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= Mental Health of North Korean Refugees = Since 2019, the influx of North Korean refugees (NKR) entering South Korea has reached over 33,000. A growing interest in the mental health status of NKR has been increasing since successful adaptation depends on their psychological wellbeing. Consequently, when investigating mental health status of NKR, numerous areas of impact can not be dismissed. From the timeline of migration: the exposure to traumatic experiences before, during, and after migration are pertinent points of impact. Human right violations while residing in North Korea, experiencing sexual violence while migrating through a third country, and struggling through acculturation stress in the new host country are some of the factors that exacerbated the risk for psychological disorders like PTSD, depression, and anxiety.

According to World Health Organization (WHO), mental health is defined as a “state of wellbeing in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community.” However, the over-vigilant priority of maintaining national identity of the North Korean regime has led to detrimental outcomes on mental health status of NKR.

Mental Health in North Korea
In a nation that has a strong sense of socialism and paternalism, complete respect and loyalty to the regime's supremacy is not an option. Hence, individual struggles and needs are depreciated and rarely expressed by the citizens of North Korea. The use of the term, "mental health" is a foreign concept to many NKR and there is very little awareness of what the two words represent. A good person who does not put themselves as the center of attention is loosely identified as someone who is mentally stable. Moreover, there is not existence of terms like depression so feelings of sadness and melancholy are often seen as personality traits. There are no mental health facilities, and instead party officials are put in place to hold organized meetings where they psychologically control the NK people. When someone is found to have mental issues, they are considered to be in the worst condition, such as a full-blown psychosis. They are sent to "Ward No 49," which is a psychiatric hospital known to citizens as a place of isolation, confinement and torture till death. Anyone with visible mental issues were considered as useless to the system and harmful to the image of the regime so they were taken away.

Upon this baseline of absence of mental health care, from 1994 to 1998 the North Korean famine (Arduous March) erupted. This catastrophe caused an enormous deterioration of already vulnerable psychological states. Starvation, death of family members, stealing and cheating others, and even eating children became a new lifestyle to survive the famine, which added to the experience of collective trauma. Still, the regime overlooked the mental health needs of their citizens and abandoned them to fend for themselves during the famine. As a result, thousands of NKR began escaping out of North Korea, in hopes to find more food and a job to make more money.

Human Right Violations
North Korea is known to be one of the worst violators of human rights even moving into the 21st century. The totalitarian country exercises strict systematic political and economic domination and life-long exposures has led to negative psychological outcomes. A study of 383 NKR residing in South Korea found that experiencing traumatic events were not the sole basis for mental health illnesses. Traumatic events included directly being and witnessing torture, discrimination, and getting arrested to go to prisons of inhumane conditions. The violation of basic human rights, witnessing political violence, and discriminatory protocols had higher likelihood of exhibiting mental health symptoms. Being denied the right to food, freedom of thought and movement, health care, livelihood and being forced into labor became the basis of depression, anxiety, and PTSD. NKR entering South Korea carried these experiences through their resettlement process, which made understanding their mental health status more difficult. These findings suggest tailoring the mental health care in South Korean resettlement centers to address the stress of human rights violations along with the layers of traumatic exposures.

Another study of 200 NKR were evaluated for risk factors of PTSD. 29.5% of the participants were found to exhibit PTSD, men experiencing more traumatic experiences. From a list of 44 traumatic events, the average number of events was 16.3 for men and 13.7 for women. The events with the most occurrences in order of highest to lowest were "witnessing public executions," "hearing news of the death of a family member due to starvation," "witnessing a beating," "witnessing a punishment for political misconduct," and "death of a family member due to illness." The results of this study revealed that the prevalence of PTSD was commonly found in traumatic experiences related to family members (missing, death, separation).

Traumatic events in third countries.
In the midst of migration out of North Korea, most NKRs travel through third countries to safely arrive in South Korea. These countries include China, Russia, Southeast-Asian countries, and the average length of stay is two to five years. Consequently, many NKRs are subjugated to additional traumatic experiences in the third countries and length of stay have shown significant associations with psychiatric symptoms. Those who stayed longer in third countries exhibited greater levels of mental health illnesses, which included depression, PTSD, anxiety, alcohol abuse, and suicidal ideation. One great area of concern in traveling through third countries is sexual victimization. Female NKRs are highly vulnerable to sexual violence during migration from North Korea to their host countries. Almost one-fourth of NRK women have reported experiencing sexual violence such as sexual harassment, rape, sex labour, and sex trafficking in North Korea and in third countries.

Mental health during resettlement in South Korea
Contrary to adults, adolescents showed an association of higher rate of psychological problems to shorter duration of stay in South Korea. Meaning that adolescents adapt better with time and struggles more in the beginning of resettlement. In adults, duration of stay did not reveal a consistent correlation to psychological wellbeing. Some were found to have more mental health issues the longer they resided in their host country. Acculturation stress is could be the reason behind why longer stay may lead to increased stress on NKRs. Further stress is exacerbated through homesickness, a sense of alienation, culture shock, feeling marginalized, and perceived discrimination. South Korea is a monocultural society and NKRs find it difficult to feel belonged since they are seen as less sophisticated "them". High levels of acculturation stress led to adverse psychological outcomes such as depression, anxiety, and PTSD. Creating a culturally adaptive program that are tailored to each individual's psychological needs is a crucial step to mitigate these gaps.