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:
- Pharmacotherapy,11
- 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.
References
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