EXPERT ANALYSIS FROM APA

SAN DIEGO (FRONTLINE MEDICAL NEWS) – Psychiatrists may encounter refugee patients from war-torn countries in virtually every part of the United States with complex mental health needs, including high rates of posttraumatic stress disorder, chronic pain, and somatic symptoms, according to two presenters at the annual meeting of the American Psychiatric Association.

Over the past decade, refugees from Middle Eastern counties – particularly Iraq, Syria, and Afghanistan – have increased fourfold as a percentage of all refugees in the United States, while those from Sub-Saharan Africa continue to make up a large share. Despite heated political wrangling, the U.S. Department of State recently increased limits on the number of refugees that can be accepted. California, Texas, New York, Michigan, Ohio, and Washington are the states resettling the most new arrivals.

Refugees with trauma exposure have high rates of posttraumatic stress disorder, chronic pain, and somatic symptoms. In addition, recent research suggests, these refugees may have poorly understood stressors related to migration and adjustment that also may be significant contributors to mental illness risk. Despite this, refugees generally have less access to mental health care than does the general population.

The presenters shared their perspectives on refugee mental health with findings that could inform the timing and nature of interventions in these potentially vulnerable populations.

Cynthia L. Arfken, PhD , of Wayne State University in Detroit, presented results from an ongoing cohort study of Syrian families presenting to a primary care clinic as part of their State Department–mandated health check upon resettlement. Arash Javanbakht, MD , also of the university, led the research.

The investigators recruited families at a primary care clinic in southeastern Michigan, where refugees receive health assessments within the first month of arrival in the United States.

The researchers consecutively enrolled and evaluated 297 individuals, including 59 children aged 6 and older (mean age, 11.3) from Syria. These families represented 95% of refugees seen at the clinic during the study period, from June to December 2016.

The researchers also collected hair and saliva samples from consenting families for a separate study looking at biomarkers and mental health outcomes.

Adults were screened for PTSD using the PTSD checklist for adults , and children for anxiety using the Screen for Child Anxiety Related Emotional Disorders, or SCARED, measure. Psychiatric nurses and bilingual health care workers helped the team obtain consent and conduct assessments.

The researchers found that 61% of the children had a probable anxiety diagnosis, and nearly 85% had probable separation anxiety. Higher child anxiety scores were associated with higher PTSD scores in mothers (P = .05).

Dr. Arfken said in an interview that she and her team were “shocked” at the high prevalence of probable anxiety disorders in the cohort, in part because they’d conducted an earlier study enrolling adult Iraqi refugees and “found hardly any psychiatric symptoms at all.”

The high levels of anxiety seen among the Syrian refugees may be related to the severity of the ongoing conflict, Dr. Arfken said. The children’s results were sufficiently jarring to the team that “we changed our whole plan,” she said, “to concentrate on following up both the children who showed distress and those who did not.” They also attempted some nonmedical interventions, such as dance and mindfulness groups.

Also at the conference, Christopher Morrow, MD, of the University of Maryland in Baltimore, presented findings from a case study that illuminates some of the potential mental health risks for resettled refugees.

Dr. Morrow described a 31-year-old man from Afghanistan who had worked for the U.S. Special Forces in Afghanistan as a translator and subsequently entered the United States as a refugee. About a year later he was admitted to an inpatient psychiatric unit after a violent suicide attempt and was treated for depression.

The researchers noted that the patient had no previous history of depression or other mental illness prior to arriving in the United States. “His symptoms developed over the course of the first year of resettlement,” Dr. Morrow said in an interview.

This patient, Dr. Morrow said, was single and was not religious, leaving him not inclined to join a mosque or other Islamic community group. He was placed in an unskilled work assignment, despite his well-developed skills as a translator. Over the course of a year, he became increasingly isolated and “decompensated to the point where there was a really violent suicide attempt.

“We think that some kind of programmed follow-up – be it a community resource or through primary care – could have helped stabilize him before he got to a point of real hopelessness,” Dr. Morrow said.

Dr. Morrow and his colleagues proposed two interventions as adjustments to current health policy for refugees: adding universal mental health screening to each refugee’s health check in the first month after arrival, and scheduling follow-up later in the resettlement process.

“If there is active follow-up, a way that you could check in with these individuals as they’re acclimating, that’s probably the point where you could intervene best,” he said.

Dr. Morrow and Dr. Arfken disclosed no conflicts of interest related to their research.

cpnews@frontlinemedcom.com

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