Screening for Emotional Distress and Mental Health*

Scholars and health policy experts have long debated the role and use of early mental health screening to detect common mental disorders in refugees. Health screening protocols for refugees arriving to the United States have been deemed inadequate, in part at least, because of the lack of mental health screening.1 The Office of Refugee Resettlement guidelines require a health screening in the first 90 days; however, there has been a lack of procedural or financial support for mental health screening for refugees.2 In fact, state refugee health coordinators surveyed in 2010 reported that only 4 of the 44 states surveyed used a formal screening instrument and 68% used informal conversation.3

Understanding a refugee’s expression of distress requires careful consideration of a variety of factors including language, culture, the individual traumatic history and the client’s medical worldview and explanatory model of illness. A full understanding of these factors is best obtained during one or a series of diagnostic assessments. Screening is best thought of as a distinct process from diagnosis or assessment with the intent to efficiently detect common mental disorders and distress with reasonably high sensitivity and specificity.

Health screening or other clinical processes should entail important considerations for communication with refugees. Refugees, by definition, have endured experiences of harm, persecution and loss of security, all of which can reduce an individual’s level of trust. Therefore careful engagement of a refugee and consideration of their need for safety are important. Based on past experiences, many refugees hesitate to speak openly or disclose too much information for fear of retaliation, persecution or that the information will be used against them. Establishing a feeling of security is necessary for an accurate measure of health symptoms of any kind. Another issue affecting communication is the respect awarded to people in authority. In many cases, refugees will not initiate communication but will only respond to specific questions, and in some cases will avoid any appearance of disagreement even when a provider’s advice goes counter to the refugee’s belief or understanding. Language and cultural barriers make using trained interpreters and translated instruments a requirement. Clinicians working with refugees must have knowledge of and follow proper interpreter protocol, including having sufficient knowledge of the cultural context to ensure, for example, that an interpreter being used is not representative of a tribe, clan or ethnic group that had previously persecuted the patient’s refugee group. Clinicians can help overcome some of the challenges of communication by using concrete simple language, and focusing on symptoms, rather than diagnosis. Also, a clinician can never assume that a refugee understands the context of the medical encounter and should take time to provide clarity their role and intention.  Because the refugee experience is one of disempowerment, refugees are best served when provided with education about procedures and services that include opportunities for choice.

Besides post-traumatic stress disorder (PTSD), anxiety, and depression, mental health conditions that should be considered for screening include traumatic or acquired brain injuries, psychosis, and conditions previously undiagnosed in adults, including developmental delays, autism spectrum disorders and similar diagnoses. These conditions are often more complex, and may require additional visits or evaluations after primary mental health screening.

In a recent survey, respondents composed of U.S. refugee health coordinators identified the need for short, culturally appropriate mental health screening tools to identify refugees who need assessment and treatment services.3 The primary challenge of a screening instrument is that refugees are heterogeneous groups who collectively experience many psychological and somatic symptoms of distress. Theoretically, a screening instrument should include symptoms that optimally predict common disorders in multiple refugee groups with high efficiency.

The Vietnamese Depression Scale (VDS) consists of 15-items that effectively identifies depression in Vietnamese refugees.4 The Harvard Trauma Questionnaire (HTQ) has a 30-item section assessing symptoms that have been used as a proxy for PTSD.5 Both instruments were developed by expert consensus methods for use in the clinical setting. The 15-item Health Leaflet (HL) developed to screen for PTSD in two Iraqi language groups reported that the HL was 0.70 sensitive and specific to diagnosis, with two items (difficulty concentrating and exposure to torture), accounting for the discriminatory performance.6 A Diagnostic and Statistical Methods (DSM-IV) based symptom checklist developed by an expert consensus process identified a psychiatric disorder in nearly 14% of the 1,058 adult refugees in the Colorado Refugee Program.2

More recently, The Refugee Health Screener-15 (RHS-15) was developed and designed to be short (15 questions) with neutral language that does not directly address violence, torture, or trauma. The RHS-15 was empirically developed to be a valid, efficient and effective screener for common mental disorders (PTSD, anxiety, and depression) in refugees.7 The RHS-15 is composed of fourteen symptom items and a distress thermometer that predict each of three diagnostic proxies for common mental disorders with sensitivity ranging between .81 and .95 and specificity ranging from of .86 to .89. As of the start of 2014, this instrument is being utilized to screen refugees in over 40 sites around the world.

One concern expressed by physicians about mental health screening with refugees is that it may cause a strong emotional reaction. There is no evidence to suggest that physicians or any other provider or agency need to be concerned with this. Screening for symptoms instead of initially discussing trauma, torture, or other emotionally laden issues, will mitigate immediate distress. Effective screening of refugees in the public health or primary care setting may increase visit time and does require a focused effort. However, the need for services is great and outcomes have shown that there is value for refugees in receiving services. Ultimately, providers can support the healing process by creating a safe and engaged connection that allows refugees to improve their understanding of the medical system and have power over their own medical care.

A more detailed discussion of screening instruments can be found in the section Assessments for Trauma and Mental Health in Refugees.

*Primarily adapted from Rhema SH, Gray A, Verbillis-Kolp S, Farmer B, Hollifield M (2013) Screening for Mental Health in Refugees, in Refugee Health Care: An Essential Medical Guide. Annamalai A (Ed), Springer, New York.

1. Kennedy J, Seymour DJ, Hummel BJ. A comprehensive refugee health screening program [see comments]. Public Health Reports. 1999; 114(5): 469-77.
2. Savin D, Seymour DJ, Littleford LN, Bettridge J, Giese A. Findings from mental health screening of newly arrived refugees in Colorado. Public Health Rep. 2005; 120(3): 224-9.
3. 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.
4. Kinzie JD, Manson SM, Vinh DT, Tolan NT, Anh B, Pho TN. Development and validation of a Vietnamese-language depression rating scale. American Journal of Psychiatry. 1982; 139(10): 1276-81.
5. Mollica RF. The Harvard Trauma Questionnaire Manual: Indochinese Versions: Harvard University; undated.
6. Sondergaard HP, Ekblad S, Theorell T. Screening for post-traumatic stress disorder among refugees in Stockholm. Nord J Psychiatry. 2003; 57(3): 185-9.
6. 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.