Central Journal of Family Medicine & Community Health

Cite this article: Patterson K, Koga PM, Ramos M (2017) Evaluating the Performance of Primary Care Mental Health Screening Instruments among California Refugees. J Family Med Community Health 4(6): 1125.

Abstract

Background: Despite the well documented mental health vulnerability of refugees, the paucity of validated screening instruments for this population has delayed the implementation of routine refugee mental health screening in the United States.

Method: This pilot screening project assessed the performance of three brief mental health screening tools (PC-PTSD, GAD-2 and PHQ-2) in detecting symptoms of post-traumatic stress disorder, anxiety and depression in a diverse sample of refugees undergoing standard post-arrival health assessments in Sacramento, California.

Results: Of the 1,643 refugees nearly 16% (n=262) screened positive for at least one mental health condition. Compared to follow-up scores on the PCL-C, BAI and BDI-II, all three screening tools demonstrated moderate sensitivity (PC-PTSD; 80%; GAD-2: 81%; PHQ-2: 73%).

Conclusion: These findings warrant the integration of standardized mental health screening into routine refugee health assessments in the state of California. Further prospective research is necessary to establish screening generalizability in a broad range of refugee populations.

*Corresponding authorKali Patterson, Department of Public Health, Center for Infectious Diseases, Office of Refugee Health, MS 5204, 1616 Capitol Ave, Sacramento, CA 95899-7377; Tel: 1-916-552-8262; 1-916-552-8260; E-mail:

Submitted: 26 July 2017

Accepted: 14 August 2017

Published: 16 August 2017

ISSN: 2379-0547

Copyright© 2017 Patterson et al.

OPEN ACCESS

Keywords• Refugee• Mental health screening• PTSD• Depression• Anxiety

Short Communication

Evaluating the Performance of Primary Care Mental Health Screening Instruments among California RefugeesKali Patterson1*, Patrick Marius Koga2, and Marisa Ramos1

1Department of Public Health, Center for Infectious Diseases, USA2Department of Public Health Sciences, University of California Davis School of Medicine, USA

ABBREVIATIONSPC-PTSD: Primary Care PTSD; GAD-2: Two-item Generalized

Anxiety Disorder scale; PHQ-2: Patient Health Questionnaire; PCL-C: PTSD Checklist – Civilian Version; BAI: Beck’s Anxiety Inventory; BDI-II: Beck’s Depression Inventory; PTSD: Post Traumatic Stress Disorder; GAD: Generalized Anxiety Disorder; FFY: Federal Fiscal Year; ORR: Office of Refugee Resettlement; CDC: Centers for Disease Control and Prevention; CDPH: California Department of Public Health; ORH: Office of Refugee Health; RHAP: Refugee Health Assessment Program; RHEIS: Refugee Health Electronic Information System; HIPAA: Health Insurance Portability and Accountability Act

INTRODUCTIONSummary

Refugees by definition are people who have undergone a multitude of traumatic events, subjecting them to an increased risk of mental health disorders including post-traumatic stress disorder (PTSD), anxiety, and depression [1-4]. Such emotional and psychological disturbances not only inhibit acculturative adjustment in host countries, but are also linked to negative health outcomes [5-9]. Thus, refugee mental health status is

a public health concern in recipient countries and U.S. federal guidelines encourage mental health symptom identification during preliminary refugee health screening [10]. Despite these recommendations there continues to be practical shortcomings in identifying and addressing refugee mental health with the primary obstacle being a deficiency in valid screening instrumentation [11-13]. The absence of adequate screening methods poses a challenge in obtaining accurate diagnosis and prevalence estimates, thus underestimating the mental health needs of refugees and hindering the development of targeted services and programs. This necessitates the standardization of existing screening tools to achieve timely mental health detection and intervention for this population. In response to these shortcomings, this pilot screening project sought to assess the performance of three mental health screening tools (PC-PTSD, GAD-2, and PHQ-2) in detecting symptoms of PTSD, anxiety, and depression in a diverse population of refugees seen at the Refugee Health Clinic in Sacramento, California.

Background

According to the United Nations High Commissioner [14], refugees are individuals who were forced to flee their country of origin due to persecution, war, or violence. A refugee has

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well-founded fears of persecution for reasons of race, religion, nationality, political opinion, or membership in a particular social group. Usually, they cannot return home or are afraid to do so. The leading causes of refugees leaving their countries are ethnic, tribal, and religious violence [15].

