The emotional distress of asylum seekers in Israel and the characteristics of those seeking psychiatric versus medical help

Abstract

Israel has become a destination for asylum seekers. Asylum seekers often experience emotional distress, but have limited access to health services and rarely use psychiatric services. This study sought to understand and characterize the use of psychiatric versus medical services by asylum seekers in Israel. We compared the emotional distress, stressful life events and previous treatment consultations of 21 psychiatric service users (PSU) and 55 medical service users (MSU) at the Open Clinic of Physicians for Human Rights in Tel-Aviv. Participants completed a socio-demographic questionnaire, the General Health Questionnaire (GHQ-12), the Stressful Life Events Scale and the Health Care Utilization Questionnaire. PSU and MSU did not have significantly different levels of emotional distress. PSU reported significantly more stressful life events during the past year than MSU (M = 5.81, SD 3.47 vs. M = 3.8, SD 2.35, p < 0.01). In comparison to MSU, PSU utilized more medical (M = 4.33, SD 2.28) and non-medical (M = 2.38, SD 1.92) services (p < 0.001) than MSU. Asylum seekers who consulted multiple treatment agencies in the last year were 1.55 times more likely to seek psychiatric treatment than those who had consulted only a few treatment agencies. Emotional distress in asylum seekers appears to be under-diagnosed in the Open Clinic and under-treated by mental health professionals. To better detect this distress, a thorough screening is recommended at assessment. Collaboration with mental health professionals and community and religious leaders consulted in the past is important and can contribute to good health care outcomes in this population.

Keywords

asylum seekers mental health services emotional distress stressful life events treatment agencies

Introduction

Migration is a process accompanied by significant socio-psychological pressures that affect migrants’ mental state. Compared to local populations, migrants, including asylum seekers and work migrants, are at increased risk of physical and mental illnesses (Kirmayer et al., 2011; Lindencrona, Ekblad, & Hauff, 2008; Magalhaes, Carrasco, & Gastaldo, 2010), including post-traumatic stress disorder (PTSD), anxiety, somatization, depression and psychotic disorders (Cantor-Graae & Selten, 2005; Lerner, Kertes & Zilber, 2005; Mirsky, 2009; Nickerson, Steel, Bryant, Brooks, & Silove, 2011; Steel et al., 2009). The increased risk for legal migrants seems to occur even when conditions of immigration are relatively favorable, as they are in Israel (Arieli, 1992; Levav, Kohn, Flaherty, Lerner, & Aisenberg, 1990; Mirsky, Kohn, Levav, Grinshpoon, & Ponizovsky, 2008; Zilber & Lerner, 1996). Refugees and asylum seekers are much more vulnerable than documented immigrants to mental illness, such as depression, anxiety and PTSD (Bhugra et al., 2011; Fazel, Wheeler & Danesh, 2005; Lindert, von Ehrenstein, Priebe, Mielck, & Brähler, 2009). They also run a high risk of developing schizophrenia and other non-affective psychotic disorders (Hollander et al., 2016). The risk of developing emotional disorders among migrants is mediated by various factors, such as adjustment difficulties, loneliness, belonging to a visible minority, perceived discrimination, level of perceived social support and the degree of fluency in the language of the host country (Berg et al., 2014; Lerner et al., 2005; Magalhaes et al., 2010; Pascoe & Smart Richman, 2009).

In addition, immigrants make less and different use of mental health services than local populations (Bhui et al., 2003; Fenta, Hyman, & Noh, 2006; Steel, Silove, Chey, Bauman & Phan, 2005; Youngmann, Pugachova, & Zilber, 2009, 2012) and tend to prefer primary medical care to mental health care, even when in emotional distress (Beiser, Gill, & Edwards, 1993; Bhui et al., 2003; Fenta, Hyman, & Noh, 2007; Perez & Fortuna, 2005; Tiwari & Wang, 2008). Kirmayer and his colleagues (2007) concluded that Canadian immigrants who have sought help from alternative or traditional healers are more likely to access mental health services than those who have not, perhaps because after seeking help from one source it becomes easier to seek it elsewhere, or because the help they received from alternative healers was not effective.

