Medical Guidelines

by Bob Martin MD
Bridge Refugee Clinic, Vancouver BC

Introduction

Although our patients at Bridge suffer in many ways, distress of the spirit and psyche is the greatest source of pain. As providers, it is difficult for us to approach this part of our patient’s lives. Knowing our patients more deeply, seeing their wounds more clearly, can require us to look evil in the eye, if not the heart, and to offer what strength we possess. Inevitably, this involves some pain for the provider: it is one of the meanings of compassion to “suffer with”- to share in the suffering of others. Though broaching the mental distress of our patients may at times be difficult, it is also an opening to something deeper, an opportunity to grow, and frequently, to be rewarded with remarkable and hopeful change in our patients.

It is a long-term goal for Bridge that our physicians should have broad competence in recognizing and treating the mental health concerns of refugees. To aid this goal is the first purpose of this guide. Our patients’ suffering is situated within a complex setting of limited resources, barriers to care, legal problems, and cross-cultural confusion. The second goal of this guide is to map out this setting and the resources and opportunities that exist. Thirdly, mental health work at Bridge presents some unique communication problems - this guide will attempt to offer some practical advice. Finally, this guide will present a practical approach to incorporating mental health work into other clinical work.

Disorders and medications which are well-described in other sources will not be dealt with at length. Rather, we will explore what is unique to working with refugees and to working at Bridge.

Why mental health work at Bridge is important

• “Anxiety and depression” is the most prevalent diagnostic code at Bridge.
• Patients whose underlying anxieties remain undiagnosed make frequent visits to Bridge for the treatment of stress-related physical complaints, and needlessly burden clinic resources.
• Psychological symptoms are inextricably entwined with physical problems.
• Refugee claimants who are not diagnosed or treated for legitimate mental health problems lose the opportunity to support their claim with medical records.
• Some patients go undiagnosed for significant periods of time. If we, in our setting, fail to diagnose problems like PTSD in our patients, it is even less likely that they will be picked up later in the community. Some of the patients we discharge without proper diagnosis or treatment end up languishing in unfortunate circumstances, and a few drift to the downtown eastside.
• We have much to offer patients who are in distress.
• A stand-alone mental health “session” is not an adequate response to the burden of illness at Bridge, nor to the problem of under-diagnosis or comorbidity with somatization disorders. Given the background prevalence of mental health problems among our patients, Bridge is in a significant sense a mental health clinic: this work needs to be woven into the fabric of what we do.

A clinical approach

The first visit

If time is short, only a little needs to be done at a first visit. The background prevalence of mental distress in Bridge patients is very high, so think about this as an underlying motive for the patient’s visit. Look at the patient’s face: are they worn, worried, exhausted? Do they have multiple somatic concerns? Try not to isolate the headache, the foot pain, the back pain, the stomach upset. It may be cliché, but we need to get a feeling for the whole patient.

You can spread the diagnosis of mental health concerns over a number of visits. On this first visit you might ask only, “Can you sleep? Do you have frequent bad dreams?” You do not need much detail of a patient’s experience to help them, and asking for more detail than you really need may be destabilizing. Reassure the patient that they can tell you as little – or as much – as they want.

Ask at the first visit if the patient is facing a refugee hearing: the various stages of this process trigger many visits to Bridge for seemingly unrelated matters.

If the patient is wary of care, prescribe them a medication for sleep or anxiety that is almost certain to make them feel better, with little risk of side effects. Start with a small dose of trazadone for sleep, or quetiapine for sleep and anxiety. Higher doses of quetiapine – up to 200mg a day – can be very useful for settling highly agitated individuals, especially where family dysfunction is resulting from the patient’s agitated state. For mood lability or dysregulation, and problematic anger, valproic acid can be helpful. And in extreme PTSD marked by significant sympathetic responses such as elevated heart-rate, fearfulness and tremulousness, propanolol can mute the fight/flight response.

