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Background: Despite an unparalleled global refugee crisis, there are almost no studies in primary care addressing real-world conditions and longer courses of treatment that are typical when resettled refugees present to their physician with critical psychosocial needs and complex symptoms. We studied the effects of a year of psychotherapy and case management in a primary care setting on common symptoms and functioning for Karen refugees (a newly arrived population in St Paul, Minnesota) with depression.Methods: A pragmatic parallel-group randomized control trial was conducted at two primary care clinics with large resettled Karen refugee patient populations, with simple random allocation to 1 year of either: (1) intensive psychotherapy and case management (IPCM), or (2) care-as-usual (CAU). Eligibility criteria included Major Depression diagnosis determined by structured diagnostic clinical interview, Karen refugee, ages 18-65. IPCM (n = 112) received a year of psychotherapy and case management coordinated onsite between the case manager, psychotherapist, and primary care providers; CAU (n = 102) received care-as-usual from their primary care clinic, including behavioral health referrals and/or brief onsite interventions. Blinded assessors collected outcomes of mean changes in depression and anxiety symptoms (measured by Hopkins Symptom Checklist-25), PTSD symptoms (Posttraumatic Diagnostic Scale), pain (internally developed 5-item Pain Scale), and social functioning (internally developed 37-item instrument standardized on refugees) at baseline, 3, 6 and 12 months. After propensity score matching, data were analyzed with the intention-to-treat principle using repeated measures ANOVA with partial eta-squared estimates of effect size. Results: Of 214 participants, 193 completed a baseline and follow up assessment (90.2%). IPCM patients showed significant improvements in depression, PTSD, anxiety, and pain symptoms and in social functioning at all time points, with magnitude of improvement increasing over time. CAU patients did not show significant improvements. The largest mean differences observed between groups were in depression (difference, 5.5, 95% CI, 3.9 to 7.1, P < .001) and basic needs/safety (difference, 5.4, 95% CI, 3.8 to 7.0, P < .001).Conclusions: Adult Karen refugees with depression benefited from intensive psychotherapy and case management coordinated and delivered under usual conditions in primary care. Intervention effects strengthened at each interval, suggesting robust recovery is possible.

Nearly 65 million people around the world have been displaced by war, conflict, and persecution since 2014 (UNHCR; United Nations High Commissioner for Refugees, 2015). This yields an average of 42,000 people refugees, asylum seekers, or internally displaced every day. Displacement has adverse and disruptive consequences, including mental health problems (e.g., anxiety, depression), impaired interpersonal relationships, and heightened conflict. These consequences are compounded by profound ambiguity associated with navigating asylum in the United States. In this article, we describe the treatment of a couple from Syria who is seeking asylum in the United States. Informed by personal and professional experience, this case illustrates how ambiguous loss theory and awareness of relevant legal processes enhance our understanding of working with asylum seekers.

Background: Despite an unparalleled global refugee crisis, there are almost no studies in primary care addressing real-world conditions and longer courses of treatment that are typical when resettled refugees present to their physician with critical psychosocial needs and complex symptoms. Our aim was to study the effects of a year of psychotherapy and case management in a primary care setting on common symptoms and functioning for Karen refugees (a newly arrived population in the study location) with depression. Methods: A pragmatic parallel-group randomized control trial was conducted at two primary care clinics with large resettled Karen refugee patient populations, with simple random allocation to one year of either: (1) intensive psychotherapy and case management (IPCM), or (2) care-as-usual (CAU). Eligibility criteria included Major Depression diagnosis, Karen refugee, ages 18-65. IPCM (n=112) received a year of psychotherapy and case management coordinated onsite between the case manager, psychotherapist, and primary care providers; CAU (n=102) received care-as-usual from their primary care clinic, including behavioral health referrals and/or brief onsite interventions. Blinded assessors collected outcomes of mean changes in depression, anxiety, PTSD, pain, and social functioning at baseline, 3, 6 and 12 months. Measures included HSCL-25 (depression and anxiety), PDS (PTSD), pain (range of 0-4), and social functioning scales (range of 0-4). Data were analyzed with the intention-to-treat principle. Results: Among 214 randomized participants, 193 completed a baseline and follow up assessment (90.2%). IPCM patients showed significant improvements in depression, PTSD, anxiety, and pain symptoms and in social functioning at 3, 6, and 12 months, with magnitude of improvement increasing over time. CAU patients did not show significant improvements. The largest mean differences observed between groups were in depression (difference, 5.5, 95% CI, 3.9 to 7.1, P<.001) and basic needs/safety (difference, 5.4, 95% CI, 3.8 to 7.0, P<.001). Conclusions: Adult Karen refugees with depression benefited from intensive psychotherapy and case management coordinated and delivered under usual conditions in primary care. Intervention effects strengthened at each interval, suggesting robust recovery is possible. Trial registration: clinicaltrials.gov Identifier: NCT03788408. Registered 20 Dec 2018. Retrospectively registered. Keywords: Refugees, Depression, Primary care, PTSD, Basic needs, Case management

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