A general approach in primary care

G.E. Jarvis, M.D. October 2, 2018

!  Reviewtheburdenofmentalhealthdisordersindifferentmigrantgroupsandtheirdeterminants

!  Identifyriskfactorsandstrategiesintheapproachtomentalhealthassessmentandtoprevention

!  Treatmentapproachtocommonmentalhealthproblemsforimmigrantsinprimarycare

!  258 million international migrants worldwide !  10% of these were refugees(UnitedNations2017)!  Immigrantswerehealthieronaverage(healthyimmigranteffect)

!  Refugeesweremoredistressed! Mentalhealthproblemsofmigrantsoftengoneglectedorunnoticed(Beiser2005;Pottieetal2010)

! ComparedtothegeneralU.S.population,immigrantsarelesslikely!  tocomefromfamilieswithpsychiatricproblems!  tobediagnosedwithanxietydisorder,depression,andPTSD

!  Forthosewhoimmigrateaschildren,psychiatricmorbidityissimilartotheU.S.average

(Salas-Wrightetal2018)

!  InimmigrantstotheU.K.!  1.5timesgreaterriskforwhitemigrants!  2-4timesgreaterriskforPakistaniandBangladeshiimmigrants

!  Upto10timesgreaterriskforblackCaribbeanandAfricangroups

!  ElevatedratesinSurinameseandMoroccansintheNetherlands

!  ElevatedratesinEastAfricanmigrantstoSweden(Kirkbride2017)

!  PrevalencerateswerehigherthanaverageforPTSD,depressionandanxiety!  AverageprevalencerangesforPTSD:9-36%!  Averageprevalencerangesfordepression:5-44%!  Averageprevalencerangesforanxiety:4-40%(Turrinietal2017)

!  ExposuretotortureandthetotalnumberoftraumaeventswerethestrongestpredictorsofPTSDanddepression(ReportedinSilove2017)

FromKirmayeretal2011,p.E961

Few published guidelines exist on primary care approaches to the mental health problems of immigrants and refugees

! The Canadian Collaboration for Immigrant and Refugee Health (CCIRH) in 2011

! The Centers for Disease Control and Prevention (CDC) in 2015

! The American Academy of Family Physicians (AAFP) in 2017

CCIRH CDC AAFP

Country Canada UnitedStates UnitedStates

Year Kirmayeretal2011 DivisionofGlobalMigrationandQuarantine2015

Mishorietal2017

Targetissue Immigrantandrefugeementalhealth

Refugeementalhealth Refugeehealth

Approach General(immigrantsandrefugees)

Specific(refugees) Specific(refugees)

Targetaudience Generalpractitioner PrimarycarementalhealthscreeningatarrivaltotheU.S.

PrimarycaregeneralhealthscreeningatarrivaltotheU.S.

Goal Identifyriskfactorsandstrategies

Toprovidesuggestionsandresources

Toimprovemedicalassessment

Recommendations Systematicinquiryintomigrationandculturallyappropriatefollowup

Learnabouttheculturalbeliefsofrefugees

Adoptcross-culturalmedicineintomedicalpractice

LERNListentomigrationstoriesEngageculturalresourcesRememberspecialpopulationsNoticecommonproblems

! Premigrationfactors! Migrationfactors! Postmigrationfactors“Youdoctorshearus,butyoudonot

listentous.Itisdifferent”(Birame,refugeefromSenegal)

! Linguisticinterpreters! Culturebrokers! Families! Communityorganizations

!  Children!  Weretheydetained?Separatedfromtheirparents?!  Whatistheirunderstandingofthemigrationexperience?!  Whathasbeentheeffectofmigrationontheirschooling/literacy?

!  Women!  Didtheysuffersexualassault/GBV/IPV/genitalmutilation?!  80%(73/91)ofrefugeewomenreportedhavingexperiencedGBV;

35/91(38%)offemalerefugeesmadeGBVtheirprincipalrefugeeclaim;38/91(42%)disclosedGBVtotheteambutitwasnottherefugeeclaim

!  Elderly!  Havetheyjoinedfamilylaterinthemigrationprocess?!  Cantheylearnnewlanguagesandmakeacontributionintheir

newcountry?!  Whatextendedfamilyandcommunitynetworkshavetheylost?

! Depression! PTSDandanxiety! Chronicpainandsomaticdisorders

ListentomigrationhistoriesEngagefamilyandcommunityresourcesRemembervulnerablepopulationsNoticecommonmentaldisorders

!  AmanisdesignatedaterroristbytheCanadiangovernment

!  Adepressedmanbringshisfamilytotheevaluation

!  Awomanstopsparticipatingwithherreligiouscommunity

!  Awomancannolongerworkinthewarehouseafteraminoraccident

!  www.mcgill.ca/tcpsych! MulticulturalMentalHealthResourceCenter(MMHRC)

!  AnnualMcGillSummerPrograminSocialandCulturalPsychiatry&AdvancedStudyInstitute

!  Positionpapersandguidelines!  Crossculturalclinicaltools!  CulturalConsultationService(CCS)

www.multiculturalmentalhealth.ca

www.mcgill.ca/ccs