarsky

(2016). Social support, mastery, and psychological distress in black and white older adults. The International Journal of Aging and Human Development, 82(2–3), 209–228.

51.

Murdie

R. A.

(2003). Housing affordability and Toronto’s rental market: Perspectives from the housing careers of Jamaican, Polish and Somali Newcomers. Housing, Theory and Society, 20(4), 183–196.

52.

Nosè

Turrini

Imoli

Ballette

Ostuzzi

Cucchi

Padoan

Ruggeri

Barbui

(2018). Prevalence and correlates of psychological distress and psychiatric disorders in asylum seekers and refugees resettled in an Italian catchment area. Journal of Immigrant and Minority Health, 20(2), 263–270.

53.

Orpana

H. M.

Lemyre

Gravel

(2009). Income and psychological distress: The role of the social environment. Health Reports, 20(1), 21.

54.

Park

Choi

Wenzel

J. A.

(2018). Racial/ethnic differences in correlates of psychological distress among five Asian-American subgroups and non-Hispanic Whites. Ethnicity & Health, 1–17.

55.

Perales

Pozo-Cruz

J. D.

Pozo-Cruz

B. D.

(2014). Impact of physical activity on psychological distress: A prospective analysis of an Australian national sample. American Journal of Public Health, 104(12), e91–e97.

56.

Phillips

M. R.

(2009). Is distress a symptom of mental disorders, a marker of impairment, both or neither? World Psychiatry, 8(2), 91–92.

57.

Power

Frank

Hertzman

Schierhout

(2001). Predictors of low back pain onset in a prospective British study. American Journal of Public Health, 91(10), 1671–1678.

58.

Raina

P. S.

Wolfson

Kirkland

S. A.

Griffith

L. E.

Oremus

Patterson

Tuokko

Penning

Balion

C. M.

Hogan

Wister

Payette

Shannon

Brazil

(2009). The Canadian Longitudinal Study on Aging (CLSA). Canadian Journal on Aging/La Revue canadienne du vieillissement, 28(3), 221–229.

59.

Rasul

Stansfeld

S. A.

Hart

C. L.

Smith

G. D.

(2005). Psychological distress, physical illness, and risk of coronary heart disease. Journal of Epidemiology & Community Health, 59(2), 140–145.

60.

Reitmanova

Gustafson

D. L.

(2009). Mental health needs of visible minority immigrants in a small urban center: Recommendations for policy makers and service providers. Journal of Immigrant and Minority Health, 11(1), 46–56.

61.

Reneflot

Evensen

(2014). Unemployment and psychological distress among young adults in the n ORDIC countries: A review of the literature. International Journal of Social Welfare, 23(1), 3–15.

62.

Rice

Mehta

Shapiro

Pope

Harth

Morley-Forster

Sequeira

Teasell

(2016). Psychological distress in out-patients assessed for chronic pain compared to those with rheumatoid arthritis. Pain Research and Management, 2016, 7071907. doi:10.1155/2016/7071907

63.

Rousseau

Crépeau

Foxen

Houle

(2002). The complexity of determining refugeehood: A multidisciplinary analysis of the decision-making process of the Canadian immigration and refugee board. Journal of Refugee Studies, 15(1), 43–70.

64.

Russ

T. C.

Stamatakis

Hamer

Starr

J. M.

Kivimaki

Batty

G. D.

(2012). Association between psychological distress and mortality: Individual participant pooled analysis of 10 prospective cohort studies. British Medical Journal, 345, e4933. doi:10.1136/bmj.e4933

65.

Ryan

D. A.

Benson

C. A.

Dooley

B. A.

(2008). Psychological distress and the asylum process: A longitudinal study of forced migrants in Ireland. Journal of Nervous and Mental Disorders, 196(1), 37–45. doi:10.1097/NMD.0b013e31815fa51c

66.

