What of PTSD in Refugees & Asylum Seekers?

Ms. K had recently arrived from a rural area in a West African country seeking asylum in Quebec, Canada. She was raised in an impoverished household with many siblings. At a young age she was married off to a man decades her senior. She felt trapped between providing her family with a source of income through her marriage, thereby upholding her family’s honour, and her own happiness. As the years passed, the abuse her husband inflicted upon her escalated until she began to fear for her life. When he strangled her with a copper wire she realized she had to leave and spent years saving money, meticulously planning her escape. Her departure would also mean abandoning her family to the mercy of her husband’s wrath. Eventually, she managed to escape.

Upon her arrival to Quebec, Canada, her documents having been forged and with no real proof of identity, she was imprisoned for months. Once released with no connections and little to no funds, she was directed to a YMCA residence which welcomes and supports refugees and asylum seekers. There she found shelter and access to resources.

In 2010 the Ministère de l’Immigration, de la Diversité et de l’Inclusion came to an agreement with the YMCA residence to welcome refugees on Quebec territory from the airport and assist them along their journey towards immigration and integration, under section 80 of la Loi sur la santé et les services sociaux (1). This assistance takes the form of short-term housing, community services and activities such as French and English conversation workshops, job search, financial assistance and health workshops, social outings and activities, as well as psychosocial support services.

The In-Canada Asylum Program allows refugees to seek asylum if they “have a well-founded fear of persecution or are at risk of torture, or cruel or unusual punishment in their home countries”. (2) These refugees have access to local settlement services as described above in order to adapt and adjust to their new lives in Canada. Refugees are granted income support from the Government of Canada via the Resettlement Assistance Program or from the Province of Quebec “for up to one year or until they can support themselves, whichever comes first” (3). Both the Canadian and provincial governments therefore have legislation set in place to meet refugees’ basic needs upon their arrival.

Despite this, refugees often face numerous hurdles on the long and arduous journey of settling in Canada. Their ambiguous legal status is a constant hurdle to their access to healthcare. The government assistance often covers little more than their monthly rent. Job opportunities are scarce given that they are not permanent residents, their previous education is often not recognized, and employers may have myriad prejudiced ideas about hiring refugees or asylum seekers. It is important to note that this is but the tip of the iceberg of a refugee’s trepidations.

I will not dwell on the innumerable challenges which refugees and asylum seekers face as they attempt to rebuild their lives in Canada. Instead, I will discuss a disorder which is highly prevalent amongst this vulnerable population (4). One which significantly hinders their ability to overcome these obstacles: Post-Traumatic Stress Disorder (PTSD).

The DSM-V describes several criteria for the diagnosis of PTSD including “exposure to actual or threatened death, serious injury, or sexual violence […] recurrent, involuntary, and intrusive distressing memories [or dreams] […] dissociative reactions (e.g. flashbacks) […] persistent avoidance of stimuli associated with the traumatic event(s) [lasting] more than one month and caus[ing] clinically significant distress or impairment in social, occupational, or other important areas of functioning” (5).

Ms. K met the diagnostic criteria for PTSD as per the DSM V. She was emotionally, physically, and sexually abused by her husband. She was riddled with the guilt of deserting her family. Recurrent nightmares left her at the mercy of chronic insomnia and in a perpetual state of fatigue. Crowded areas such as the metro, enclosed spaces and physical touch often triggered painful flashbacks and as a result she developed avoidance patterns with hypervigilance and exaggerated startle responses. Mood lability and poor concentration made it difficult for her to find work, socialize, and follow her lawyer’s instructions to gain status and avoid deportation. At her court hearings, she is compelled to re-live her painful memories in order to convince the judge that granting her status is a worthwhile endeavor. In clinic, we scrutinize her scars and ask her to recount the unfortunate events through which she’d acquired them so that we may sketch them on a diagram and describe them in a letter which may turn the tide in her favour in court. Here, Ms. K must incessantly relive the most scarring moments of her existence.

It’s no wonder that her as well as many other refugees and asylum seekers struggle to make a home in Canada and to contribute to society while suffering from PTSD (4). A noteworthy 9% of adult refugees are diagnosed with PTSD, often with comorbid major depression. Although nearly 80% of patients with either PTSD or acute distress disorder recover spontaneously upon reaching safety, a subset of patients become chronically symptomatic and may resort to self-destructive behaviours including suicide and substance abuse. (6)

In Canada, it is known that despite being a high risk population for PTSD, refugees underutilize mental health services. This is perhaps due to a cultural stigma associated with mental health in the context of limited health literacy. The patient may not be able to identify their distress as a mental health issue and will therefore not seek help for it. Often, they may present to a family physician with somatic complaints for which there is no evidence of disease. Patients may also fear being judged by their healthcare professionals as strong feelings of shame and inadequacy often plague their sense of self-worth after having survived much trauma. These are recognized barriers for refugees seeking mental health care which may be further exacerbated by unemployment, social isolation, and discrimination (4).

