Assessing Mental Health Needs and Disparities Among Syrian Refugees Resettled in Michigan  

Introduction

Since March 2011, the Syrian conflict has given rise to the largest humanitarian crisis in the modern era, with the crisis progressively intensifying due to inadequate services, resources, and assistance. This conflict has led to more than 14 million displaced individuals within Syria, and refugees dispersed globally (UNHCR, 2023). Syrian refugees sought refuge in more than 130 countries around the world, with the majority living in neighboring countries such as Jordan, Iraq, Turkey, and Lebanon (UNHCR, 2023). As the conflict unfolded, the escalating number of individuals impacted by it surpassed the capacity of neighboring countries and the international community to respond to their growing needs, creating a disparity between demand and available support (International Medical Corps, 2023, United Nations Office for Coordination of Humanitarian Affairs, 2023).

Over the last decade, researchers have investigated and documented short-term and long-term psychological and mental health impacts experienced by refugees and displaced individuals (Bogic et al., 2015; Hollifield et al., 2009; Steel et al., 2009). It is now established that the physical and psychological stressors refugees encounter in their country of origin, during the transition to host countries and throughout resettlement periods, place them at a heightened risk for emotional distress, mental disorders, and various adverse health outcomes (APA, 2016; Hollifield et al., 2009; Polcher & Calloway, 2016; Shawyer et al., 2017; Steel et al., 2009). Literature on refugees’ mental health shows a high prevalence of multiple conditions, including depression, generalized anxiety, post-traumatic stress disorders, somatization, and substance abuse (Bogic et al., 2015; Hollifield et al., 2009; Sangalang et al., 2019; Taylor et al., 2014; Silove et al., 2017 Steel et al., 2009).

While many refugees show high resilience and ability to cope with severe stressors, some need supportive psychosocial services to navigate challenges and develop a healthy lifestyle (UNHCR, 2023). To promote mental health for refugees, the United Nations High Commisioner for Refugees (UNHCR) proposed integrating mental health services into medical services (UNHCR, 2023). However, studies consistently show refugees underutilize mental health services (Roberts et al., 2011 Sue et al., 2019; Weissbecker & Leichner, 2015).

Mental Health Services in the US

In the United States, various mental health services are available to support refugee populations, including community health clinics and specialized programs designed for trauma survivors. Initiatives backed by the Office of Refugee Resettlement (ORR) aim to provide targeted assistance through community-based programs to address the mental health needs of refugees. However, significant gaps remain in both accessibility and cultural competency. Despite the existence of these resources, many refugees face barriers that prevent them from fully utilizing available services. A substantial number of refugees remain unaware of the mental health resources accessible to them, largely due to inadequate outreach efforts and lack of community education on mental health topics (Magwood et al., 2022). Research indicates that increasing awareness is crucial to improving service utilization. Language barriers often complicate communication between refugees and providers, which can diminish the effectiveness of care. Furthermore, there is a noticeable shortage of providers trained in cultural competency; many refugees report feeling misunderstood or alienated when their unique cultural backgrounds and lived experiences are not recognized in treatment. This disconnect can foster distrust and lead to premature disengagement from mental health care (Wong et al., 2016). Additionally, research highlights systemic issues within the US refugee resettlement framework that contribute to these challenges. Behavioral health assessments during domestic medical screenings are inconsistent (Afkhami & Gorentz, 2019).

The 2012 ORR Revised Medical Screening Protocol aims to address refugees’ health needs by identifying acute and communicable illnesses while connecting them to ongoing care (CDC, 2014). Though it recommends behavioral health assessments, including screenings for depression and PTSD, these assessments are not mandatory, leading to inconsistent implementation (Afkhami & Gorentz, 2019). Moreover, funding for refugee-specific mental health initiatives remains insufficient, and many programs lack culturally and linguistically appropriate services. Stigma surrounding mental health care within refugee communities further exacerbates these challenges, often hindering refugees from seeking the assistance they need, even when they express a desire for psychological support (Wong et al., 2016). Without targeted interventions, such as increasing funding, training bilingual and bicultural providers, and implementing culturally sensitive approaches to care, the mental health challenges faced by refugee populations are likely to persist, leaving critical needs unaddressed. As such, it is imperative to address these gaps in care to ensure refugees receive the comprehensive mental health support they require for successful resettlement and long-term well-being (Magwood et al., 2022).

