Mental Health

A Healthcare Provider’s Guide to Understanding and Addressing Substance Misuse in Refugees and Asylees with an Islamic Migration Background” (March 2024) Margaret Lawrence, MS4

Substance use disorders (SUDs) include the use of alcohol, pharmaceuticals, or street drugs at a clinically significant level resulting in development of tolerance, withdrawal, craving, and impairment in key functions required for human life and survival.1 Increasingly prevalent worldwide and a significant cause of morbidity and mortality globally, SUDs develop within a complex context and have significant implications for individuals, families, and communities. Refugees and forced migrants may be particularly vulnerable to substance misuse given their more frequent exposure to trauma, co-morbid mental health disorders, acculturation challenges, and socioeconomic inequality within migration and post-migration settings.2,3 Furthermore, these individuals may be more hesitant to report substance (mis)use given deeply rooted stigma around such activities within their systems of religion and the fear of being marginalized within their communities.4 In the last 10 years, 36% of refugees entering the United States have identified as Muslim.5 Within Islam, the use of substances, broadly referred to as khamr, is expressly forbidden, or haram.6,7 However, religious belief alone does not constitute immunity against the development of substance (mis)use and the path to resettlement increases both substance access and exposes individuals to various challenges that may precipitate the use of substances as a means of coping or self-medication.2 Given the increasing number of displaced people worldwide and the unique factors predisposing such populations to SUDs, it is critical to examine substance use within this population and to provide healthcare providers with recommendations and resources to more effectively screen for and support refugees and asylees with SUDs. This paper intends to illuminate and contextualize barriers to adequate substance use screening in Muslim refugees as well as to underscore the critical need for tailored screening, prevention, and recovery support resources for persons with an Islamic migration background resettled in non-Islamic majority countries.

School-based Mental Health Interventions for Refugee Children and Adolescents: A Review of the Evidence So Far” (February 2023) William Ford, MS4

As the global refugee population continues to grow and the conflicts displacing them continue to stretch on longer, more and more refugee children every year will need schooling in their host countries. These children face many challenges and barriers to receiving a good education including language and cultural barriers, poverty, and interruption of their education in their country of origin. Many of these children are traumatized by the events leading to their departure from their country of origin and have mental health concerns in addition to the other barriers they face. Schools in host countries can be sources of stress for these children, but they can also be important settings for interventions aimed at preventing and treating mental illnesses that can result from the traumas they have faced. This paper reviews the evidence for school-based mental health interventions for child and adolescent refugees. A wide variety of interventions have been delivered in the past two decades, mostly focusing on psychosocial supports and psychotherapies. While a number of non-randomized observational and quasi-experimental studies have shown evidence that school-based interventions can improve subjective wellbeing as well as objective measures of symptoms of post-traumatic stress disorder, depression, and anxiety, the overall strength of the evidence is weak. More randomized trials with larger sample sizes are needed to better characterize the effectiveness of these interventions, and interventions need to be larger in scope and target multiple layers of stressors to achieve meaningful benefits for child and adolescent refugees.

Trauma-Informed Primary Care of Refugees(September 2021) Abigail Piccolo, MS4

Refugee patients experience high rates of trauma, from experiences that occurred before migration, events during the migration journey, continued stressors following resettlement and intergenerational trauma. There is a well-established, dose-dependent relationship between trauma and adverse health outcomes due to the physiologic and behavioral impacts of trauma. Addressing the impacts of trauma in primary care is vital to improving the health ofrefugee populations and trauma-informed care is a framework for helping patients heal from their trauma. Trauma-informed services are grounded in an understanding of the effects of trauma on the body and brain, in order to resist retraumatization of patients in the healthcare setting, recognize signs of trauma, and be able to respond in a way that promotes healing from trauma. This paper introduces the basic concepts of trauma-informed care with specific recommendations for caring for refugee patients in the primary care setting.

