Guidance for Mental Health Screening during the Domestic Medical Examination for Newly Arrived Refugees

Quick Guide for Mental Health Screening

Screening is designed to determine who should be referred for mental health diagnosis and management. Timely referrals may assist refugees in living more productive and healthier lives following resettlement. Major Depressive Disorder, Posttraumatic Stress Disorder (PTSD), anxiety and adjustment disorders, and substance abuse are the most common mental health diagnoses seen among refugees. The key steps in conducting the domestic mental health screening are outlined below:

Step 1: Review overseas records for documentation of:

  • type and severity of any trauma/abuse
  • physical and mental disorders with associated harmful behaviors
  • substance-related disorders

Step 2: Ask directly about symptomology, functionality, and suicidal ideation as part of an integrated history and physical examination, helping to minimize stigmatization.

  • Note symptoms classically associated with mental health problems such as insomnia, changes in appetite and eating behaviors, nightmares, muscle tension, headaches, and/or diffuse body pain with no known etiology.
  • Mental health is generally stigmatized, and the patient may be more receptive to questions if they are posed as part of the individual’s overall health rather than as an isolated or focused “mental” or “psychiatric” intensive interview.

Step 3: Screening:

  • For adults (≥ 18 years age), screen using standardized tools employing one of two approaches (Table 1)
    • Single tool, screening for a range of symptoms associated with diverse potential Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnoses OR
    • Combination of tools, with each tool geared to a narrow range of symptoms and likely diagnoses
  • For children and adolescents (< 18 years of age), screen with a structured or semi-structured assessment, integrated into the overall health assessment.

Step 4: Screen for substance abuse and educate about possible legal consequences of these behaviors in the United States.  Make appropriate referrals if refugee is interested, and services are available. Interested refugees should also be connected with community resources and support groups.

Step 5: For those in need of mental health support and assistance, develop an impairment-related action plan with associated management and/or referral.

Scope

The goal of the domestic mental health screening is to identify and evaluate refugees in need of mental health support and assistance. Screening is not designed to diagnose mental health conditions, but rather to identify individuals who should be referred for appropriate mental health diagnosis and management. Timely referrals to mental health services may assist refugees in living more productive and healthier lives following resettlement. Urgent mental health concerns must be addressed per clinic protocol, including immediate hospitalization, if indicated. Acute psychiatric emergencies (e.g. suicidal/homicidal ideation) are seen infrequently during the domestic refugee examination. However, in the case of acute psychiatric emergencies, immediate evaluation and inpatient psychiatric hospitalization may be necessary.

Background

Refugees often experience extremely difficult situations in their home country, as well as during displacement, transit, and resettlement. While these difficult experiences are risk factors for mental health problems, an individual’s mental and emotional response to these circumstances varies based on unique factors such as:

  • Level of direct exposure to or participation in traumatic events and/or abuse
  • Duration and intensity of prior traumatic experiences
  • Individual disposition and psychological resilience
  • Perceived economic and physical security post-resettlement
  • Ability to identify and utilize coping mechanisms and support networks, including family and community groups
  • Access to education

Many groups, including youth, the elderly, and women, may be more likely to be exposed to traumatic events that can exacerbate mental health conditions. Elderly refugees may be vulnerable to physical and emotional abuse, and experience social isolation, which can have a lasting effect on mental health and life after resettlement. Although refugee youth can be incredibly resilient, many are exposed to the same traumatic events as adult family members. They often endure the loss of family members and homes, and education disruption, which may significantly influence their developmental trajectories. Political and civil unrest, war, and displacement may make it difficult for families to find a safe environment for their children, increasing their vulnerability to many types of abuse, and hindering optimal development [2]. Additionally, women and children are disproportionately targeted by violence and represent the majority of all victims of armed conflicts. Sexual violence towards women and girls is often systematic, and perpetrators may include bandits, insurgents, military or border guards, as well as community members. Survivors of sexual assault may also be subject to discrimination and may not receive psychological support, potentially resulting in profound emotional distress and difficulty with resettlement [3].