Sakurai

Nishi

Kondo

Yanagida

Kawakami

(2011). Screening performance of K6/K10 and other screening instruments for mood and anxiety disorders in Japan. Psychiatry and Clinical Neurosciences, 65(5), 434–441.

67.

Sarason

Gurung

R. A. R.

(1997). Close personal relationships and health outcomes: A key to the role of social support. In Duck

(Ed.), Handbook of personal relationships: Theory, research and interventions (2nd ed., pp. 547–573). Wiley.

68.

Schieman

Van Gundy

Taylor

(2001). Status, role, and resource explanations for age patterns in psychological distress. Journal of Health and Social Behavior, 42(1), 80–96.

69.

Sharpley

Wark

Hussain

McEvoy

Attia

(2015). The influence of social support on psychological distress in older persons: An examination of interaction processes in australia. Psychological Reports, 117(3), 883–896.

70.

Shaw

S. A.

Karim

Bellows

Pillai

(2019). Emotional distress among Rohingya refugees in Malaysia. Intervention, 17(2), 174–180.

71.

Sherbourne

C. D.

Stewart

A. L.

(1991). The MOS social support survey. Social Science & Medicine, 32(6), 705–714.

72.

Simich

Hamilton

Baya

B. K.

(2006). Mental distress, economic hardship and expectations of life in Canada among Sudanese newcomers. Transcultural Psychiatry, 43(3), 418–444.

73.

Singh

McBride

Kak

(2015). Role of social support in examining acculturative stress and psychological distress among Asian American immigrants and three sub-groups: Results from NLAAS. Journal of Immigrant and Minority Health, 17(6), 1597–1606. doi:10.1007/s10903-015-0213-1

74.

Smith

(2019, April 30). Canadian public opinion on immigration, refugees “remarkably steady”, new survey finds few Canadians see immigrants and refugees as a major national issue. CIC News. https://www.cicnews.com/2019/04/majority-of-canadians-maintain-positive-views-of-immigration-new-survey-finds-0412240.html#gs.gwhvn8

75.

Stallman

H. M.

McDermott

B. M.

Beckmann

M. M.

Kay Wilson

Adam

(2010). Women who miscarry: The effectiveness and clinical utility of the Kessler 10 questionnaire in screening for ongoing psychological distress. Australian and New Zealand Journal of Obstetrics and Gynaecology, 50(1), 70–76.

76.

Stewart

M. J.

(2014). Social support in refugee resettlement. In Simich

Andermann

(Eds.), International perspectives on migration, refuge and resilience: Promoting resilience and mental health among resettled refugees and forced migrants (pp. 91–107). Springer, Dordrecht.

77.

Torres

J. M.

Wallace

S. P.

(2013). Migration circumstances, psychological distress, and self-rated physical health for Latino immigrants in the United States. American Journal of Public Health, 103(9), 1619–1627.

78.

Vasiliadis

H. M.

Chudzinski

Gontijo-Guerra

Préville

(2015). Screening instruments for a population of older adults: The 10-item Kessler Psychological Distress Scale (K10) and the 7-item Generalized Anxiety Disorder Scale (GAD-7). Psychiatry Research, 228(1), 89–94.

79.

Walther

Kröger

Tibubos

A. N.

T. M. T.

von Scheve

Schupp

. . .Bajbouj

(2020). Psychological distress among refugees in Germany: A cross-sectional analysis of individual and contextual risk factors and potential consequences for integration using a nationally representative survey. BMJ Open, 10(8), e033658

80.

Wilson

R. S.

Evans

D. A.

Bienias

J. L.

De Leon

C. M.

Schneider

J. A.

Bennett

D. A.

(2003). Proneness to psychological distress is associated with risk of Alzheimer’s disease. Neurology, 61(11), 1479–1485.

81.

World Health Organization (WHO) and the Calouste Gulbenkian Foundation. (2014). Social determinants of mental health. WHO. www.who.int/mental_health/publications/gulbenkian_paper_social_determinants_of_mental_health/en/