The term “refugees” is used throughout this document to include several categories of entrants who are eligible to receive federal refugee services including refugees, asylees, entrants from Cuba and Haiti, certified victims of human trafficking, and other eligible groups.

During the Federal Fiscal Years (FFY) of 2012 and 2013 approximately 128,088 new refugee arrivals were admitted to the U.S., and 54,566 affirmative and defensive asylees were granted asylum [16]. During this same time period, California alone received 11,546 (9%) refugees and 13,155 (24%) asylees; making California the second largest recipient of refugees and the largest recipient of asylees in the nation [16].

Refugee mental health

Prior to migration, refugees have most likely undergone severe and often life threatening events such as exposure to war, violence, oppression, torture, rape, natural disasters, famine, internment in refugee camps, human trafficking, physical displacement outside one’s home country, and loss of kinship and family members. In addition refugees are faced with a myriad of post-migration circumstances including poverty, language barriers, acculturative stress, low levels of education and job skills, loss of social capital and social down drift, unsafe communities, and discrimination/prejudice [2]. Together these pre- and post-migration factors have a profound impact on emotional and psychological wellbeing [3,17]. In fact numerous studies have found that pre-migration and migration-related traumas and losses, combined with post-resettlement stressors may explain a substantial part of the variation in levels of mental distress in refugee populations [18-21].

Given their exposure to trauma and loss in addition to adjustment-related stressors, it is no surprise that refugees are at increased risk for mental health disorders; namely Post Traumatic Stress Disorder (PTSD), anxiety, and depression [1,3,22]. Indeed mental health disturbances (i.e., informal diagnoses of PTSD, depression, and anxiety) are among the most commonly reported urgent health concerns for refugees [4], and prevalence estimates have shown that a greater proportion of refugees suffer from these disorders compared to the general population [1,3,23,24].

For refugees, the presence of psychological and emotional distress further confounds an already challenging feat of adapting to their host country. Post-migration endeavors such as English language acquisition, finding stable and safe housing, securing employment, forming social relationships and support networks, and rebuilding one’s lost social capital are largely dependent on one’s psychological and emotional stability. For example, in their recent examination of the psychological sequelae of immigrants and refugees from Sub-Saharan Africa, Steel and colleagues [25] found that anxiety, depression and PTSD were among the predictors of acculturation (i.e., language acquisition, social integration and adoption of customs and traditions). In addition

to adaptation challenges, trauma and stress-related psychological disorders are also associated with negative health outcomes such as cardiovascular disease [6,7], immune dysregulation [5,8] and other general medical conditions [9]. These relationships are often bidirectional such that challenges with adaptation and poor health can also function as antecedents to the development of mental health disorders. As such, a refugee often becomes stuck in a vicious cycle in which their ability to recover and thrive is stunted by the interplay of psychological, socioeconomic and health-related factors [26]. Thus, refugee mental health is a public health concern which necessitates the implementation of policies and programs guaranteeing systematic mental health evaluation and treatment for this particularly vulnerable population [27].

Lack of mental health screening and valid measures

The Refugee Act of 1980 was passed by Congress in order to standardize resettlement services for all refugees admitted to the U.S. Under this act, newly arrived refugees are entitled to receive a comprehensive health assessment and referral for health services. The Office of Refugee Resettlement (ORR) in collaboration with the Center for Disease Control and Prevention (CDC) has provided guidelines for refugee health assessment which include mental health screening for refugees over the age of 16 during the first 90 days after arrival to the USA [10,28]. However, despite these guidelines, mental health continues to be neglected during routine refugee health screenings [11,22]. In their 2010 survey of state refugee health coordinators Shannon et al. [13], reported that only 4 of the 44 states surveyed used a formal mental health screening instrument.

The most widely reported barrier to mental health screening is an absence of validated screening instruments for refugees [11,13]. When screening is performed it is often limited to informal conversation and basic questions rather than standardized screening instruments [13]. Refugees already undergo time intensive health screenings, often spanning the course of several days. As such, public health clinics consistently report a lack of time and resources as a major hurdle in screening for mental health. Consistent with the conclusions of previous studies [13,29], these factors highlight the need for brief, culturally validated mental health screening instruments that are accessible to public health settings and can be easily adopted by states which perform refugee health assessments.