Many lesbian, gay, bisexual, transgender, queer or questioning, intersex, and asexual (LGBTQIA) refugees suffer from significant mental health consequences as a result of a lifetime of cumulative trauma. Traumatic events may include forced heterosexual marriage, ‘corrective’ rape, and coerced sexual orientation conversion interventions [4, 5]. Those who are perceived by others as behaving in gender non-conforming ways are often targeted starting in childhood [68]. In the beginning stages of a humanitarian crisis, LGBTQIA people are more likely to be excluded from basic protectionsAlienation from government and NGOs can affect long-term coping and resilience in LGBTQIA individuals [4, 9, 10].  After leaving their country of origin, LGBTQIA refugees risk continuous dangers while in transit to their resettlement destination, especially if traveling through nations with laws of intolerance and even in their ultimate resettlement community.

While most refugees will live healthy lives after resettlement, many experience significant psychological symptoms that can be managed or alleviated with mental health screening and treatment [11].

Mental Health Components of the Integrated History and Physical Examination

Past Medical History
The goals of the mental health component of the required overseas medical examination are:

  • To identify and diagnose any physical or mental disorder, including alcohol-related disorders.
  • To identify any harmful behavior associated with a disorder.
  • To identify the use of drugs, other than those required for medical reasons, and diagnose any substance-related disorder.
  • To determine the remission status of any disorder previously diagnosed.
  • To determine the likelihood of recurrence of harmful behaviors associated with a physical or mental disorder.

The Technical Instructions for Panel Physicians (TIs) outline the components of the overseas medical examination and provide additional guidance for the panel physician in classifying applicants.The absence of findings on the overseas examination does not preclude the existence of mental health needs, therefore, domestic screening remains important. Clinicians performing the domestic medical screening should review all overseas records for documentation including types and severity of trauma. These records may offer background for providers and guide discussion without having the patient repeat potentially traumatizing memories during the domestic screening.

As patients discuss symptoms or display signs or behaviors consistent with mental health issues, clinicians should react in the same non-judgmental manner as if responding to acute and identifiable physical maladies or injuries. Clinicians should be aware that mental health symptoms in refugees may appear months or years after arrival and may need to be addressed in the refugee’s medical home. Examples of behaviors/observations that may indicate significant mental health issues include:

  • Visible distress or crying during the visit
  • Acting withdrawn or slow to communicate during the visit
  • Uncontrolled laughter or making light of tragic situations
  • Elevated startle reflex
  • Tangential or disorganized thoughts
  • Signs of psychosis, such as auditory or visual hallucinations [12]

When appropriate, asking about suicidal ideation in a direct, calm manner may elicit frank and truthful answers [13]. For example:

“With everything people have had to endure in their home country, then being uprooted to come to the US and facing challenging circumstances here, some people have thoughts about suicide or hurting themselves. Do you have those thoughts?”

Mental Health Screening Tools – Adult (≥ 18 years)

Numerous screening tools have been developed or used by experts in refugee mental health (Table 1). When assessing the usability of specific tools, it is important to remember that some refugees are pre-literate in their first language or may need assistance understanding the meaning of questions or response options (such as Likert scales or distress thermometers). Validation including age recommendations in one group may not be transferable to all individuals.

Mental health screening is important for everyone, as a primary care provider can provide appropriate prescriptions, medication management, and recommend known community resources. When resources are available for intervention, a more comprehensive screening should be considered. Clinicians should consider ONE of the following two approaches for the initial refugee mental health screening:

  1. Use of a single tool that screens for a wide range of symptoms associated with diverse potential DSM diagnoses (such as the Refugee Health Screener-15 [RHS-15]) OR
  2. Use of a combination of tools (must screen for PTSD, anxiety, and depression), with each geared to a narrow range of symptoms and potential diagnoses. Depending on the tools, it is possible to start with more limited screening tools (e.g., Patient Health Questionnaire-2 [PHQ-2]), and in follow-up care, proceed to more comprehensive testing (e.g., Patient Health Questionnaire-9 [PHQ-9]) for those describing significant distress.