The low rate and different pattern of mental health service-use among migrants may result from economic and socio-cultural barriers, such as language, different cultural conceptualizations of mental health problems, a lack of awareness of available services, low levels of trust in health workers, low rates of referral from primary care physicians and a belief in the power of traditional healers from their native cultures (Franks, Henwood, & Bowden, 2007; Lindert, Schouler-Ocak, Heinz, & Priebe, 2008; Magalhaes et al., 2010; Whitley, Kirmayer, & Groleau, 2006). Stigma associated with psychiatric disorder may also block or lengthen the path to care for mental health problems (Alonso et al., 2008).

In recent decades, in the context of global migration, Israel has become a target destination for migrant workers and asylum seekers. By the end of 2013 Israel became home to 123,000 undocumented immigrants, including 53,636 asylum seekers from Africa (mainly Sudan and Eritrea) and 69,449 migrant workers without visas (Population and Immigration Authority, 2013). African asylum seekers in Israel live mainly in southern Tel Aviv, one of the city’s poorest neighborhoods. The Israeli government has adopted restrictive policies towards asylum seekers, causing them economical and psychological instability and excluding them from participating fully in Israel’s social, political and health systems (Furst-Nichols & Jacobsen, 2011; Reynolds, 2013). As visible minorities, they may also be vulnerable to social exclusion and racism (Beiser, 2009; Scott, 2014).

In addition, according to a survey by the ‘Physicians for Human Rights (PHR) – Israel Open Clinic’ of 1044 consecutive adult asylum seekers from Eritrea and Sudan seeking health services, both men and women were consistently exposed to traumatic events during their passage through the Sinai Peninsula. Victims of kidnapping and human trafficking were exposed to sexual assault, and deprived of water and/or food (Nakash et al., 2015a). It is estimated that between 2007 and 2012, 4000 asylum seekers did not survive the journey (van Reisen et al., 2012).

Since asylum seekers in Israel are not eligible for mandatory national health insurance, one of their main health service options is the PHR Open Clinic. Established in 1998, the clinic delivers free health services to populations without access to the national health system. It provides primary health care and specialized services, including free psychiatric treatment. Hospitals (general and psychiatric), social welfare agencies and non-government organizations refer undocumented immigrants to the clinic, and some patients self-refer (Lurie, personal communication, March, 21, 2016). However, very few access psychiatric services. Between 1998 and 2010, over 28,000 users attended the clinic. All service users were routinely examined by a nurse. Sixty percent were examined by general practitioners (GPs), but only 350 were treated in the psychiatric clinic (Dick, Fennig & Lurie, 2015). This suggests a profound underutilization of psychiatric services by asylum seekers. One possible explanation for this is that GPs in the clinic failed to detect emotional distress in these patients (Dick et al., 2015). In a convenience sample of 97 patients who consulted GPs, over 50% reported experiencing emotional distress, but only about 8% were diagnosed as being in emotional distress or suffering from a psychiatric illness, and only 5% were referred on for psychiatric evaluation. The under-diagnosis of emotional distress and mental health problems in the intercultural encounter between Western health professionals and patients from other cultures, especially in asylum seekers, is well documented in the literature (Alegría et al., 2008; Kortmann, 2010). The greater the level of emotional distress experienced by migrants, the greater the number of treatment agencies they turn to (Kirmayer et al., 2007).

This study aims to extend our understanding of the use of psychiatric services by asylum seekers and to examine whether or not the under-diagnosis of emotional distress in primary care in this population can explain their under-use of specialized mental health services. For this purpose, two groups of patients at the Open Clinic were compared: asylum seekers treated by a psychiatrist (psychiatric service users [PSU]); and those treated by a GP (medical service users [MSU]). These groups were compared on: (a) level of emotional distress; (b) stressful life events experienced during the last year; and (c) number of treatment agencies used during the previous year. The predictive value of these variables was examined in relation to the type of treatment received by the participants (psychiatric versus medical).

Methods

Participants

A total of 76 asylum seekers who received medical (MSU, n = 55) or psychiatric (PSU, n = 21) treatment in the Open Clinic between April and October, 2012 participated in the study. Adults (over the age of 18) who visited the clinic at least once were eligible to participate. The mean age of participants was 34.1 (SD = 9.5); women comprised 53.9% (n = 41) of the sample and men 46.1% (n = 35).

