Are asylum seekers in the UK at increased risk of suicide?

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Dr Karen Wetherall (funded by Scottish Association for Mental Health, SAMH)

Asylum seekers in the UK

The UN Refugee Agency (UNHCR, 2023) reported that, in the year ending September 2023, more than 114 million people worldwide fled their homes due to conflict, persecution and human rights violations, which was an increase of 1.6 million compared to the previous year.  Over the same time, the UK Home Office reported 75,340 (relating to 93,296 people) asylum applications in the UK, which included 4,656 applications from unaccompanied asylum-seeking children. A total of 38,761 people were granted refugee status or other protection following an asylum application, which is the highest number granted in a year since 2002 (Home Office, 2023).

A range of studies have suggested that the mental health of those seeking asylum is poorer than that of the general population. Specifically, a systematic review of refugees and asylum seekers in high income countries suggests that they have higher rates of post-traumatic stress disorder (PTSD), depression, and anxiety disorders than the host populations, which indicates a potential mental health challenge to host countries (Henkelmann et al., 2020). Indeed, asylum seekers and refugees resettled in western countries could be about ten times more likely to have PTSD compared to the age-matched general population (Fazel et al., 2005). Importantly, these elevated mental health disorders are a risk factor for suicide and self-harm.

Rates of suicide, suicide attempts and suicidal ideation in asylum seekers globally

A recent systematic review aggregated the global rates for suicide, suicidal ideation and suicide attempts in displaced people, including asylum seekers (Cogo et al., 2022), with the suicide rates having a very wide range (4.0 to 51.2 per 100,000 person-years), making it hard to interpret the risk profile of this group globally. For those studies that directly compared asylum seekers with the host population in high income countries, there was evidence of a higher suicide risk in studies conducted in the Netherlands (Koppenaal et al., 2003) and Sweden (Mittendorfer-Rutz and Hollander 2020). For example, the suicide rate was 51.2 per 100,000 among unaccompanied minors/youth in Sweden, which compares to 6.1 per 100,000 in the host population (Mittendorfer-Rutz and Hollander 2020).

The evidence base for suicidal ideation and attempts in asylum seekers is more sparse, most studies investigate refugees that have been granted asylum who often report a lower risk of suicide compared to the host population, potentially due to their acquired asylum status (Cogo et al., 2022). A recent meta-analysis reported the overall prevalence of suicidal ideation and attempts among refugees in non-clinical populations (Haase et al., 2022), finding that suicidal ideation rates (20.5%; 22.3% for women, 27.7% for men) were higher for refugees compared to the global prevalence data, but not for suicide attempts (overall prevalence of 0.57%). A further study in Denmark found an elevated rate of suicide attempts for asylum seekers, including minors; the rate of suicide attempt was 842.0 per 100,000 person-years for asylum-seekers and 92.3 per 100,000 person-years for the general population (Khan Amiri et al., 2023). Therefore, although some findings are mixed, there is evidence of increased suicide risk in western nations.

Suicide in UK asylum seekers

Even though asylum seekers appear to be at increased risk for suicide, ethnicity and asylum status is not a requirement for recording within English and Welsh coroner reports, creating challenges in knowing the true suicide rates in those who are seeking asylum (Cohen et al., 2020). In Scotland, ethnicity has been recorded on a voluntary basis since 2012, although there is no recording of asylum or refugee status.

The Home Office do not keep an official record of deaths and their causes in asylum seekers, including those in Home Office accommodation. Therefore, the investigation and reporting of asylum seeker deaths and suicides has been adopted by independent organisations such as Liberty Investigates (libertyinvestigates.org.uk/), as part of the Asylum Memorial Project (https://www.asylumseekermemorial.co.uk/). Their findings, published by the Guardian newspaper, suggest that a total of 23 asylum seekers are thought to have killed themselves in Home Office accommodation since 2020, more than double the total in the previous four years (Guardian, 2023).

The National Confidential Inquiry into Suicide and Safety in Mental Health investigates available data from mental health patients who died by suicide, and findings suggest the suicide rate between 2011 and 2017 for patients seeking to stay in the UK was around 23.8 per 100,000, higher than the non-migrant suicide rate of 10.6 per 100,000 population for the same period (Tham et al. 2023). Of those who died by suicide, compared to non-migrants, those seeking to stay were:

  • more likely to be from an ethnic minority group (76% vs 7%),
  • more were deemed low long-term risk for suicide (76% vs. 57%),
  • a higher proportion died within three months of discharge from psychiatric in-patient care (19% vs. 14%),
  • more had a diagnosis of schizophrenia and other delusional disorders (31% vs. 15%), and
  • more had experienced recent life events compared to non-migrants (71% vs. 51%).

These findings suggest that the asylum-seeker patients may have more complex needs and are likely to require support from a range of social and health care services.

Self-harm and suicide attempts in the community

Complete figures for self-harm in the community by asylum seekers remains unknown, as ethnic monitoring data in accident and emergency departments does not identify this. Therefore, there have been recommendations for more adequate recording of asylum status and ethnicity in the monitoring of community self-harm when people attend emergency departments (Cohen et al., 2008).

