Intensive psychotherapy and case management for Karen refugees with major depression in primary care: a pragmatic randomized control trial

Abstract

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.

Global Mental Health and Services for Migrants in Primary Care Settings in High-Income Countries: A Scoping Review

“…Most articles were excluded because they were not conducted in the primary care setting, did not include mental health services or interventions, were not written in English, or were editorials or abstract proceedings. Subsequently, 19 articles were included: Asgary et al, 2006 (study 1); Bertelsen et al, 2018 (study 2); Bosson et al, 2017 (study 3); Dalgaard et al, 2020 (study 4); Dick et al, 2015 (study 5); Schaeffer and Jolles, 2019 (study 6); Ahmad et al, 2017 (study 7); Furler et al, 2010 (study 8); Jensen et al, 2013 (study 9); Kirmayer et al, 2003 (study 10); Samarasinghe et al, 2010 (study 11); McMahon et al, 2007 (study 12); Njeru et al, 2016 (study 13); Northwood et al, 2020 (study 14); Polcher and Calloway, 2016 (study 15); Rousseau et al, 2013 (study 16); Sorkin et al, 2019 (study 17); Weine et al, 2003 (study 18); White et al, 2015 (study 19) [ 24 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 , 67 , 68 , 69 , 70 , 71 ]. Five articles were used as companion reports [ 68 , 69 , 70 , 71 , 72 ].…”

“…For vulnerable populations, socioeconomic stressors are closely connected to their mental health and can prevent them from benefiting from mental health treatment [ 54 ]. The study by Dalgaard et al [ 54 ] found that it was important to help parents determine the most immediate problems in order to stabilize the family and help them benefit from therapy; we identified two studies that offered social services and case management to patients [ 54 , 60 ].…”

“…Similarly, the study by Sorkin et al [ 65 ] found that a multicomponent health information technology mental health screening intervention helped primary care providers with diagnosing and providing evidence-informed care to Cambodian refugees. In terms of integrating mental health care into primary care, the study by Northwood et al [ 60 ] conducted a pragmatic RCT on adult Karen refugees in two primary care clinics. Compared to baseline, IPCM patients showed significant improvements in depression, PTSD, anxiety, and pain symptoms and in social functioning at 3, 6, and 12 months.…”

Pragmatic trials of pain therapies: a systematic review of methods

“…Only 7 trials (12%) were fully industry funded, 26 , 29 , 35 , 94 , 97 , 104 , 127 44 trials (77%) had public funders, and 5 (9%) were funded by mixed sources. 50 , 59 , 67 , 83 , 85 Funding sources were not reported in one trial. 91 Most trials were conducted in the United States (35%), followed by the United Kingdom (14%), Australia (7%), and Norway (7%).…”

Exploring Factors Associated with Functional Change and Predictors of Participation Improvement—A Two Years Follow-Up on People with Depression

“…The variables used in our study were constrained by the database and contacting subjects was impossible due to subject anonymity. The third limitation is the model’s R 2 of 0.11, which infers that other factors can predict the functional recovery of social participation, e.g., psychotherapy [ 28 ]. Future studies may address different factors.…”