Instruments

General Health Questionnaire-12 (GHQ-12) is a 12-item self-report questionnaire widely used as a measure of mental health status and as a screening instrument to detect risk of psychiatric disorders. It measures self-reported depression, anxiety, somatic symptoms and social withdrawal in the 30 days prior to the completion of the questionnaire (Goldberg & Blackwell, 1970; Goldberg & Williams, 1988). Sample items are: ‘In the last 30 days have you lost much sleep over worry?’; ‘… been feeling unhappy or depressed?’. Items are scored on a scale from 0–3, with higher scores reflecting greater emotional distress. Scores range from 0 to 36, for the 12 items in total, and internal reliability (Cronbach’s alpha) in the current study was 0.61. The GHQ-12 has been widely used in many countries including Israel (Dick et al., 2015; Levav et al., 2007; Ponizovsky et al., 2007).

Recent Life Events (or Stressful Life Events) is a 14-item self-report questionnaire that assesses the number of stressful life events experienced in the past year (Kirmayer et al., 2007). The questionnaire includes events relevant to specific groups of migrants, with main topics including: family, work or school, housing, health, and discrimination. Scoring is dichotomous (0–1), and ranges between 0 and 14. Sample items are: ‘In the last 12 months, have you had troubles at work or school?’; ‘… problems with your children?’ (for a complete list of questions, see Table 4).

Health Care Utilization is a 14-item self-report questionnaire used to calculate the number of lifetime hospitalizations and visits to medical and non-medical agencies (Kirmayer et al., 2007). The Health Care Utilization questionnaire was used in this study to determine the number of treatment agencies each participant had visited. Scores are dichotomous (0–1), and range between 0 and 14. Sample items are: ‘In the last 12 months, have you visited a hospital emergency room?’; ‘… a family doctor or GP (general practitioner)?’ (for a complete list of questions, see Table 3).

A demographic questionnaire inquired about age, sex, country of origin, language spoken, number of visits to the clinic (during the entire past treatment period in the clinic), frequency of religious services attended (number of visits to religious services), marital status, level of education, employment status during the past year (no job, full time job or part time job) and duration of stay in Israel.

All questionnaires, instructions and informed consent forms were short and easy to complete. The questionnaires were translated from English into Tigrinya (spoken in Eritrea) and Arabic (spoken in Sudan). Most asylum seekers spoke English, but those who did not completed the Arabic or Tigrinya versions.

Each questionnaire was translated by two independent translators, native speakers of the target language with excellent knowledge of the source language. They were then back-translated by two independent translators whose mother tongue was the source language and who had excellent knowledge of the target language. The original versions of the questionnaires were compared to the back translations by the first set of translators and any differences discussed and resolved. The GHQ-12 was translated into Arabic for use in a 2003–2004 national Israeli survey (Levav et al., 2007; Ponizovsky et al., 2007), and was therefore translated only into Tigrinya by the research team. It is noteworthy that even though health conceptualization may differ between Arabic speakers in Israel and Sudan, our two independent Sudanese translators claimed that the major concepts used in the Israeli–Arabic version of the GHQ-12 are quite similar to the Sudanese–Arabic concepts. We therefore used the Israeli–Arabic version of the questionnaire used in the national Israeli survey.

Procedure

The study was approved by the Internal Review Boards of the Abarbanel Mental Health Center and the Ruppin Academic Center. The investigators (NK, RY and a research assistant) approached potential participants in the waiting room, and obtained written informed consent following a thorough explanation of the study procedures. The request to take part in the study was made either in English or in the native language of the potential respondents (mostly Tigrinya, Arabic), with a help of a staff member of the clinic who translated what was said. Service users who agreed to participate in the study completed the questionnaires in English or their native language. Individuals who could not read completed the questionnaires with the assistance of the researchers and translators.

According to the Open Clinic records, 873 patients received treatment during the recruitment period (April–October 2012): 790 received non-psychiatric medical treatment and 83 psychiatric treatment. All service-users were routinely evaluated by a nurse, who decided whether or not the person would be further referred to a GP. The GP decided whether or not the patient should be referred to a psychiatrist or another therapist. Referrals by both nurses and GPs were based on clinical evaluations and general impressions. No specific set of criteria was used. Once patients had been referred to a psychiatrist, they could make appointments directly, without the involvement of the GP. The Open Clinic operates on Sundays, Tuesdays and Wednesdays. Psychiatric services were available on a random subset of these days, according to a monthly, pre-determined schedule. Accordingly, the researchers usually arrived once or twice a week, on a day when they knew that both medical and psychiatric services would be available. About 202 patients were approached and asked to participate in the study. Of these, 142 were MSU and 60 PSU. Sixty percent refused to participate, that is, 85 MSU and 36 PSU. Two of the 57 MSU and three of the 24 PSU who agreed to participate in the study were excluded from the sample because they were not asylum seekers. Thus, 55 MSU (38.7%) and 21 PSU (35%) formed the final sample.