A Home Office evaluation of accommodation and support services experienced by asylum seekers in Glasgow during COVID-19 (Laing, 2020) suggested that the move of asylum seekers from self-contained accommodation to hotels had a detrimental impact upon mental health, with reports of self-harm (including suicidal behaviour) by Glasgow-based asylum seekers increasing over 3 fold (from 21 incidents in April 2020 to 75 in July 2020), with mental health related issues also increasing (from 12 to 53 in the same time frame). Those supporting asylum seekers found the temporary nature of the living conditions in hotels, combined with existing stressors, lead to increased vulnerability. The report suggests there is consistent evidence that access to specialist mental health services is limited in capacity and the situation has been exacerbated by COVID-19 response.

Suicide and suicide attempts by asylum seekers in detention centres

In their systematic review of self-harming behaviours of asylum seekers in Europe, Gargiulo et al. (2021) found that many determinants for suicidal behaviours in detention were connected to the application for asylum (e.g. uncertainty regarding the outcome, slowness of the procedures) and the impact the increased social isolation had upon distress, anxiety and depression. Previous research suggests that adults, adolescents and children experienced high levels of mental health problems while in detention, including anxiety, depression and PTSD, with detention duration associated with severity of mental symptoms (von Werthern et al., 2018).

In the UK specifically, a study comparing the self-harm rate of asylum seekers in detention centres (using ‘scanty’ data from Immigration Removal Centres, coroners’ and Prison Ombudsman’s reports) to that of prisoners, found the available data suggested a rate of 12.97% for detained asylum seekers while the mainstream prisoners’ rates vary between 5% and 10% (Cohen et al., 2008). In asylum detainees who died by suicide, 78% were single, 67% had prior contact with mental health services and 44% had prior self-harm history. The authors highlighted the inconsistent or non-existent data recording for self-harm in asylum-seeking detainees, despite this they suggest there are elevated levels of self-harm and suicide for detained asylum seekers.

Self-harm and suicide attempt data from four prominent immigration removal centres, obtained from the Home Office by the Scottish Refugee Council (published in The Guardian, 2023), provides information about self-harm incidents requiring medical treatment from January 2018 until 30 September 2023. Over this period, 1,743 self-harm and suicide attempts requiring medical treatment were reported across the four sites, and they suggest that safeguarding in detention was dysfunctional, allowing people’s mental health was to deteriorate.

In Scotland, an inspection report from Dungavel Immigration Detention Centre found no suicide deaths and three self-harm incidents in the past 12 months, although over that time fifty-five detainees had received support under the assessment, care in detention and teamwork (ACDT) case management for detainees at risk of suicide or self-harm (HM Chief Inspector of Prisons, 2021). It suggested that most detainees required ACDT support because of the impact of detention on their well-being. The report found a lack of active involvement of Home Office staff in those deemed at risk, and an inconsistency in case management plans. An earlier report in The Herald newspaper (2018) found that at points in 2017, of 145 detainees in Dungavel, 20 (14%) were on active suicide watch. It is suggested that a combination of factors increase this risk, including the indefinite and oppressive nature of the detention, and the vulnerability of the detainees.

Further reports have suggested that within UK detention centres, a culture of racism, the impact of privatisation and sub-contracting in the detention, and deportation of ‘failed’ asylum seekers have added to stress and re-traumatisation, exposing the neglect of a vulnerable group, leading to deaths by self-harm and inadequate treatment (Athwal et al., 2014). Indeed, a government review into the welfare of detainees (Shaw, 2016) made recommendations for the immediate reduction in detention levels of asylum seekers, and of the amount of time they are detained if is deemed necessary, highlighting that the that detention in and of itself undermines welfare, and contributes to vulnerability, and more needs to be done to mitigate the impact upon mental health.

Unaccompanied asylum-seeking children

Unaccompanied minors in detention emerged as a particularly vulnerable category (Gargiulo et al., 2021; von Werthern et al., 2018). Ehntholt et al. (2018) found a high prevalence of psychiatric disorder (PTSD, MDD) in this group and 36% presented with self-harm and suicide attempts. At 3 years post-detention, 89% met diagnostic criteria for psychiatric disorders and reported high PTSD symptoms. The authors suggest the additional stress of age dispute procedures and detention was judged to have been harmful. Indeed, Gargiulo and colleagues (2021) proposed that adolescent asylum seekers and refugees may experience an identity crisis due to the experience of a double ‘transition’, of both adolescent developmental changes along with the uncertainty of migrating, and self-harm functions may include feeling a sense of self.

A report by The Guardian (2021) highlighted an urgent call by child and migrant rights organisations to prioritise unaccompanied children, as figures revealed they were waiting longer than adults for a decision on their claim, and this would directly increase their risk of self-harm and suicide. They report that at least 11 children who have come to the UK seeking sanctuary have been identified as having taken their own lives, most of whom were awaiting a decision on their claim.

Vulnerability to suicide

As highlighted, the elevated rates of mental health conditions, in particular PTSD, incur increased risk for suicidal thoughts and behaviours (Turecki et al., 2019). Asylum seekers may be vulnerable to suicide as many of the risk factors for suicide more broadly cross-over with those seeking asylum, for example, being single and male; social and emotional isolation; experiences of trauma, loss, and bereavement; experience of torture and armed conflict; alienation because of language and employment barriers; and poverty (Cohen et al., 2020).

