“Mental Health on Arrival: An Analysis of Refugee Mental Health in Utah” Ji won Chang Refugee Health Program January 2015 UTAH DEPARTMENT OF HEALTH 288 North 1460 West Salt Lake City, Utah 84114 P a ge | ii Acknowledgments This research endeavor was made possible through the help and support of numerous individuals. First and foremost, I would like to personally thank the Refugee Health Program staff at the Utah Department of Health for the opportunity to conduct this analysis. In particular, special thanks to my internship mentor, Chelsey Butchereit. Without her expertise and dedication this research paper would not have been possible. Second, I would like to express my utmost gratitude to Professor Patricia Bromley, who, as my master’s thesis advisor, has continuously provided valuable feedback, guidance, and inspiration. Finally, the Refugee Health Program at the Utah Department of Health recognizes the efforts of resettlement agencies, health clinics, and health care providers in Utah, all of whom play a critical role in the health screening process, the collection of data, and also provide timely and adequate care for refugees in the state of Utah. The Refugee Health Program also acknowledges the efforts of other partners in reporting refugee health data and supporting staff who contributed to this report. Please direct questions or comments to: Utah Department of Health Bureau of Epidemiology Refugee Health Program Phone: (801) 538-6191 Fax: (801) 538-9913 288 North 1460 West PO Box 142104 Salt Lake City, Utah 84114-2104 MENTAL HEALTH ON ARRIVAL: AN ANALYSIS OF REFUGEE MENTAL HEALTH IN UTAH P a ge | iii Executive Summary The United States has the largest resettlement program in the world and welcomes more than half of all refugees resettled through the United Nations High Commissioner for Refugees (UNHCR) each year.1-3 The state of Utah resettles more than 1,000 refugees every year and is currently home to 25,000 refugees.4,5 While starting anew provides unparalleled hope and opportunity for many, hardships and significant losses during pre- and post-migration put refugees at a significant risk for psychiatric disorders.6-8,11-16,18 Mental health screenings, services, and follow-up care may be necessary to establish successful refugee self-sufficiency, resettlement, and integration into society. While recommended by the Centers for Disease Control and Prevention (CDC) and others,6-9 various barriers have inhibited the provision of routine mental health screenings for newly arriving refugees.24 Utah, recognizing the impact of mental health on the well-being of its refugees, is among the few states that have historically screened for mental health conditions during the domestic screening process. Utilizing this mental health information collected during initial screenings, this study, through a secondary data analysis, established the baseline prevalence of mental health conditions and risk factors among refugees resettled in Utah during the period beginning October 1, 2009 to September 30, 2014. This analysis further described how mental health issues varied by age, sex, and nativity/culture. It determined best approaches and provided recommendations for maintaining the quality of the mental health data collected. This study was conducted with the assistance of the Refugee Health Program (RHP) at the Utah Department of Health (UDOH) to help the health department, other refugee resettlement stakeholders, health care providers, and key decision makers in the state better understand, meet, and anticipate the mental health needs of its current and newly arriving refugee population. It was a step towards promoting awareness of and addressing mental health conditions of refugees arriving in Utah to help facilitate appropriate services and successful resettlement to Utah.4 MENTAL HEALTH ON ARRIVAL: AN ANALYSIS OF REFUGEE MENTAL HEALTH IN UTAH P a ge | iv Key Findings  More than one-fourth of the total refugee population (27%) arriving in Utah had symptoms of mental health conditions.  Among the 27%, 10% had anxiety, 9% had depression, and 25% showed symptoms of having suffered torture and violence.  Of those with at least one risk factor, 15% had more than one concurrent risk factor.  Of the Refugee Health Screener -15 scores reported, 39% had a high enough score to be referred for follow-up mental health services.  The highest burden of mental health conditions and risk factors were among those between the ages of 45 and 64 years (41%).  A higher percentage of women had mental health conditions and were twice as likely to be referred for services as men.  Prevalence of risk factors did not vary with sex.  Nearly half of the Iraqi (52%), Sudanese (47%), and Afghani (45%) populations were symptomatic of mental health conditions.  Most nativity/cultures had higher levels of anxiety than depression.  Past experience with torture and violence was the most common risk factor, even after stratifying by age and nativity/culture.  By far, the Iraqi and Sudanese populations had the highest collective burden of the three risk factors: torture and violence, anxiety, and depression.  The nativity/cultures with the highest burden of anxiety, depression, and torture and violence were DRC Congolese (17%), Afghani (8%), and Sudanese (7%).  