Challenges and Opportunities of Caring for Refugees

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Armed conflicts in multiple regions of the world have led to international displacement of millions of people during the past few years. Decades of ongoing war and unrest in Iraq, and several years of war in Syria, have exposed millions of people in these 2 countries to chronic and cumulative stress and trauma. The US has been accepting Iraqi refugees, and the former administration planned to welcome 10,000 Syrian refugees to this country.

In addition to a humanitarian crisis, the refugees are now part of the US political discourse. The highlighting of the political implications of accepting refugees has led to involvement of the American people in the conversation through social media and at the dinner table.

Lost in this discussion are the mental health needs of Syrian and other refugees. This is not surprising as the main focus of resettlement has been on security and their immediate housing, finances, and physical health care needs. Moreover, mental health assessment, which requires greater language and cultural proficiency, is more challenging than conducting a physical examination because of language and cultural differences.

PTSD in refugees

Unfortunately, the extant literature is not very helpful in predicting how many of the new refugees will have PTSD or other mental health problems. Across studies on refugee populations settled in different parts of the world, the prevalence of PTSD has been as low as 2% (surprisingly less than the US general population) and as high as 86%.¹ Studies restricted to Middle Eastern refugees have not been more consistent.^1-4 Besides sampling and measurement differences among the studies, the range in prevalence could well be due to various factors, including:

• Sources of trauma (eg, torture, resource deprivation, exposure to war)

• Distance from the conflict areas prior to departure from the home country

• Extent and duration of exposure to cumulative trauma and number of traumatic events

• Loss of an immediate family member to trauma

• Separation from the family during resettlement

• Time since exposure to trauma

• Difficulties faced prior to and during resettlement in the new environment

Familiarity with the culture and language of the new environment; perception of being welcomed; financial, housing, and health care resources in the new environment; employment; and level of uncertainty can all affect the ongoing level of stress, which in turn can reduce or increase severity of the PTSD/depression symptoms, below or above the diagnostic threshold.

Trauma among Syrian refugees

As home to one of the largest Arab communities in the US, the State of Michigan has welcomed thousands of refugees from Iraq and Syria. During the past year, our research team at the Wayne State University Department of Psychiatry and Behavioral Neurosciences-in collaboration with a well-respected social service agency, the Arab American Chaldean Council-has been assessing trauma and its impact on Syrian refugees. We interview children and adult refugees during the first few weeks of their arrival in the US. We collect demographic data; screen for PTSD, depression, and anxiety; and collect biological samples to examine genetic vulnerability, the role of inflammation, and cumulative level of physiological stress during the few months prior to arrival in the US.

Data have been collected on nearly 500 refugees. Having been able to recruit more than 90% of the eligible refugees, we believe that our findings will be robustly representative of the refugee population. Our team of interviewers consists of bicultural and bilingual doctors, and their experience in clinical work and the level of cultural trust have contributed to our success with recruitment.

Our findings suggest a high level of distress: a third of the adults screen positive for PTSD (compared with a 7.8% lifetime prevalence in the general population⁵). Almost half of the refugees screen positive for anxiety and for depression. Not surprisingly, comorbid depression is seen in more than 80% of refugees with PTSD. More than half of the children screen positive for a potential anxiety disorder, and their level of symptoms correlates with the severity of PTSD symptoms in their mothers. Lastly, the percentage of children who screen positive for PTSD is more than 4 times that of the general US child and adolescent population.⁶

Genetic data obtained from saliva will be used to see if genetic risk and vulnerability factors found in other traumatized groups can be replicated in this unique population. Previous work in whites and African Americans has linked polymorphism in a few genes involved in serotonin and norepinephrine neurotransmission as well as in hypothalamic-pituitary-adrenal axis regulation to vulnerability to PTSD, especially in the context of childhood trauma.⁷ In addition, cumulative evidence links inflammation to the development of PTSD and symptom severity.8 Inflammation markers including interleukin (IL)-1β, IL-6, tumor necrosis factor-α, and C-reactive protein are associated with PTSD. In our study, we measure salivary inflammation markers. Finally, measurement of cortisol accumulation in hair will help us determine the level of cumulative physiological stress during the few months before arrival in the US.

