Mental Health in Primary Care for New Arrivals

Mental Health in Primary care for new arrivals

Part of the New Arrivals in Primary Care Curriculum

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Module created by: Victoria Kyerematen, MD, MS Family Medicine, PGY2

Welcome!

Background

MODULE 2

Screening tools

This interactive course is designed for healthcare professionals addressing the mental health needs of New Arrivals in Primary Care.

Trauma in New Arrivals

Trauma Informed Care

Patient Resources

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Duration: 30 minutes

Mental Health in New Arrivals

• Prevalence varies greatly and is likely underestimated.

• Depression and Anxiety plus non DSM measures of distress are higher than the DSM only diagnoses amongst this population

There is a hypothesized constellation of symptoms that contribute to this burden of mental health:

• Constant state of instability
• insecurity
• hypervigilinence

Table of contents

Mental Health in New Arrivals

Acculturative Stress

stress experienced by immigrants as they try to adapt to a new culture while preserving their own culture

Mental Health SCREENING

Mental Evaluation should include screening assessments for:

Single Screening tool:

• Refugee Health Screener
• Minnesota Wellness and Emotions Check
• WHO - 5

OR

Combintion of tools screening tools that includes Anxiety, Depression, Trauma

• Harvard Trauma Questionnaire
• Hopkins Symptom Checklist-25 (anxiety/depression)

• Primary Care PTSD-5

• PHQ, GAD

PLUS

Substance Abuse Screening

Table of Contents

Scroll through for examples of the screening tools. Many are available on your EMR.

Challenges to Screening

• Likert Scale-- provide tangible items like glasses of water
• Screening vs resources available
• Length of screening scores
• Culturally appropriate scores

• Wellbeing assessments may be a more effective way to measure and address distress

Triple Trauma Paradigm

Country of Origin

Host country

Flight

Trauma of what motivated the originally journey. [The persecution or fear of persecution] This is the historical trauma

Trauma from the journey leaving home country and going to another country. The physical danger, emotional drama, guilt of leaving others behind. This is can also be categorized as interpersonal trauma. Trauma between individuals.

Trauma from a hostile legal system or hostile residents, social isolation, loss of family, culture, identity. This is structural trauma, created by systems within a society

Trauma in Pediatric Patients

Somatic and Behaivoral Symptoms

Trauma is more likely to present as behavioral or somatic symptoms in pediatric patients.

Michael, a 32 year old man comes to your clinic for an urgent care visit to discuss his insomnia. He tells you he is new to Chicago and has recently completed a Domestic Medical Screening Exam.

Michael, a 32 year old man comes to your clinic for an urgent care visit to discuss his insomnia. He tells you he is new to Chicago and has recently completed a Domestic Medical Screening Exam.

Michael, a 32 year old man comes to your clinic for an urgent care visit to discuss his insomnia. He tells you he is new to Chicago and has recently completed a Domestic Medical Screening Exam.

Michael, a 32 year old man comes to your clinic for an urgent care visit to discuss his insomnia. He tells you he is new to Chicago and has recently completed a Domestic Medical Screening Exam.

Trauma informed care

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TRAUMA INFORMED CARE

TRAUMA

Substance Abuse and Mental Health Services Administration (SAMHSA)

events or circumstances experienced by an individual as physically or emotionally harmful or life-threatening, which result in adverse effects on the individual’s functioning and well-being

Safe, Caring, Inclusive

Trauma & New Arrivals

Table of Contents

Trauma Informed Care

Principles

• promoting physical and psychological safety
• building trusting relationships with patients and families
• providing peer support
• collaborating with patients and families
• supporting and fostering agency
• promoting intersectionality

Trauma Informed Care

Institutional Practice

• Create a safe environment for new arrivals
• evidence diversity is welcomed

• Use positive and welcoming language

• Use interpreters

• Ask patients about their comfort throughout the visit
• i.e. do they want the doors open or closed?

