"Ulysses’ Dilemma: When to Medicalize or Demedicalize Refugee Traumatic ?” “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, , 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 , numbing, arousal ()

Pain and apparently disproportionate disability

Anxiety disorder

Unexplained physical symptoms

Major depressive disorder

Impact on family (such as family arguments, 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 . • 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 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 ,MD, MPH questionnaire translated into Arabic. This study measures VIRTIS & UC Davis School of Medicine psychiatric disorders such as PTSD, anxiety, and depression using Anxiety and Depression 0.512 Eduard A. Poltavskiy (MSc) UC DavisPHS Dept the Arabic translations of PTSD Checklist Civilian (PCL-C), Becks Anxiety and Post Migrations Living Problems 0.374 Department Chair: Stephen McCurdy (MD, MPH) Anxiety Inventory (BAI), and Beck’s Depression Inventory. A factor VIRTIS Arab Refugee Health Program analysis was done on PMLP and univariate and multivariate Depression and Post Migration Living Problems 0.435 Iraqi Refugee Community of Sacramento analyses measured correlations to psychopathology. Depression and PTSD 0.317

9 Ulysses Project - Challenges

To medicalize of to demedicalize?

Subthreshhold PTSD Ulysses • PCL-C scores <45 • Achotegui’s Seven • Depression Mournings (losses) • Anxiety The refugee is a normal human The refugee is a moderately being living under extreme mentally ill patient in need of stress, in need of a antidepressants, anxiolytics, substantial and psychological counseling Psychosocial preventive (CBT or CPT) intervention and support (orientation, navigation, mentoring, integration)

10 POST-RESETTLEMENT LIFE STRESSORS AND HEALTH

DISPARITIES IN REFUGEE POPULATIONS IN CA

Not only American health care services providers can lack cultural competence but also the refugee themselves. And this is how their predicament starts in the post- resettlement phase in America, and is partially a root-cause of their health disparities: 1. No language skills 2. Ignorance about accessing and navigating healthcare services 3. Incongruent refugee health beliefs, constructs, and expectations 4. Alone, on their own 90 days after landing in an alien environment

Most often, refugees arrive in California having lived under dire conditions with little or no access to healthcare services and with no understanding of western medical care practices or the concept of preventive health care.

Hence the need of a close collaborative partnership of UCD Health System, counties, and NGOs, with the refugee communities they serve.

11 Afghan Refugee Community Demographics

Although population estimates vary, local community groups and city officials estimate that there are approximately 60,000 Afghans in Northern CA, with the largest number of Afghan families living in the city of Fremont followed by Sacramento The Afghan community consists of people, primarily refugees and asylees, from both rural and urban areas of Afghanistan with very different educational and socio-economic backgrounds as well as their second generation children. The community includes Pashtu and Dari speakers. Many older Afghans have limited English speaking ability, and a number of the elderly Afghan women, in particular, remain illiterate in their own language, so the CA Afghan television provides a vital communication link.

Post-resettlement as a condition of high risk

 Refugees in acute crisis situations leave their homelands suddenly, with little prior planning, and with no choice about their destination (Kunz, 1981). Enduring memories of severe trauma experienced in their countries of birth accompanied by the stress of often treacherous journeys of forced migration and confusing demands of unexpectedly adjusting to a new way of life in a strange land distinguish the mental health needs of refugees from voluntary migrants. Voluntary immigrants feel pulled to a land of new opportunities and have time to contemplate and prepare for that new life, whereas refugees are pushed from a land of danger (Stein, 1981, p. 322).

 Dr. Koga states that 61% of the refugees he saw between 2012-2015 at Sacramento County Refugee Health Clinic have PTSD with another 25% having subthreshhold PTSD. In his expert opinion, PTSD is the primary mental health issue in the Afghan community. Left untreated and psychosocially unassisted properly, the subthreshhold condition progresses into clinical PTSD in two years after resettlement (Koga, 2015).

