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When to Medicalize Or Demedicalize Refugee Traumatic Stress?” “My Name Is Nobody.” Homer, the Odyssey

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When to Medicalize Or Demedicalize Refugee Traumatic Stress?” “My Name Is Nobody.” Homer, the Odyssey "Ulysses’ Dilemma: When to Medicalize or Demedicalize Refugee Traumatic Stress?” “My name is Nobody.” Homer, The Odyssey Marius Koga, MD, MPH Ahmad Fahim Pirzada, MD Yolo County Health & Human Services June 09 19, 2016 21st Century Global Migration Population Mobility A Serious Policy Challenge • 214 million people on the move internationally (asylees, refugees, and immigrants) • three-quarters of a billion people migrating within their own countries (IDPs) • Policy-making on migration and health is conducted within sector silos that frequently have different goals. Population mobility is wholly compatible with health-promoting strategies for migrants if decision-makers coordinate across borders and policy sectors. 1 Every year, approximately 70,000 refugees and 400,000 immigrants resettle to the United States from overseas. According to the U.S. Department of Homeland Security, Office of Immigration Statistics 2012 Annual Flow Report, approximately 187,856 new refugee arrivals were admitted to the U.S., and 75,441 affirmative and defensive asylees were granted asylum during the period of October 1, 2009, through September 30, 2012. During the same period of time, according to the same data source, California received 18,731 (10%) of newly arriving refugees and 27,158 (36%) of affirmative and defensive asylees, making it one of the largest recipient of newly arriving refugees and affirmative and defensive asylees in the nation 2 War Trauma & Refugee Mental Health Time course of reactions Traumatic event Acute Acute Acute Chronic stress stress PTSD PTSD reaction disorder 4-12 12 first 48 up to 4 weeks weeks + hours weeks 3 Post Traumatic Stress Disorder (PTSD) Response to specific traumatic / extreme event DSM IV Diagnostic condition & ICD-10 Diagnostic condition 1. Experience intense fear 2. Persistent re-experience 3. Avoidance of associations 4. Persistent increased arousal since event 5. Flashbacks 6. Hyper-arousal – sleep, irritability, concentration, hyper-vigilance, startle Traumatic alteration & dysregulation of affect, behavior, and meaning Alterations Complex PTSD • alterations in self perception; chronic guilt • chronic affect dysregulation and shame, feelings of self blame of • difficulty modulating anger ineffectiveness, of being permanently damaged. • self destructive and suicidal • alterations in perceptions of perpetrator; behaviour adopting distorted beliefs and idealising • difficulty modulating sexual the perpetrator. involvement • alterations in relationships with others; • impulsive and risk taking behaviours inability to trust or maintain relationships, a tendency to re-victimisation, a tendency • somatization to victimise others. • Alterations in attention and • despair and hopelessness; loss of consciousness: dissociation; amnesia previously sustaining beliefs; loss of faith; adopting a toxic faith 4 Post-Traumatic Stress Disorder (PTSD) Bremner hypothesized that hippocampal damage represents the anatomical basis for the psychological effects of stress. (mind-body perspective) Data from MRI studies showed an 8% reduction of left hippocampal volume in Vietnam vets and similar decreases in the right sides of physically and sexually abused women. (-) Cortisol is released in relation to stressor severity. An important role of cortisol in stress is to contain other biological stress responses 5 Psychological Consequences of Trauma Acute anxiety, numbing, arousal (acute stress disorder) Pain and apparently disproportionate disability Anxiety disorder Unexplained physical symptoms Major depressive disorder Impact on family (such as family arguments, depression in family members) Post-traumatic symptoms and disorder Avoidance and phobic anxiety Outcomes in PTSD • Self-concept: altered and reinterpreted as vulnerable and in constant danger. • Worldview: The perception of the world changes into a nightmare. • Personality: One’s attitudes, behaviors, and actions change to match the destructive reinterpretation of the world. 