As psychiatrists, we assess, diagnose, and manage psychiatric problems in older adults. We also have an important role as their advocates and in promoting positive attitudes toward this group. Only in the 1950s was there increasing recognition that older age did not necessarily equate to senility, that treatment of psychiatric disorders in this group was possible, and could have good outcomes (Roth, Reference Roth1955). There is, however, still an undercurrent of pervasive negative attitudes toward the elderly, and their psychiatric needs continue to be marginalized, with less attention from the media, funding bodies, and even from our medical and surgical colleagues (Penson et al., Reference Penson, Daniels and Lynch2004).
Our knowledge of older asylum seekers is an illustration of this situation. The majority of the literature and media coverage focuses on adults and children with little to no consideration of issues relating to the elderly asylum seeker. Even allowing for the smaller number of older asylum seekers—in Australia, 394 people older than 60 years (1.5%) lodged a protection claim in 2012–2013 (compared to 16%, which is the number of claims lodged by people under 18 years) (Department of Immigration and Border Protection, 2013)—there is a dearth of studies investigating their mental health.
An asylum seeker is defined as any person who has fled their own country and is seeking international protection as a refugee, whose claim has not yet been determined. Under the United Nations Refugee Convention (1951) and its Protocol (1967), a person is owed protection, and recognized as a refugee, if they are outside their country (in contrast to an internally displaced person) and are unable or unwilling to return due to a well-founded fear that they will be persecuted because of their race, religion, nationality, political opinion, or membership of a particular social group. As of April 2011, 147 member states of the United Nations are signatories to either the convention or protocol. They are obligated to allow people fleeing persecution to seek asylum, and have their refugee claims processed.
The vexing issue of asylum seekers and refugees has been a longstanding social and political issue thrown into sharp relief by recent developments in North Africa and Syria. Ongoing war, conflict, and religious persecution in Syria, the Congo, South Sudan, Central African Republic and Mali, have forced more than 1.5 million individuals to leave their country recently and seek asylum elsewhere. In addition, at least 456,000 people applied for asylum in over 170 countries in the first half of 2013 (United Nations High Commissioner for Refugees, 2013b).
Although countries may be signatories to the convention and protocol, each country has their own interpretation of their obligations, which often depends on the country's immigration and political system. As can be seen in Tables 1 and 2, a disproportionate burden of caring for asylum seekers falls on the world's poorest countries, while the leading industrialized asylum resettlement nations, the United States, Germany, France, Sweden, and the United Kingdom, only accepted 190,700 new applications in 2012 (United Nations High Commissioner for Refugees, 2012). In contrast, this year saw Lebanon accept its 1 millionth refugee from Syria, and this is anticipated to reach 1.5 million by year's end (United Nations High Commissioner for Refugees, 2013a).
Table 1. Top 10 major refugee-hosting countries, end of 2012 (adapted from UNHCR Global Trends 2012)
Table 2. Top 10 rankings of countries who accept number of refugees per 1,000 inhabitants, 2012 (adapted from UNHCR Global Trends 2012)
While there are established reports of high rates of mental illness, such as posttraumatic stress disorder (PTSD), depressive and anxiety disorders, and other psychiatric symptomatology in adult asylum seekers compared to the general community (Burnett and Peel, Reference Burnett and Peel2001), we have little information about older asylum seekers in terms of epidemiology and prevalence of mental illness. Moreover, we know relatively little about the mental health consequences for asylum seekers as they age. One follow up study of 483 Cambodian refugees settled in the United States (with a mean follow up age of 52 years) found there were still high rates of PTSD (62%) and major depression (51%) in this group after two decades. Bivariate analyses demonstrated that older age, being retired or disabled and being under employed were also associated with higher rates of these mental disorders (Marshall et al., Reference Marshall, Schell, Elliott, Berthold and Chun2005).
A combination of: premigration trauma, such as religious persecution, racial discrimination, war, and other conflict; migration trauma, such as hazardous boat trips and experiences in refugee camps; and postmigration living difficulties, including the protracted process of refugee status determination, detention, lack of language skills, and poor access to services, all contribute to psychiatric symptoms experienced by asylum seekers. Being held in immigration detention centres (IDCs), potentially exposes asylum seekers to poor living conditions, the deprivation of liberty, mistreatment by officers, and being involved or witnessing other traumas such as riots, hunger strikes, and self-harm, which can contribute to adverse mental health consequences (Silove et al., Reference Silove, Steel and Mollica2001; Steel and Silove, Reference Steel and Silove2001; Sultan and O’sullivan, Reference Sultan and O'sullivan2001; Mares et al., Reference Mares, Newman, Dudley and Gale2002; Steel et al., Reference Steel, Momartin, Bateman, Hafshejani and Silove2004). In some countries, processing of visa applications occurs offshore, where centres may be less appropriate for housing large numbers of people, including those of an older age. Lack of nutritious food and physical activity may lead to exacerbation of physical problems. There may also be insufficient access to medical care for ongoing management of chronic medical problems such as diabetes and hypertension, but also disorders related to overcrowding and poor hygiene such as infections, and tropical diseases including dengue fever and malaria (Sultan and O’sullivan, Reference Sultan and O'sullivan2001; Phillips, Reference Phillips2010; Green and Eagar, Reference Green and Eagar2010).
