Abstract
BackgroundDespite an unparalleled global refugee crisis, there are almost no studies in primary care addressing real-world conditions and longer courses of treatment that are typical when resettled refugees present to their physician with critical psychosocial needs and complex symptoms. We studied the effects of a year of psychotherapy and case management in a primary care setting on common symptoms and functioning for Karen refugees (a newly arrived population in St Paul, Minnesota) with depression.MethodsA pragmatic parallel-group randomized control trial was conducted at two primary care clinics with large resettled Karen refugee patient populations, with simple random allocation to 1 year of either: (1) intensive psychotherapy and case management (IPCM), or (2) care-as-usual (CAU). Eligibility criteria included Major Depression diagnosis determined by structured diagnostic clinical interview, Karen refugee, ages 18–65. IPCM (n = 112) received a year of psychotherapy and case management coordinated onsite between the case manager, psychotherapist, and primary care providers; CAU (n = 102) received care-as-usual from their primary care clinic, including behavioral health referrals and/or brief onsite interventions. Blinded assessors collected outcomes of mean changes in depression and anxiety symptoms (measured by Hopkins Symptom Checklist-25), PTSD symptoms (Posttraumatic Diagnostic Scale), pain (internally developed 5-item Pain Scale), and social functioning (internally developed 37-item instrument standardized on refugees) at baseline, 3, 6 and 12 months. After propensity score matching, data were analyzed with the intention-to-treat principle using repeated measures ANOVA with partial eta-squared estimates of effect size.ResultsOf 214 participants, 193 completed a baseline and follow up assessment (90.2%). IPCM patients showed significant improvements in depression, PTSD, anxiety, and pain symptoms and in social functioning at all time points, with magnitude of improvement increasing over time. CAU patients did not show significant improvements. The largest mean differences observed between groups were in depression (difference, 5.5, 95% CI, 3.9 to 7.1, P < .001) and basic needs/safety (difference, 5.4, 95% CI, 3.8 to 7.0, P < .001).ConclusionsAdult Karen refugees with depression benefited from intensive psychotherapy and case management coordinated and delivered under usual conditions in primary care. Intervention effects strengthened at each interval, suggesting robust recovery is possible.Trial registrationclinicaltrials.gov Identifier: NCT03788408. Registered 20 Dec 2018. Retrospectively registered.
Highlights
Despite an unparalleled global refugee crisis, there are almost no studies in primary care addressing real-world conditions and longer courses of treatment that are typical when resettled refugees present to their physician with critical psychosocial needs and complex symptoms
The aim of the present study was to evaluate the benefits of intensive, coordinated psychotherapy and case management in primary care on common symptoms and social functioning in refugees, relative to a comparison group who received care as usual from their primary care provider and usual referrals for mental health services
Of the 58 ineligible patients, 33 did not meet criteria for Major Depressive Disorder (MDD); 19 were already receiving individual psychotherapy or case management; 4 were unable to participate in psychotherapy due to cognitive impairment; 1 required inpatient psychiatric care not available through the intervention; and 1 patient moved to another state
Summary
Despite an unparalleled global refugee crisis, there are almost no studies in primary care addressing real-world conditions and longer courses of treatment that are typical when resettled refugees present to their physician with critical psychosocial needs and complex symptoms. Resettled refugee populations present in primary care settings with a host of complex, interrelated biopsychosocial needs and profound access barriers involving culture, language, transportation, and health literacy [10,11,12,13]. These barriers, in concert with severe trauma and years of medical neglect preresettlement, create challenges for primary care clinics regarding elevated risk of severe disease, poor health outcomes, and high need for already limited clinic resources. Existing research [14,15,16] has described gaps in care for refugees navigating the U.S medical system in particular
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