1. LORIN BOYNTON, MD & JAKE BENTLEY, MA Assessment and Management of Refugee Mental Health in Primary Care

2. Flexible Agenda Culturally Competent Care Clinical Case Discussion Cultural Case Study: Somali Refugees Research in local Somali community  Implications for primary care Resources  EthnoMed.org  UW Psychiatry Residency Training Program (online)  Prazosin article

3. LORIN BOYNTON, MD Culturally Competent Care

4. Why is it important? 2009: 27million refugees and immigrants-10% 2008 US Census: Minorities now 33% of US pop- majority by 2042 Increasing ethno-cultural diversity in US Health care policy and practices Principles of CCC apply to all patients Focus on Refugees and Immigrants

5. Ethno-cultural diversity

6. Challenges facing refugees/ immigrants in the clinical encounter Language barriers Differences in held values and cultural practices Deficits in cultural competence of providers

7. Definition of CCC High quality care delivered in a culturally sensitive manner

8. Objectives Levels at which culturally sensitive care occurs. Frameworks for clinical use.

9. Levels Individual level Group Practice level Institutional level

10. Individual level- what counts? Good communication Trust Relationship

11. Good communication Verbal – competent interpreter who the patient trusts Non-verbal- patience - kindness - respect - demonstrate an interest in understanding culture of pt - etiquette/ greeting

12. Trust No racism, prejudice or bias Pt must feel valued and understood Authority figure- be careful what you ask

13. Relationship Through good communication and trust relationships are built with patients

14. Connection Not always possible to gain knowledge/ background ahead of time in order to increase the chance of connection with a patient It is important to be open to unexpected chances of connection

15. Group practice level-what counts? Access to services Reminder calls- language; calender Continuity of care Respect- from the front desk to the exam room

16. Institutional level- what counts? Support of programs like Housecalls Interpreter services Hiring practices- diversity in the workforce Cultural Competence training programs Policies that ensure a fair environment for all personnel and patients

17. Frameworks for increasing cultural sensitivity and awareness Kleinman’s Eight Questions DSM IV Cultural Formulation

18. Arthur Kleinman’s Eight questions: 1. What do you think caused your problem? 2. Why do you think it started when it did? 3. What does your sickness do to you? How does it work? 4. How severe is your sickness? How long do you expect it to last? 5. What problems has your sickness caused you? 6. What do you fear about your sickness? 7. What kind of treatment do you think you should receive? 8. What are the most important results you hope to receive from this treatment?

19. Cultural Formulation Cultural Identity Cultural Explanations of Illness Cultural Factors related to Psychosocial Environment and Level of Functioning Cultural elements of individual/ clinician relationship Overall cultural assessment for diagnosis and care

20. Conclusion Providing culturally competent care leads to improved patient-provider relationships and communication This in turn leads to enhanced health care outcomes and reduced disparities

21. Clinical Case Discussion: How do we make a difference? “We convince by our presence” Walt Whitman

22. Cross-Cultural Assessment of Psychological Symptoms among Somali Refugees Jake Bentley, M.A.

23. Brief Cultural Profile: Somalia  Somalia is a war-torn, sub-Saharan East African country  A lack of centralized government since 1991 has contributed to the proliferation of inter-clan conflict and ultimately the emergence of civil war.  As of the end of 2006, ~460,000 Somalis were internationally displaced, representing an 18% increase in prevalence from one year prior (UNHCR, 2007)

24. Brief Cultural Profile: Somalia  Mental health is categorical  “sane” and “insane”  Traditional treatments  Quranic readings  Herbal remedies  Ritualistic ceremonies  Mental illness carries stigma  Somalis seek to resolve mental illness within the family  As a result, clinical treatment may only be sought after all other resources have been exhausted

25. Somali Mental Health  Somali refugees have been found to be at risk for:  PTSD  Depression  Anxiety  Somatization  Anecdotal clinical evidence  Relationship w/traumatic exposure remains unclear  Acculturative stress has been linked to depression  May be persistent years after resettlement Bhui et al., 2003; Bhui et al., 2006

26. Process of Migration Pre-Migration  Native cultural factors  Traumatic events Migration  Potential for additional traumatic experiences  Deprivation (e.g. physical, educational)  Malnutrition Post-Migration  Acculturation  Psychosocial challenges (e.g. discrimination, low SES)  Intergenerational conflict

27. Psychiatric Assessment in refugee populations Challenges are presented due to:  cross-cultural and linguistic differences  diverging perceptions about health and mental health  Arthur Kleinman’s notion of explanatory models  although many psychological disorders contain consistent features across cultures, cultural variations in perceptions and interpretations of bodily or cognitive experiences alter how the disorder is experienced by members of a given group. (Kleinman & Benson, 2006; Kleinman, 1987)