Anticipate drug side effects with the patient, and expect confusion. Get them back quickly for follow-up, within a week or two, to keep your treatment plan from falling apart. And make sure they bring all medicine bottles to every visit, and briefly review their use each time: you will be surprised at what you find. It helps to have a very low threshold for blister-packing medications, even for younger people: expect that half of your patients are not taking their medications as directed.

Beware of medicalizing the patient’s distress too much: PTSD is not finally a problem between synapses. What your patient really has is a heart that has been broken, and for good reason. He or she is walking into your office from an unstable life filled with experiences of people who have been frequently indifferent and sometimes cruel. You can begin to heal this simply by being a presence – a consistent and kind presence.

Finally, on a first visit, the single most therapeutic thing you can say to a patient is, “I want you to come back to see me”.

The second visit

At the next visit you can continue to develop your assessment of the patient while also dealing with their physical concerns. Screen the patient for depression, PTSD, and panic disorder, as these are all common. Patients often experience their mental distress as a private and isolated madness: just diagnosing them and giving them permission to feel bad can bring enormous relief.

Measure their readiness for counseling, or for medicines with more discouraging side effects, like SSRIs. Sertraline is the drug of choice for PTSD, and has good efficacy for quelling nightmares - a great relief to the patient. An array of other symptoms often disappear with sertraline too, so it may be wise to hold off on referrals and invasive investigations of patient complaints until you have mitigated the patient’s anxiety problems: most things can wait. Treat their symptoms seriously, but avoid over-medicalizing them: this is sure to increase their anxiety.

Many people fear addiction to medications, so address this up front. Also reassure them that with effort, they can get better – but that it will generally take months and more. Their commitment to treatment will be more durable if their expectations are realistic.

Subsequent visits

The patient’s full background can be filled in gradually: a referral to a psychologist, counselor or psychiatrist can help a lot with this.

Also consider ordering bloodwork at this visit that may pertain to the patients psychological symptoms. The following tests form a baseline: CBC, ferritin, B12, TSH, creatinine, LFTs, RPR, and HIV.

Besides a usual history about panic symptoms, delusions and the like, look at provoking and protecting factors. Is their family with them in Canada? Significantly, is their family safe?

Ask about housing, finances, and whether they are successfully learning English. Learn if they are isolated: sometimes it is a great help to connect patients with groups or other patients. Some patients will benefit greatly from being given a recreation pass so that they can use a pool or gym. Encourage walks in the park, and volunteerism. For some people, being a member of a church is comforting.

Also, it is key that you know if they are facing legal matters.

For patients who are very distressed or suicidal, counsel them to simply live from visit to visit at Bridge: it is much easier for them than facing the whole future at once. Don’t be afraid to briefly bring them in every day if necessary, and create a safety net for them of visits with the settlement worker, physicians and nurses. Also look for community supports for them. Make them feel held.

How to talk to patients about mental health

It is necessary for each provider to develop a way of talking about mental health problems that is suited to our patients, with their wide range of cultural backgrounds, and their significant differences in levels of literacy and education.

Many of our patients, especially those from more conservative cultures, do not have a Westerner’s consciousness of psychological difficulties, or a vocabulary for them. Words like “stress” and “depression” may not mean much, or worse, they may signal weakness, in which case patients will often deny experiencing them - no matter how much trauma is in their background. All people fear being labeled.

Because of these fears, our patients typically present their distress in physical complaints. Patients with PTSD are particularly prone to somatizing their distress, and a pattern of headaches, fatigue, insomnia, body pains, pelvic pain, stomach symptoms and so on is a strong clue for an anxiety-based problem. The chronic muscle tension experienced by these patients is also the source of many symptoms throughout the body. And patients are especially prone to unusual symptoms at sites of injury from torture or abuse.

In speaking with a patient it is important to convey safety and to avoid labeling. If you think a patient may be reluctant to admit to certain symptoms, normalize them by saying, "Many people who have gone through difficult experiences like yours have these kinds of problems… Do these affect you?” Give the patient permission to feel crazy: normalize their distress. It may also be necessary to see a patient for their somatic symptoms for some time before they will trust you enough to admit to psychological distress.