California Refugee Health Assessment Program (RHAP)

The California Department of Public (CDPH), Office of Refugee Health (ORH), allocates federal funds to local health jurisdictions who administer the Refugee Health Assessment Program (RHAP) [30]. Under RHAP, refugees who enter California are eligible to receive comprehensive medical assessments which include early diagnosis, intervention, referral, and health education for chronic and communicable diseases, assessment of immunization status for children and adults, and continuity of care through medical referrals to health providers. On October 1, 2012, the RHAP was enhanced to assess refugee mental health by including three brief primary care screening measures to identify symptoms of post-traumatic stress disorder (PTSD), anxiety, and depression.

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MATERIALS AND METHODS

Setting and participants

This pilot screening project was conducted at the Refugee Health Clinic in Sacramento, California which provides RHAP assessments to newly arrived refugees in Sacramento County. Participants included all refugees 16 years of age or older who received RHAP screening between October 1, 2012 and January 30, 2015.

Procedures

Refugee Health Clinic providers administered the RHAP assessment, which included three mental health screening tools (PC-PTSD, GAD-2, and PHQ-2) to identify symptoms of PTSD, anxiety and depression. Translation in person or via telephone was provided for refugees who did not speak English. Individuals with mental health screening scores above designated cut-points were referred to an on-site mental health provider for further psychological evaluation and referral. These follow-up visits were generally scheduled within the same week of clients’ health assessment. Refugees in the follow-up group were evaluated for all three mental health conditions (PTSD, anxiety and depression) regardless of the particular area red-flagged by their screening scores. For example, if an individual screened high only for depression, they were also evaluated for anxiety and PTSD. If a patient met the criteria for a significant mental health condition during the follow-up evaluation, they were referred to primary care for further diagnosis and treatment. Informed consent was obtained by all individual patients included in this pilot project. The screening and follow-up evaluation for this pilot screening project were included as an extension of services provided under the California Department of Public Health, therefore no IRB approval was required.

Data collection

Mental health screening data was collected via the Refugee Health Electronic Information System (RHEIS), a web-based database that allows local health jurisdictions to report refugee health data to CDPH/ORH electronically in real time. Follow-up psychological evaluation data was manually collected by a mental health provider. To prevent patient identification and protect confidentiality all data collection procedures followed guidelines set by the Health Insurance Portability and Accountability Act (HIPAA).

Screening instruments

The following instruments were incorporated into the RHAP assessment to screen for symptoms of post-traumatic stress disorder (PC-PTSD), anxiety (GAD-2), and depression (PHQ-2).

Primary Care PTSD (PC-PTSD). The PC-PTSD is a 4-item screening tool developed to detect PTSD symptomatology in primary or other medical settings [35]. Refugees were asked to reply “yes” or “no” to questions assessing past month experience of the four primary symptoms of PTSD (re-experiencing, numbing, avoidance, and hyperarousal). If a patient answered “yes” to any two questions they were referred for further evaluation of PTSD. Though conventional uses of the PC-PTSD rely on a cut score of 3, we chose a less conservative cut score of 2 in order to maximize

retention and account for cultural (i.e., mental health stigma) and language barriers which may increase the likelihood of false negative responses. A cut score of 2 has been shown to have good sensitivity and specificity (91% and 71% respectively) in primary care settings [31].

Two-item Generalized Anxiety Disorder scale (GAD-2). The GAD-2 is a two-item measure of anxiety symptoms. Refugees were asked “Over the last 2 weeks, how often have you been bothered by any of the following problems?” 1) “Feeling nervous, anxious, or on edge;” 2) “Not being able to stop or control worrying.” Responses ranged from “never” to “every day,” with item scores ranging from 0 to 3. Thus, the total score of the GAD-2 can range from 0 to 6. A score of 3 or higher was indicative of GAD and that patient was referred for further evaluation of GAD symptoms. The GAD-2 has demonstrated high sensitivity and specificity for generalized anxiety disorder, and high specificity for panic disorder and social anxiety disorder [32].

Patient Health Questionnaire (PHQ-2). The PHQ-2 is a brief, 2-item screening tool for detecting depressive symptomatology. Refugees were asked “Over the last 2 weeks, how often have you been bothered by any of the following problems?” 1) “little interest or pleasure in doing things;” 2) “feeling down, depressed, or hopeless.” Potential responses included “not at all,” “several days,” “more than half the days,” and “nearly every day,” which were scored as 0, 1, 2, and 3, respectively. Thus, the PHQ-2 score can range from 0 to 6. A refugee scoring a 3 or higher was referred for further evaluation of depressive symptoms. The PHQ-2 has demonstrated good sensitivity (82.9%) and specificity (90%) for detecting major depressive disorder and is comparable to longer screening measures [33].