Trauma Informed Care

Trauma Informed Care

Strength based care: acknowledge and promote strengths, resiliency, and capacity to heal from trauma Prevent re-traumatization: create an immigrant friendly environment Promote Trusting Relationships: serve as a barrier to toxic stress “window of tolerance”: practice of sharing emotions within a tolerable range; ASK if it’s okay to discuss Recognize the impact of trauma, manifestations of trauma, and screen! Treat the manifestations appropriately Two generational approach (with peds) Know your local resources -- make sure they are safe/trustworthy Trauma does not always end with migration ADVOCACY!

Strategies

“No one chose to be a refugee, no one chooses this life, but together we can have a better experience”

- Yasin Refugee from Myanmar speaking to other refugees about the importance of community support

Summary

Mental Health in New Arrivals

Mental health is a complicated and layered topic within primary care for new arrivals. It is important to screen, assess, and treat all mental health conditions with cultural awareness and applying the principles of trauma informed care.

EMERGENCY SERVICES

Middle Eastern Immigrant and Refugee Alliance (MIRA)

• Free mental health counseling and advocacy services for women who are refugees
• Languages: Arabic

Address: 6420 N California Ave, Chicago, IL 60645Phone number: 773-409 4597Mujeres Latinas en Acción

• Free services for victims of domestic violence and sexual assault
• Parenting classes for all ages.
• Languages: Spanish and English

Address: 2124 W. 21st Pl. Chicago, IL 60608 Phone number: 773-890-7676Center on Halsted

• Advances community and secures the health and well-being of the LGBTQ people of Chicagoland and throughout the Midwest

Address: 3656 N Halsted St, Chicago, IL 60613 Phone: (773) 472-6469Website: https://www.centeronhalsted.orgApna Ghar

• Domestic and Gender violence services -- crisis intervention, emergency housing, counseling
• Arabic, Spanish, Amharic, Hindi/Urdu, Tamil, Polish, French, Tigrinya, Italian, English

Address: 4350 N. Broadway, 2nd Floor Chicago, IL 60613 24-hour Crisis Hotline: (773) 334-4663

additional community organiations

NAMI Mental Health Hotline : 312-563-0445 Suicide Prevention Lifeline : 1-800-273-8255 Illinois Domestic Violence Hotline : 1-877-863-6338 Health Alternative Services alternative to the emergency room for those experiencing emotional stress Languages: Spanish and English Address: 5001 W. Fullerton Ave. Chicago, IL. Phone: 312-850-0050 Walk-Ins or Calls Welcome

• Syrian Community Network
• ICNA
• RefugeeOne
• World Relief Chicagoland
• Centro Romero

• TRELLUS (formerly Asian Human Service Family Health)

National Alliance on Mental Illness – Chicago (NAMI)

• Free recovery-focused groups and family support groups
• No ID required. The family and recovery group takes place in Spanish
• Every second and fourth Thursday of the month from 6 to 8 p.m, family & recovery group in Spanish

Address: 1801 W. Warner Ave., Suite 202, Chicago, IL 60613Helpline number: 833-626-4244Coalition of Immigrant Mental Health

• collaborative community based and research informed initiative

Mental Health Resource Directory: https://www.ourcimh.org/mh-resources

References

Patient Resources

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COllaborators

Faculty: Christopher Boisselle, MD Milap Bhatt, DO Team Members: Desiree Sosa Lopez, MD Safia Ahmed, MD Trina Bhattarai, DO Collaborators: Northside Refugee & Asylum Seeker Coalition Special Thanks to Emily Ledesma, LCSW, PMH-C ELI mentor: Suzanne Allen, MD, MPH AAFP Emerging Leaders Institute

This project was completed with support from the American Academy of Family Physicians Foundation through its Family Medicine Leads Emerging Leader Institute program.

