Welcoming Syrian Refugees into our Healthcare System

Transcription

1 Welcoming Syrian Refugees into our Healthcare System Lisa Andermann, MPhil, MD, FRCPC Mount Sinai Hospital; Associate Professor, Equity, Gender and Populations Division, Department of Psychiatry, University of Toronto Hart House - June 21, 2016

2 What we know about refugee mental health when coming to Canada What we can and cannot expect when caring for Syrian refugees with regards to mental health Potential service and accommodation needs Resources and tools

3

4

5 To screen or not to screen? Pushing for disclosure of traumatic events in well-functioning individuals who have survived torture or sexual- and gender-based violence could be harmful This increases the risk of inducing trauma, as well as raising issues of stigma and consequent ripple effects on family and community Recommend against systematic screening for PTSD, but suggest that practitioners be alert for associated signs and symptoms (e.g., unexplained somatic symptoms, sleep disorders or mental health disorders such as depression or panic disorder). Pottie et al, CMAJ, posted Dec. 8, 2015

6

7 Recommendations on PTSD from Canadian Collaboration for Immigrant and Refugee Health 1. Do not conduct routine screening for exposure to traumatic events (unless it is pt s primary complaint)... pushing for disclosure of traumatic events in well-functioning individuals may result in more harm than good. 2. Be alert for signs and symptoms of PTSD, esp. in context of: - unexplained somatic symptoms, Many persons having had a trauma exposure do fine once they find safety and social supports. Family perspective is essential Remember: Phase 1 trauma treatment is safety and stabilization Most people recover after reaching safety -sleep disorders, -depression or panic disorder, - address functional impairment

8 Hassan, G., Kirmayer, LJ, Mekki-Berrada, A. et al. UNHCR, 2015

9 Risk Factors for PTSD Brewin 2000, Shalev 2002 Pre Trauma: Gender Younger age at trauma SEC Education Intellect Race <0.2 *Psychiatric History *Childhood abuse Other previous trauma Other adverse childhood events *Family Psychiatric History >0.2 Trauma: Post trauma: Trauma Severity Lack of social support Ongoing life stressors 0.3

10 DSM-IV ASSOCIATED FEATURES AND DISORDERS IN PTSD 1. Guilt feelings about surviving 2. Auditory hallucinations and paranoid ideation 3. Impaired affect modulation 4. Self destructive and impulsive behavior 5. Dissociative symptoms 6. Somatic complaints 7. Feelings of ineffectiveness, shame, despair, or hopelessness 8. Feeling permanently damaged 9. Loss of previously sustaining beliefs 10. Hostility 11. Social withdrawal 12. Feeling constantly threatened 13. Impaired relationships with others 14. A change from the individual s previous personality characteristics

11 DSM 5 specify Dissociative symptoms either: Depersonalizatrion Derealisation With delayed expression diagnostic criteria met 6 months or longer after the TE PTSD in children 6 years of younger

12 Does everyone who is traumatized get PTSD? General population: 60.5% of men and 51.2% of women had one Criterion A event. Life time prevalence of PTSD: 5.0% for men and 10.4% for women

13 Longitudinal Course of PTSD Symptoms 6% recovered 53% recovered 58% recovered 15-25% UNRECOVERED Weeks 3 months 9 months YEARS Shalev & Yehuda, Psychological Trauma 1998

14

15 Summerfield s Critique The use of psychiatric words to describe suffering implies that PTSD is universal and context-independent. This medicalization of suffering infers all suffering is pathological, an illness or disease, and must be treated within a medical model It obscures the political and economic causes. PTSD tools are based on the DSM IV, applied to non western cultures they export our understandings by assuming and prescribing answers, failing to consider different cultural experiences. Suffering is inevitable for human beings and traumatic experience ubiquitous to heal we have always needed the institutions of society where meaning and culture is sequestered: schools for our children, mosques, temples, churches, synagogues, work, health care, sport, community centers, pubs Less treatment more assistance with rebuilding the infrastructure which houses the culture s system of meanings.