Risk factors that have been found to be related to suicidal ideation in refugees include an inability to provide for family (e.g. work disability), low levels of social support, anxiety, depression, high mental distress, low quality of life and insecure visa status (Haase et al., 2022).

Trauma

In their qualitative study, Taylor et al. (2020) identified themes relating to trauma and suicide risk in asylum seekers and refugees in the UK. Important themes included a sense of loss (of stability, connections, belonging, dignity) and feeling of struggle (with not being believed, concealing emotions). Participants reported that their experience of trauma included suicidal ideation, sleeping problems, flashbacks, and high levels of anxiety. A lack of social support and the protracted nature of the asylum-seeking process were particularly problematic, however, characteristics relating to resilience and posttraumatic growth were also reported.

Social connections and isolation

A systematic review of studies investigating social isolation in refugees and asylum seekers in English-speaking countries found that studies highlight social disconnection as an important determinant of mental health and suicide risk among immigrant populations (Aran et al., 2022). Indeed, the more connected a refugee feels to their families and their community, the better their overall health and wellbeing, which decrease the mental health issues that form part of the causal pathway for suicidal ideation and attempts.

Barriers to receiving mental healthcare

Qualitative research has found that asylum seekers find primary care services difficult to navigate, with reasons including language barriers, lack of awareness of the purpose of the NHS; additional costs such as travel; and the perception of discrimination relating to race, religion, or immigration status (Kang et al., 2018). Examining UK-wide policies, guidance and practices for mental healthcare for UK asylum seekers, Pollard and colleagues (2021) identified existing barriers to accessing mental health care in the UK. As well as communication challenges, they found a lack of funding, resources, and political will.  Potential enablers of better access included improving social support, cultural adaptions to provision of heath care, and supportive policy changes. Recommendations included culturally appropriate approaches that include asylum-seeker specific mental health services, with greater resources from the UK Government, and a call to relax the hostile environment policies.

The mental health charity Mind (2009) highlighted the contradictory nature of Government policy, which simultaneously recognises the vulnerability of this population, but also implements hostile immigration policies which have a devasting impact upon wellbeing. Mind recommended increasing the availability of interpreter services (including in primary care), increasing awareness and provision of cultural differences/ services in healthcare, and addressing gaps in service provision for a more co-ordinated approach.

Suicide prevention training

It may be beneficial for staff working with and supporting refuges and asylum seekers to receive culturally appropriate suicide prevention training. A recent literature review (Ingram et al., 2022) suggested that such suicide prevention training should incorporate several key facets, including:

  • increasing competence and confidence to identify and respond to suicide risk,
  • understanding cultural differences in healthcare and how this may impact refugees recognition of mental health and suicide as a health matter,
  • the importance trauma informed practices in care, considering the lived experience of refugees and asylum seekers.

These findings suggest that there needs to be an increased focus upon meeting the needs of vulnerable asylum seekers within healthcare settings to mitigate risk of self-harm and suicide.

Conclusions

The appropriate reporting of suicide attempts and deaths of those seeking asylum in the UK should be a priority for government and healthcare. Despite this lack of effective reporting, there is evidence that asylum seeker populations are at increased risk for suicide and self-harm, particularly those in detention centres. Worryingly, this includes unaccompanied minors, who report elevated self-harm and mental health diagnosis. Many factors have been identified that can contribute to this increased risk, not least the asylum-seeking process itself and the hostile environment policies that are implemented by the UK government. Recommendations from across the research studies highlight the need for a multi-agency approach, including the provision of mental health services aimed at asylum seeker populations. More research is required to understand who is at risk, and how best to mitigate this, within the UK context.

Recommendations

There are some key failings and gaps in knowledge in the monitoring and treatment of vulnerable people who are seeking asylum in the UK. Considering this, several recommendations have been made that may help to address these.

  1. Improving data collection: more adequate recording and monitoring of suicides and self-harm in the community by asylum seekers and refugees is required to fully appreciate the scale of the issue. Additionally, an exploration of levels of suicidal ideation and non-hospital treated self-harm in asylum seeker groups, as well as identifying risk factors, would be advantageous.
  2. Breaking down language barriers: to aid the appropriate support of vulnerable asylum seekers, ready access to interpreters should be a priority, both in healthcare and asylum seeker accommodation (including detention centres).
  3. Bespoke mental health services: Services need to be developed or adapted to be more culturally sensitive and accessible to those in need. This includes considering how mental health and suicide is approached in different countries, including a recognition of contrasting norms and potential stigma.
  4. Culturally appropriate suicide prevention training: Those who are working to support asylum seekers should receive suicide prevention training that builds confidence in discussing suicide and incorporates a recognition of cultural facets of mental health.
  5. Adopting a multi-agency approach: An increasingly linked up approach, whereby asylum seeker support services, including third sector and NGOs, work with healthcare and the Home Office representatives to provide a more targeted approach to asylum seeker mental health and suicide prevention.


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