Guidelines for mental health screening during the domestic medical examination for newly arrived refugees
Published Date:April 16, 2012
Corporate Authors:National Center for Emerging and Zoonotic Infectious Diseases (U.S.), Division of Global Migration and Quarantine.
Description:Long-distance journeys and resettlement entail a set of engulfing life events (losses, changes, conflicts, and demands) that, although varying widely in kind and degree, may severely test a refugee's emotional resilience. Resettlement in a new country can produce profound psychological distress, even among the best prepared and most motivated. Given the nature of life-threatening experiences prior to and during flight from their home countries or (country of asylum/host country), as well as the difficult circumstances of existence in exile, refugees may be at particularly high risk for psychiatric symptoms.
Risk factors that may predispose refugees and asylum seekers to psychiatric symptoms and disorders include: exposure to war, state-sponsored violence and oppression, including torture, internment in refugee camps, human trafficking, physical displacement outside one's home country, loss of family members and prolonged separation, the stress of adapting to a new culture, low socioeconomic status, and unemployment. Studies have shown a high prevalence of depression, post-traumatic stress disorder (PTSD), panic attacks, somatization, and traumatic brain injuries in refugees. Depression and PTSD are prevalent in refugees who are not in clinical care for mental health, in addition to those identified for mental health interventions. Significant psychiatric symptoms may be present during the first few months following arrival to the United States. Various factors, including language, culture, religion, stigma, lack of transportation, work conflicts, and lack of child care, may constitute barriers for refugees accepting mental health diagnosis and/or treatment. However, reports suggest that early intervention may be helpful, despite cultural and other barriers to mental health treatment for refugees.
For most refugees, the domestic medical screening evaluation is the first interaction with the U.S. health-care system. As such, it presents an opportunity to educate them about mental health issues, discuss expected stress responses, and also acts as an opportunity to provide mental health resources. The goal of mental health screening during the domestic medical examination is to identify and triage refugees in need of mental health treatment. In the extreme, these mental health issues may be life-threatening. However, even when the problem is not an immediate threat, when identified and treated, improved mental health hygiene may assist refugees to integrate and live more productive lives in their new homeland. Addressing mental health issues in newly arrived refugees presents tremendous challenges to the care provider and the U.S. health-care system. Although this document cannot provide solutions to these challenges, it provides suggestions and resources for primary clinicians for mental health screening during the initial domestic medical examination. The recommendations provided must be tailored to a specific clinic's abilities and time, community referral resources, and the health system's ability to address issues identified.
General Points About Refugee Mental Health Screening
• Health clinics providing screening should have a good working relationship with refugee resettlement agencies. These agencies often provide transportation to and from health screening appointments and may facilitate ongoing primary care and consultation. Additionally, refugee resettlement case workers may have important observations or information that may be informative to clinicians regarding individual refugees.
• Acute psychiatric emergencies (e.g., suicidal/homicidal ideation) are seen infrequently during the domestic refugee examination, but do occasionally occur. In such cases, patients may not be able to wait for outpatient referral and formal psychiatric evaluation and hospitalization may be necessary. Clinical facilities conducting the domestic medical examination should have a mechanism in place for expedited referral for psychiatric evaluation in urgent situations.
• Clinicians performing the evaluations should attempt to educate themselves about the history and cultural beliefs of the refugee populations they serve. The Cultural Orientation Resource Center Website may be useful to clinicians trying to familiarize themselves with new cultures of populations resettling to the United States. (www.cal.org/co/overseas/prog_high_archive.html).
• Medically trained interpreters should be used during patient interviews whenever possible. Bicultural interpreters are preferred. If an interpreter is not available in person, telephone interpreter services can be utilized. In addition, medical staff should be trained in how to use interpreter services.
• Mental health screening may be different in each resettlement location, depending on both staffing of the particular health screening clinic and availability of local mental health services for referral.
• Refugees may not volunteer or admit symptoms at initial screening, but symptoms may emerge several months or years after resettlement. Therefore, follow-up primary care referral for on-going health care is imperative. Ideally, primary care clinicians should be familiar with refugee care, including diagnosis and treatment (and/or referral) of commonly encountered mental health conditions.
• Clinicians should be aware that many refugees, particularly those from cultures with stigmas against acknowledging psychiatric symptoms, may present with stress-related somatic symptoms. Refugees with unexplained somatic symptoms such as headaches, stomachaches, or back pain may benefit from referral to a mental health professional.
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