lorin boynton, md & jake bentley, ma assessment and management of refugee mental health in...
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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.