If a patient tells you a little of their traumatic experiences, you risk re-traumatizing them if you respond to them clinically instead of personally. Don’t leave them hanging in silence. Honor what is personal in their experience by saying that you are sorry for what they have gone through, that they did not deserve this, that these things should not happen to anyone. It takes little effort, but it makes a difference.

Also, it is sometimes best to minimize the use of labels like “depression”, at least for those patients who seem wary. Some patients will appreciate a diagnosis they can read about, but for others it may be better to talk empirically and in terms of mechanisms. Many patients who deny stress or depression will readily endorse the suggestion that they have “tired nerves”. Use explanations like “if you walk too much, your knees wear out. If you worry too much, your nerves wear out” – patients understand these and sometimes appreciate them more than a psychiatric label. Equally, present medication options in a practical way, in terms of potential benefits like reduced nightmares, better sleep, and more energy.

Referral options

See this directory of mental health services.

The refugee process and legal concerns

For refugee claimants, the legal process is long and difficult. And for many of these claimants, success or failure in their claim is a matter of life and death. Added to this, many are confused about the process, and they can be quite passive in pursuing their claim.

It is important to inquire about your patient’s situation for many reasons. Sometimes our patients lose and are deported in spite of having legitimate claims. This can be a painful and desperate process for doctor and patient alike, and is best avoided.

Unfortunately, some of our patients have immigration consultants rather than lawyers working for them, and may not understand the difference. Or they have a poor lawyer. Some lawyers rarely win their cases, and others rarely lose. You do not need to inquire specifically about who your patient’s lawyer is, but do warn them that not all lawyers are equal and they need to be careful.

Claimants are allowed by Legal Aid to change lawyers at least once and without giving reason. However, if they lose their first hearing, 99% of their chance for success is lost.

Understanding the refugee process: stressors by group

1. Refugee claimants: ongoing stress of preparing for hearing, meeting with lawyer, telling the story of persecution/torture, high risk of refusal of claim, deportation, financial problems, increase in symptoms prior to hearing. Refugee claimants often arrive alone and are lonely, having left loved ones behind, often abruptly, with years ahead of them before reunification.
2. Convention refugees: settlement issues, language and cultural issues, whole families arriving including the elderly who have bigger adjustment issues, often coming from situations of deprivation, poverty, war, internal displacement, etc.
3. Refused claimants: appealing claim with tiny chance of success, often without IFH or income – may be cut off welfare. Often very fearful about dangers of being deported back to country of origin.

Communication tips

Conclusion

A few final words. It isn’t possible to do meaningful mental health work without continuity – remember that your own gentle, attentive presence is the most significant therapeutic tool that you have. Continuity of care is essential if you are to be effective in stabilizing traumatized individuals.

At first, see the patient often. Later, when they are more stable, spread the visits farther apart. If you have your initial encounters with the patient too far apart, the trail will be lost – for example, the patient will return after two months and you will learn that they stopped the medication 6 weeks ago because of side effects. Initial visits that are too far apart also lead to many urgent visits and emergency room visits that are generated by anxiety.

Don’t under-treat. Don’t stop increasing or changing medications until either your patient’s symptoms are controlled, or you have run out of options.

Believe in your own therapeutic value. It may be difficult to feel that you have a right – or the skill – to deal with very traumatized individuals who have been through personal tragedies that may seem quite far from the experience of life that you understand. But in its essence working with traumatized people is not that complicated. Just be kind, be present, and learn by doing.

Appendix

No-Charge Psychiatric Medication Program (Plan G). Details here.

Addressing the mental health needs of refugees in primary care settings by the Refugee Health Technical Assistance Center - Dr. Allen Keller and Dr. Samantha Stewart.

A mental health screening template for clinicians by Dr. Bob Martin.