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.

Purpose The purpose of this paper is to explore the “active ingredients” of integrated behavioral health care (IBHC) from the perspective of Karen refugee participants in an IBHC intervention. Design/methodology/approach This paper is based on in-depth, semi-structured interviews with participants (n=40) who have received an IBHC intervention for one year. These qualitative data are supplemented by descriptive quantitative data from those same participants. Findings This research suggested that IBHC increased awareness and access to behavioral health services, and that IBHC may be especially amenable to treating complex health conditions. The research also found that IBHC provided a point of regular contact for patients who had limited time with their primary care providers, which helped to enhance access to and engagement with health care. Practical implications IBHC has the potential to meet the complex needs of Karen resettled refugees living in an urban setting in the USA. Originality/value IBHC is a promising approach to help meet the mental health needs of refugees in the USA. There are, however, gaps in knowledge about the “active ingredients” of IBHC. This paper helps fill these gaps by studying how IBHC works from the perspective of a group of Karen refugees; these are critical perspectives, missing in the literature, which must be heard in order to better address the complex conditions and needs of resettled refugees.

Refugees and torture survivors often present with complex physical, mental, and social conditions. Collaborative care is a promising service delivery approach that addresses the needs of patients with complex conditions. This article reviews the broader field of collaborative care with a focus on content areas relevant to refugees and torture survivors. Doing so, it identifies the potential benefits and limitations of integrated care for these populations, and it highlights future research directions for collaborative care with torture survivors and refugees. Meta-analyses based on research in diverse populations suggest that collaborative care is effective in reducing symptoms of depression and anxiety and in increasing treatment satisfaction and medication adherence. Randomized controlled trials suggest positive results for collaborative care on posttraumatic stress disorder, severe and persistent mental illness, and key chronic health conditions. Research, however, shows inconsistent results for collaborative care on substance abuse, quality of life, and cost-effectiveness, as well as in older adult populations. Although the research on collaborative care is mostly promising in areas directly relevant to refugees and torture survivors, there is limited research on collaborative care with these populations and what does exist provides inconsistent results. Considering the complex needs of and barriers to care faced by refugees and torture survivors, as well as the evidence for the efficacy of collaborative care in relation to key difficulties experienced by these populations, we argue that there is a clear need and an evidence-based justification for additional research on collaborative care with refugees and torture survivors.

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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. 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