Undocumented adult migrants in Sweden: mental health and associated factors

People living in a country without a residence permit are often labelled as undocumented or irregular. This group is not homogenous: some are tourists, students or labour migrants overstaying their visas or residence permits. Others may have entered the country without permission, most often due to poverty and with the purpose to improving this situation. A third group consists of refugees who have entered the country legally in order to seek asylum but whose asylum claims have finally been rejected [1]. Although these subgroups are also heterogeneous, it can be expected that undocumented former asylum-seekers will make up a particularly vulnerable group [2]. Many of them are victims of war, violence and forced migration. Moreover, they may have experienced further trauma while fleeing and/or during a prolonged asylum process where they may experience their traumatic experiences being disapproved.

A common feature of persons in an undocumented situation is that they are ‘deportable’: if their status is disclosed they risk deportation to their country of origin. The consequences of this differ between the groups mentioned. For most tourists and students, they are probably relatively minor in relation to rejected asylum-seekers, for whom deportation may be regarded as posing a potential danger to life. The latter group in particular could thus be expected to live under heavy stress and in constant fear, often aggravated by previous traumatic experiences as well as social and economic hardship, all potentially increasing the risk of ill-health [3].

Undocumented migrants (UMs) in Sweden have traditionally mainly consisted of former asylum-seekers, although the number of EU citizens exceeding the permitted period of residence without a labour contract of three months has increased in recent years. Living as an UM in Sweden is complicated since access to basic services as well as welfare system requires the individual to have a unique ten-digit personal ID number. However, since 2013 new laws have been passed giving UM adults access to health care and dental care ‘that could not be deferred’, while children have full access to health care, dental care and schooling [4].

Despite their vulnerability described above, there is a lack of epidemiological data on UMs. In a European review, Woodward et al. [5] found that most published studies on UMs were qualitative. Sampling descriptions were often of poor quality, and only four studies used randomisation techniques. Most (80%) studies focused on access to health care, and many are clinical samples. Castañeda et al. [6] interviewed 183 UM patients who attended a health clinic that provided the bulk of health care for UMs in Berlin in 2004–2006 and 2008. The focus was on understanding how ‘illegality’ influenced UM experiences, medical treatment and convalescence. Results showed that living as an undocumented migrant was associated with health effects in various ways: it reduced the overall quality of care for mothers and infants, delayed the seeking of help, was associated with difficulties in accessing medication for patients with chronic illnesses and created difficulties in accessing care for acute health concerns. Furthermore, there was a lack of mental health care and there were high rates of generalised stress, anxiety that affected health in such a way that both patients and physicians referred to it as the ‘illegal syndrome’.

Schoevers et al. [7] interviewed 100 UM women in the Netherlands and found that 65% of them rated their health as ‘poor’. The majority were suffering from anxiety (78%), insomnia (75%), agitation (71%), depressed mood (64%), and nightmares (53%). In a German study by Kuhne et al. [8] of 96 UMs who attended a non-governmental organisation for medical counselling, many respondents rated their health-related quality of life as low. In addition, the authors conducted an ethnographic study and found that the three factors the respondents felt impeded their health most were socioeconomic conditions, experiences of criminalisation and late access to health care facilities. Other risk factors for mental illness among UMs were found in a scope literature review [9] where mental illness among UMs was associated with barriers to health care, exploitative work conditions, pregnant women being denied care, women being exposed to domestic violence [10], and, in relation to trafficking, being at risk of developing HIV/AIDS and STIs [11]. UMs described their experiences of living undocumented as ‘degrading’ and ‘unbelievable’ [12], living with a constant fear of deportation and anxiety over health care costs, experiences of isolation, social exclusion [10] and lack of social support [13].

Despite high numbers of asylum-seekers in Sweden, knowledge of health and living conditions among UMs is still scant, and there is a lack of population-based studies in particular [1]. With the exception of a few studies such as a study by Wahlgren et al. [14] investigating causes of deaths among UM, a study from Stockholm County Council [15], a recent study of UM women seeking perinatal care [16], two PhD theses [17, 18] and master’s theses [19, 20], findings on UMs stem from smaller studies performed by non-governmental organisations (NGOs) such as the Red Cross [21], Doctors in the world [22] and Doctors without borders [23]. These studies describe highly precarious living conditions. UMs in Sweden live in expensive housing with limited space, in temporary conditions and are confined to dangerous and poorly paid work in the informal sector [22–24]. In a study performed in 2005 [23] it was found that among 102 persons visiting an informal health clinic, almost 40% had no work and 45% had only occasional work. Most were underpaid, and worked in the informal sector in cleaning, construction, restaurants and shops. Of the respondents, 23 persons answered questions about mental health and half were suffering from anxiety and depression (Hopkins Symptom Checklist). Sixty-four per cent regarded their mental health as impaired during their time as undocumented migrants. As mentioned, this data is based on small samples of unclear representativeness [1].