An Overview of Mental Health in the Child and Adolescent Refugee Population” (July 2021) Lauren Taylor

The child and adolescent refugee population is a unique and vulnerable group. Providing healthcare for this population during the resettlement period is a complex task. Healthcare providers must be cognizant of the psychological stress endured by refugees and the subsequent mental health consequences. Unsurprisingly, the current literature suggests that the prevalence of mental illness in child and adolescent refugees is higher than the general population. This paper is an overview of child and adolescent mental health and strives to provide key insights regarding risk and protective factors, screening, diagnosis, and interventions. The results of this research illuminate the complexity of the refugee population and highlight the need for further robust research.

Keywords: Refugees, Child and Adolescent Refugees, Mental Illness

Stressors Affecting Parenting in Refugees and Potential Interventions to Support Healthy Parenting” (June 2021) Brett Jackson

Refugees are at increased risk of psychological distress and mental illness such as PTSD and depression. The mental health of primary caregivers directly and indirectly affects their children. Pre-migratory stressors, such as trauma and violence, are known to increase incidence of child emotional and physical abuse. Post-migratory stressors, such as financial hardship, acculturation, and language barriers can lead to caregiver distress, harsh parenting, and eventually child emotional and behavioral problems. Several parental support interventions are currently under investigation. Some community-based, group parent support education programs show promise in addressing caregiver psychologic distress and improving parenting in refugee populations.

Keywords: Refugees, Parenting, Support Interventions, Psychological Distress, Stressors

Social Isolation and its Impacts on Refugee Mental Health” (June 2021) Kimberly Boatman

While the process of leaving one’s home country and resettling into a new location and culture can bring with it a variety of challenges and health care considerations, the experience of social isolation is also important to address as it can have an impact on mental health and wellbeing. This paper explores the recent literature addressing social isolation including how it has been defined, factors that increase the risk of social isolation as well as protective factors that help ameliorate social isolation, the ways in which social isolation can negatively impact mental health, and intervention strategies to combat social isolation. In addition to published literature, methods the IFMC have used are included as additional potential intervention strategies to implement moving forward.

Keywords: Social Isolation, Refugee, Intervention Strategies

An Overview Of Somatization In The Refugee Population” (April 2021) Kara MacIntyre

Somatization, or the expression of medically unexplained symptoms that cause distress and impairment, is a common problem in the refugee population. Refugees are often subjected to traumatic experiences and repeated stressors, such as torture, abuse, and postmigration living difficulties, which can lead to the development of trauma-related disorders, such as anxiety, depression, and somatization. The pathogenesis of somatization in refugees can be explained by multiple mechanisms such as an undiagnosed physical illness, the result of past trauma, and cultural stigma. There is a well-documented co-occurrence of somatization with other psychological disorders, especially with PTSD. With the increasing numbers of refugees encountering the western health system, it is important that physicians and other healthcare providers are able to recognize and treat conditions that affect this population, especially somatization. Many patients require psychological treatment in addition to their medical treatment, and cognitive-behavioral therapy has been found to be the most effective psychological therapy for depression, anxiety, and somatization. General treatment tenets for somatization and related disorders include building a strong, positive relationship between the physician and the patient, scheduling frequent, supportive visits, and avoiding medication or testing when the interventions are not indicated. It is also important to keep in mind the barriers to treatment that refugees may face, such as language, health literacy, or cultural stigma.

Keywords: Somatization, Refugee, Psychological Disorders, Cognitive-behavioral Therapy, Barriers to Treatment

Sports Programs for Refugee Children and their Effect on Psychosocial Wellbeing in the Context of Cultural Sensitivity” (November 2020) Tim Chastanet

Sports programs are a unique and effective was to treat psychiatric disorders in children at refugee camps. Logistically the standard western methods of helping kids cope with childhood trauma are not feasible for that many children in the setting of a refugee camp. Sports programs help with resiliency, a key factor for psychosocial wellbeing in children. The sports programs were significantly more effective when the refugees’ cultures were kept in mind when developing the intervention.