Follow-Up evaluation instruments

Refugees meeting the cut point score criteria for any of the three screening tools were referred for further psychological evaluation by a mental health provider. The following instruments (PCL-C, BAI, BDI-II) were used during the follow-up evaluation to identify clinical symptoms of PTSD, anxiety, and depression. These scores were then used to assess the performance of the three preliminary screening tools (PC-PTSD, GAD-2, and the PHQ-2 respectively).

PTSD Checklist – Civilian Version (PCL-C). The PCL-C is a 17-item self-report measure in which participants assess the severity of each of the 17 DSM-IV symptoms of PTSD using a 5-point Likert scale [34]. The PCL-C has a good internal consistency [35], has been well validated against gold standard diagnostic tools such as CAPS and SCID [36], and has high sensitivity and specificity for detecting PTSD in primary care settings [37]. A total symptom severity score (range = 17 - 85) is created by summing the scores from each of the 17 items. A clinical diagnosis of PTSD can be made by determining whether the total severity score exceeds a given cut point. This investigation used a conservative cut point score of 45, to minimize the likelihood of false positives.

Beck’s Anxiety Inventory (BAI). The Beck Anxiety Inventory (BAI) is a 21-item multiple-choice self-report inventory that measures the severity of anxiety symptoms in adults and adolescents [38]. The BAI can be used to assess and establish a baseline anxiety level, as a diagnostic aid, to detect the

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effectiveness of treatment as it progresses, and as a post-treatment outcome measure. Each of the items on the BAI is a simple description of a symptom of anxiety in one of its four expressed aspects: (1) subjective (e.g., “unable to relax”), (2) neurophysiologic (e.g., “numbness or tingling”), (3) autonomic (e.g., “feeling hot”) or (4) panic-related (e.g., “fear of losing control”). Each symptom is rated on a 4-point scale ranging from 0-3, thus total symptom severity scores derived from the 21 items can range from 0 to 63 points. A total score of 0 - 7 is interpreted as a “Minimal” level of anxiety; 8 - 15 as “Mild”; 16 - 25 as “Moderate”, and; 26 - 63 as “Severe.” For this investigation a cut point score of 35 was used to classify individuals with clinical levels of anxiety. The BAI is psychometrically sound with internal consistency (Cronbach’s alpha) ranging from .92 to .94 for adults and test-retest (one week interval) reliability as high as .75 [38-39] (Beck et al. 1988; Beck and Steer, 1990). The BAI has also been validated in non-Caucasian populations [40].

Beck’s Depression Inventory (BDI-II). The BDI-II is one of the most widely used instruments for measuring the severity of depression. Its 21 items are designed to identify psychological and somatic symptoms of 2-week major depressive episodes as defined by DSM-IV criteria [41]. The BDI-II is psychometrically sound, demonstrating high internal consistency (α=.90) and high retest reliability (Pearson r =0.73 to 0.96). The BDI-II has shown good sensitivity and specificity when compared to gold standard measures of depression and has been validated within primary care medical settings [42-43]. The BDI-II scores are derived via the sum of 21 items which are rated on a 4-point scale ranging from 0 to 3. Thus the maximum total score is 63. Though appropriate cutoff scores may vary by the type of sample [43], scores are generally interpreted as follows: 0 to 13 indicates minimal depression; 14 to 19 indicates mild depression; 20 to 28 indicates moderate depression; and 29 to 63 indicates severe depression [41]. The present investigation adopted a conservative cutoff score of 35 to identify cases of significant depression.

Analysis

Mental health screening scores were used to estimate the prevalence of refugee patients who screened positive for post-traumatic stress disorder (PTSD), anxiety, and depression. The frequency and percent of those who screened positive for at least one mental health condition were then examined across demographic sub-groups. To obtain performance estimates, screening outcomes of the PC-PTSD, GAD-2, and PHQ-2 were compared to corresponding scores on the PCLC, BAI, and BDI II respectively. We calculated sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratios including 95% confidence intervals for each estimate. We also examined the performance of screening tools across the top three countries of origin (Iraq, Afghanistan and Iran) which comprised nearly 87% of the group with positive screening scores. All analyses were performed using SAS® software, Version 9.4 of the SAS System for Windows [44].