Data analysis

Analyses were performed using SPSS version 19.0. In order to clarify the use of psychiatric services, independent sample t-tests were conducted to measure group differences in emotional stress, stressful life events and multiple treatment agencies. A logistic regression analysis examined the impact of emotional distress, stressful life events and multiple treatment agencies (independent variables), on the probability of the participants seeking psychiatric treatment (dependent variable).

Results

Table 1 presents the characteristics of the study groups. There were no group differences in gender, education, employment status or marital status during the past year. PSU were significantly older than MSU (t ₍₄₆₎ = 2.16, p < .05), were more likely to be English speakers (χ²₍₁₎ = 5.68, p < .05), had been in Israel longer (χ²₍₁₎ = 13.77, p < .001) and had visited the clinic more times than non-psychiatric patients (χ²₍₁₎ = 4.94, p < .05). Most were less religious (χ²₍₅₎ = 11.18, p < .05) and their countries of origin were more diverse (χ²₍₂₎ = 23.74, p < .001).

Table 1.

Comparison between psychiatric service users (PSU) and medical service users (MSU): Descriptive data (N = 76).

Study group	PSU (n = 21)		MSU (n = 55)
Demographic variables	n	%	n	%
Gender
Male	10	47.6	25	45.5	χ²₍₁₎ = .029
Female	11	52.4	30	54.5
Marital status
Married	9	42.9	26	48.1	χ²₍₃₎ = .92
Living with partner	4	19.0	7	13.0
Divorced/widowed/ separated	1	4.8	5	9.3
Single	7	33.3	16	29.6
Years of education
1–5 years	3	14.3	11	21.2	χ²₍₂₎ = 0.50
6–12 years	10	47.6	24	46.2
12 + years	8	38.1	17	32.7
Languages spoken by Participants
English	17	81	28	51	χ²₍₁₎ = 5.68*
Tigrinya	2	10	41	75	χ²₍₁₎ = 26.15***
Arab	5	24	9	16	χ²₍₁₎ = 0.56
Amharic	1	4.8	4	7.3	χ²₍₁₎ = 0.15
Employment status
No job	11	52.4	31	56.4
Full-time job	4	19.0	3	5.5
Part-time job	7	33.3	19	34.5
Religion
None	2	9.5	1	1.8	χ²₍₅₎ = 11.18*
Protestant	3	14.3	2	3.6
Roman Catholic	2	9.5	10	18.2
Orthodox	8	38.1	35	63.6
Muslim	5	23.8	7	12.7
Buddist	1	4.8	–	–
Frequency of religious services attended
Never	6	30.0	10	18.2	χ²₍₃₎ = 1.50
A few times a year	6	30.0	17	30.9
About monthly	2	10.0	5	9.1
Weekly or more often	6	30.0	23	41.8
Duration of stay in Israel
Arrived in Israel before 2009	17	81.0	18	33.3	χ²₍₁₎ = 13.77***
Arrived in Israel 2010–2012	4	19.0	36	66.7
Country of origin
Sudan and Eritrea	5	23.8	41	83.7	χ²₍₂₎ = 23.74***
West Africa	6	28.6	4	8.2
Other *	10	47.6	4	8.2
Number of clinic visits**
1–3 times	4	19.0	21	47.7	χ²₍₁₎ = 4.94*
4 + times	17	81.0	23	52.3

Notes: *Such as south or west Asia, America, south or central Africa, Former USSR. **during the entire past treatment period in the clinic. *p < .05 **p < .01 ***p < .001.

Data on emotional distress, stressful life events and multiple treatment agencies are presented in Tables 2 and 3. PSU had sought help from significantly more treatment agencies during the previous year than MSU (M = 4.33, SD = 2.28, M = 2.38, SD = 1.92, respectively, t ₍₇₄₎ = –3.74, p < .001), especially from social workers (χ²₍₁₎ = 5.39, p < .05) and psychologists (χ²₍₁₎ = 10.34, p < .01). Most of the participants had been treated in emergency rooms (51.3%) and visited GPs (30.3%) or medical specialists (27%). About 27% of the participants reported they turned to NGOs, 15% turned to helpers or healers from within the community for a health problem and 19% turned to helpers or healers from a religious group (Table 3).

