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Assessment and Management of Refugee Mental Health in Primary Care . Lorin Boynton, MD & Jake Bentley, MA. Flexible Agenda. Culturally Competent Care Clinical Case Discussion Cultural Case Study: Somali Refugees Research in local Somali community Implications for primary care Resources

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assessment and management of refugee mental health in primary care

Assessment and Management of Refugee Mental Health in Primary Care 

Lorin Boynton, MD & Jake Bentley, MA

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

Lorin Boynton, MD

why is it important
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
challenges facing refugees immigrants in the clinical encounter
Challenges facing refugees/ immigrants in the clinical encounter
  • Language barriers
  • Differences in held values and cultural practices
  • Deficits in cultural competence of providers
definition of ccc
Definition of CCC
  • High quality care delivered in a culturally sensitive manner
  • Levels at which culturally sensitive care occurs.
  • Frameworks for clinical use.
  • Individual level
  • Group Practice level
  • Institutional level
individual level what counts
Individual level- what counts?
  • Good communication
  • Trust
  • Relationship
good communication
Good communication
  • Verbal – competent interpreter who the patient trusts
  • Non-verbal- patience - kindness - respect - demonstrate an interest in understanding culture of pt - etiquette/ greeting
  • No racism, prejudice or bias
  • Pt must feel valued and understood
  • Authority figure- be careful what you ask
  • Through good communication and trust relationships are built with patients
  • 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
Group practice level-what counts?
  • Access to services
  • Reminder calls- language; calender
  • Continuity of care
  • Respect- from the front desk to the exam room
institutional level what counts
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
frameworks for increasing cultural sensitivity and awareness
Frameworks for increasing cultural sensitivity and awareness
  • Kleinman’s Eight Questions
  • DSM IV Cultural Formulation
arthur kleinman s eight questions
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?
cultural formulation
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
  • 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
Clinical Case Discussion:How do we make a difference?

“We convince by our presence”Walt Whitman

brief cultural profile somalia
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 somalia1
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 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
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
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
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
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


  • 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)
model1 trauma predicting symptoms
Model1: Trauma Predicting Symptoms
  • Harvard Trauma Questionnaire (HTQ):
    • Trauma Events Subscale (# of events)
    • 16-item symptom subscale
    • Diagnostic cutoff = 2.00
model 2 somatization as mediator
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 pmld moderates depression
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
implications for primary care
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 care1
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
  • 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.