Clinical Encounters with refugees suffering from mental health problems

Despite a higher incidence of mental health problems, refugees tend to be less represented among patients receiving specialist mental health care than the majority population. This apparent paradox may indicate that the health services do not sufficiently meet the needs of this group. The project's overall objective has been to contribute to a research-based platform for how mental health services can be adapted to the needs of refugees. In particular, the project aimed to provide knowledge about mechanisms affecting refugees' access to and use of mental health services, emphasizing the GP's role. Part-project 1 has conducted focus group interviews (N=77, number of groups=13) and a survey (N=633) among Syrian, Afghan, and Somali refugees focusing on "explanatory models" for mental health problems, as well as coping behavior and help sources considered most useful. Refugees from these countries with one to two years of residence participated in gender-divided focus group interviews. Initially, they were presented with a vignette describing a person of the same gender and country of origin, with symptoms of depression or PTSD in line with the DSM and ICD criteria. Afterward, they answered questions with reference to this fictive person about possible explanations for the condition and the advice they would have provided if she/he had been their friend. The survey also consisted of measures of integration, mental health, and experience with consulting a GP. The symptoms were mostly understood as natural reactions to extreme events and difficult life situations before, during, and after the escape. Being "mentally ill" and requiring treatment tended to be seen as equivalent to "madness” and associated with significant social stigma. Some informants expressed concerns that information given to healthcare personnel and interpreters would be shared with family or others in their social network. Emotional and social support from family and others with similar experiences was seen as most helpful in alleviating the symptoms. In the interviews, many emphasized that advice from parents, spouses, and in some cases, religious authorities was decisive for whether and where they would seek help. In the survey, respondents were asked to rank help sources according to assumed usefulness. Syrian and Afghan participants indicated they would first seek help from God and then partner and mother. The most indicated barriers to seeing a GP included 'language barriers,' 'I don't think it would help’, 'the waiting times are too long, and 'I don't think my GP would understand'. Social integration and feelings of connectedness with the host country (psychological integration) correlated positively with the likelihood of seeking help from the GP. The results from the interviews across groups and contexts highlighted that many thought it was essential that "helpers" had refugee backgrounds and/or shared the same culture. The project's second sub-project examined the consultation between GPs and refugee patients and the possible implications of patients' background (refugee vs. Norwegian-born) and gender for diagnoses, recommended treatment, and possible referral to the specialist health service. Interviews examined GPs' (N=15) views on conditions that prevent or facilitate diagnosis and good treatment. The most critical challenges were language barriers, different expectations and understandings of mental health problems, and feeling unprepared. Facilitating conditions were trust between GP and patient and that the doctor experienced the work as meaningful. An online experimental study was also carried out. Participants (N=133) were randomized to watch a film vignette of a simulated consultation with either a female Norwegian, female Somali, male Norwegian or male Somali vignette character presenting the same symptoms of depression. GPs indicated which diagnoses, assessments, and treatments they would endorse for the patient and their level of certainty in that decision. There was less consensus regarding the primary diagnosis for Somali characters vs. Norwegian characters. Somalis more frequently received PTSD diagnoses, while Norwegians received diagnoses of depression. GPs endorsed sick leave more often for Norwegian characters and medication for physical complaints for Somali characters. There were no differences in the GPs' self-reported uncertainty related to whether the patient was of Somali or Norwegian origin. Results from the project have been incorporated into a web-based resource/training program for students, GPs, and healthcare personnel.

The project has aimed to contribute to a research-based platform to strengthen and tailor mental health services to meet the needs of refugees. Based on new knowledge from the project, we have developed a web-based resource program for GPs and other mental health care professions (psychologists and psychiatrists) as well as students. A significant finding from the project is that many refugees prefer psychosocial support from people of similar backgrounds (refugees and/or from the same country) rather than seeking help from health services. This output has several implications. Firstly, the results indicate the need to recruit more mental health professionals with ethnic minority backgrounds. Secondly, cultural competence and migration health should be integrated in health and social education programs. Thirdly, integrating paid refugee peer-helpers in health and social services can potentially aid services in overcoming the scarcity of mental health specialists, reduce costs, and minimize stigma and other barriers associated with accessing and using public mental health care services. Researchers in the project have introduced to municipalities a low-intensity, scalable psychological intervention (Problem Management+) for refugees delivered by non-specialized peer helpers. The intervention, developed and recommended by the World Health Organization is being tried out by Bergen Municipality, and other municipalities are expected to follow. The University of Bergen has funded a Ph.D. to evaluate the intervention. We shall evaluate the potential impact of the program on "users" as well as on refugees engaged as "helpers". The project has produced new methods in five different languages for assessing explanatory models for mental health illnesses among refugees in post-migration and camp contexts. These methods are available for use by the research community. Additionally, psychological instruments have been translated and culturally adapted for Afghanistan, Syria, and Somalia refugees. The project results have been disseminated to the international scientific community and relevant user groups (refugees, national and international NGOs, municipalities, clinicians, GPs, and humanitarian workers) through a variety of measures, including podcasts, online training resources, chronicles, lectures, webinars, and scientific papers.

Providing efficient mental health services for an increasing refugee population represents a challenge for the Norwegian society. Statistics show large differences between immigrants and natives in contact with specialist mental health services, with noticeably low use among immigrants from Somalia and Asia. This project aims to build a research-based platform to enhance and tailor mental health services to meet the needs of refugees. Specifically, it will provide knowledge about mechanisms impacting their access and use of mental health services, with a focus on the general practitioner (GP). The project will include two parts. Essential to the first part is building more research-based knowledge on how refugees interpret and prefer to cope with mental health problems, including their experience with public health services. Refugees from Somalia, Syria and Afghanistan will participate in focus-group interviews and a survey in which they are introduced to a vignette character with symptoms of depression or PTSD, and asked about efficient coping strategies and help-seeking behaviour. The second project part will examine how mental health problems presented by refugee patients are perceived, diagnosed, and handled by GPs. Focus-group interviews with GPs will assess frequently occurring challenges experienced in medical encounters with refugee patients. Next, we will produce video films of patients (case stories) with symptoms of post-traumatic stress disorders or depression, based on the narratives from the interviews and the survey. For each patient, GP?s will fill out questionnaires on diagnosis, recommended therapy, referral to mental health services, sickness leave, and medications. The project will also evaluate the potential impact of patient?s gender and background (refugee vs. native-born) on GPs? judgments. The results will be integrated into training programs for GPs and other health care professions, thus strengthening the foundation for knowledge-based practice.