RESULTSScreening outcomes

Between October 1, 2012 and January 30, 2015, a total of 1,643 refugees received mental health screening in the Sacramento

Refugee Health Clinic. Of those, 262 (15.95%) had screening scores above designated cut points for at least one of the three screening measures. Based on scores on the PC-PTSD, GAD-2 and PHQ-2, 168 (10.23%) screened positive for PTSD, 182 (11.08%) screened positive for anxiety, and 139 (8.47%) screened positive for depression respectively.

The demographic distribution of the entire screening sample and of those who screened positive (i.e., above designated cut scores) for any on any of the three screening measures is summarized in Table 1. Comparison tests revealed some variation in demographic characteristics between those who screened positive and the overall screening sample. For example, refugees who met the screening criteria for follow-up mental health evaluation were slightly older and were more likely to be female

Table 1: Demographic distribution of refugees who received mental health screening in Sacramento, CA between 10/01/12 and 1/30/2015.

Screened Positive n (%)

Total Screened n (%)

Age (years) 16-20 16 (6.11) 158 (9.62)21-30** 71 (27.10) 603 (36.70)31-40 63 (24.05) 429 (26.11)41-50* 52 (19.85) 226 (13.76)51-60*** 41 (15.65) 129 (7.85)≥61 19 (7.25) 98 (5.96)Education (years) 0-8 53 (20.87) 258 (15.84)9-11 44 (17.32) 292 (17.93)12 73 (28.74) 440 (27.01)13-16 72 (28.35) 539 (33.09)17-20 12 (4.72) 90 (5.52)21 or higher 0 (0.00) 10 (0.61)Sex Male* 119 (45.42) 884 (53.80)Female 143 (54.58) 759 (46.20)Language (Top 5) Arabic 103 (39.31) 571 (34.75)Farsi* 74 (28.24) 352 (21.42)Dari 30 (11.45) 203 (12.36)Russian*** 7 (2.67) 190 (11.56)Pashto 15 (5.73) 99 (6.03)Country of Origin (Top 10) Afghanistan 93 (35.77) 565 (34.43)Iraq 101 (38.85) 553 (33.70)Ukraine** 6 (2.31) 150 (9.14)Iran* 31 (11.92) 115 (7.01)Moldova 4 (1.54) 57 (3.47)Russia* 0 (0.00) 33 (2.01)Belarus 0 (0.00) 20 (1.22)Congo* 9 (3.46) 19 (1.16)Armenia 3 (1.15) 18 (1.10)Burma 1 (0.38) 14 (0.85)Notes: Screened positive indicates patients who scored above cut points for at least one mental health condition (n=262); Total screened indicates all patients (n=1,643); *p< 0.05; ** p< 0.005; *** p< 0.0001; Variations in sample size are due to missing data.

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than the overall screening sample. Also, primary language and county of origin were similar for both groups with the exception of the Russian language and the countries of Ukraine and Russia which were proportionally lower in refugees who screened positive. In addition, those who screened positive had a higher proportion of Farsi speakers and alsowere more likely to be from Iranor from Congo.There were no other significant differences between those who screened positive for any of the three mental health screening measures and the overall screening sample (See Table 1 for significant p values).

Of the 262 refugees who were referred for follow-up mental health evaluation, 18 declined and 104 were scheduled for follow-up evaluation but did not come to their appointment. This resulted in the final sample of 140 refugees whose follow-up mental health evaluation scores were used to evaluate the performance of the three preliminary screening tools.

Among the 140 seen for follow-up evaluation, 117 (83.57%) had scores that met the cut point criteria for at least one mental health condition. For individual diagnosis, 57 (40.71%) met the criteria for anxiety disorder using cut point scores on the BAI, and 74 (52.86%) met the criteria for severe depression based on BDI II scores. Post-Traumatic Stress Disorder (PTSD), the most prevalent mental health condition, was detected in 82 (58.57%) patients using PCLC scores.