In Europe, all countries have ratified the International Covenant on Economic, Social and Cultural Rights (ICESCR) [25] and the Charter of Fundamental Rights of the European Union [26]. These international conventions include binding commitments concerning the right to the highest attainable standard of physical and mental health. The practical meaning of the right to health is further developed in General Comment 14 [27]. The ICESCR also includes the right of the basic needs for life, such as access to essential food that is nutritionally adequate, shelter, housing and sanitation, and these rights apply regardless of whether the individual has legal status to stay in the country. Human rights are not an entitlement but, as the Office of United Nation High Commissioner for Human Rights (OHCHR) states [28], states still need to think how they shall guarantee that all people, citizens as well as non-citizens, have their human rights met in their social policies. In Sweden, UM have access to health care “that cannot be deferred”. However, assistance from the Social Services have varied, since the municipalities have interpreted the Social Service Act differently.

In this study of 104 UMs, 88 persons answered questions about mental health. We found alarmingly high rates of depression, anxiety and PTSD with similar prevalences among men and women. Living conditions were precarious overall, and an many reported harassment, political reasons or war as an important reason for leaving the country of origin. An unstable housing situation was identified as a major risk factor for poor mental health.

Our study showed very high prevalences of depression. The prevalence of moderate depression was 13% and that of severe depression as high as 58%. These figures can be compared to findings from a population-based Swedish study from 2009 by Johansson et al. [35], where 11% of the adult Swedish population reported clinically significant depression and 5% major depression (Patient Health questionnaire Depression Scale PHQ-9). Other findings on general population samples in the United States [36] and Norway [37] show prevalences of approximately 7% in the populations suffering from depression within the last 12 months. Myhrvold et al. [38] found in a Norwegian clinical study that 87% of UM patients were suffering from symptoms of major depression (Hopkins Symptom Checklist).

We also found that 30% suffered from moderate to severe anxiety and 39% from severe anxiety. This is much higher than the Swedish general population, where 15% reported clinically significant anxiety (measured on the Generalised Anxiety Disorder Scale). Point prevalence was 9% [35]. Our rates are in closer agreement with the Norwegian study, in which 87% of UM suffered from symptoms of anxiety [38] and are similar to the first study on mental health among UMs in Sweden 2005 where 23 UMs were interviewed and 57% had depression and 48% anxiety (Hopkins Symptom Checklist-25) [23]. These findings suggest that living as a UM implies severe stress and constant worries, which have a profound impact on mental health. The burden of depression and anxiety in our study increased with older age, suggesting that young UMs were somewhat more resilient in this stressful situation. Rates of poor mental health were, however, also high in the youngest age group, and this resilience should therefore not be overestimated.

PTSD prevalence (58%) was much higher in our sample than in both a systematic review of unselected refugee populations (resettled refugees with a residence permit) in Western countries, in which Fazel et al. [39] found that 9% had PTSD and in German study by Fuhrer et al. [40] with 214 adult asylum seekers 18% had PTSD (Harvard Trauma Questionaire). This suggests that for PTSD to be overcome it is crucial that the person feels safe and secure in a long-term perspective, and access to care and counselling is crucial. For UMs this state is never present. Instead they live with fear and insecurity in dealing with daily events and constant stress. Thus, for resettled migrants healing has been possible with successful integration.

Except for the stress-related factors previously mentioned, adverse social and economic conditions increase the risk of developing an illness but may also hamper recovery from existing illness. Our study showed both high rates of mental health problems and harsh living conditions. Having an unstable housing situation was associated with particularly high scores on both the anxiety and depression scales, with 31% living in temporary places or shelters. It seems likely, however, that this is just the heaviest of risk factors in a cumulative load of daily stressors and fears that create the context for this very poor mental health situation. Homelessness was also associated with anxiety and depression in another study [38]. It was also striking that 57% of the UM in our sample stated that they were often hungry and that churches and voluntary organisations were important in providing food as well as meeting basic social needs such as clothes and items necessary to survive the day. Half of respondents in our sample also had children in Sweden to take care of, and many depended on the charity to make ends meet.

Although UMs endure harsh conditions and the majority state that their health has deteriorated while being undocumented, they had still chosen to stay in Sweden. There were many reasons for this: they feared returning to their country of origin since there was a war going on there, they feared going back for political reasons, for religious reasons, or they belonged to a minority and feared harassment. For many it was better to stay and apply for asylum again after four years when rejection decisions expire in Sweden or to move somewhere else than to travel back to the country of origin due to a fear of what they would encounter there.

When human rights to reasonable living conditions, such as food, housing and safety are severely abused, severe mental health problems are the consequence. This study presents current findings on mental illness among UMs in Sweden and indicates a great need for care and counselling. Furthermore, Sweden has ratified the International Covenant on Economic, Social and Cultural Rights [25] and the Charter of Fundamental Rights of the European Union, and has thus accepted that all individuals have a right to health. This also implies the right to basic necessities for life such as food, housing and access to health care. This study shows that there is a high burden of illness among UM in Sweden, illness that is related to the social determinants of health. Sweden is responsible for fulfilling its obligations towards these human rights: to respect, protect, and fulfil these obligations towards all people staying in the country.