There is limited data regarding the mental well-being of recently arrived Syrians in the United States. Most studies on Syrian refugees’ health status have been conducted in other resettlement countries (Armstrong-Mensah et al., 2023).). This scarcity can be attributed to the relatively low number of Syrian refugees who have resettled in the US (less than 0.5 percent of the global Syrian refugee population), and the fact that the arrival of Syrian refugees’ only began in 2015, after going through extensive vetting processes (Javanbakht et al., 2018). Michigan ranked second to California, with more than 1,029 Syrian refugees resettled in Michigan since 2012, and the majority resettled in Southeast Michigan ( migrationpolicy.org). State officials expect 2,583 more refugees arriving to Michigan in 2024, a 42% increase from the year before. Thirty-six percent of these refugees are expected to be of Syrian descent (UNHCR, 2022).

Mental Health Needs Among Syrian Refugees in Michigan

Syrian refugees in Michigan represent a vulnerable group whose mental health is impacted by cultural stigma and service barriers, making it essential to explore their help-seeking behaviors. A study in Detroit was conducted with 157 Syrian refugee adults during mandatory health screenings in primary care offices. The results indicated that 32% of the participants showed signs of possible post-traumatic stress disorder (PTSD), 40% exhibited possible anxiety, and 48% displayed possible depression (Javanbakht et al., 2018). A similar study was performed among a convenience sample of 25 Syrian refugees in metropolitan Atlanta. The findings revealed higher rates than the Detroit metropolitan study, with 60% of the sample experiencing symptoms of anxiety, 44% reporting symptoms of depression, and 84% reporting symptoms of PTSD, with only 20% of the participants having received help from a mental health professional. The barriers reported included a lack of transportation and insufficient information (M’zah et al., 2019).

Michigan, home to one of the largest Arab American communities in the US, serves as a significant setting for examining the mental health needs of Syrian refugees. This population has endured extraordinary challenges, including the trauma of war and displacement, as well as the complexities of resettlement in a foreign cultural and linguistic environment. The stress of the Muslim travel ban, implemented shortly after the resettlement of many Syrian refugees, further exacerbated these difficulties, creating an atmosphere of uncertainty and fear about their status and future in the United States. The Syrian American Refugee Network (SARN), established by the Syrian diaspora community, has been instrumental in addressing these challenges by providing vital support and bridging critical gaps in the existing healthcare system. While SARN’s efforts have alleviated some immediate stressors associated with resettlement, they have also underscored broader systemic issues, including persistent barriers to mental health care that Syrian refugees continue to encounter. The combination of SARN’s resources and Michigan’s established Arab American community creates a unique landscape for understanding how cultural, systemic, and social factors impact mental health outcomes and service utilization among refugees.

Despite the availability of mental health services in the US, including community-based clinics and trauma-focused programs, systemic barriers—such as cultural stigma, language obstacles, and a shortage of culturally tailored services—have significantly hindered their ability to access and effectively utilize these resources. The Michigan Syrian refugee community offers an important opportunity to study the intersection of these barriers and the effectiveness of diaspora-driven support initiatives, like SARN, in addressing them. Insights gained from this research can inform the development of culturally responsive and scalable mental health interventions tailored to the unique needs of this vulnerable population.

This study aims to assess the service needs among Syrian refugees in Michigan by examining the prevalence of psychological disorder symptoms, the help-seeking behaviors (past year use and future use intention), and the factors influencing the use of mental health services. Additionally, the research investigates the relationships between experiencing mental health disorder symptoms and help-seeking behaviors. By identifying these relationships, the study offers critical insights into the challenges faced by Syrian refugees in accessing mental health care, especially in the context of additional stressors such as the Muslim travel ban, and highlights opportunities to enhance culturally appropriate interventions.

Methods

Data Analysis

Results

Discussion

The goal of screening participants for mental health symptoms following 2–5 years of resettlement is to assess the prevalence of psychological disorders and prioritize mental health services for Syrian refugees residing in Michigan. The findings indicate alarming rates of potential mental health issues, with 65% of participants screening positive for at least one disorder, such as depression, anxiety, or PTSD. These rates underscore a significant level of psychological distress within the Syrian refugee community in Michigan. Moreover, only 18% of participants reported having accessed mental health services in the past year, indicating a notable gap in service utilization. This trend is consistent with broader research showing that available programs, such as community mental health centers, are often underused due to barriers including stigma, language barriers, and a lack of awareness regarding available resources.

To address these obstacles, increased outreach efforts, a greater number of bilingual providers, and culturally sensitive service delivery methods are essential. The gap between the expressed interest in mental health services and actual service utilization echoes findings from existing literature, which suggests that despite the availability of services, refugees frequently encounter barriers that hinder access, such as stigma and lack of information.