There is less documented about the mental health of asylum seekers living in the community, but postmigration stressors such as discrimination, lack of access to health services and housing, financial stressors, lack of employment/work rights, social isolation, and concern for family left behind may also contribute to the persistence of poor mental health in this group (Lindencrona et al., Reference Lindencrona, Ekblad and Hauff2008). A prolonged or problematic refugee determination process (RDP) may be a significant postmigration stressor with studies demonstrating lower levels of depression and PTSD, and improved quality of life, in asylum seekers whose claims have been processed more rapidly (Ryan et al., Reference Ryan, Benson and Dooley2008; Steel et al., Reference Steel, Silove, Bird, Mcgorry and Mohan1999).
Asylum seeker status may limit access to important services relevant to older age, such as obtaining financial assistance (ie. the age pension), free healthcare, and appropriate accommodation, including entry in to residential care. They may not be able to access general practitioners and specialist services easily, or obtain aides such as glasses, dentures, walking frames, and hearing devices (Norredam et al., Reference Norredam, Mygind and Krasnik2006; Spike et al., Reference Spike, Smith and Harris2011). In addition, although many older people do not work, asylum seekers of older age who might choose employment or voluntary work, may be not permitted to do so.
There are other critical issues which are relevant to older age. From our clinical experience and research in victims of abuse, aging war veterans and Holocaust survivors, we have some notion of how aging can uniquely impact on the mental health of older people. Advancing age may represent a differential vulnerability factor which moderates the impact of exposure to a stressor (Averill and Beck, Reference Averill and Beck2000), and it has been suggested that older adults are more vulnerable to stressors, as they may have less coping skills, physical and cognitive deterioration, and less social and financial support. The effects of trauma in older people may also be different to those experienced by younger people. Preoccupation with the trauma, avoidance, sleep disturbance, intrusive thoughts, and crying may be more frequent, compared to younger and middle aged adults (Hagstrom, Reference Hagstrom1995).
Cognitive impairment and dementia can worsen PTSD symptoms, because the mechanisms and strategies which keep traumatic memories under control may weaken, resulting in a reactivation of these memories. Flashbacks may also recur. These may result in associated depressive and anxiety symptoms (Grossman et al., Reference Grossman, Levin, Katzen and Lechner2004).
Furthermore, cultural norms of help-seeking behaviour and different expressions of symptoms (Bhugra and Becker, Reference Bhugra and Becker2005), poor mental health literacy, stoicism, and lack of knowledge of where to obtain appropriate treatment (Gilgen et al., Reference Gilgen2005), all could contribute to potentially adverse mental health outcomes in older asylum seekers.
Nonetheless, past research suggests that older people may cope better owing to “psychological immunization” by earlier life events (Henderson, Reference Henderson1994). They can be remarkably resilient and may manage stress comparatively well, as their life experience can help them adjust with difficulties and negative events in later life (Bell, Reference Bell1978). Being more positive and accepting of oneself, displaying optimism, and having strong social networks have all been found to contribute to “successful ageing” (Anstey and Luszcz, Reference Anstey and Luszcz2002). Resilience may involve both individual factors such as positive temperament, beliefs in internal control, self-efficacy, and social resources such as family cohesion and supportive communities (Ayalon, Reference Ayalon2005)
With changing immigration policies, and the real potential for asylum seekers to remain in detention, or in the community, for prolonged periods of time, there may be a growing number of older asylum seekers in many countries. We need to consider the mental health ramifications of this situation, as there is a lack of definitive research in this area. Improved access to basic needs, such as housing, nutrition, financial assistance, and healthcare, could assist in alleviating the adverse effects. This area needs to be explored, in order to get a better understanding of these issues, to inform recommendations and interventions. This will allow us to advocate better for this marginalized group of people, and influence social and public policy for positive change.
We must not forget the example of Dr Sigmund Freud. We know him as the father of psychoanalysis, a giant in 20th century thought, and a family man. He was also an older asylum seeker. He was 82 years old when forced to flee Vienna with his family, when Austria was annexed by the Nazis in 1938. Due to his Jewish religion and being the founder of psychoanalysis, Dr Freud had been subject to interrogation and threats by the Gestapo, and had many of his books burnt and substantial sums of money extorted. Because of his renown and personal connections, he was fortunate enough to be able to secure a safe passage to London, but left behind four sisters who died in concentration camps. Even though his journey to London was relatively smooth, he had family and other supports, he was able to communicate in English, and he managed to continue to work, we know from his writings that despite these advantages, Dr Freud had health problems and ongoing challenges with adjusting to life in his new home. Being forced to flee one's country of origin can happen to anyone, at any age, and at anytime. Most asylum seekers do not have such connections, are more impoverished and potentially are at much higher risk of adverse outcomes.
Conflict of interest
None