Screening performance estimates

Table 2 provides performance estimates and associated values for screening measures. When compared to corresponding follow-up evaluation test scores, the PC-PTSD, GAD-2, and PHQ-2 demonstrated moderate sensitivity; 80%, 81%, and 73% respectively. However, specificity was low for all three tests; 28%, 27% and 42% respectively. The analysis of screening performance by the top three countries of origin revealed higher sensitivity of the PC-PTSD, GAD-2 and PHQ-2 for patients from Iraq (83%, 95% and 82%) compared to the overall sample. However sensitivity was much lower among all country of origin sub-groups (See Table 3).

DISCUSSIONThis pilot screening project sought to assess the performance

of three primary care mental health screening measures in identifying PTSD, anxiety and depression among refugees during routine domestic health screenings in Sacramento, California. Our results demonstrated high sensitivity for PC-PTSD, GAD-2 and the PHQ-2, indicating that these instruments are capable of detecting severe symptoms of PTSD, anxiety and depression in this diverse refugee population. However, our findings also suggest differential screening performance by country of origin in that performance estimates were slightly better for refugees from Iraq compared to those from Iran and Afghanistan. Specificity was low for all three measures regardless of country of origin.

In our sample of refugee patients 10.23% screened high for PTSD, 11.08% for GAD, and 8.47% screened high for depression. These estimates are higher than that of corresponding U.S. population estimates where PTSD, GAD, and depression are detected in 3.5%, 3.1%, and 6.7% respectively [45]. The relatively high proportion of positive mental health screening scores supports federal recommendations for the inclusion of mental health screening during preliminary health evaluations for refugees.

Following initial resettlement refugees often experience what is referred to as a “honeymoon” phase. During this brief period, which may last anywhere from 1 to 3 months post-arrival, a refugee may feel a sense of relief for having rid oneself of overseas conflict and migration-related stressors in addition to a new found hope for opportunity in their host country [46]. This post-arrival euphoria is assumed to temper or delay the expression of mental health symptoms, and individuals who are at risk may go undetected if screened during this time period. This poses a challenge for incorporating mental health screening into standard refugee health evaluations as they are most commonly administered within 30-90 days of arrival. Indeed, the majority of patients evaluated in this pilot project received mental health screening within 30 days of arrival which may have thwarted the sensitivity of screening instruments to detect clinical cases. That screening tools demonstrated adequate sensitivity for detecting mental health conditions despite the potential reductions in sensitivity further supports the inclusion of mental health screening in preliminary refugee health evaluations.

Table 2: Mental health screening performance estimates for refugee patients who received follow-up psychological evaluation (n=140).

ScreeningFollow-up Sensitivity Specificity PPV NPV LR(+) LR(-)- + (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI)

PC-PTSD PCLC

- 16 16 .80 .28 .61 .50 1.11 .71

+ 42 66 (.70-.88) (.17-.41) (.51-.70) (.32-.68) (.90-1.33) (.28-1.14)

GAD-2 BAI

- 23 11 .81 .27 .43 .68 1.12 .70

+ 60 46 (.68-.89) (.18-.39) (.34-.53) (.49-.83) (.91-1.32) (.25-1.14)

PHQ-2 BDI II

- 28 20 .73 .42 .59 .58 1.27 .64

+ 38 54 (.61-.83) (.30-.55) (.48-.69) (.43-.72) (.95-1.59) (.34-.94)Abbreviations: PPV: Positive Predictive Value; NPV: Negative Predictive Value; LR: Likelihood Ratio; PC-PTSD: Primary Care PTSD; GAD-2: Two-item Generalized Anxiety Disorder scale; PHQ-2: Patient Health Questionnaire; PCL-C: PTSD Checklist – Civilian Version; BAI: Beck’s Anxiety Inventory; BDI-II: Beck’s Depression Inventory; PTSD: Post Traumatic Stress Disorder; GAD: Generalized Anxiety Disorder.

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Nevertheless, programs, interventions, and prospective studies should consider re-evaluating mental health symptoms at later time periods beyond the “honeymoon” phase to account for the dynamic unraveling of mental health symptoms over the course of refugee resettlement.

Other screening tools have been developed and validated for refugees. However, these measures are often time consuming and require additional training on the part of those administering the screening [12,47]. Over the course of this project 1,643 refugee patients were screened for mental health conditions. As the number of refugee arrivals in Sacramento County grows each year, so does the pressure placed on refugee health providers to administer timely refugee health screening (including mental health) with limited time and resources. Thus there is a need for brief screening tools that can be easily administered by any primary care provider. By implementing more accessible tools such as the PC-PTSD, GAD-2, and the PHQ-2 we hope to broaden the reach of mental health screening for refugees in Sacramento and the state of California.