12 Iraqi refugees demographics

 Three decades of war, civil strife, and political chaos have led Iraqis to seek refuge in US, Canada, EU, and some Middle East countries (Jordan and Lebanon)  Many Iraqi refugees to US have found new homes in San Diego, San Francisco, and Greater Sacramento area  Between 2007-2011, 560 Iraqi refugees resettled in Sacramento, California  During 2011-2013, the nr increased 5 times (from 560 to almost 3,000 Iraqi refugees  In March 2016 the Iraqi refugees population in Sacramento is estimated at 4,600

Health disparities in Iraqi and Afghan refugee communities

There are substantial disparities (differences) between the health status of Iraqi refugees and the status of the general population of Sacramento:

1. Higher rates of uncontrolled Diabetes Mellitus (DM) Type II

2. Higher rates of uncontrolled Hypertensive Disorder

3. Higher rates of uncontrolled Coronary Artery Disease (CAD)

4. Higher rates of smoking

5. Higher rates of PTSD, depressive and anxiety disorders

6. Higher rates of prostate and cervical cancer CAUSE? Lower access to screening, early detection, and lower treatment rates of all of the above conditions

13 Health workforce disparities in the Afghan and Iraqi refugee communities

 Compared to native, English speaking Sacramentans, Afghan and Iraqi refugees have much less providers who speak Arabic and are culturally competent with Muslim Afghans and Iraqis in the following areas  Family Practice doctors and nurses (RNs and LVNs)  Psychiatrists  Physical Therapists, Respiratory Therapists, Occupational Therapists, Ultrasound Technicians  OB/GYN and cardiologists who  Surgeons  Hospice for terminally ill Afghan and Iraqi patients  Health careers college program representatives

Psychological Counseling Workforce Disparities

 Compared to native, English speaking Sacramento's, Iraqi refugees have much less providers who speak Arabic, Farsi, Dari, or Pashto and are culturally competent with Muslim Afghans and Iraqis:

 Licensed Psychologists Psy.D)

 Therapists such as Licensed Marriage & Family Therapists (LMFTs)

 Licensed Clinical Social Workers (LCSWs)

 counselors

14 2013 Iraqi Health Survey conducted by UC Davis and Mesopotamia Organization

Ziegahn, l., Ibrahim, S., Al-ansari, B., Mahmood, M., Tawffeq, R., Mughir, M., Hassan, N., DeBondt, D., Mendez, l., Maynes, E., Aguilar-Gaxiola, S., & Xiong, G. (2013). The Mental and Physical Health of Recent Iraqi Refugees in Sacramento, California. UC Davis Clinical and translational Science Center. Sacramento: CA: UC Davis.

Survey Finding #1

Iraqi refugees found the U.S. health care system difficult to understand in four primary domains: (1)the referral system for specialized care, the length of time involved, and all the steps in between, (2) the separation of dental and vision services from the rest of healthcare, (3) the seemingly arbitrary nature of which conditions are covered by insurance and which are not, and (4)language barriers—either because English was still a new language, or because “medical language” was not comprehensible

15 Survey Finding #2

Mental health resources are not widely understood by Iraqi refugees coming to the U.S. In addition, the vast majority of participants in this study did not access mental health care, either out of lack of knowledge about options, unwillingness to bring up the subject of trauma with providers, or cultural and linguistic barriers to the understanding of how mental health is viewed and treated in the U.S.

Survey Finding #3

Primary care health providers know little about Iraqi refugees, their health needs, the effects of trauma on Iraqi mental and physical health, and the refugees’ need for transparent communication of referral processes.

16 Proposed Solutions to Disparities

 Much better orientation beyond first 90 days

 Navigation of health, legal, and education systems

 Mentoring (careers)

 Employment through partnership with employers

 Cultural competence or proficiency, not “sensitivity”

 Support for IMGs to increase diversity on the medical and healthcare workforce

 Social integration and civic engagement through partnering with refugee communities

Veteran, Immigrant, & Refugee Trauma Institute of Sacramento

• Founded in 2009 by a former refugee, Dr. Marius Koga, as an bridge between communities, UCD, and CDPH • Recruited bilingual, bicultural, professionally trained providers & researchers, all former or current refugees • Networked with community leaders, ethnic media (radio, TV, newspapers), and local public TV • Partnered with UCD PHS Dept. and with local & international universities (Kyrgyzstan, Afghanistan, Ukraine, Spain, Turkey) • A refugee-driven translational research organization • Training/internship site for UCD students • RISE: Research; Instruction; Service; Empowerment www.virtis-ptsd.org

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