Challenges and opportunities

Syrian refugees have unique challenges to face in the US. Besides cultural and language differences, downward social status drift, difficulties with housing and unemployment, and changes in the family dynamics (children may have to take a more prominent role in the family as they adapt faster to language, culture, and technology), Syrian refugees face additional stress because of the ongoing political discourse. To researchers of stress and trauma and to clinicians who deal with anxiety, the negative effects of lack of control and uncertainty are a familiar concept. Symptom severity can increase during times of uncertainty surrounding employment, relationships, and academic function, which can lead to relapse of mental illness previously in remission.

Following the issuance of executive orders and changing policy on welcoming Syrian refugees in the US, this uncertainty and lack of control have increased significantly. Refugees are extremely stressed, afraid that they may have to leave the country and go back to the dangerous situation from which they fled. Families are terrified that their loved ones, who after years of uncertainty were accepted to come to the US, won’t be able to join them, and consequently their lives may be in danger. There have even been times that refugees worried that answering researchers’ questions could lead to deportation.

The role of mental health professionals in caring for the refugee population may be complicated as well. First, psychiatrists in general are less equipped with tools for addressing and treating trauma than for other disorders. Although many residencies have extensive training for treatment of psychosis, bipolar disorder, and depression, they are not as detailed in diagnosis and treatment of trauma and PTSD. The clinical picture gets even more complicated as patients do not always admit to trauma symptoms, and many avoid this sensitive and painful area.

Trauma experts commonly see patients who have been struggling with PTSD or other effects of trauma for years before it was addressed. Given the high rate of exposure to trauma and stress in the refugee population and the diverse forms and levels of presentation of trauma, mental health professionals have to be sensitive and alert when exploring symptoms of trauma.

Language barriers and cultural differences are other challenges faced in an effort to provide quality treatment. Symptom presentations may be different, and somatic symptoms may be more common. Acceptance of psychopharmacological intervention, drug metabolism, and medication adverse effects may differ. Meaningful material may be lost in translation, and acceptance of the patient-centered model of care may be challenging.

Although in the era of DSM and psychopharmacology the focus is more on biological treatments, psychosocial issues are critical in understanding the level of stress in this population. There is a need for culturally attuned and sensitive interpreters, and a focus on the impact of trauma on the entire family unit. Challenges of any population dealing with poverty and downward socioeconomic drift have to be faced. A careful focus on children is necessary-accumulating evidence indicates the important role of childhood poverty for later adult trauma, depression, and medical illness.

Because of lack of access and uneven geographical distribution of providers with needed language and cultural skills, telepsychiatry can be a valuable asset. It has been used to address PTSD in refugee populations resettling in the Middle East with reasonable acceptance.9 However, barriers to reimbursement complicate this procedure. Our team is working to develop family-oriented care combined with telepsychiatry. In this model, a bicultural social worker goes to families’ homes to address different aspects of the needs of the family. A psychiatrist is available through telepsychiatry to provide in-home care with the help of the social worker when needed.

Finally, as there is a multitude of different opinions about the entry of refugees to the US, mental health providers have to work diligently to keep their personal and political opinions out of medical care. As mental health providers, we have to be advocates for this vulnerable population and voice the need for treatment of their “invisible wounds.” In less than 2 decades, a 6-year-old Syrian child who came here as a refugee will be an American adult. Based on what happens during the next 2 decades, this child may become an integrated, functional, happy, and productive American, or a segregated, less functional, and marginalized member of society. We have a critical role in advocacy and mental health care as well as in promoting the integration of refugees into their new country.

Editor’s note: The study of risk and resilience among Syrian refugees in Southeast Michigan has been featured on STAT News, CBS Detroit, and CNN.

