In order for refugees to receive treatment and services for distress, barriers to care must first be identified and overcome. In 2010, only 18% of state refugee health coordinators reported that they use any standard instruments to screen the mental health of incoming refugees making detection of mental health services difficult.1 Until recently, a lack of an efficient and valid culturally-informed instrument for detecting common mental disorders (CMD) across refugee groups was a primary barrier. This has been remedied by the development of the Refugee Health Screener-15 (RHS-15), which is an efficient instrument shown to be valid for detecting common mental disorders in at least three ethnic refugee populations.2
Refugees encounter a myriad of obstacles that prevent their receipt of treatment and services for CMD. Major barriers to the detection of CMD include cost, inaccessible care, lack of mental health services, and cultural or conceptual differences in health perceptions.3
It has also been shown that general health disparities in refugees and marginalized populations are partly due to the effects of both pre- and post-migration stress4-8 and poor general access to and engagement in care.9 These disparities are driven by multiple structural and internal barriers.3, 10 The structural barriers include resettlement challenges such as shelter, food, and employment insecurity; affordability, limited mental health services, inadequate interpretation, access to urgent care only, and poor provider cultural competency. The internal barriers include mental illness itself, fatalism, mistrust, and perceived discrimination. There are also barriers of social assimilation, including difficulty navigating a complex system and inadequate community support.9
Various specific professional treatments have shown some preliminary efficacy for CMD in refugees once they actually obtain care. As of this writing, there is no standard of care for treatment of CMD in refugees. Interventions that have shown efficacy in research studies include the following:
- Culturally-adapted psychotherapy for PSTD, depression, and anxiety,12-17
- Psychological first aid,18
- School-based education and trauma healing exercises for children,19, 20
- Multi-family disclosure, education, and support,21, 22
- Trauma disclosure and testimony therapy for adults and children,23-26
- The use of lay-counselors for larger populations,27, 28
- Qigong and tai’chi,29
- Dance and movement therapies.30
While all of these studies represent good work about treatment efficacy, it is critical to highlight that no studies definitively identify the most efficacious or specific treatment(s) for the broad range of refugees. Also, the studies do not provide knowledge about the effectiveness of a more culturally-informed system of stepped care for refugees. Such a system of care would reduce barriers to health care by addressing them from the time refugees enter the medical care system at the domestic medical health evaluation. Culturally-informed care is a way to encourage hope, trust, and a sense of fairness. In addition, culturally sensitive care help refugees understand and begin to build bridges between explanatory models of the refugee patient and the U.S. medical/psychiatric system.
There is some support for a culturally-informed model of care using adjustment support groups to deliver education, support, and linkages to community services. During the support groups, refugees are provided peer and professional support while also being assessed on an ongoing basis for the need of further professional treatment. Such a culturally-informed model of care deserves further attention and research to promote healing for the complex distress in refugees.
1 Shannon P, Im H, Becher E, Simmilink J, Weiling E, O’Fallon A. Screening for war trauma, torture, and mental health symptoms among newly-arrived refugees: A national survey of U.S. refugee health coordinators. J Immigr Refugee Studies. 2012; 10(4): 380-94.
2. Hollifield M, Verbillis-Kolp S, Farmer B, Toolson EC, Woldehaimanot T, Yamazaki J, et al. The Refugee Health Screener-15 (RHS-15): development and validation of an instrument for anxiety, depression, and PTSD in refugees. General Hospital Psychiatry. 2013; 35(2): 202-9.
3. Ovitt N LC, Nackerud L. Refugees’ response to mental health screening. International Social Work. 2003; 49(2): 235-50.
4. Carswell K, Blackburn P, Barker C. The relationship between trauma, post-migration problems and the psychological well-being of refugees and asylum seekers. Int J Soc Psychiatry. 2011; 57(2): 107-19.
5. Fenta H, Hyman I, Noh S. Determinants of depression among Ethiopian immigrants and refugees in Toronto. Journal of Nervous & Mental Disease. 2004; 192(5): 363-72.
6. Laban CJ, Gernaat HB, Komproe IH, van der Tweel I, De Jong JT. Postmigration living problems and common psychiatric disorders in Iraqi asylum seekers in the Netherlands. Journal of Nervous & Mental Disease. 2004; 193(12): 825-32.
7. Momartin S, Steel Z, Coello M, Aroche J, Silove D, Brooks R. A comparison of the mental health of refugees with temporary versus permanent protection visas. Med J Aust. 2006; 185(7): 357-61.
8. Porter M, Haslam N. Predisplacement and postdisplacement factors associated with mental health of refugees and internally displaced persons: a meta-analysis. JAMA. 2005; 294: 602-12.
9. Asgary R, Segar N. Barriers to health care access among refugee asylum seekers. Journal of Health Care for the Poor and Underserved. 2011; 22(2): 506-22.
