Assessment and Management of Refugee Mental Health in Primary Care

1. Assessment and Management of Refugee Mental Health in Primary Care  Lorin Boynton, MD & Jake Bentley, MA

2. Flexible Agenda • Culturally Competent Care • Clinical Case Discussion • Cultural Case Study: Somali Refugees • Research in local Somali community • Implications for primary care • Resources • EthnoMed.org • UW Psychiatry Residency Training Program (online) • Prazosin article

3. Culturally Competent Care Lorin Boynton, MD

4. Why is it important? • 2009: 27million refugees and immigrants-10% • 2008 US Census: Minorities now 33% of US pop- majority by 2042 • Increasing ethno-cultural diversity in US • Health care policy and practices • Principles of CCC apply to all patients • Focus on Refugees and Immigrants

5. Ethno-cultural diversity

6. Challenges facing refugees/ immigrants in the clinical encounter • Language barriers • Differences in held values and cultural practices • Deficits in cultural competence of providers

7. Definition of CCC • High quality care delivered in a culturally sensitive manner

8. Objectives • Levels at which culturally sensitive care occurs. • Frameworks for clinical use.

9. Levels • Individual level • Group Practice level • Institutional level

10. Individual level- what counts? • Good communication • Trust • Relationship

11. Good communication • Verbal – competent interpreter who the patient trusts • Non-verbal- patience - kindness - respect - demonstrate an interest in understanding culture of pt - etiquette/ greeting

12. Trust • No racism, prejudice or bias • Pt must feel valued and understood • Authority figure- be careful what you ask

13. Relationship • Through good communication and trust relationships are built with patients

14. Connection • Not always possible to gain knowledge/ background ahead of time in order to increase the chance of connection with a patient • It is important to be open to unexpected chances of connection

15. Group practice level-what counts? • Access to services • Reminder calls- language; calender • Continuity of care • Respect- from the front desk to the exam room

16. Institutional level- what counts? • Support of programs like Housecalls • Interpreter services • Hiring practices- diversity in the workforce • Cultural Competence training programs • Policies that ensure a fair environment for all personnel and patients

17. Frameworks for increasing cultural sensitivity and awareness • Kleinman’s Eight Questions • DSM IV Cultural Formulation

18. Arthur Kleinman’s Eight questions: • What do you think caused your problem? • Why do you think it started when it did? • What does your sickness do to you? How does it work? • How severe is your sickness? How long do you expect it to last? • What problems has your sickness caused you? • What do you fear about your sickness? • What kind of treatment do you think you should receive? • What are the most important results you hope to receive from this treatment?

19. Cultural Formulation • Cultural Identity • Cultural Explanations of Illness • Cultural Factors related to Psychosocial Environment and Level of Functioning • Cultural elements of individual/ clinicianrelationship • Overall cultural assessment for diagnosisand care

20. Conclusion • Providing culturally competent care leads to improved patient-provider relationships and communication • This in turn leads to enhanced health care outcomes and reduced disparities

21. Clinical Case Discussion:How do we make a difference? “We convince by our presence”Walt Whitman

22. Cross-Cultural Assessment of Psychological Symptoms among Somali Refugees Jake Bentley, M.A.

23. Brief Cultural Profile: Somalia • Somalia is a war-torn, sub-Saharan East African country • A lack of centralized government since 1991 has contributed to the proliferation of inter-clan conflict and ultimately the emergence of civil war. • As of the end of 2006, ~460,000 Somalis were internationally displaced, representing an 18% increase in prevalence from one year prior (UNHCR, 2007)

24. Brief Cultural Profile: Somalia • Mental health is categorical • “sane” and “insane” • Traditional treatments • Quranic readings • Herbal remedies • Ritualistic ceremonies • Mental illness carries stigma • Somalis seek to resolve mental illness within the family • As a result, clinical treatment may only be sought after all other resources have been exhausted