Table 2.

Comparison of emotional distress, stressful life events and multiple treatment agencies among PSU and MSU asylum seekers receiving treatment at the Open Clinic (N = 76).

Study group	All participants (N = 76)	PSU (n = 21)	MSU (n = 55)	Significance
Study variables
Emotional distress (GHQ-12) In past 30 days
Mean	18.98	21.0	18.21	t₍₇₄₎ = −1.89
(SD)	(5.82)	(6.44)	(5.44)
Range	0–36	0–36	0–36
Stressful life events In last 12 months
Mean	4.35	5.81	3.8	t₍₇₄₎ = −2.44*
(SD)	(2.83)	(3.47)	(2.35)
Range	0–14	0–14	0–14
Multiple treatment agencies In last 12 months
Mean	2.92	4.33	2.38	t₍₇₄₎ = −3.74***
(SD)	(2.20)	(2.28)	(1.92)
Range	0–14	0–14	0–14

Note: *p < .05 **p < .01 ***p < .001.

Table 3.

Comparison of multiple treatment agencies in the last 12 months between PSU and MSU asylum seekers receiving treatment at the Open Clinic (N = 76).

	All participants (N = 76) (%)	PSU (n = 21) (%)	MSU (n = 55) (%)	Significance
Hospital emergency room	51.3	47.6	52.7	NS
Hospitalized for any physical symptom, illness or problem	35.5	19	41.8	NS
Family doctor or GP (General Practitioner)	30.3	47.6	23.6	NS
Psychiatrist	29.3	100	1.9	χ²₍₁₎ = 70.26, p < .00
Medical specialist	27	28.6	26.4	NS
Voluntary agency for any health problem	26.7	28.6	25.9	NS
Helpers or healers from a religious group for any health problem	18.7	19	18.5	NS
Social worker	17.1	33.3	10.9	χ²₍₁₎ = 5.39, p < .05
Helpers or healers from within the community for any health problem	14.9	5	18.5	NS.
Psychologist or psychotherapist	13.2	33.3	5.5	χ²₍₁₎ = 10.33, p < .01
Hospitalized for problems with emotions, nerves, mental health or with use of alcohol or drugs (in lifetime)	13.2	47.6	0	χ²₍₁₎ = 30.16, p < .001
Traditional or alternative medicine on your own at home	8	5	9.1	NS
Other professional for a problem with nerves, worries, emotions, stress or mental illness	5.3	10	3.6	NS
Traditional or alternative medicine practitioner	4	10	1.8	NS

Note: *p < .05 **p < .01 ***p < .001.

Table 4.

Comparison of stressful life events in the last 12 months between PSU and MSU asylum seekers receiving treatment at the Open Clinic (N = 76).

	All participants (N = 76) (%)	PSU(n = 21) (%)	MSU (n = 55) (%)	Significance
Had troubles because you did not have enough money	69.3	70	69.1	NS
Had illness or death in your family	40.8	66.7	30.9	χ²₍₁₎ = 8.04**
Had troubles at work or school	46.6	57.9	42.6	NS
Had troubles because of people not understanding your language	52.6	57.1	50.9	NS
Had problems with government agencies	24.0	47.6	14.8	χ²₍₁₎ = 8.92**
Had troubles because of the neighborhood you live in	28.4	42.9	22.6	NS
Had troubles with housing	49.3	42.9	51.9	NS
Had arguments or fights with friends	22.7	40	16.4	χ²₍₁₎ = 4.67*
Been the victim of a crime or assault	20.8	40	13.5	χ²₍₁₎ = 6.16*
Had troubles with prejudice or discrimination	28.0	38.1	24.1	NS
Had troubles with your spouse or other adults in your family	25.0	35	21.2	NS
Had troubles with the police or the law	14.5	23.8	10.9	NS
Had violence in your family	14.5	23.8	10.9	NS
Had problems with your children	14.3	18.2	12.5	NS

Note: *p < .05 **p < .01 ***p < .001.