10. Fung K, Wong YL. Factors influencing attitudes towards seeking professional help among East and Southeast Asian immigrant and refugee women. Int J Soc Psychiatry. 2007; 53(3): 216-31.
11. Boynton L, Bentley J, Strachan E, Barbato A, Raskind M. Preliminary findings concerning the use of prazosin for the treatment of posttraumatic nightmares in a refugee population. J Psychiatr Pract. 2009; 15(6): 454-9.
12. Hinton DE, Otto MW. Symptom Presentation and Symptom Meaning Among Traumatized Cambodian Refugees: Relevance to a Somatically Focused Cognitive-Behavior Therapy. Cogn Behav Pract. 2006; 13(4): 249-60.
13. Hinton DE, Hofmann SG, Pollack MH, Otto MW. Mechanisms of efficacy of CBT for Cambodian refugees with PTSD: improvement in emotion regulation and orthostatic blood pressure response. CNS Neurosci Ther. 2009; 15(3): 255-63.
14. Otto MW, Hinton DE. Modifying Exposure-Based CBT for Cambodian Refugees with Posttraumatic Stress Disorder. Cogn Behav Pract. 2006; 13(4): 261-70.
15. Paunovic N, Ost LG. Cognitive-behavior therapy vs exposure therapy in the treatment of PTSD in refugees. Behav Res Ther. 2001; 39(10): 1183-97.
16. Renner W. The effectiveness of psychotherapy with refugees and asylum seekers: preliminary results from an Austrian study. J Immigr Minor Health. 2009; 11(1): 41-5.
17. Smajkic A, Weine S, Djuric-Bijedic Z, Boskailo E, Lewis J, Pavkovic I. Sertraline, paroxetine, and venlafaxine in refugee posttraumatic stress disorder with depression symptoms. J Trauma Stress. 2001; 14(3): 445-52.
18. Brymer MJ, Steinberg AM, Sornborger J, Layne CM, Pynoos RS. Acute interventions for refugee children and families. Child Adolesc Psychiatr Clin N Am. 2008; 17(3): 625-40, ix.
19. Fazel M, Doll H, Stein A. A school-based mental health intervention for refugee children: an exploratory study. Clin Child Psychol Psychiatry. 2009; 14(2): 297-309.
20. Gupta L, Zimmer C. Psychosocial intervention for war-affected children in Sierra Leone. Br J Psychiatry. 2008; 192(3): 212-6.
21. Weine SM, Raina D, Zhubi M, Delesi M, Huseni D, Feetham S, et al. The TAFES multi-family group intervention for Kosovar refugees: a feasibility study. J Nerv Ment Dis. 2003; 191(2): 100-7.
22. Weine S, Kulauzovic Y, Klebic A, Besic S, Mujagic A, Muzurovic J, et al. Evaluating a multiple-family group access intervention for refugees with PTSD. J Marital Fam Ther. 2008; 34(2): 149-64.
23. Lustig SL, Tennakoon L. Testimonials, narratives, stories, and drawings: child refugees as witnesses. Child Adolesc Psychiatr Clin N Am. 2008; 17(3): 569-84, viii.
24. Neuner F, Schauer M, Klaschik C, Karunakara U, Elbert T. A comparison of narrative exposure therapy, supportive counseling, and psychoeducation for treating posttraumatic stress disorder in an african refugee settlement. J Consult Clin Psychol. 2004; 72(4): 579-87.
25. Onyut LP, Neuner F, Schauer E, Ertl V, Odenwald M, Schauer M, et al. Narrative Exposure Therapy as a treatment for child war survivors with posttraumatic stress disorder: two case reports and a pilot study in an African refugee settlement. BMC Psychiatry. 2005; 5: 7.
26. Weine SM, Kulenovic AD, Pavkovic I, Gibbons R. Testimony psychotherapy in Bosnian refugees: a pilot study. American Journal of Psychiatry. 1998; 155(12): 1720-6.
27. Neuner F, Onyut PL, Ertl V, Odenwald M, Schauer E, Elbert T. Treatment of posttraumatic stress disorder by trained lay counselors in an African refugee settlement: a randomized controlled trial. J Consult Clin Psychol. 2008; 76(4): 686-94.
28. Stepakoff S, Hubbard J, Katoh M, Falk E, Mikulu JB, Nkhoma P, et al. Trauma healing in refugee camps in Guinea: a psychosocial program for Liberian and Sierra Leonean survivors of torture and war. Am Psychol. 2006; 61(8): 921-32.
29. Grodin MA, Piwowarczyk L, Fulker D, Bazazi AR, Saper RB. Treating survivors of torture and refugee trauma: a preliminary case series using qigong and t’ai chi. J Altern Complement Med. 2008; 14(7): 801-6.
30. Harris DA. Dance/movement therapy approaches to fostering resilience and recovery among African adolescent torture survivors. Torture. 2007; 17(2): 134-55.