Lorin Boynton, MD

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Assessment and Management of Refugee Mental
Health in Primary Care 

• Lorin Boynton, MD Jake Bentley, MA

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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

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Culturally Competent Care

• Lorin Boynton, MD

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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

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Ethno-cultural diversity
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Challenges facing refugees/ immigrants in the
clinical encounter

• Language barriers
• Differences in held values and cultural practices
• Deficits in cultural competence of providers

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Definition of CCC

• High quality care delivered in a culturally
  sensitive manner

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Objectives

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

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Levels

• Individual level
• Group Practice level
• Institutional level

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Individual level- what counts?

• Good communication
• Trust
• Relationship

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Good communication

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

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Trust

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

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Relationship

• Through good communication and trust
  relationships are built with patients

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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

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Group practice level-what counts?

• Access to services
• Reminder calls- language calender
• Continuity of care
• Respect- from the front desk to the exam room

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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

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Frameworks for increasing cultural sensitivity
and awareness

• Kleinmans Eight Questions
• DSM IV Cultural Formulation

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Arthur Kleinmans 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?

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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

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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

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Clinical Case DiscussionHow do we make a
difference?

• We convince by our presence
  Walt Whitman

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

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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

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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
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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

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Psychiatric Assessment in refugee populations

• Challenges are presented due to
• cross-cultural and linguistic differences
• diverging perceptions about health and mental
  health
• Arthur Kleinmans 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)
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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

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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
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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)

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Sample Characteristics

Table. Demographic Information for Sample of Somali refugees (N 74) Table. Demographic Information for Sample of Somali refugees (N 74) Table. Demographic Information for Sample of Somali refugees (N 74) Table. Demographic Information for Sample of Somali refugees (N 74)
n
Sex
Male 48 64.9
Female 19 25.7
Age
18 to 25 27 36.7
26 to 30 9 12.2
31 to 40 5 6.8
41 to 50 2 2.8
51 to 60 3 4.2
61 to 70 8 11
71 and older 8 11
Marital Status
Married 24 32.4
Unmarried 42 56.8
Religious Orientation
Muslim 49 66.2
Unreported 25 33.8
Length of Residence in U.S.
lt 1 to 3 Years 10 13.7
3 to 5 Years 12 16.3
5 to 10 Years 16 21.7
gt than 10 Years 24 32.1
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Model 1
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Model1 Trauma Predicting Symptoms

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

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Endorsement of PTSD Symptoms

Table. Percentage of Participants Endorsing PTSD Symptoms on the HTQ Table. Percentage of Participants Endorsing PTSD Symptoms on the HTQ Table. Percentage of Participants Endorsing PTSD Symptoms on the HTQ Table. Percentage of Participants Endorsing PTSD Symptoms on the HTQ Table. Percentage of Participants Endorsing PTSD Symptoms on the HTQ
n
Recurrent thoughts or memories of the most hurtful or terrifying events Recurrent thoughts or memories of the most hurtful or terrifying events Recurrent thoughts or memories of the most hurtful or terrifying events 22 29.7
Feeling as though the event is happening again Feeling as though the event is happening again Feeling as though the event is happening again 32 35.1
Recurrent nightmares Recurrent nightmares Recurrent nightmares 17 22.9
Feeling detached or withdrawn from people Feeling detached or withdrawn from people Feeling detached or withdrawn from people 17 22.9
Unable to feel emotions Unable to feel emotions Unable to feel emotions 14 19.9
Feeling jumpy, easily startled Feeling jumpy, easily startled Feeling jumpy, easily startled 14 19.9
Difficulty concentrating Difficulty concentrating Difficulty concentrating 15 20.3
Trouble sleeping Trouble sleeping Trouble sleeping 18 24.3
Feeling on guard Feeling on guard Feeling on guard 18 24.3
Feeling irritable or having outbursts of anger Feeling irritable or having outbursts of anger Feeling irritable or having outbursts of anger 17 23
Avoiding activities that remind you of the traumatic or hurtful event Avoiding activities that remind you of the traumatic or hurtful event 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 Inability to remember parts of the most hurtful or traumatic events Inability to remember parts of the most hurtful or traumatic events 17 22.9
Less interest in daily activities Less interest in daily activities Less interest in daily activities 20 27
Feeling as if you dont have a future Feeling as if you dont have a future Feeling as if you dont have a future 18 24.3
Avoiding thoughts or feelings associated with the traumatic or hurtful events Avoiding thoughts or feelings associated with the traumatic or hurtful events 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 Sudden emotional or physical reaction when reminded of the most hurtful or traumatic events Sudden emotional or physical reaction when reminded of the most hurtful or traumatic events 17 23
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Model 2
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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

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Model 3
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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

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Current Psychosocial Stressors

Table. Report of Moderately Serious to Very Serious Post-Migration Stressors Table. Report of Moderately Serious to Very Serious Post-Migration Stressors Table. Report of Moderately Serious to Very Serious Post-Migration Stressors Table. Report of Moderately Serious to Very Serious Post-Migration Stressors Table. Report of Moderately Serious to Very Serious Post-Migration Stressors
n
Worry about family back home Worry about family back home Worry about family back home 43 58.1
Separation from family Separation from family Separation from family 33 44.6
Inability to return home in case of emergency Inability to return home in case of emergency Inability to return home in case of emergency 29 39.3
Poverty 28 37.9
Not able to find work Not able to find work Not able to find work 21 28.5
Poor access to dentistry care Poor access to dentistry care Poor access to dentistry care 21 28.5
Loneliness and boredom Loneliness and boredom Loneliness and boredom 21 28.5
Bad job conditions Bad job conditions Bad job conditions 20 27.1
Poor access to counseling services Poor access to counseling services Poor access to counseling services 19 25.7
Little government help with welfare Little government help with welfare Little government help with welfare 19 25.7
Little help with welfare from charities Little help with welfare from charities Little help with welfare from charities 19 25.7
Poor access to long-term medical care Poor access to long-term medical care Poor access to long-term medical care 18 24.4
Discrimination 17 23
Isolation 17 23
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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

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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

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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.