Iraqi refugees were 1.4 times more likely to be referred than Sudanese refugees and nearly10 times (9.5) more likely than Ethiopian/Eritrean refugees. MENTAL HEALTH ON ARRIVAL: AN ANALYSIS OF REFUGEE MENTAL HEALTH IN UTAH P a ge | v Abbreviations AF Afghani IZ Iraqi AK Arkanese KA Karen BM Burmese KC Kachin BT Bhutanese KM Kunama CN Chin KRI Karenni CU Cuban MO Mon DC Congolese (Democratic RG Rohingya Republic of Congo) SB Somali Bantu ER Eritrean SH Shan ET Ethiopian SO Somali IR Iranian SU Sudanese MENTAL HEALTH ON ARRIVAL: AN ANALYSIS OF REFUGEE MENTAL HEALTH IN UTAH P a ge | vi List of Tables & Figures Table 1: Summary Statistics of Refugee Age at Arrival Table 2: Summary Statistics of Refugee Age at Arrival by Sex Table 3: Study Population by Nativity/Culture Figure 1: Age at Arrival by Age Category Figure 2: Distribution of Age at Arrival by Sex Figure 3: Study Population by Nativity/Culture Figure 4: Nativity/Culture by Age Category Figure 5: Percentage of Population Aged 14-24 Years Old Figure 6: Percentage of Population Aged 25-44 Years Old Figure 7: Percentage of Males and Females by Nativity/Culture Figure 8: Percentage of Mental Health Conditions and Risk Factors Figure 9: Percentage of Refugees with 1 Risk Factor or More Figure 10: Distribution of RHS 1 Scores Figure 11: Distribution of RHS 2 Scores Figure 12: Age Distribution of Those with Mental Health Conditions and Risk Factors Figure 13: Frequency of Risk Factors and Mental Health Conditions by Sex Figure 14: Percentage of High RHS-15 Scores by Sex Figure 15: Mental Health Conditions and Risk Factors by Nativity/Culture Figure 16: Percentage of High RHS-15 Scores by Nativity/Culture Figure 17: Percentage of Population Aged 45-64 Years Old Figure 18: Percentage of Population Aged 65-84 Years Old Figure 19: Percentage of Population Aged 85+ Years Old Figure 20: Distribution of RHS 1 Scores by Sex Figure 21: Distribution of RHS 2 Scores by Sex MENTAL HEALTH ON ARRIVAL: AN ANALYSIS OF REFUGEE MENTAL HEALTH IN UTAH P a ge | vii Table of Contents Acknowledgments ii Executive Summary iii Key Findings iv Abbreviations v List of Tables & Figures vi Introduction & Background 9 US Refugee Resettlement 9 Gaps in the Resettlement Process 9 Utah’s Resettlement Process 9 Significance of Study 10 Research Question 10 Objectives 10 Methodology & Research Design 11 Study Design 11 Inclusion & Exclusion Criteria 11 Procedures 11 Data Definition Table 13 Statistical Analysis 14 Results & Findings 15 Refugee Demographics 15 Refugee Mental Health Conditions 19 Mental Health Conditions by Age 22 Mental Health Conditions by Sex 22 Mental Health Conditions by Nativity/Culture 24 MENTAL HEALTH ON ARRIVAL: AN ANALYSIS OF REFUGEE MENTAL HEALTH IN UTAH P a ge | viii Summary and Conclusion 25 Review of Findings 25 Study Limitations & Recommendations 26 Recommendations for Future Studies 27 References 28 Appendix 32 Appendix A. Additional Graphs 32 Appendix B. Excerpts from the Utah Refugee Health Program Manual 35 Appendix C. Refugee Health Screener-15 45 Appendix D. New Health Screening Form 48 MENTAL HEALTH ON ARRIVAL: AN ANALYSIS OF REFUGEE MENTAL HEALTH IN UTAH P a ge | 9 Introduction & Background and manmade, such as war, state-sponsored violence, political oppression, and natural disasters, as well as the loss of family members, “Refugees add to America’s vitality and forced migration, and resettlement. 6-8,11-18 As a diversity by making substantial result of these experiences, this population has a contributions to our economic and cultural higher burden of mental health conditions and is life.”3(pp3) ten times more likely than the general population to suffer from conditions, such as post-traumatic US Refugee Resettlement stress disorder (PTSD).19-23 Most common The United Nations High Commissioner afflictions among refugees include PTSD, for Refugees (UNHCR) defines a refugee as a depressive disorders, anxiety disorders, brief person who is outside their country of nationality reactive psychoses, and adjustment reactions.6 and is unable or unwilling to return due to fear of Barriers such as the availability of persecution; this persecution can be related to services have inhibited the routine provision of race, religion, nationality, membership of a mental health screenings in newly arriving particular group, or political opinion.1 The United refugees.24 Other barriers include language, States (US) is an imperative host to the different cultural or conceptual perceptions of worldwide resettlement process. While only1% health, 6,8,24 and the lack of knowledge about of the total refugee population in need is resettled effectiveness of screening and treatment. 24 into third countries, more than half are resettled However, it is becoming increasingly evident that into the United States.1,2 early detection and treatment of mental health Due to escalating global unrest, refugee conditions is necessary. Mental illness can be arrivals have increased over the past few years highly debilitating, impacting a refugee’s ability with the US resettling nearly 70,000-80,000 to thrive, often resulting in unforeseen refugees annually.1-3 According to the State externalities, such as costs to the health care Department’s Bureau of Population, Refugees, system. 