PSU had also experienced more stressful life events than MSU over the past year (M = 5.81, SD = 3.47, M = 3.8, SD = 2.35, respectively, t ₍₇₄₎ = –2.44, p < .05). Specifically, they had experienced more arguments or fights with friends (χ²₍₁₎ = 4.67, p < .05), illness or death in the family (χ²₍₁₎ = 8.04, p < 0.01), problems with government agencies (χ²₍₁₎ = 8.92, p < .01), and more often reported having been a victim of a crime or assault (χ²₍₁₎ = 6.16, p < .05) (Table 4). No group difference in the level of emotional distress was observed (Table 2). Significant positive correlations were found, for the whole sample, between stressful life events and emotional distress (r = 0.39, p < .01), and between stressful life events and multiple treatment agencies (r = 0.48, p < .01).

To examine the impact of emotional distress, stressful life events and multiple treatment agencies on the probability of seeking psychiatric versus medical treatment, we conducted a logistic regression (Table 5). For both PSU and MSU, the regression model was statistically significant (χ²₍₃₎16.18, p = .001). The model explained 27.7% (NagelkerkeR²) of the variance in treatment modality (psychiatric vs. medical). It was found that having sought help from multiple treatment agencies increased the probability of seeking psychiatric treatment by 155% (p < .05). This means that the odds of asylum seekers who sought multiple treatment agencies in the past year (that is, made use of more medical and non-medical services) seeking psychiatric treatment were 1.55 times higher than for those who sought treatment from fewer multiple agencies. However, emotional distress and the number of stressful life events during the past year did not affect the chances of seeking psychiatric treatment.

Table 5.

Logistic regression results: predictors of psychiatric care by emotional distress, stressful life events and multiple treatment agencies in asylum seekers receiving treatment at the Open Clinic (standardized coefficients, N = 76).

Regression measures
Factors	Beta	SE	Odds Ratio
Emotional distress (GHQ-12)	0.07	0.05	1.07
Stressful life events	0.08	0.12	1.08
Multiple treatment agencies	0.44*	0.17	1.55

Note: *p < .05 **p < .01 ***p < .001.

Discussion

This study compared the mental health status of asylum seekers who received medical care with those who received psychiatric treatment at the PHR Open Clinic in Israel. A tendency for asylum seekers to be under-diagnosed and under-treated for mental health problems was observed. PSU were older then MSU on the average, had been in Israel for longer, were less religious and had visited the clinic more times, possibly because they tended to have physical problems that had to be resolved first. Participants in our study, regardless of group status, reported suffering from high levels of emotional distress. The lack of difference in the levels of emotional distress between PSU and MSU might be explained by extreme levels of emotional distress (ceiling effect), with low variance within and between groups. These levels are much higher than levels of emotional distress in the Jewish and Arab Israeli populations (3–3.5 points on a scale of 0–12 vs. 18.21–21 on a scale of 0–36 in our study) (Ponizovsky et al., 2007) and than immigrants in various European countries seeking outpatient care (5.9 points on a scale of 0–12 vs. 18.21–21 on a scale of 0–36 in our study) (Tarricone et al., 2009).

Nonetheless, our findings support the assumption that emotional distress and psychiatric disorders were under-diagnosed and under-treated in the asylum seekers treated at the Open Clinic. It should be stressed that high levels of emotional distress do not necessarily indicate the presence of a mental health problem. Despite their extreme distress, only 28% of our sample was treated by a mental health professional. MSU may have received some treatment for mental health issues, but such treatment was not provided by mental health professionals. Since language barriers are a major impediment to health service access for migrants (Brisset et al., 2014), the PSU group may have received psychiatric treatment more often than the MSU group because their knowledge of English enabled them to communicate more effectively with psychiatrists. Dick et al. (2015), in a cross-sectional study that examined the emotional distress of service users in the Open Clinic and its detection by GPs, found that while over one-half of 97 asylum seekers experienced emotional distress and psychopathology, this was identified in only 8% of cases by GPs. Whereas Dick et al. (2015) examined emotional distress and psychopathology in a convenience sample seeking general medical advice, the participants in the current study were seeking medical or psychiatric treatment. Some had been referred to psychiatric treatment by a GP working in the Open Clinic and others were referred via other NGO sources. This no doubt explains the higher percentage of asylum seekers who received psychiatric treatment (28%, n = 21).

These results replicate findings from other studies (Bhui et al., 2003; Kirmayer et al., 2007), showing, for example, that Ethiopian immigrants in Israel, who have universal access to health services, tended to be under-diagnosed by their GPs. Only 7% of the Ethiopian patients treated in primary care clinics or specialist (non-psychiatric) outpatient clinics were diagnosed appropriately by their doctors (Youngmann, Zilber, Workneh, & Giel, 2008).