6 Meaning according to Epictetus Greece: The Temple of Asclepius It is not as important what happens to a person, as to the meaning that the person gives to what has happened. Epictetus We can seldom have complete control over the external circumstances in our life situations. However, the attitude we choose to take toward our life situations is within our control. Viktor Frankl Western bias? South Eastern Europe 7 THE MENTAL HEALTH COST OF MASS VIOLENCE & TORTURE 0 50 100 SERIOUS MENTAL ILLNESS PSYCH. INCAPACITATION SERIOUS FAMIILY CONFLICT CLNICAL DEPRESSION/PTSD FEAR OF GOVERNMENT SEEKING JUSTICE/REVENGE PHYS, MENTAL EXHAUSTION Percentage of General Population DEMORALIZATION SOURCE: Scientific American, v282, June 2000:54-57 Feeling No Trust in Others, Past Week 60 50 Not at all 40 A little 30 Quite a bit Percent 20 Extremely Often 10 0 PTSD depression asymptomatic depression and PTSD Symptom Status, 1999 (378 refugees) 8 Ulysses: In Between PTSD and Acculturation Stress/Post-Resettlement Hardship • PTSD or subthreshold PTSD is common among war refugees • Common feature: dissociation • (depersonalization and derealization) • Emotional encoding of places, beings, relationships, and things is missing either due to dissociation or to relocation to an alien environment (USA) • Iraqi Study for Ulysses Project Mental Health Correlates of Post Resettlement Stressors in Iraqi Refugees Omar Gardizi, B.S. UC Davis Public Health Sciences Patrick Marius Koga, M.D. M.P.H UC Davis Public Health Sciences, UC Davis School of Medicine Introduction Results Discussio n Following the conclusion of Operation Iraqi Freedom, California Gender Moderate Severe Extreme Gender Low Moderate High Results demonstrate that there is a positive correlation between the PMLP and anxiety, also between PMLP and depression. has seen a large influx in of Iraqi refugees. Substantial numbers Depressio Depressio Depressio Anxiety Anxiety Anxiety These issues can be further specified by looking at frequency at have relocated in San Diego and the Greater Sacramento area. n n n (cause for concern) which refugees answered issues as “Very Serious” and While these refugees are often victims of traumatic experiences, Male 5 17 3 “Serious.” Issues include: post resettlement experiences (unemployment, poor English Male 0 11 13 -English speaking skills (especially in finding work) Female 13 13 1 skills, poor socioeconomic condition, etc), may also be of -Education on cultural supports in community Female 1 12 14 importance in predicting psychological stress and mental well All 18 30 4 -Knowledge of healthcare system (including dental care access) All 1 23 27 -Help from resettlement agencies, charities and welfare being. This is the first VIRTIS study to examine the correlation of -Overall poor perception of life post resettlement with severity of PTSD, anxiety and depression -Unfavorable living conditions in Iraqi refugees. Post Migration % Answered as PTSD Civilian % Answered as Living Problems “Very Serious” Issue Checklist “Occurs Often” Next steps: Having Difficulty 38.46% -VIRTIS will partner with religious and cultural organizations to Difficulty 30.77% Concentrating aid in pschosocial interventions communicating in Repeated Disturbing 36.54% -Further studies with larger population to compare comorbid Objectives English conditions and post migration stressors Dreams No Welcome 32.69% -Implement early intervention to aid in social support (finding Suddenly Feeling As If a 34.62% 1. Assess the mental health status of 51 Iraqi Brochure in Arabic employment, navigating healthcare system, etc) refugees 18-65 years of age who have completed Stressful Experiencing 12-36 months of resettlement in the Greater Separation From 34.62% Were Occurring Sacramento Area, by conducting assessments Family Feeling Very Upset 53.85% for PTSD, depression and anxiety disorders Unable to Return 37.25% When Reminded of 2. Assess the Iraqi perceived stressors and barriers Home Something Stressful to a successful resettlement References 3. Identify the current resettlement services Poor Access to Dental 35.54% Having Angry Outbursts 35.54% available to Iraqis and their utilization Care Burnett, A. and Peel, M. “Asylum Seekers and Refugees in ” 4. Identify Iraqi immigrant community based Britain: Health Needs of Asylum Seekers and Refugees. BMJ: British Medical Journal, 2001; 322(7285), 544. organizations and initiate partrnerships Resettlement Issues % Reported Silove D, Field A, Steel Z, Manicavasagar V. “Compounding 5. Develop strategies to reduce mental stress and of premigration trauma and postmigration stress in Asylum improve social assistance Unemployed 76.85% Seekers.” Journal of Psychology.1997; 131: 463-470. Slewa-Younan, S. et al. “A Systematic Review of Post- Lack of Access/Possession of a Car 59.62% traumatic Stress Disorder and Depression Amongst Iraqi Survived Physical Trauma/Violence 59.62% Refugees Located in Western Countries.” Journal of Immigrant Minority Health. 2014. 10(1007). Witnessed Physical Trauma/Violence 36.54% Refugees in Sacramento, California.” UC Davis Clinical and Methods Translational Science Center. 2014. Sacramento: CA: UC Lack of Any Social Support 71.15% Davis 51 Iraqi refugees were interviewed with the assistance of 6 Acknowledgements assistants fluent in Arabic. Worries about resettlement stressors Faculty Advisor: Irva Hertz-Piccioto, PhD, UC Davis were gathered with the Post Migration Living Problems (PMLP) Correlation Between Conditions and Post-Migration Correlation Coefficient (R) Practicum Preceptor: Marius Koga
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