16 Psychological Principles for PTSD Prophylaxis in Canada Foster a sense of security and self-efficacy Protection from further threat or fear of further threat Reliable supply and access to basic needs Reinforce the natural support systems e.g. the informal community leaders who might be spiritual leaders, teachers, physicians etc e.g. appropriate places of worship, foster societal groupings that are comfortable for Syrians e.g. musical evenings, Syrian cooking evenings, men s checker board evenings Inclusion of the refugees into decisions that involve them Information and education to orientate them to Canada Respond to the needs as voiced by the refugees (Slide credit C. Pain)

17 DSM-IV Cultural Formulation I. Cultural identity: Ethnicity, Language, Involvement with culture of origin and host culture II. Explanatory Model- Cultural explanations of the illness; Help seeking experiences and plans III. Cultural factors in the psychosocial environment: Stressors and supports IV. Cultural elements of the clinician-patient relationship V. Overall Cultural Assessment

18 Explanatory Models (Kleinman) 1.What do you think caused your problem? 2.Why do you think it started when it did? 3.What does your sickness do to you? How does it work? 4.How severe is your sickness? How long do you expect it to last?

19 Explanatory Models (Kleinman) 5.What problems has your sickness caused you? 6.What do you fear about your sickness? 7.What kind of treatment do you think you should receive? 8.What are the most important results you hope to receive from this treatment?

20 Berry Model of Acculturation Acculturation Attitudes - Is it considered to be of value to maintain relationships with other groups? - Is it considered to be of value to maintain cultural identity and characteristics? Yes No Yes Integrated Assimilated No Separated Marginalized * Need to take into account issues of stigma, power, racism, discrimination

21 Cultural Formulation Interview (DSM-V) More structured interview suggestions Supplementary modules with additional questions including special populations, children & adolescents, older adults, immigrants & refugees, gender identity

22

23 Settlement services are vital CCVT Programs and Services Mental Health Settlement Services Children & Youth ESL Computer Training Public Education East Toronto Downtown Local Immigration Project International Projects

24 Kids New To Canada Multicultural Mental Health Resource Centre (MMHRC)

25 Wednesday Feb. 10 All day event Webinars: Wed, Jan. 13, 2016: Reactions to war and systemic violence: differentiating distress from mental illness. Dr. Clare Pain. Wed, Jan. 20, 2016: La santé mentale des réfugiés syriens. Dre Ghayda Hassan.

26 March 7 from 1:00 PM 2:30 PM

27

28

29 Summary of recommendations for Syrian refugees Syrian refugees have faced: Primary care clinicians: war crimes, human rights violations Should not routinely screen for trauma poverty Remain alert for: prolonged displacement may have physical and mental health implications. Access to: safe and adequate housing employment and income Family cohesion - keeping parents and children together during & after the integration process impairment of social functioning high levels of suffering that may be related to post-traumatic stress disorder, depression or anxiety disorders, exposure to war-related violence refer to appropriate services for assessment and follow-up. Pottie et al, CMAJ, posted Dec. 8, 2015

30 Post-traumatic growth Changes in perception of the self: Identify strengths and new possibilities Greater intimacy in relating to others Changed philosophy of life: New priorities, appreciation and spirituality Tedeschi and Calhoun, 1995 Weiss and Berger, 2010

31 Treating refugees in Canada: lessons learned Do whatever you reasonably can to help solve the problem. Nonspecific supportive interventions Do whatever you can to facilitate function and optimize mood. Empathy, advocacy, reassurance All new Canadians will feel better as they learn English: they can then read the newspapers, make phone calls to services, talk to their children s teacher, read food and medication packaging learning English is excellent psychological treatment and mental health prophylaxis (Slide credit C.Pain)

32 This is an opportunity to improve our own cultural competence and familiarity with newcomer mental health To advocate for better health care for *all* refugees For more information: Pillar 4 - Department of Psychiatry