28. Assessing Somali Mental Health Few diagnostic questionnaires have been specifically designed for use with refugee populations  Hollifield and colleagues (2002) found that 125 different measures were used in the studies with 12 of these measures being designed specifically for use with refugee populations  Psychometric properties of these measures have been under-reported  Reliability  Validity  Sensitivity  Specificity

29. Research in Local Community The purpose of our project was to:  Provide preliminary psychometric evidence for a PTSD symptom questionnaire for use with Somalis  Evaluate the relative influence of pre- and post-migration factors on Somali mental health  Investigate the role of somatization in the report of psychiatric symptoms by Somalis Trauma Culture Somatization X

30. Measures Demographic form Harvard Trauma Questionnaire (HTQ) Traumatic Life Events PTSD Diagnostic Scale Hopkins Symptom Checklist -25 (HSCL-25) Depression Anxiety Symptom Checklist 90 – Somatization Subscale Post-Migration Living Difficulties Questionnaire (PMLD)

31. Sample Characteristics Table. Demographic Information for Sample of Somali refugees (N = 74) n% Sex Male4864.9 Female1925.7 Age 18 to 252736.7 26 to 30912.2 31 to 4056.8 41 to 5022.8 51 to 6034.2 61 to 70811 71 and older811 Marital Status Married2432.4 Unmarried4256.8 Religious Orientation Muslim4966.2 Unreported2533.8 Length of Residence in U.S. < 1 to 3 Years1013.7 3 to 5 Years1216.3 5 to 10 Years1621.7 > than 10 Years2432.1

32. Model 1

33. Model1: Trauma Predicting Symptoms  Harvard Trauma Questionnaire (HTQ):  Trauma Events Subscale (# of events)  16-item symptom subscale  Diagnostic cutoff = 2.00

34. Endorsement of PTSD Symptoms Table. Percentage of Participants Endorsing PTSD Symptoms on the HTQ n% Recurrent thoughts or memories of the most hurtful or terrifying events 2229.7 Feeling as though the event is happening again 3235.1 Recurrent nightmares 1722.9 Feeling detached or withdrawn from people 1722.9 Unable to feel emotions 1419.9 Feeling jumpy, easily startled 1419.9 Difficulty concentrating 1520.3 Trouble sleeping 1824.3 Feeling on guard 1824.3 Feeling irritable or having outbursts of anger 1723 Avoiding activities that remind you of the traumatic or hurtful event 1621.6 Inability to remember parts of the most hurtful or traumatic events 1722.9 Less interest in daily activities 2027 Feeling as if you don’t have a future 1824.3 Avoiding thoughts or feelings associated with the traumatic or hurtful events 1416.2 Sudden emotional or physical reaction when reminded of the most hurtful or traumatic events 1723

35. Model 2

36. Model 2: Somatization as Mediator  No mediation found for symptoms of PTSD  PTSD actually mediates the trauma-somatization relationship  Results indicated that, with the inclusion of Somatization in the model, the relationship between trauma and depression and anxiety became statistically non-significant  Said another way, trauma caused somatic complaints which in turn caused symptoms of depression and anxiety

37. Model 3

38. Model 3: PMLD Moderates Depression Results:  High # of living difficulties makes depression in low trauma group worse  This effect not seen for those w/ high trauma exposure  Trauma led to greater depression for those in the low to medium living difficulties group

39. Current Psychosocial Stressors Table. Report of Moderately Serious to Very Serious Post-Migration Stressors n% Worry about family back home4358.1 Separation from family3344.6 Inability to return home in case of emergency2939.3 Poverty2837.9 Not able to find work2128.5 Poor access to dentistry care2128.5 Loneliness and boredom2128.5 Bad job conditions2027.1 Poor access to counseling services1925.7 Little government help with welfare1925.7 Little help with welfare from charities1925.7 Poor access to long-term medical care1824.4 Discrimination1723 Isolation1723

40. Implications for Primary Care PTSD carries a different course than other mood disturbance (e.g. depression & anxiety)  Not significantly impacted by current stressors  Not accounted for by somatic complaints Somalis with mental health concerns are more likely to present to primary care than other settings  Also likely to present somatically for mood disturbance

41. Implications for Primary Care Treating somatic complaints alone may help with symptoms of depression and anxiety  Physical activity  Traditional treatments  Massage therapies  Relaxation & sleep improvement Counseling and resources to assist with psychosocial stressors can also reduce depressive symptomatology Handout: Four visit model of care  Link: scroll to page 21scroll to page 21

42. Resources EthnoMed.org UW Psychiatry Residency Training Program  Online Religion, Spirituality & Culture Curriculum Online Religion, Spirituality & Culture Curriculum Boynton, L., Bentley, J.A., Strachan, E., Barbato, A., & Raskind, M. (2009). Preliminary findings concerning the use of prazosin for the treatment of posttraumatic nightmares in a refugee population. Journal of Psychiatric Practice, 15(6), 454-459.