25. Somali Mental Health • Somali refugees have been found to be at risk for: • PTSD • Depression • Anxiety • Somatization • Anecdotal clinical evidence • Relationship w/traumatic exposure remains unclear • Acculturative stress has been linked to depression • May be persistent years after resettlement Bhui et al., 2003; Bhui et al., 2006

26. Process of Migration • Pre-Migration • Native cultural factors • Traumatic events • Migration • Potential for additional traumatic experiences • Deprivation (e.g. physical, educational) • Malnutrition • Post-Migration • Acculturation • Psychosocial challenges (e.g. discrimination, low SES) • Intergenerational conflict

27. Psychiatric Assessment in refugee populations • Challenges are presented due to: • cross-cultural and linguistic differences • diverging perceptions about health and mental health • Arthur Kleinman’s notion of explanatory models • although many psychological disorders contain consistent features across cultures, cultural variations in perceptions and interpretations of bodily or cognitive experiences alter how the disorder is experienced by members of a given group. (Kleinman & Benson, 2006; Kleinman, 1987)

28. Assessing Somali Mental Health • Few diagnostic questionnaires have been specifically designed for use with refugee populations • Hollifield and colleagues (2002) found that 125 different measures were used in the studies with 12 of these measures being designed specifically for use with refugee populations • Psychometric properties of these measures have been under-reported • Reliability • Validity • Sensitivity • Specificity

29. Research in Local Community • The purpose of our project was to: • Provide preliminary psychometric evidence for a PTSD symptom questionnaire for use with Somalis • Evaluate the relative influence of pre- and post-migration factors on Somali mental health • Investigate the role of somatization in the report of psychiatric symptoms by Somalis X

30. Measures • Demographic form • Harvard Trauma Questionnaire (HTQ) • Traumatic Life Events • PTSD Diagnostic Scale • Hopkins Symptom Checklist -25 (HSCL-25) • Depression • Anxiety • Symptom Checklist 90 – Somatization Subscale • Post-Migration Living Difficulties Questionnaire (PMLD)

31. Sample Characteristics

32. Model 1

33. Model1: Trauma Predicting Symptoms • Harvard Trauma Questionnaire (HTQ): • Trauma Events Subscale (# of events) • 16-item symptom subscale • Diagnostic cutoff = 2.00

34. Endorsement of PTSD Symptoms

35. Model 2

36. Model 2: Somatization as Mediator • No mediation found for symptoms of PTSD • PTSD actually mediates the trauma-somatization relationship • Results indicated that, with the inclusion of Somatization in the model, the relationship between trauma and depression and anxiety became statistically non-significant • Said another way, trauma caused somatic complaints which in turn caused symptoms of depression and anxiety

37. Model 3

38. Model 3: PMLD Moderates Depression • Results: • High # of living difficulties makes depression in low trauma group worse • This effect not seen for those w/ high trauma exposure • Trauma led to greater depression for those in the low to medium living difficulties group

39. Current Psychosocial Stressors

40. Implications for Primary Care • PTSD carries a different course than other mood disturbance (e.g. depression & anxiety) • Not significantly impacted by current stressors • Not accounted for by somatic complaints • Somalis with mental health concerns are more likely to present to primary care than other settings • Also likely to present somatically for mood disturbance

41. Implications for Primary Care • Treating somatic complaints alone may help with symptoms of depression and anxiety • Physical activity • Traditional treatments • Massage therapies • Relaxation & sleep improvement • Counseling and resources to assist with psychosocial stressors can also reduce depressive symptomatology • Handout: Four visit model of care • Link: scroll to page 21

42. Resources • EthnoMed.org • UW Psychiatry Residency Training Program • Online Religion, Spirituality & Culture Curriculum Boynton, L., Bentley, J.A., Strachan, E., Barbato, A., & Raskind, M. (2009). Preliminary findings concerning the use of prazosin for the treatment of posttraumatic nightmares in a refugee population. Journal of Psychiatric Practice, 15(6), 454-459.