Keywords: Refugees, Sports, Children, Psychiatric Disorders, Cultural Sensitivity, Culture

The Impact of Sexual Violence in the Democratic Republic of the Congo: Implications for the Care of Congolese Refugees” (July 2019) Allison D. Bosch

The Democratic Republic of the Congo (DRC) remains a hotbed of instability, violence, and human rights violations, driving the displacement and migration of millions of its citizens. The conflict in the DRC is characterized by widespread sexual violence. This paper assesses the profound physical and psychosocial consequences that persist through the process of migration and resettlement for victims of sexual violence from the DRC. A review of the limited survey data available indicates that providers should utilize a trauma-informed approach to best assist in the process of recovery for Congolese refugees who have experienced sexual violence. The effects of sexual violence, particularly psychosocial distress, are often compounded by pre-migration exposure to additional conflict-related traumas, and by the accumulation of post-migration stressors. By identifying and evaluating these stressors, healthcare providers can more effectively evaluate and manage the unique medical and psychosocial needs of this patient population.

Keywords: Refugees, Congolese, Trauma

Impact of Family Separation in Refugee Populations” (August 2018) Rachel Mayo

Refugees often experience family separation after relocation to the United States and other host nations.   Family separation is a significant stressor affecting overall health in various ways.  This paper explores research documenting these health effects.  Additionally, the paper provides a summary of barriers to family reunification, including current policies and costs.  Special consideration is given to the effect of separation on children, a particularly vulnerable population.  Lastly, practical topics for providers serving refugees dealing with family separation are discussed.

Keywords: Refugees, Family Reunification, Child Separation


The Concept of Depression in Afghan Refugees” (January 2018) Thuy Ho

Depression is one of the most common issues for which patients from any population are seen by primary care providers. For patients with a refugee background, depression is especially prevalent, along with other psychological conditions such as post-traumatic stress disorder (PTSD) and anxiety. Refugees experience displacement and disruption of life during the resettlement process, and many refugees are also exposed to trauma and violence, which play a role in the development of depression. People from Afghanistan comprise a significant portion of the refugee population in Charlottesville, VA, who receive care at the University of Virginia International Family Medicine Clinic. This paper provides an overview of the conceptualization, symptoms, and treatment of depression in the cultural context of refugees from Afghanistan using a patient case and published literature, and includes an appendix of a validated, culturally-adapted symptom checklist for mental health assessment research.

Keywords: Mental Health, Afghan, Depression, Concepts of Mental Illness


“From Classroom to Clinic: A Discussion of Mental Health Access for Refugee Youth in Charlottesville, Virginia” (April 2017) Nicele Puente

This introductory study investigates mental health support available for refugees aged 14-20 in Charlottesville, Virginia, by assessing the integration of clinical and education resources to support refugee youth. The methods used include subjective survey responses from primary health care providers, public school educators, and local community managers to determine “the perception of need in this population, how effectively the existing system connects potential patients to care, and how the process of patient identification and referral can be improved.” Responses from the 18 survey participants are discussed, and facilitating and limiting factors are identified.  Six recommendations based on the findings include: perform a standard baseline mental health screen on all eligible family members; make it a priority to obtain the family “flight history” soon after arrival; establish early contact between the primary care physician and the ESL and/or primary teacher; normalize mental wellness concepts and assessments with refugee families early and often; emphasize language support appropriate to the communication needs of refugee youth and their adult representatives; establish an interdisciplinary protocol specifically for the custody and communication of mental health information between appropriate providers”.  Both clinicians and educators agree on the importance of considering the “life experience” of the refugee youth and the need to improve communication and collaboration to better support the young refugees in their care.  Acting on this shared sentiment with a more coordinated approach would improve the identification process and allow more children in need to connect with services.

Keywords: Mental Health, Refugee Youth, Clinicians, Teachers, Resettlement, Stress, Trauma, Language Barriers, Communication, Collaboration


Barriers to Mental Health Treatment within the Congolese Population” (October 2016) Stephanie Espinoza

Congolese refugees are one of the major groups resettled in central Virginia. This paper explores the background of this population and the recent crisis situations in the Democratic Republic of the Congo, tying this history to an increased risk for and higher prevalence of mental health illness. Barriers to mental health treatment are explored, including a different perception of mental illness, dependence on treatment within their own community, and lack of mental health screening. Possible interventions are also set forth, including community service, education, and mental health screening.