Table 1. Select Refugee Mental Health Screening Tools for Adults (as of April 2019)

Table 1. Select Refugee Mental Health Screening Tools for Adults (as of April 2019): Broad Screening for Common Mental Health Conditions
Broad Screening for Common Mental Health Conditions
Tool Name Tool Details
Refugee Health Screener-15 (RHS-15external icon) *** Purpose Screens for common mental health conditions (anxiety, depression, PTSD, adjustment, coping), but not for domestic violence, substance use, or psychotic disorders.
Format 15-item tool, with 14 Likert scale responses and a pictorial “distress thermometer”
Scoring Numerical responses for questions 1-14 are added. If total score for questions 1-14 is ≥12 (elevated level of emotional distress), refer to supportive services. Referrals should be given to respondents indicating distress is ≥5.
Administration Clinicians (medical assistants, nurses, doctors, nurse practitioners), social workers, or resettlement caseworkers
Validation* Yes, initial study among 3 refugee groups [14]; additional research available with multiple cultural groups [15, 16];adolescents ≥14 years [17]
Languages** Amharic, Arabic, Burmese, Farsi, French, Karen, Kurdish, Nepali, Russian, Spanish (Cuban dialect), Spanish (Mexican dialect), Tigrinya, Somali, Swahili
Table 1. Select Refugee Mental Health Screening Tools for Adults (as of April 2019): Diagnosis-Targeted Screening (select tool from each group, and use in combination)
Diagnosis-Targeted Screening (select tool from each group, and use in combination)
Post-Traumatic Stress Disorder
Tool Name Tool Details
Harvard Trauma Questionnaire (HTQexternal icon)**** Purpose Inquiries about trauma events, and symptoms associated with trauma
Format 30-item tool with Likert scale responses
Scoring For scoring information review the Measuring Trauma, Measuring Torture manual.
Administration Under supervision of psychiatrist, medical doctor, or psychiatric nurse
Validation* Yes, in select populations [18]
Languages** Bosnian, Cambodian, Croatian, Japanese, Lao, Vietnamese, Tibetan [19]
Primary Care PTSD Screen for DSM-5 (PC-PTSD-5external icon) Purpose Assess for exposure to traumatic events and identify probable PTSD in primary care settings.
Format 6 item questionnaire; 1 question to determine trauma exposure, and 5 yes/no questions, if appropriate.
Scoring If respondent denies exposure, screen is complete (0 score). Screen is “positive” (probable PTSD) if respondent answers “yes” to 3/5 follow-up questions.
Administration Person with training and under supervision of psychiatrist, medical doctor, and/or psychiatric nurse.
Validation* Yes, in veterans [20]
Languages** Korean [21]
PTSD Checklist for DSM-5 (PCL-5)external icon Purpose Assesses the presence and severity of PTSD symptoms and can be used to quantify and monitor symptoms over time.
Format 17-item self-report measure
Scoring Sum scores for all 17 items (response options ranging from 1 to 5) to determine the total symptom severity score pdf icon[PDF – 3 pages]external icon (range=17-85). Approximate score for referral is 45-50.
Administration Self-report instrument that can be read by respondents or facilitated to them either in person or over the phone.
Validation* Yes, in select populations [22]
Languages** French [23]
Depression
Tool Name Tool Details
Patient Health Questionnaires PHQ-2external icon and PHQ-9external icon Purpose PHQ-2 is used as a front-line screening to assess depressed mood and anhedonia over the past two weeks. PHQ-9 is used to gain deeper insights.
Format Interview, but also available in written form if refugee is comfortable with literacy and Likert scale responses
Scoring A “moderate” response or higher on either item on the PHQ-2 is considered positive and should be followed by administering the PHQ-9. A PHQ-9 score ≥10 warrants follow-up.
Administration Healthcare provider
Validation* Yes, for patients ≥13 years of age (PHQ-2) [24, 25] and as young as 12 years of age

(PHQ-9) [26-29]

