1. WHAT DO WE KNOW?

2.  WHO: An average of more than 50% of refugees present mental health problems….  WHO: PTSD or depression 30-40% in post conflict populations Bulletin of WHO, Jan, 2005 83 (1)  CDC: 30-70% of people who have lived in war zones suffer from symptoms of post traumatic stress (PTSD) and depression

3.  Bhutanese refugees: 3 out of 4 have had PTSD at some point in life (Medicine, Conflict &Survival, 24 (2008) 5-15)  Karenni refugees: depression 42%, anxiety 41%, and PTSD 4.6% (Science &Medicine, 58 (2004) 2637–2644 )  Iranian, Iraqi, Lebanese, Somali, Columbian, Salvadoran, Ethiopian, Angolan and Bangladeshi 8 years after exile: 50% PTSD (The Journal of Nervous and Mental Disease, 185 (1997)39-45  Burmese political exiles: 40% depression (American Journal of Public Health, 86 (1996)1561-69) See: An Annotated Bibliography on Refugee Mental Health,2005 www.refugeewellbeing.samhsa.gov

4.  Prevalence of serious mental disorder in 7000 refugees resettled in western countries: a systematic review. The Lancet, (2005) Volume 365, Issue 9467, Pages 1309-131420

5.  Depression:  Estimated 8% of refugees resettled in the United States had major depression  Higher than the population rate and similar to the rate in primary care patients in U.S  Anxiety  4% of the refugees were reported to have Generalized Anxiety Disorder  9% adults were diagnosed with post-traumatic stress disorder  44% of refugees with PTSD also had major depression  11% of 260 refugee children from three countries met criteria for PTSD

6.  War trauma has been found to be highly predictive of PTSD but not of depression ( Hsu et al., 2004 Clinical Psychology Review, Volunte24, Issue 2 May 2004, Pages 193-213)  Refugees with a dx of PTSD and depression had higher rates of suicidal ideation than those with only PTSD but a lower rate of suicide attempts Acta Psychiatrica Scandinavica.96:108-117 PTSD in the absence of depression was more predictive of suicidal behavior than PTSD with depression The Lancet, Volume 365, Issue 9467, Pages 1309-1314

8.  9.2% of adults screened positive for MH sxs  37% accepted MH services  63% did not  What would that look like in Minnesota?  9.2% = 147 refugees  55 would accept services

9.  Help seeking  Waiting lists  Poor provider location  Treatment population limitations  SPMI  Admitted torture survivors  Psychotropic meds without psychoed or referral  Providers unwilling to work with interpreters  Ethical and legal obligations of licensed providers

10.  Eight months of health insurance  Transportation  Interpreter services  Specialty clinics:  CUHCC  Wilder SE Asian Program  Center for Victims of Torture  County Mental Health Clinics, Rule 29 Clinics and private practitioners  Federal law requires that we see these clients if referred to us

11.  Lack of shared problem understanding  Professional focus: war trauma and PTSD  Refugee focus: family separation and unemployment as the cause of distress  Lack of understanding of presentation of suffering

12. Sometimes it just wanders off like a butterfly and that is when you are sad and that’s when you get sick and if it comes back to you that is when you are happy and you are well. Sometimes the soul goes away but the doctors don’t believe it…The doctors can fix some sicknesses that involve the body and blood but for us Hmong some people get sick because of their soul so they need spiritual healing.” From: The Spirit Catches You and You Fall Down by Anne Fadiman

13.  High levels of somatic presentation of distress  Idioms of distress  Culturally specific experiences of suffering  Not to be confused with mental illness  “While the distress experiences seen in diverse cultural groups sometimes signify the presence of physical or psychological disorders, they may also symbolically represent interpersonal and intra-psychic conflicts, or may be culturally coded ways of expressing social discontent” (Arnault, et.al., “Is there an Asian idiom of distress? Somatic Symptoms in Female Japanese and Korean Students. Archives of Psychiatric Nursing. 2008 February ; 22(1): 27–38.)