Exploring National Practices and Barriers Related to Mental Health Screening of Refugees

Purpose: A recent meta-analysis of 181 surveys of over 80,000 refugees from 40 different countries reported a prevalence rate of 30.6% for posttraumatic stress disorder (PTSD) and 30.8% for depression (Steel et al., 2009). The strongest factor associated with PTSD was torture followed by cumulative exposure to traumatic experiences.   When resettling in the United States, refugees face multiple barriers to stability including lack of employable skills and language and cultural adjustment difficulties (Morris, Popper, Rodwell, Brodine, & Brouwer, 2009).  Such mental health problems make it difficult for people to secure and maintain employment.  The national alliance for mental illness estimates that 60-80 percent of people who live with mental illness are unemployed and, for people living with the most severe mental illnesses, unemployment rates can be as high as 90 percent (National Association of State Mental Health Program Directors, 2007).    The Harvard Mental Health Letter (2010) estimates further that an investment in mental health care pays productive dividends at rates ranging from 4.5-1 to 18-1 .  This paper reviews current mental health screening practices and training needs based upon a national survey of refugee health coordinators.  It discussed what is at stake in terms of long term cost and feasibility of mental health screening of refugees in the public health system.

Methods:  The research team developed a survey to explore practices, knowledge gaps and the perceived need for a mental health screening protocol for refugees. A survey was sent to the Refugee Health Coordinators for each state in the U.S., including the District of Columbia.  Two states without Refugee Health Coordinators, Mississippi and Wyoming, were excluded from the survey.  Data were collected using a web-based survey tool managed by the University of Minnesota College of Education and Human Development. The web-based survey comprised 28 semi-structured questions on mental health screening and referral practices.  To analyze the survey data, we used descriptive statistics including frequencies, proportions, means, standard deviations and cross tabulations. We also conducted correlation analysis between refugee arrival data, state refugee program data and screening rates. Multiple response analyses were performed on types of screening tools and barriers to screening and social service access. Open ended survey responses were categorized and singe responses to “other” categories were listed.  PASW 18 for Windows was used for the analysis.  Qualitative data from follow-up interviews with 10 states was listed by state and categorized.  Additional information concerning the process of informal interviewing was summarized.     

Results: Only half of the states provide any mental health screening to newly arrived refugees.  Of the states that provide screening for mental health symptoms, more than half utilize informal conversation.  Further, less than half the states reported directly asking refugees about their exposure to war trauma or torture.  The most frequently cited reasons for not providing mental health screening were the lack of culturally sensitive instruments and the lack of time and resources.

Implications:  These barriers underscore the need for brief, culturally validated instruments for screening refugees in the public health setting.