A comparison of the mental health of refugees with temporary versus permanent protection visas

In recent years, Western countries have introduced stringent measures to restrict the inflow of asylum seekers.1 From 1992 to 2005, Australia implemented a policy of mandatory detention of all asylum seekers who arrived by boat or without valid travel documents. Mental health professionals have raised concerns that prolonged detention can re-traumatise people fleeing persecution and abuse,1 issues that have been reiterated by successive Commissions of Inquiry,2-4 and by clinicians involved with detainees’ welfare.5-7 Until recently, proponents of the detention policy argued variously that detainees were not mentally ill, that any existing mental illness was related to pre-existing problems, and/or that the psychological care provided in detention centres was adequate.3,8 Calls by bodies such as the Australian Medical Association for independent research into detainees’ mental health have gone unheeded.9

The few studies conducted of detainees’ mental health have revealed elevated levels of psychiatric disturbance,10 with length of confinement appearing to be associated with a progressive deterioration in mental state.6,11,12 A study of detained asylum seekers in the United States suggested that release from detention with secure residency improved mental health status, at least in the short term.13 The security and certainty associated with obtaining a permanent visa may be pivotal in gradually reducing refugee-related symptoms of anxiety, depression and post-traumatic stress.14

About 90% of detained asylum seekers in Australia have been recognised as refugees after rigorous assessments based on the United Nations Convention on Refugees. However, since 1999, on release from detention, these refugees have been given temporary protection visas (TPVs), not permanent protection visas (PPVs) with the full entitlements of Australian citizens (Box 1).

The uncertainty and lack of access to assistance which accompanies temporary protection status may compound the effects of prolonged detention. Hence, despite having the same ethnic background, people who hold TPVs may differ substantially from those with PPVs in terms of their mental health and their prospects for a secure resettlement trajectory.

Since 1993, Australia has hosted about 20 000 settler-arrivals from Iran and Afghanistan.15 These countries have been affected by political instability and conflict for over 20 years, with widespread human rights abuses occurring. Large numbers of citizens have fled. Iran and Afghanistan share strong historical and cultural links, both speaking Persian dialects.

We compared the mental health of holders of PPVs and TPVs from Persian-speaking backgrounds, and assessed the predictors of psychiatric status in these two groups.

Box 2 presents the demographic data for the study sample. The refugees with PPVs and TPVs had lived in the Australian community for a short time (a mean of about 3 months), but TPV holders had previously been held in immigration detention for an average of 12 months. Males predominated among TPV holders, typical of the TPV population in Australia. A substantially larger number of male TPV holders were geographically separated from their spouse.

Our study provides consistent evidence that the migration trajectory experienced by TPV holders, particularly adversity in detention and ongoing living difficulties, is accompanied by persisting and wide-ranging mental health problems and associated disability.

Our data and those from a parallel investigation22 represent the first systematic documentation of the mental health of refugees in Australia who have experienced detention followed by temporary protection. Assessing the impact of these experiences is important, as they are central to the strategies adopted by Australia, and, increasingly, other Western countries, for deterring the inflow of asylum seekers.

TPV holders exceeded PPV holders on all measures of psychiatric disturbance and mental disability. Consistent with the body of refugee literature, regression analyses showed that trauma was a predictor of all mental health indices. Nevertheless, TPV status made a substantial additional contribution, being by far the greatest predictor of PTSD symptoms, accounting for 68% of the variance. Adverse prior detention experiences and current living difficulties each made substantial and independent contributions to PTSD symptoms. Current living difficulties were also associated with general distress, anxiety and depressive symptoms.

Investigations in detention centres in Australia6,10-12 and abroad13,26 have indicated that confinement under harsh conditions is associated with deterioration in the mental state of detainees. Studies among asylum seekers living in the community,20,21,27,28 have also shown the compounding effects of past trauma, postmigration living difficulties and insecurity about the future.

The limitations of our study include potential transcultural measurement error and sampling biases. Measures were specifically chosen because of their past psychometric performance when applied across cultures and we applied standard translation–back translation methods. A native Persian-speaker (S M) with considerable experience in transcultural research undertook all interviews. She clarified the meaning of items with participants wherever necessary. Although the Early Intervention Program provided access to about half of the off-shore humanitarian arrivals (PPV holders) and most of the TPV holders in NSW during the study period, the coverage of PPV holders varied substantially by subcategory, with non-sponsored refugees (the largest group) being well represented (83%), but sponsored PPV holders less well represented (15%). If this sampling bias had any effect, it would be to reduce differences between TPV holders and the PPV group, as the under-represented group is well supported on arrival by existing family and social networks, a fact that is likely to mitigate mental distress.29

TPV holders with insecure residency may be more likely to be plaintive in their attitudes and hence exaggerate their problems. However, the TPV group had been recognised as refugees and had only recently been released from detention, so there was no immediate personal benefit to them to obtain further documentation or publicity relating to their cases. They were fully aware that their residency status would only be considered some years later, and that refugee determinations would be based solely on whether they were deemed at risk of future persecution in their home countries, and not on the subject of inquiry in our study. Furthermore, there were no differences between PPV and TPV holders in reporting past trauma exposure and the overall levels of abuses reported are not excessive compared with other refugee groups studied in Australia20,21 or worldwide.30-33

Since our research was completed, Australia has revised its immigration policies, substantially limiting mandatory detention and allowing for external review of the grounds for detention after 2 years. TPV holders have been allowed to apply for permanent residency under alternative immigration streams. Several factors undoubtedly shaped these changes, but concerns about the mental health of detainees proved to be a decisive feature of the debate. Hence, health professions must continue to monitor the interplay of policy and mental health outcomes in this and other vulnerable groups.