The most reported barrier identified in this study was a lack of awareness about the mental health services available, emphasizing the need for prioritized outreach and education initiatives that could significantly enhance service utilization among Syrian refugees. This study suggests that the challenges in accessing mental health services reported by participants align with previous research on refugees (DeSa, S et al, 2022)). The predominant barriers identified were a lack of knowledge and access to information about available mental health resources.

Additionally, issues related to shame and fear of judgment from community members were highlighted, along with language barriers and a general lack of trust. It is crucial for providers and researchers to comprehend and address the barriers that influence Syrian refugees’ willingness to seek help, both before and after engaging with mental health professionals. Tackling these challenges should contribute to the establishment of programs and services that genuinely cater to the needs of this population. While mental health screenings upon arrival in the US are standard, as recommended by the Centers for Disease Control and Prevention (CDC), the lack of follow-up psychological evaluations raises concern.

Many Syrian refugees appear unaware of the mental health services available to them, suggesting follow-up assessments were likely not conducted. This absence of information may stem from insufficient emphasis on mental health resources or the challenges posed by cultural and language barriers. The study also identified social stigma as a significant barrier, a recurring theme in the literature on refugee mental health (Bartolomei et al., 2016; Sue et al., 2019; UNHCR, 2015). The fear of being labeled as mentally unstable or weak, particularly among Syrian males, often inhibits individuals from seeking help. Mental illness may carry feelings of guilt, stemming from beliefs that it signifies a lack of faith in God or an inability to accept divine will. The study’s findings illuminate a notable discrepancy between the expressed need for psychological support and the actual utilization of mental health services. This gap appears to result more from limited-service awareness than from the availability of quality services. Future research should focus on evaluating the quality and accessibility of these services to ensure they resonate with the specific needs of the refugee population.

The analysis also revealed a concerning trend of premature discontinuation of mental health services. Among those who sought professional help, many engaged in only a few sessions. This early termination may arise from perceptions of treatment being ineffective or culturally inappropriate. Discrepancies between refugees’ expectations of treatment and the therapists’ approaches may also play a role, as might the absence of bicultural and bilingual professionals skilled in understanding and connecting with the refugees’ unique experiences. Interestingly, most participants who indicated no desire for professional help exhibited low scores on measures of depression, anxiety, and PTSD symptoms. In contrast, those with high symptom scores demonstrated a greater interest in seeking professional assistance. While the correlation between these variables (p = 0.001) is significant, it aligns with the expectation that individuals experiencing mental health issues are more likely to recognize their need for support.

Despite acknowledging barriers such as stigma, this group showed a willingness to seek help in coping with their mental health challenges. Further research is necessary to bridge the gap between perceived needs for mental health services and actual service utilization. Understanding how various challenges and barriers mediate the use of mental health services can inform the development of tailored interventions designed for those most likely to benefit.

To reconcile the disparity between the availability and utilization of mental health services, future studies should assess the accessibility and effectiveness of these services for refugees in the US. Attention should also be given to evaluating the quality and cultural appropriateness of existing mental health resources, ensuring they align with the unique needs of refugee populations.

In addition, it is vital to explore treatment-related factors, such as the duration of therapy, therapeutic approaches, and the cultural competencies of therapists. Investigating how these elements influence treatment outcomes and the likelihood of early termination can yield valuable insights. Future research should also delve into holistic approaches in addressing the mental health needs of Syrian refugees, as daily stressors and needs significantly impact their well-being. Such approaches should encompass factors like employment, acculturation, language proficiency, and overall health, as these elements are intricately linked to mental health disorders.

The current study identified social stigma as an additional obstacle, a recurring theme in refugee mental health literature (Bartolomei et al., 2016; Sue et al., 2019; UNHCR, 2015). Seeking mental health services or consulting professionals, such as psychiatrists, is linked to skepticism and fear of being stigmatized as mentally unstable or weak, particularly among Syrian males. Mental illness is further connected to feelings of guilt, often rooted in the prevailing belief that it signifies a lack of faith in God and an inability to accept divine will. The findings of this study reveal a substantial disparity between the expressed interest in consulting a professional and the actual reporting of such consultations. The significant gap observed between the desire to seek assistance and the lack of utilization of services implies that the failure to access services cannot solely be attributed to a lack of interest, stigma, or shame. The findings of this study also show the premature discontinuation of mental health services. Among those who reported consulting a professional, their participation was limited to just a few sessions. This phenomenon may be attributed to the perception of treatment as ineffective, unhelpful, or not culturally suitable. An additional factor for early termination could be the disparity between the refugees’ expectations of treatment and the therapist’s approach to assessment and intervention. Other contributing factors may include the absence of bicultural, bilingual professionals equipped with the skills to establish a connection and comprehend the intricacies of the refugees’ experiences. They may lack cultural competency training to address the specific needs of this population effectively.