Predictors of the high levels of emotional distress characteristic of all subjects were found to be both exposure to traumatic events on the way to Israel (Nakash et al., 2015b; van Reisen et al., 2012); and more recent adverse social and environmental factors, such as the double stigma of being both immigrants in a new society and dark-skinned non-Jews (Anteby-Yemini, 2015), impoverished conditions and extreme feelings of persecution and isolation (Duman, 2014). The pressure and stress to which refugees and asylum seekers are exposed in their host countries have been found to complicate or delay recovery (Porter & Haslam, 2005). The long duration of the asylum procedure for most asylum seekers in Israel has been identified as an additional significant risk factor for emotional distress and psychiatric problems (Laban, Gernaat, Komproe, Schreuders, & De Jong, 2004).

In addition, we found that PSU had experienced more stressful life events during the past year than MSU, specifically, more arguments or fights with friends, incidents of illness or death in the family, and had encountered problems with government agencies. PSU also reported more frequently than MSU having been victims of crime or assault. Although all asylum seekers had experienced multiple stressful life events during the last year, those whose emotional distress was related to significant others (close friends or first-degree family members) and/or problems with government agencies, tended more often to seek psychiatric services than other immigrants. These findings are consistent with a study conducted with Iraqi asylum seekers in the Netherlands, that found that stress related to family issues, unemployment and asylum procedure best predicted psychopathology (Laban, Gernaat, Komproe, vand der Tweel, & De Jong, 2005).

During the previous year, more than 50% of the participants had sought treatment from more than one medical service agency (for example, emergency rooms, GPs or medical specialists). However, PSU and MSU had sought help from traditional healers and religious leaders with similar frequency. These agencies offer psychological support, a sense of belonging to the homeland community and a religious framework, important to most asylum seekers (Sabar, 2015). PSU had sought help from more treatment agencies, especially social workers and psychologists from various NGOs, than MSUs. It seems reasonable to assume that the social workers and psychologists who treated them often detected emotional problems that required a referral to psychiatric care in the Open Clinic. Asylum seekers who had sought help from multiple treatment agencies were 1.55 times more likely to seek psychiatric treatment than those who sought help from fewer agencies. Referral to psychiatric care may therefore be a last resort, after other health services have failed to bring relief.

The finding that PSU had sought help more frequently than MSU is supported by previous studies, including a study with Iraqi asylum seekers in the Netherlands (Laban, Gernaat, Komproe, & De Jong, 2007), and immigrants to Canada (Kirmayer et al., 2007, 2011). PSU seem to have sought more help than MSU from NGO social workers and psychologists before seeking psychiatric care or while waiting for it. This ‘shopping behavior’ is understandable if they were seeking relief from their high levels of emotional distress. Stigma, lack of trust in psychiatric services and cultural differences, including somatization as an expression of emotional distress, could be additional barriers to the timely use of psychiatric care at the Open Clinic in Israel (Ayazi, Lien, Eide Shadar, & Hauff, 2014; Franks et al., 2007; Kirmayer et al., 2007; Kirmayer & Sartourius, 2007).

A study by Laban et al. (2007) of health service use in Iraqi asylum seekers in the Netherlands found that psychopathology predicted the use of medical specialists (non-psychiatrists), but not mental health services. Kirmayer and colleagues (2007, 2011) showed that Canadian immigrants sought help from multiple caregivers before applying to mental health services, and that multiple contacts with health professionals raised the probability of their using psychiatric services. This pattern is also supported by other studies of mental health patients in non-Western countries, such as Ethiopia (Bekele, Flisher, Alem, & Baheretebeb, 2009), India (Faizan, Raveesh, Ravindra, & Sharath, 2012), Bangladesh (Giasuddin, Chowdhury, Hashimoto, Fujisawa, & Waheed, 2012) and Bali (Kurihara, Kato, Reverger, & Tirta, 2006). In Ethiopia and Eritrea, for instance, it is customary for families to treat and support mentally ill family members at home (Alem, Jacobsson, Araya, Kebede, & Kullgren, 1999; Araya & Aboud, 1993). Before seeking psychiatric consultation, people in non-Western countries, suffering from mental health problems generally turned to medical services or alternative medicine practitioners. Moreover, in such non-Western countries, psychiatric problems are conceptualized and treated differently than in Western countries (Ayazi et al., 2014; Araya & Aboud, 1993; Grisaru, Budowski & Witztum, 1997; Hodes, 1997; Kirmayer & Sartorius, 2007; Uzoma & Ohaeri, 1989). Modern psychiatric services tend to be scant, inaccessible and very expensive, leading most people suffering from mental health problems to prefer seeking help from priests, sheikhs, witchdoctors or traditional healers (Bekele et al., 2009; Ghebrat et al., 2008; Giel, Gezahegn & van Luijk, 1968; Singh & Singh, 2014; WHO, 2006). People given psychiatric diagnoses in Eritrea, Sudan and West African countries usually apply to mental health services only when traditional treatment does not provide relief (Alem et al., 1999; Singh & Singh, 2014; WHO, 2006).