Keywords: Mental Health, Congolese, Treatment Barriers, Screening, Interventions


Translated Mental Health Screening Tools in Refugee Populations” (August 2016) Sara Julian

Immigrant and refugee populations may be particularly vulnerable to mental health disorders, and addressing mental health issues in these populations can be very difficult. This paper asserts that many primary care providers miss diagnoses of mental health disorders, but validated screening tools can help to minimize this problem. However, translation of these tools can be challenging due to “cultural relevance, eliciting accurate answers in the face of stigma, and differences in symptom presentation and conception of disease.” In addition, clinicians must be familiar with cutoff values and appropriate usage of each screening tool. This paper focuses on well-validated translations of several tools in languages commonly encountered at the IFMC and other primary care clinics at UVA. These languages include Spanish, Nepali, and Arabic. Ideal cutoff values for screening purposes are noted with each. Screening tools explored include the Hopkins System Checklist and Harvard Trauma Questionnaire, screening tools for depression such as the PHQ-9, and additional tools for depression screening in special populations such as the Hospital Anxiety and Depression Scale (HADS) for inpatients and the Edinburgh Postnatal Depression Scale (EPDS) for pregnant women.

Keywords: Mental Health, Screening Tools, Cultural Relevance, Translation, Spanish, Nepali, Arabic, HSCL, HTQ, PHQ-9, HADS, EPDS


An Overview of the Unique Mental Health Challenges Facing the Bhutanese Refugee Population” (November 2014) Spencer Liebman

The Lhotsampa are a Nepalese-speaking group of people who lived in Bhutan but were forced to leave in the early 1990s for political or cultural reasons. This paper provides an overview of unique mental health challenges in this population. Many of this group suffered physical torture and other abuses, including 90% who reported also suffering torture not involving the body according to one referenced study. The tortured group had significantly more PTSD, depression, and anxiety symptoms than the control group of refugees who had not been subject to torture. The torture group also complained of more musculoskeletal, vision, hearing, sleep, sexual desire, and appetite problems. The paper further discusses the diagnostic characteristics of PTSD as a diagnosis featuring western ideals, which may not appropriately capture the impact on the lives of Bhutanese or other Southeast Asian populations. Concepts of mental illness among SE Asian populations are briefly explored. Clinicians working with this population need to be alert for symptoms of depression, anxiety, and PTSD, but also need to recognize somatization, dissociation, and negative coping strategies as possible markers for greater mental health distress.

Keywords: Mental Health, Bhutanese, Torture, PTSD, Depression, Anxiety, Concepts of Mental Illness


Emigration History and Symptom Survey” (August 2005) Brandon Webb

This project is a collection of survey tools and scoring instructions for use in screening refugees for mental health symptoms or illness. Tools for use include: Hopkins Symptom Checklist-25 Anxiety Subscale, Hopkins Symptom Checklist-25 Depression Subscale, Symptoms Checklist-90 Somatization Subscale, Harvard Trauma Questionaire PTSD Symptoms Subscale, Emigration History Questionaire, and English Proficiency Questionaire. Scoring instructions include how to score the surveys as well as cutoff values that are diagnostically significant.

Keywords: Emigration History, Symptom Survey, Screening Tools, HSCL, HTQ


Somatization: Issues in Refugee Mental Health” (September 2003) Jennifer Edwards

Abstract: “In this review I discuss the phenomenon of somatization in the refugee population. Somatization may be defined loosely as the presentation in a medical setting with medically unexplained symptoms. However, this definition lacks both clinical and investigative utility in that it addresses neither etiology, nor the specific and quantifiable details of presentation.  Thus, any discussion of somatization must begin with an attempt to resolve the prevailing and often contradictory uses of the term.  In addition, such a discussion becomes increasingly complex when one applies the word, which is steeped in Western theory of the nature of mind and body experience, to cultures of an entirely foreign ken.  Thus, the implications of cross-cultural study of somatization must also be addressed.  Finally, I will briefly review some studies of demographic variables associated with somatization, somatization as a response to trauma, and somatization within the refugee population specifically.  In conclusion, I will address an area which I believe deserves further investigation: the role of language in somatization.”

Keywords: Somatization, Mental Health, Language, Culture, Trauma