Languages** Arabic, Nepali, Spanish, Somali
Anxiety and Depression
Tool Name Tool Details
Hopkins Symptom Checklist 25 (HSCL-25external icon) Purpose An inventory measuring symptoms of anxiety and depression
Format 25-item interview: 10 items for anxiety and 15 items for depression, each eliciting a Likert scale response.
Scoring 3 scores are calculated. Total score is the average of all 25 items. Anxiety score averages the 10 anxiety items. Depression score averages the 15 depression items.
Administration Healthcare workers under the supervision and support of a psychiatrist, medical doctor, and/or psychiatric nurse
Validation* Yes, in select populations [30]
Languages** Bosnian, Cambodian, Croatian, Japanese, Laotian, and Vietnamese [31]. Validated in Arabic [32], Croatian, Lao, Vietnamese [33], Dinka [34], Hmong [35], Pashto [36], Urdu [37], and Russian [38].
Alcohol Dependence
Tool Name Tool Details
CAGE questionnaire Purpose Assesses alcohol dependence
Format 4-item, relatively non-confrontational questionnaire, administered in <1minute, pencil-and paper self-administered, interview, and computer self-administered
Scoring 1 point for yes response. 1 point detects 90% of those with alcohol-related problem/diagnosis. 2 points or higher has 93% sensitivity/76% specificity for identification of “Excessive drinking” and 91% sensitivity/77% specificity for identification of “alcoholism”
Administration Clinicians (medical assistants, nurses, doctors, nurse practitioners) or technician (no training necessary)
Validation* Yes, in psychiatric patients 16 and older [39]
Languages** Flemish, French, Hebrew, Japanese, Kiswahili, Korean, Mandarin Chinese, Polish, Portuguese, Spanish, Swahili (Tanzanian) [40]

*Validation refers to peer reviewed validation in a specific cultural group (unless noted otherwise), and clinicians should use their best judgment to determine if a screening tool is appropriate to use.

**This list may not be comprehensive.

***The English version of the RHS-15 is for informational purposes only. It is not intended for use in refugee populations. Bilingual versions of the RHS-15 have been translated by professional translators along with the participation of each refugee community so that each question is asked correctly according to language and culture. Using the English version negates the sensitivity of this instrument.

****The Harvard Trauma Questionnaire is a proprietary tool. There is a cost associated with its use.

Note: While many of these tools have been developed for use in adults, some have also been validated for use in adolescents.

Mental Health Status Examination and Screening–Pediatrics (<18 years)

While there is currently no “gold standard” for pediatric mental health screening, the emerging best practice for the mental health status examination is a structured or semi-structured assessment that is integrated into the overall health assessment. The mental health screening for children and adolescents depends largely on age. However, the following observations are critical in the mental status examination of all children and adolescents:

  • Overall development
  • Engagement with parents or caregivers and clinicians
    • Children with mental health issues may appear withdrawn, anxious, angry, or otherwise distressed.
    • Parents with mental health issues may have difficulty engaging with their children.

Children, 0-5 years of age

For children from birth through 5 years of age, mental health screening may consist of the mental status examination including overall development and engagement with parents/caregivers. It is important to remember that development and engagement may be perceived differently among cultures.

Children, 6-13 years of age

It is important to elicit both symptomatology and functional impairment in a semi-structured assessment.

Most refugee children aged 6 and over can be interviewed. Table 2 provides sample questions for refugee children as well as their parents. These questions are meant to guide screening providers in evaluating levels of distress and coping ability. They do not constitute a validated tool. The number of questions, wording, and order should be determined by the clinician. There is no exact cut-off for a positive screen using assessment questions. Rather, if symptoms are severe enough such that they interfere with school or family functioning, further treatment or mental health referral is indicated. In addition to assessment questions, screening should include clinical observations, and any parental concerns. When conducting the assessment with refugee youth, initial questions should aim to build rapport. Inquiries about school may be informative, yet lack of formal education may be a sensitive topic. Refugee children may have had or are currently having traumatic experiences at school. Note that outward reaction to trauma may present differently among children. Drawing or other forms of artistic expression may be helpful in eliciting information from youth, if clinic capacity allows.

Adolescents, 14 years of age and older

The RHS-15 has been validated for use in adolescents aged 14 years and over [17]. The use of the RHS-15 (or, if not available, the questions included in Table 2), in combination with the mental status exam and select parent/caregiver observations (see Table 2) will generally constitute a reasonable screening. The PHQ-2 (validated for patients 13 years of age and older [25]), and the PHQ-9 (validated in patients as young as 12 years [29]) may also be useful in adolescents. Be aware that some topics such as sexual history, substance use, and use of corporal punishment in the home may merit additional sensitivity with some refugee populations. If such topics are broached, the refugee youth should be made aware of the limits of confidentiality in the screening setting.

