LORIN BOYNTON, MD & JAKE BENTLEY, MA

Assessment and Management of Refugee Mental Health in Primary

Care 

Flexible Agenda

Culturally Competent CareClinical Case DiscussionCultural Case Study: Somali RefugeesResearch in local Somali community

Implications for primary care

Resources EthnoMed.org UW Psychiatry Residency Training Program (online) Prazosin article

LORIN BOYNTON, MD

Culturally Competent Care

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 USHealth care policy and practicesPrinciples of CCC apply to all patientsFocus on Refugees and Immigrants

Ethno-cultural diversity

Challenges facing refugees/ immigrants in the clinical

encounter

Language barriersDifferences in held values and cultural

practicesDeficits in cultural competence of providers

Definition of CCC

High quality care delivered in a culturally sensitive manner

Objectives

Levels at which culturally sensitive care occurs.

Frameworks for clinical use.

Levels

Individual levelGroup Practice levelInstitutional level

Individual level- what counts?

Good communicationTrustRelationship

Good communication

Verbal – competent interpreter who the patient trusts

Non-verbal- patience - kindness - respect - demonstrate an interest in understanding culture of pt - etiquette/ greeting

Trust

No racism, prejudice or biasPt must feel valued and understoodAuthority figure- be careful what you ask

Relationship

Through good communication and trust relationships are built with patients

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

Group practice level-what counts?

Access to servicesReminder calls- language; calenderContinuity of careRespect- from the front desk to the exam

room

Institutional level- what counts?

Support of programs like HousecallsInterpreter servicesHiring practices- diversity in the workforceCultural Competence training programsPolicies that ensure a fair environment for all

personnel and patients

Frameworks for increasing cultural sensitivity and awareness

Kleinman’s Eight QuestionsDSM IV Cultural Formulation

Arthur Kleinman’s Eight questions:

1. What do you think caused your problem?2. Why do you think it started when it did?3. What does your sickness do to you? How does it

work?4. How severe is your sickness? How long do you

expect it to last?5. What problems has your sickness caused you?6. What do you fear about your sickness?7. What kind of treatment do you think you should

receive?8. What are the most important results you hope to

receive from this treatment?

Cultural Formulation

• Cultural Identity• Cultural Explanations of Illness • Cultural Factors related to Psychosocial

Environment and Level of Functioning • Cultural elements of individual/ clinician

relationship • Overall cultural assessment for diagnosis

and care

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

Clinical Case Discussion:How do we make a difference?

“We convince by our presence”

Walt Whitman

Cross-Cultural Assessment of Cross-Cultural Assessment of Psychological Symptoms among Psychological Symptoms among

Somali RefugeesSomali Refugees

Jake Bentley, M.A.

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)

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

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

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

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)

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

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

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)

Sample Characteristics

Table. Demographic Information for Sample of Somali refugees (N = 74)

n %SexMale 48 64.9Female 19 25.7Age18 to 25 27 36.726 to 30 9 12.231 to 40 5 6.841 to 50 2 2.851 to 60 3 4.261 to 70 8 1171 and older 8 11Marital StatusMarried 24 32.4Unmarried 42 56.8Religious OrientationMuslim 49 66.2Unreported 25 33.8Length of Residence in U.S.< 1 to 3 Years 10 13.73 to 5 Years 12 16.35 to 10 Years 16 21.7> than 10 Years 24 32.1

Model 1

Model1: Trauma Predicting Symptoms

Harvard Trauma Questionnaire (HTQ): Trauma Events Subscale (# of events) 16-item symptom subscale Diagnostic cutoff = 2.00

Endorsement of PTSD Symptoms

Table. Percentage of Participants Endorsing PTSD Symptoms on the HTQn %

Recurrent thoughts or memories of the most hurtful or terrifying events 22 29.7

Feeling as though the event is happening again 32 35.1

Recurrent nightmares 17 22.9

Feeling detached or withdrawn from people 17 22.9

Unable to feel emotions 14 19.9

Feeling jumpy, easily startled 14 19.9

Difficulty concentrating 15 20.3

Trouble sleeping 18 24.3

Feeling on guard 18 24.3

Feeling irritable or having outbursts of anger 17 23

Avoiding activities that remind you of the traumatic or hurtful event 16 21.6

Inability to remember parts of the most hurtful or traumatic events 17 22.9

Less interest in daily activities 20 27

Feeling as if you don’t have a future 18 24.3

Avoiding thoughts or feelings associated with the traumatic or hurtful events 14 16.2

Sudden emotional or physical reaction when reminded of the most hurtful or traumatic events 17 23

Model 2

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

Model 3

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

Current Psychosocial Stressors

Table. Report of Moderately Serious to Very Serious Post-Migration Stressors

n %

Worry about family back home 43 58.1

Separation from family 33 44.6

Inability to return home in case of emergency 29 39.3

Poverty 28 37.9

Not able to find work 21 28.5

Poor access to dentistry care 21 28.5

Loneliness and boredom 21 28.5

Bad job conditions 20 27.1

Poor access to counseling services 19 25.7

Little government help with welfare 19 25.7

Little help with welfare from charities 19 25.7

Poor access to long-term medical care 18 24.4

Discrimination 17 23

Isolation 17 23

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

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

Resources

EthnoMed.orgUW 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.