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MODULE 1

MODULE 1

References

CDC. “Mental Health.” Immigrant and Refugee Health, Centers for Disease Control and Prevention, 14 May 2024, www.cdc.gov/immigrant-refugee-health/hcp/domestic-guidance/mental-health.html. Center for Health Care Strategies. “Video title as described above.” Trauma-Informed Care Implementation Resource Center. Available at: https://www.traumainformedcare.chcs.org/trauma-informed-champions-from-treaters-to-healers/. Close, C., Kouvonen, A., Bosqui, T. et al. The mental health and wellbeing of first generation migrants: a systematic-narrative review of reviews. Global Health 12, 47 (2016). https://doi.org/10.1186/s12992-016-0187-3 CIMH. “Mental Health Resources.” The Coalition for Immigrant Mental Health, 2021, ourcimh.org/mh-resources. E. Penuela-O'Brien, M. W. Wan, D. Edge and K. Berry , "Health professionals’ experiences of and attitudes towards mental healthcare for migrants and refugees in Europe: A qualitative systematic review," Transcultural Psychiatry, vol. 60, no. 1, pp. 176-198, 20232. Hollifield, Michael & Verbillis-Kolp, Sasha & Farmer, Beth & Toolson, Eric & Woldehaimanot, Tsegaba & Yamazaki, Junko & Holland, Annette & Clair, Janet & Soohoo, Janet. (2013). The Refugee Health Screener-15 (RHS-15): Development and validation of an instrument for anxiety, depression, and PTSD in refugees. General hospital psychiatry. 35. 10.1016/j.genhosppsych.2012.12.002. JA Ewing “Detecting Alcoholism: The CAGE Questionaire” JAMA 252: 1905-1907, 1984. Kroenke, K. & Spitzer, R.L. (2002). The PHQ-9: A new depression and diagnostic severity measure. Psychiatric Annals, 32, 509-521. Miller KK, Brown CR, Shramko M, Svetaz MV. Applying Trauma-Informed Practices to the Care of Refugee and Immigrant Youth: 10 Clinical Pearls. Children (Basel). 2019 Aug 20;6(8):94. doi: 10.3390/children6080094. PMID: 31434278; PMCID: PMC6721394. MN Dept of Health. “Domestic Refugee Health Screening Guidancemental Health Screening.” Domestic Refugee Health Screening Guidance Mental Health Screening - MN Dept. of Health, July 2022, www.health.state.mn.us/communities/rih/guide/10mentalhealth.html#NaN. Peterson, Sarah. “Effects.” The National Child Traumatic Stress Network, 4 Sept. 2018, www.nctsn.org/what-is-child-trauma/trauma-types/refugee-trauma/effects. Spitzer, R. L., Kroenke, K., Williams, J. B. W., Löwe, B. (2006). A brief measure for assessing generalized anxiety disorder: The GAD-7. Archives of Internal Medicine, 166(10), 1092-1097.

Complete Course

Mental Health in Refugees

according to one meta-analysis published in 2020 there was a prevalence of the following MH conditions between 2003 and 2020

• PTSD 31.46%
• Depression 31.5%
• Anxiety disorders 11%
• psychosis was 1.51%

Blackmore R, Boyle JA, Fazel M, Ranasinha S, Gray KM, Fitzgerald G, Misso M, Gibson-Helm M. The prevalence of mental illness in refugees and asylum seekers: A systematic review and meta-analysis. PLoS Med. 2020 Sep 21;17(9):e1003337. doi: 10.1371/journal.pmed.1003337. PMID: 32956381; PMCID: PMC7505461.

• 82% prevalence of reported trauma among undocumented Mexican immigrants, with 3% estimate of PTSD
• One meta-analysis estimated the prevalence PTSD to be 31%, depression 31%, and anxiety 11%, and psychosis 1.5% amongst refugees and asylum seekers globally

New arrivals often face multiple sources of trauma that can significantly impact their well-being. These sources include persecution, war or violence, and a well-founded fear of persecution based on race, religion, nationality, political opinion, or membership in a particular social group. Additionally, the trauma of the journey itself, adapting to a new country and culture, and the isolation that can come with it further contribute to their distress. Understanding that these factors may influence their quality of life is crucial for providing effective and compassionate care

Giacco, D., Laxhman, N., & Priebe, S. (2018). Prevalence of and risk factors for mental disorders in refugees. Seminars in Cell & Developmental Biology, 77, 144–152. https://doi.org/10.1016/j.semcdb.2017.11.030

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