Table 2. Sample assessment questions for parents and children during the domestic mental health screening

Table 2. Sample assessment questions for parents and children during the domestic mental health screening
Questions for Parents of Refugee Children (2 to <18 years) Questions for Refugee Children (6 to <18 years) *
Symptoms
  • Do you have any concerns about your child’s behavior?
  • Do you have concerns about the way your child is developing physically or emotionally?
  • Do you have concerns about the way your child learns new things?
  • Has your child witnessed or experienced any traumatic events?
  • Have you and your child ever been separated for long periods?
  • Do you have trouble sleeping?
  • Do you have changes in your appetite?
  • Do you get jumpy easily when you hear loud noises (i.e. door closes, a book drops on the floor)?
  • Do you ever have bad dreams or nightmares? Do they remind you of things that really happened to you in the past?
  • Do you  often think about things that happened to you in the past?
  • Do you feel too sad? If so, when?
  • Do you ever feel like you do not want to be alive? If yes, do you ever think about or have you ever harmed yourself?
  • Do you get angry easily?
Functional Impairment (In deciding whether to refer for mental health treatment, these questions should be weighted heavily):
  • In the past month, including now, do your child’s emotional/behavioral problems or difficult experiences impair his/her ability to:
    • Interact or play with peers/children their own age?
    • Get along well with family members?
    • Function in school (if they had the opportunity to attend)?
  • In the past month, including now:
    • Have you had any difficulty  interacting or playing with other peers/children or your family?
    • Is it difficult for you to have fun?

 

*Use clinical judgement in determining which questions are appropriate for the child or adolescent to answer. Ask parents if child is unable or unwilling to answer questions.

Substance Abuse Screening

As part of the domestic medical screening process, providers should inquire about drug, alcohol, and tobacco use. Providers should familiarize themselves with culturally specific substances, including local names of substances. Substance use may be permitted, or even encouraged, within some communities. Therefore, it is important to educate refugees on any legal or health ramifications. The National Institute of Drug Abuseexternal icon and the World Health Organizationexternal icon have published information on substance use/abuse and commonly used drugs. Below are two examples of commonly used substances in specific refugee communities:

  • Betel nutexternal icon is chewed or smoked throughout Southeast Asia (including Bhutan, Nepal, Burma, Malaysia, Taiwan, and Thailand). It is not a controlled substance in the US. It is a mild stimulant, appetite suppressant, and is addictive. In many cultures, use begins in early adolescence. Children will typically disclose use when asked. Betel nut use is associated with dental staining, tooth decay, oral cancer, and milk-alkali syndrome [41].
  • Khatexternal icon, a controlled substance in the US, is used throughout Eastern Africa and the Horn of Africa (Ethiopia, Somalia, Djibouti, Uganda, and Kenya), and the Arabian Peninsula (Egypt, Yemen). Individuals chew the leaf, which is a mild stimulant and appetite suppressant [42]. Khat has been associated with tachycardia and hypertension [43], and may lead to oral cancer [44].

When screening determines a significant substance use or addiction:

  • Providers should explain that substance use/abuse sometimes occurs as a way to cope with past trauma, displacement, torture, or significant social distress [45]. Additionally, providers should emphasize that substance use/abuse can be a form of self-medication to make it easier to deal with stress, anxiety, and depression. It is most effective to ask about substance use/abuse with specific questions (i.e. “How much you drink?” versus “Do you use substances?”).
  • Inform refugees of possible legal consequences of substance use/abuse in the US.
  • If violent behaviors, parental neglect, or driving while impaired are concerns, explain the social, health, and legal consequences of such actions.
  • Make appropriate community referrals (if available) for refugees interested in slowing or quitting drug, alcohol, or tobacco use. If there are no existing community resources, refer to acommunity or religious leader.
  • Consider potential for dual diagnoses in determining appropriate referrals (e.g., community mental health services, culturally specific community centers, etc.).

