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Original Investigation
August 14, 2019

Risk of Psychosis Among Refugees: A Systematic Review and Meta-analysis

Author Affiliations
  • 1Department of Psychiatry and Psychotherapy, Campus Charité Mitte, Charité–Universitätsmedizin Berlin, Berlin, Germany
  • 2Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
  • 3Institute of Health Economics and Clinical Epidemiology, University Hospital of Cologne, Cologne, Germany
  • 4Berlin School of Mind and Brain, Berlin, Germany
  • 5Bernstein Center of Computational Neuroscience, Berlin, Germany
JAMA Psychiatry. 2019;76(11):1133-1140. doi:10.1001/jamapsychiatry.2019.1937
Key Points

Question  Is the incidence of nonaffective psychosis higher among refugees compared with the native population and nonrefugee migrants in a host country?

Findings  In this systematic review and meta-analysis of 9 studies, refugees were at a higher relative risk of developing nonaffective psychoses compared with the native population and nonrefugee migrants. In studies with a low risk of bias, the relative risk increased statistically significantly to 1.39 for refugees compared with nonrefugee migrants and to 2.41 for refugees compared with the native population; available evidence was limited to Western host countries only.

Meaning  Refugee experience may represent an independent risk factor in nonaffective psychosis in migrants, which suggests a need for psychiatric prevention strategies and outreach programs for this group.


Importance  This systematic review and meta-analysis is, to date, the first and most comprehensive to focus on the incidence of nonaffective psychoses among refugees.

Objective  To assess the relative risk (RR) of incidence of nonaffective psychosis in refugees compared with the RR in the native population and nonrefugee migrants.

Data Sources  PubMed, PsycINFO, and Embase databases were searched for studies from January 1, 1977, to March 8, 2018, with no language restrictions (PROSPERO registration No. CRD42018106740).

Study Selection  Studies conducted in Denmark, Sweden, Norway, and Canada were selected by multiple independent reviewers. Inclusion criteria were (1) observation of refugee history in participants, (2) assessment of effect size and spread, (3) adjustment for sex, (4) definition of nonaffective psychosis according to standardized operationalized criteria, and (5) comparators were either nonrefugee migrants or the native population. Studies observing ethnic background only, with no explicit definition of refugee status, were excluded.

Data Extraction and Synthesis  The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) and the Meta-analysis of Observational Studies in Epidemiology (MOOSE) guidelines were followed for extracting data and assessing data quality and validity as well as risk of bias of included studies. A random-effects model was created to pool the effect sizes of included studies.

Main Outcomes and Measures  The primary outcome, formulated before data collection, was the pooled RR in refugees compared with the nonrefugee population.

Results  Of the 4358 screened articles, 9 studies (0.2%) involving 540 000 refugees in Denmark, Sweden, Norway, and Canada were included in the analyses. The RR for nonaffective psychoses in refugees was 1.43 (95% CI, 1.00-2.05; I2 = 96.3%) compared with nonrefugee migrants. Analyses that were restricted to studies with low risk of bias had an RR of 1.39 (95% CI, 1.23-1.58; I2 = 0.0%) for refugees compared with nonrefugee migrants, 2.41 (95% CI, 1.51-3.85; I2 = 96.3%) for refugees compared with the native population, and 1.92 (95% CI, 1.02-3.62; I2 = 97.0%) for nonrefugee migrants compared with the native group. Exclusion of studies that defined refugee status not individually but only by country of origin resulted in an RR of 2.24 (95% CI, 1.12-4.49; I2 = 96.8%) for refugees compared with nonrefugee migrants and an RR of 3.26 (95% CI, 1.87-5.70; I2 = 97.6%) for refugees compared with the native group. In general, the RR of nonaffective psychosis was increased in refugees and nonrefugee migrants compared with the native population.

Conclusions and Relevance  Refugee experience appeared to be an independent risk factor in developing nonaffective psychosis among refugees in Denmark, Sweden, Norway, and Canada. These findings suggest that applying the conclusions to non-Scandinavian countries should include a consideration of the characteristics of the native society and its specific interaction with the refugee population.

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