With the implementation of mental health screening comes the added responsibility for identifying services and resources for those refugees who screen positive. A large concern among stakeholders and advocates is a lack of capacity for providing mental health interventions which consider the unique challenges in treating this diverse population such as language barriers, cultural norms, mental health stigma, lack of transportation, etc [4,11]. This topic is well beyond the scope of this project, however in order to design refugee mental health intervention models there must first be validated measures for accurately defining the mental health needs and barriers for this this population. Thus, the integration of mental health screening into standard refugee health assessments is not only helpful for early detection and treatment, but can provide rich information that can be used to solicit funding and inform the development of evidence-based interventions and targeted programs.

LIMITATIONSThere are notable limitations to the present investigation.

First, follow-up mental health evaluation was only performed for refugees who screened high during the preliminary mental health assessment thus misrepresenting the number of true or false negatives in the final analysis. This limitation is a likely culprit in

explaining the low estimates of specificity and associated values (i.e., NPV). Future investigations would improve by adopting a more rigorous evaluation of screening performance which would include all participants (regardless of preliminary screening scores) in follow-up evaluation in order to generate more accurate performance estimates.

There was a substantial lack of retention for follow-up evaluation where only 50% of referred patients attended follow-up appointments. This reduction of the final sample likely produced a misrepresentation of the population, thus reducing the validity of performance estimates. According to the Sacramento Refugee Health Clinic, the primary reason for missed follow-up appointments was a lack of transportation and/or interfering work schedules. This circumstantial limitation unveils the challenges many refugees face in accessing mental health care. Indeed it is reasonable to speculate that individuals with limited resources (i.e., transportation and work flexibility) are among the refugees who are in most need of mental health evaluation and services. Therefore future investigations and/or interventions should work to remove or reduce such barriers in an effort to improve refugee access to mental health evaluation and services.

CONCLUSIONRefugee mental health vulnerability lies in the exacerbation

of pre-migration traumas under prolonged exposure to acculturative stress during their post-resettlement period. However the true prevalence of mental health disorders in refugees is likely underestimated as refugees do not commonly receive mental health screening post arrival. In order to accurately describe the mental health needs of refugees, standardized mental health screening should be incorporated into routine domestic refugee health evaluations. In so doing, this might aid in the improvement of targeted programs and services for addressing the mental health needs of this population. This pilot project demonstrated the utility of the PC-PTSD, GAD-2 and the PHQ-2 in identifying mental health conditions during routine post-arrival refugee health evaluations in California. We hope to use these findings to inform the development of future prospective studies to validate these screening tools within the refugee population. Such efforts would adopt more rigorous sampling methods in order to achieve a true test of screening performance. By implementing standardized screening tools

Table 3: Mental health screening performance estimates by top 3 countries of origin.

Screening PC-PTSDa GAD-2b PHQ-2c

Country Sensitivity (95% CI)

Specificity (95% CI)

Sensitivity (95% CI)

Specificity (95% CI)

Sensitivity (95% CI)

Specificity (95% CI)

Iraq.83 .19 .95 .18 .82 .30(.69-.93) (.04-.46) (.75-1.00) (.08-.34) (.66-.92) (.12-.54)

Iran.78 .23 .67 .20 .50 .50(.40-.97) (.05-.54) (.35-.90) (.03-.56) (.21-.79) (.19-.81)

Afghanistan

.78 .35 .70 .35 .67 .50(.56-.93) (.16-.57) (.46-.88) (.17-.56) (.41-.87) (.31-.69)

Notes: Performance estimates based on corresponding follow-up cut point scores: aPCLC; bBAI;cBDI-II.Abbreviations: PPV: Positive Predictive Value; NPV: Negative Predictive Value; LR: Likelihood Ratio; PC-PTSD: Primary Care PTSD; GAD-2: Two-item Generalized Anxiety Disorder scale; PHQ-2: Patient Health Questionnaire; PCL-C: PTSD Checklist – Civilian Version; BAI: Beck’s Anxiety Inventory; BDI-II: Beck’s Depression Inventory; PTSD: Post Traumatic Stress Disorder; GAD: Generalized Anxiety Disorder.

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into routine refugee health assessments, we hope to broaden the reach of mental health screening and improve the wellbeing of refugees in the state of California.

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