On the other hand, primary care physicians may not feel comfortable treating and managing PTSD in such a vulnerable population given the complexity of extreme traumas, and language as well as cultural barriers which they face. Available screening tools have not been tested for diagnostic accuracy and cultural validity in refugees and so their sensitivity and specificity in this population remains unknown. Moreover, victims of organized violence experience trauma which affects not only individuals but also entire families. For example, children with PTSD may not present with symptoms as clear-cut as those observed in adults, thereby rendering its recognition and diagnosis ever more challenging. (4) Physicians who do cater to the needs of this population find no support system for themselves, and so they may feel isolated as their mental health takes a toll as a well. These are barriers to providing optimal mental health services for refugees encountered at the level of the physician. Addressing refugee mental health is therefore a complex, multi-faceted challenge requiring a multidisciplinary team approach favoring integrated treatment with a family perspective.

As previously described, in order to obtain permanent resident status in Canada refugees must endure several court proceedings to make their case. This process is lengthy and refugees live in constant fear of repatriation throughout, which exacerbates their PTSD symptoms substantially. This was the case for Ms. K. Every time a court date approached, her flashbacks, insomnia, and somatic symptoms intensified and she would present to clinic in crisis. Being interrogated in court in attempts to prove the credibility of her misfortunes certainly did not help. Although there are excellent resources and legislation ensuring that refugees’ basic needs are met upon their arrival and as they settle in Canada, perhaps a more compassionate approach to obtaining status in Canada is warranted.

For primary care physicians, the Canadian Collaboration for Immigrant and Refugee Health does not recommend routine screening for PTSD in refugees given that disclosure of traumatic events, particularly in the presence of family members, may do more harm than good in well-functioning individuals. However, “in the context of unexplained somatic symptoms, sleep disorders or mental health disorders such as depression or panic disorder, [a] clinical assessment [is warranted] to address functional impairment” with a high suspicion of PTSD in mind. Once diagnosed, PTSD should be treated using a combination of Cognitive Behavioral Therapy (CBT) and/or pharmacotherapy according to the most recent guidelines. This recommendation is largely based on low quality evidence given its paucity in the refugee population. (4)

Alternatively, the National Institute for Clinical Excellence adopted a “phased intervention model” to address PTSD in refugees and asylum seekers. During phase I, this population still faces the very real threat of deportation back to the traumatic environment and so “intervention should focus on practical, family and social support.” During phase II and III where status is obtained, the focus should be directed towards the patient’s priorities such as “social integration and/or treatment of symptoms.” (4) Importantly, this approach has not been validated by any clinical trials.

In 2013, the World Refugee Survey revealed that Brazil was the only country graded “A” in the categories of “refoulement/physical protection; detention/access to courts; freedom of movement and residence; and right to earn a livelihood.” (7) This highlights the insight that a survey of refugees and asylum seekers can provide into the pitfalls of the refugee settlement system in Canada, and more specifically in Quebec. For example, would they benefit from a cultural broker who also serves as an interpreter to help them navigate the healthcare and legal systems? This as well as many other questions can only be answered by adequate surveillance data of the refugees and asylum seekers in Quebec, Canada. Physician advocacy for this vulnerable patient population which virtually has no voice is also of crucial importance. As physicians, we’ve been endowed with the privilege of prestige and power within our society. This comes with the responsibility of becoming the voice for vulnerable populations.

I pray that we may all have the courage, strength, and perseverance to continue to advocate for our patients to the best of our ability.

References

1. “Housing Services.” YMCA Quebec., The YMCAs of Québec, ymcaquebec.org/en/Community-Programs/Housing-Services.
2. “Refugees and Immigrants: A Glossary.” Refugees and Immigrants: A Glossary | Canadian Council for Refugees, Canadian Council for Refugees, ccrweb.ca/en/glossary.
3. Government of Canada, Immigration, Refugees and Citizenship Canada, Communications Branch. “How Canada’s Refugee System Works.” Government of Canada, Immigration, Refugees and Citizenship Canada, Communications Branch, 3 Apr. 2017, www.cic.gc.ca/english/refugees/canada.asp.
4. Tugwell, P., et al. “Evaluation of Evidence-Based Literature and Formulation of Recommendations for the Clinical Preventive Guidelines for Immigrants and Refugees in Canada.” Canadian Medical Association Journal, vol. 183, no. 12, 2010, doi:10.1503/cmaj.090289.
5. Merali, Zamir, et al. “Post-Traumatic Stress Disorder.” Toronto Notes 2016, Toronto Notes for Medical Students, Inc., 2016, pp. 1208–1209.
6. Carlson JM. Mental health and health-related quality of life in tortured refugees. Copenhagen (Denmark): University of Copenhagen; 2005.
7. Becker, Elisabeth. “The Four ‘Best’ Countries for Refugee Resettlement.” UN Dispatch, 3 Nov. 2015, www.undispatch.com/the-four-best-countries-for-refugee-resettlement.