Most participants who expressed no interest in seeking professional help also scored low on measures of depression, anxiety, and PTSD symptoms. Participants who scored high in symptoms of anxiety, depression, and PTSD expressed a higher interest in seeing a professional. While the correlation between the two variables was significant, p = 0.001, it is not surprising, as individuals experiencing a mental disorder are more likely to express interest in mental health services. Furthermore, this correlation emphasizes that these participants had insight and awareness regarding their need for mental health care. Despite acknowledging the presence of barriers, such as fear of stigma, these individuals exhibited a willingness to seek help when coping with symptoms of mental disorders.

More research is needed to address the existing gap between perceived needs for service and the utilization of services. This nuanced understanding could facilitate the development of personalized interventions and services to enhance overall effectiveness. Examining how challenges and barriers mediate and impact the utilization of mental health services can also help tailor services for those most likely to benefit from them.

Furthermore, exploring treatment-related factors, such as the duration of treatment, theoretical approach, and the cultural competencies of therapists, is essential. Investigating how these factors influence treatment outcomes and early termination would be valuable.

Future research should also focus on the effectiveness of using holistic approaches with Syrian refugees because everyday needs and stressors, directly and indirectly, affect their mental health. Holistic approaches should address factors such as employment, acculturation, language skills, and general medical health, as they are all interlaced with mental health disorders.

Limitations of the Study

A word-of-mouth approach, a common strategy used with hard-to-reach populations, was used to recruit a convenience sample. This method poses a limitation on the generalizability of the study’s outcomes. Another limitation is using self-report instruments to screen for mental health disorders rather than relying on clinical assessments. Despite the successful application of the HSCL-25 and HTQ instruments in cross-cultural refugee populations in the US, self-report instruments can potentially inflate the prevalence of mental health disorders (Bogic et al., 2015). Self-reported assessments are susceptible to social desirability bias (Cohn et al., 2004), where participants may tend to respond in a socially acceptable manner, impacting the accuracy of the participants’ responses. In Syrian culture, psychological disorders often carry negative labels and stigma, which might affect participants’ reluctance and hesitancy to respond openly and honestly.

Conclusion

This study identified a high prevalence of mental health symptoms among Syrian refugees resettled in Michigan, coupled with a low rate of service utilization. These findings underscore the need for targeted interventions to raise awareness about available mental health resources and address barriers to accessing these services. The study identified a significant association between experiencing symptoms of mental health disorders and expressed interest in seeking mental health services. However, the low utilization of these services suggests that barriers and awareness must be addressed to bridge this gap.

Early detection and interventions are recommended to facilitate the healing process for Syrian refugees and help them develop coping skills to navigate their unique life demands and stress. Psychological support services and mental health interventions need to be holistic and comprehensive in their approach to addressing the multifactorial stressors and barriers this population deals with daily.

Future research should focus on evaluating the effectiveness of existing mental health programs for refugees in the US, particularly their accessibility and cultural relevance. Policy efforts should prioritize increasing funding for refugee-specific mental health services and training for providers to enhance cultural competency. More studies are needed on refining the definition of “mental health care needs” for refugee populations, evaluating the quality of available mental health services to ensure they align with these needs. Qualitative approaches may provide deeper insights into the barriers affecting help-seeking behaviors.

Acknowledgment

We are incredibly grateful to all the Syrian refugee participants who agreed to participate in this study. We hope the findings of this study will bring awareness and understanding to their experiences.

Funding

This research received no specific grant from any funding agency, commercial or not-for-profit sectors.

Author Contributions

All authors contributed to the study conception and design. Material preparation and data collection were performed by Loubna Alkhayat. Data analyses were performed by Olga J. Santiago. The first draft of the manuscript was written by Loubna Alkhayat and Olga J. Santiago reviewed the manuscript. All authors reviewed, read and approved the final manuscript.

Ethics Approval

This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee of Wayne State University Date: 9/29/2019/Protocol No. 1909002540.

Consent to Participate

Participants were provided with an information sheet in Arabic before starting the assessment. No personal identifying information was collected. All soft copies of de-identified anonymous data were stored in a locked computer.

Data

The data supporting the findings of this study can be available upon request from the principal investigator.

Conflicts of interest

The authors have no relevant financial or non-financial interests to disclose.