Impairment-Related Action Plan

An appropriate impairment-related action plan should be developed based on:

  • Reviewing pre-departure records
  • Observed somatic symptoms of mental health problems during the integrated screening examination
  • Collecting collateral information from family members or social workers
  • Using one or more screening tools
  • If substance use is reported, screen for substance abuse with a validated tool such as the CAGE Questionnaire [46]

A refugee’s severity of symptoms and ability to function in daily life places them into one of the four following categories with associated management and/or referral:

  1. Crisis Situation
    Clinics should have an existing crisis response plan for all patients in the rare event of the disclosure of suicidal or homicidal thoughts, or other unsafe crisis situations (such as domestic violence/abuse). Developing a crisis response plan is beyond the scope of this document.
  2. Mental Illness Requiring Immediate Follow-up
    Refugees traveling with a waiver for a Class A mental health condition must see a healthcare provider immediately upon arrival and make arrangements to receive psychiatric treatment and evaluation. The initial visit should include consideration of safety of self and others, as well as medication continuity or changes. Chronic, serious, or acute mental health illnesses may require immediate or rapid follow-up. Refugees presenting with new and severe mental health symptoms after arrival require immediate referral to care, and follow-up to ensure that a care connection has been established. If there are no or few available mental health/psychiatric resources, an immediate appointment should be made with a primary care provider. This provider should be made aware of the nature and significance of the mental health symptoms.
  3. Mental Illness or Psychiatric Symptoms Requiring Routine Follow-up
    Refugees with Class B mental health conditions have been diagnosed with a significant mental health condition prior to departure that may impair daily function. The Biodata and Significant Medical Condition (SMC) overseas forms may contain recommendations on how soon a refugee should be seen by a provider. Refugees should also arrive with 8 weeks of prescribed medications. Refugees with known mental health concerns should be connected to care as soon as possible to avoid deterioration or becoming lost in the healthcare system. Refugees may have been recently diagnosed with mental health conditions that are neither a crisis nor severe, but that affect resettlement efforts and adjustment to life in the United States. These symptoms may be detected on mental health screening (screening positive but not severe) or be observed but do not cause grave disability or inability to function. These refugees should receive routine referral to care. In the absence of a mental health provider, the refugee’s primary care provider should be informed of their symptoms, and the refugee should be encouraged to make an appointment and discuss these symptoms with their provider.
  4. No Identified or Significant Mental Health Symptoms
    All refugees have directly or indirectly experienced trauma and/or loss. However, most refugees are not in need of clinical mental health services. All refugees should receive psychoeducation on the mental health impacts of resettlement and be encouraged to reach out should symptoms emerge or worsen. Psychoeducation and providing patients and family members with information and support to better understand and cope with illness is an evidence-based therapeutic intervention.

Making a Referral

Based on available overseas records and findings of the domestic mental health screening, a referral to a mental health provider may be appropriate. Most mental health conditions can be managed by primary care providers. However, in some instances, a referral to a mental health professional may be indicated. Some refugees may be reluctant to follow-up with a mental health professional. Common barriers for refugees following up with a mental health provider include:

  • Reluctance to seek out services
  • Stigma around mental health and a lack of understanding of mental health diagnoses and treatments
  • Logistical barriers to care including:
    • Lack of resources to get to the location for services
    • Difficulties in scheduling appointments, asking questions, refilling medications due to limited interpretation services
    • Visit times only available during hours of work
  • Families overwhelmed by their own migration experiences
  • Lack of access to culturally-informed mental health services
  • Lack of availability or access to pediatric mental health services
  • Lack of provider awareness of available local services
  • Limited referral networks from schools, pediatric clinics, etc.

Referral best practices include:

  • Contacting potential resources to develop a shared understanding for preferred referral procedures.
  • Ensuring that mental health providers have cultural and linguistic skills, as well as resources (or interpreters) to work with new arrivals. If not, discuss with refugee community leaders, resettlement agencies, or the state Refugee Health Program to develop an appropriate strategy.
  • If a refugee accepts the referral, make the appointment in their presence. Transportation and care coordination may require assistance from resettlement agencies or screening clinic support staff. A Release of Information Form should be completed to enable this coordination.
  • Ensure that the screening clinic or the referral site will make reminder calls about the appointment in the patient’s language one week and one day prior to the appointment.
  • The refugee should be a partner in the care plan. The provider should confirm that the refugee plans to attend any upcoming appointments.

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