Resettled Iraqi refugees have been identified as a highly vulnerable group with reports indicating they present with higher degrees of emotional trauma and poorer health compare to other refugee groups . However, evidence on psychological distress levels over time in refugees has been unclear. While some studies proposed a positive association between longer length of resettlement and good mental health [14–16], others argued that length of stay in a host country can negatively impact mental health in refugees with chronic or increased levels of psychological distress over time [20, 21].
This study sought to further explore this area by comparing levels of psychological distress reported in two samples of Iraqi refugees in Australia for differing lengths of time. Additionally, we described the impact of certain demographics factors on levels of psychological distress in the two groups of refugees. Finally, level of psychological distress in the overall refugee group was compared with that in the general Australian population. Our results demonstrated that those refugees with the longer period of resettlement in Australia were more distressed than those with a shorter length of stay. In particular the observed difference was greater in the 45–54 age group. Other variables such as gender or marital status did not statistically influence levels of psychological distress in either group. Finally, levels of severe psychological distress were significantly higher among Iraqi refugees compared to the general Australian population.
This study supports the notion that the period following initial resettlement remains important for those of refugee background, and may be associated with a worsening pattern of psychological distress. This is consistent with literature that indicates that factors post-settlement such as spending too much time reflecting on past experiences, current international events, separation from family, lack of social support in the host country, marriage stressors and conflict or feeling overwhelmed by resettlement challenges and concerns can contribute to increased levels of psychological distress . It has also been argued that the pattern of distress over time might be explained by the fact that, in the early stages of resettlement, individuals experience a ‘honeymoon’ period of positivity about being in a new country. However, as time progresses, refugees come to face the more sophisticated educational, social and financial challenges of later resettlement . This is particularly relevant if such challenges are not appropriately supported by host communities . In an editorial by Silove and Ekblad , it was noted that although preventing trauma experienced by refugees in their homelands is beyond the control of most government officials and clinicians, ensuring that recipient countries provide effective resettlement services is an avenue that has been demonstrated to minimise and mitigate the established links between post-migration stressors and psychological distress. Some of these services which Australia currently provides include encouraging family reunion, offering opportunities for work and education and the provision of targeted specialist mental health services for those in need. However, there is still much work to be done including addressing the unfortunate increase in racism and perceived discrimination, perhaps fuelled by the increase in the threat of global terrorism (past and currents events) [32, 33]. Such experiences of intensified discrimination can only further exacerbate refugee’s feelings of not belonging, fear and insecurity which has been identified as an ongoing mental health hazard with some researchers pointing that receiving countries must increase community awareness about the seriousness of discrimination and its effects .
Another factor that may be related to increased levels of psychological distress over time is evidence of underutilisation of mental health services  and generalised stigma associated with mental health problems amongst refugees . In addition, when investigating the types of help-seeking amongst refugees, an Australian-based study indicated that Iraqi refugees rarely seek professional mental health services such as a psychiatrist and instead tended to wait until problems become critical or are acute before seeking professional help . Evidence of low levels of mental health literacy in Iraqi refugees, namely, lack recognition of mental health disorders and lack of knowledge of treatment options or professional services reported in an Australian-based study  provides an area of potential targeted intervention. One such way forward is to develop appropriate community and individual psycho-education programs for the refugee community, which can have a positive impact on professional help-seeking behaviour . Additionally, developing better guidelines for those working in resettlement agencies, and welfare and educational providers who often assist refugees in early and later stages of migration, so that they are better equipped to respond to mental health crises and offer mental health first aid to affected individuals, would be beneficial. Similarly, General Practitioners and other health professionals should be kept aware that the psychological issues well known to affect those of refugee background can persist for many years, and may even worsen.
Limitations of this study must be noted. These were cross-sectional measures in two disparate groups of refugees, not the same cohort over time. It is possible that the group resettled for longer had worse mental health status when they first arrived, perhaps due to greater stressors pre-migration, and could have in fact improved over time. Another possibility is that those refugees with longer period of resettlement could have been exposed to greater post-displacement traumatic events than those who recently arrived to the country, giving way to poorer mental health. As such, there is a clear need for future research directions to explore psychological distress in Iraqi refugees in a longitudinal cohort, ensuring that it is consistent and replicable by including full demographic profiles, and relevant pre-displacement and post-displacement factors including exposure to potentially traumatic events.
Strengths of this study, in our view, is the relatively large sample size, especially compared to other studies conducted on mental health with refugee populations, with reported sample sizes ranging from 29 to 262 participants within each group . Another strength is that this study focused on refugees from just one country, Iraq, which is different from other studies that have included refugees with different countries of origin , heterogeneity that exits amongst different refugees groups with regards to factors such as religion and ethnicity and trauma exposure may impact on results. Although participants in the long-term resettled group were volunteers attending the AMEP classes, by recruiting from colleges in Western Sydney, which has the highest concentration of resettled Iraqi refugees in Australia, some attempt at redressing representativeness was made.