The present study has a number of limitations. First, the findings are based on a clinical sample of people who sought medical or psychiatric services. Therefore, the external validity of our results is limited. Second, the PSU group was relatively small (n = 21) and all variables may not have been normally distributed. Third, there is a possible sampling bias (low percentage of responses), since asylum seekers may have been worried about their migration status and fearful of authority, limiting their willingness to participate in research (De Jong, Komproe & Van Ommeren, 2003).

In addition, it should be noted that the GHQ-12 assesses symptomatology not psychiatric diagnoses. We therefore do not know the psychiatric diagnoses of the participants. A DSM-related tool may have detected more psychiatric problems/disorders in the PSU, and identified specific psychiatric problems in the MSU. Finally, although the study questionnaires were translated using the translation-back-translation method by three independent persons, no pilot study was conducted using the translated questionnaires, so that cultural differences in understanding and answering some of the questions may have influenced the findings.

Conclusion

The findings of this study add to the accumulating evidence of high levels of emotional distress among asylum seekers seeking medical care. PSU experienced more stressful life events than MSU. Both groups of patients sought help and comfort from multiple treatment agencies, including religious leaders and traditional healers, but PSU sought help from more treatment agencies, especially social workers and psychologists. Our findings support the assumption that emotional distress is under-detected among asylum seekers treated at the Open Clinic. This means that most of these patients did not receive the psychiatric treatment they may have needed. This lack of diagnostic capacity could be remedied by screening for emotional distress at the assessment of those seeking medical help in the Open Clinic and elsewhere. Collaboration with past or present social workers, hospitals and psychologists could also improve the mental health care of these patients, while collaboration with community and religious leaders could promote mental health literacy and expedite access to care.

Footnotes

Acknowledgements

We are grateful to the anonymous asylum seekers who trusted us and let us have a glance into their lives. We deeply acknowledge the aid of Dr Rachel Bachner-Melman, Dr Lilac Lev Ari and Professor Ada Zohar for their wise advice and support.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Biographies

Naama Kiat, MA, is completing her internship in clinical psychology at the Adult Outpatient Clinic, Ramat Hen Mental Health Center, Clalit Health Service Fund. She also has a private practice in Nathania, Israel, where she treats children, youth and adults from all walks of life.

Rafael Youngmann, PhD, is a clinical psychologist and senior lecturer at the Ruppin Academic Center, Emek Hefer, Israel. He lectures in the Department of Behavioral Sciences and on the MA Clinical Psychology Program, of which he is head. He is a member of the Israel Association of Analytical Psychology (IAAP) and an IAAP Training Analyst. For the past 30 years, Dr Youngmann has been intensely involved in research and consultation on culture and mental health issues in immigrant populations, especially Ethiopian immigrants, refugees and asylum seekers in Israel. His publications focus on idioms of distress, mental health services research, suicidal behavior and patterns of success in immigrants.

Ido Lurie, MD MPH, is a psychiatrist and a psychotherapist, the director of Kfar Saba Adult Clinic, Shalvata mental health center, Clalit Health Service Fund. He is also the director of Gesher (Hebrew-Bridge) Clinic, Ministry of Health, a clinic for asylum seekers and victims of trafficking. Dr Lurie is an adjunct lecturer at the School of Public Health, Sackler School of Medicine, Tel Aviv University (TAU), Israel, and a clinical instructor at the psychiatry department, TAU. His main areas of research are immigration, culture, trauma, human rights and socio-economic inequality.

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