26-33 and Migration, more than 3 million refugees have Resettlement into the US involves been resettled in the US in the past 35 years.2 The adjusting to societal norms. Language, financial state of Utah alone resettles about 1,100 refugees and occupational demands, and psychiatric yearly, and over 25,000 refugees, speaking more conditions often impair a refugee’s ability to cope than 40 different languages, currently reside effectively with these significant life changes.6,25 within Utah’s borders.4,5 Resettlement can be overwhelming and may exacerbate existing or accelerate the onset of Gaps in the Resettlement Process mental disorders. Furthermore, these types of Resettlement into third countries illness have been shown to be associated with provides unparalleled hope and opportunity to other health problems, such as cardiovascular many, but hardships and significant losses during diseases and inflammatory symptoms and pre- and post-migration put refugees at increased diseases.26-33 risk for psychiatric disorders. Refugees may require mental health services in order to Utah’s Resettlement Process successfully transition, integrate, and become The state of Utah, recognizing the vital contributing members of society.4,6 The Centers importance of mental health for the well-being of for Disease Control and Prevention (CDC) and a refugees, offers a comprehensive and holistic myriad of studies6-9 recommend that mental health screening that includes a mental health health screening and follow-up care be provided assessment. Upon arrival in Utah, various to refugees upon arrival.10 Unfortunately due to agencies ensure that refugees have, among other multiple barriers, mental health screenings or services, monetary, employment, housing, services are not a standard practice in the US.6 education, health and acculturation assistance and Refugees’ predisposition to mental support.4 The Refugee Health Program (RHP), conditions and disorders largely results from housed in the Division of Disease Control and exposure to environmental crises, both natural Prevention, Bureau of Epidemiology, Utah UTAH DEPARTMENT OF HEALTH 288 North 1460 West Salt Lake City, Utah 84114 P a ge | 10 Department of Health, specifically coordinates process of conducting the study, a goal was to and promotes health services to facilitate establish additional methods to standardize and successful resettlement and integration into the maintain the quality of the mental health data community.4 collected from this point forward. A second goal The mission of the RHP is to, “…foster was to utilize the information in the Refugee community health partnerships with those Health Access Database to report on the mental serving refugee populations through culturally health status of refugees being resettled to Utah. appropriate health screening, education and This is the first study to provide baseline referrals.”4(pp11) The RHP focuses on services in information with respect to the prevalence of five priority areas, including the provision of a mental health conditions among refugees in the comprehensive and holistic refugee health state of Utah. It will allow the RHP, refugee screening. In accordance with the Refugee Act of resettlement stakeholders, health care providers, 1980,2 the RHP contracts and establishes and key decision makers in Utah to better partnerships with local health care providers, understand, meet, and anticipate the needs of its local health departments, screening clinics, and current and newly arriving refugee population. It resettlement agencies to provide an extensive is a step towards promoting awareness and health screening to all refugees within 30 days of addressing mental health conditions to help arrival in Utah. facilitate appropriate services and successful The purpose of the domestic health resettlement and integration into Utah.4 screening is to “reduce the spread of infectious disease, ensure ailments are identified and Research Question treated, promote preventive health practices, and This study aimed to determine the to ensure good health practices to facilitate prevalence of mental health conditions and risk successful integration and self-sufficiency.”5(pp2) factors among refugees resettled in Utah between Utah’s domestic health screening includes a October 1, 2009 and September 30, 2014, and to physical exam, tests for sexually-transmitted describe variation in health status by age, sex, and diseases and parasites, assessment of chronic nativity/culture. illnesses, immunizations, presumptive treatment Objectives for parasites, tuberculosis screenings, and a mental health assessment (Appendix B).4 The specific objectives of this study: Information from these screenings is reported on health screening forms (HSFs) that 1. Standardize how mental health are relayed to and compiled by the RHP staff into information is collected and entered into the Utah Refugee Health Access Database. The the state database; health information collected is used to ensure that 2. Clean, update, and identify all data on newly arriving refugees receive timely services refugees who received a mental health and follow-up care as indicated. Additionally, screening (≥ 14 years old) between this information is analyzed and disseminated in October 1, 2009 and September 30, 2014; reports describing refugee arrivals and health 3. Determine the prevalence of mental screening results for refugee health and health conditions and risk factors for resettlement stakeholders in Utah. specific populations; 4. Conduct statistical analyses to determine Significance of Study how the prevalence of mental health Given the evidence, the RHP conditions varies by age, sex, and acknowledges that a valuable and unique nativity/culture; and, component of its screening program and refugee 5. Provide recommendations and make health database is the mental health information changes to maintain data quality moving collected. This study was conducted with two forward. overarching goals in mind. First, through the MENTAL HEALTH ON ARRIVAL: AN ANALYSIS OF REFUGEE MENTAL HEALTH IN UTAH