MORE ABOUT Arash Javanbakht, MD

[[{"type":"media","view_mode":"media_crop","fid":"59838","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_4180262585187","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"7537","media_crop_rotate":"0","media_crop_scale_h":"190","media_crop_scale_w":"250","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"font-size: 13.008px; float: right;","title":" ","typeof":"foaf:Image"}}]]I was born and raised in Mashhad, the second largest city in Iran, located in the northeast of the country. As a child I wanted to be an astrophysicist or movie director, but as an adult I ended up directing the Stress, Trauma, and Anxiety Research clinic! I visited the US about 10 years ago to give a grand round at Wayne State University and was offered a position that allowed me to stay and collaborate on research. After completing a research track residency at the University of Michigan with a focus on neurobiology and the treatment of anxiety and PTSD, about 2 years ago I returned to the Wayne State University Department of Psychiatry and Behavioral Neurosciences as a tenure-track assistant professor.

I treat patients with anxiety and PTSD in the office and through telepsychiatry. As a practicing psychiatrist, I use medications and psychotherapy. My focus is on improving patients’ social life, educating patients on the benefits of exercise and healthy nutrition, and engaging patients with what they find meaningful. As a researcher, I am excited about learning the neurobiology of anxiety and trauma, and how psychotherapy changes the brain. I find how changes in the brain translate into behavior fascinating. I also work on using technology in advancing the quality of psychiatric care and in improving accessibility.

I speak Farsi (the official language of Iran) and English and can understand formal Arabic, as well as a little French. My hobbies include boxing (I do not fight; my nose is too easily accessible), longbow archery, traveling, pottery, and gardening. When I was a medical student, I wrote a book on Jungian dream analysis, which actually got published! Hailey is my black Lab, a loyal friend who loves to share her toys with people. I have always been fascinated by the teachings of ancient Iranian Sufism, which focuses on discovery of one’s true self, beyond what one is told should or should not be.

Disclosures:

Dr. Javanbakht is Assistant Professor, Director of Stress, Trauma, and Anxiety Research Clinic (STARC), Department of Psychiatry and Behavioral Neuroscience, Wayne State University; and Adjunct Assistant Professor, Department of Psychiatry, University of Michigan in Ann Arbor. Dr. Arfken is Professor, Department of Psychiatry and Behavioral Neurosciences, Wayne State University in Detroit, MI.

The authors report no conflicts of interest concerning the subject matter of this article.

References:

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2. Karam EG, Mneimneh ZN, Karam AN, et al. Prevalence and treatment of mental disorders in Lebanon: a national epidemiological survey. Lancet. 2006;367:1000-1006.

3. Alpak G, Unal A, Bulbul F, et al. Post-traumatic stress disorder among Syrian refugees in Turkey: a cross-sectional study. Int J Psychiatry Clin Pract. 2015;19:45-50.

4. Wright AM, Talia YR, Aldhalimi A, et al. Kidnapping and mental health in Iraqi refugees: the role of resilience. J Immigr Minor Health. 2017;19:98-107.

5. Kessler RC, Sonnega A, Bromet E, et al. Posttraumatic stress disorder in the National Comorbidity Survey. Arch Gen Psychiatry. 1995;52:1048-1060.

6. Kilpatrick DG, Ruggiero KJ, Acierno R, et al. Violence and risk of PTSD, major depression, substance abuse/dependence, and comorbidity: results from the National Survey of Adolescents. J Consult Clin Psychol. 2003;71:692-700.

7. Banerjee SB, Morrison FG, Ressler KJ. Genetic approaches for the study of PTSD: advances and challenges. Neurosci Lett. 2017;pii:S0304-3940.

8. Michopoulos V, Powers A, Gillespie CF, et al. Inflammation in fear- and anxiety-based disorders: PTSD, GAD, and beyond. Neuropsychopharmacology. 2017;42:254-270.

9. Nassan M, Frye MA, Adi A, Alarcón RD. Telepsychiatry for post-traumatic stress disorder: a call for action in the Syrian conflict. Lancet Psychiatry. 2015;2:866.