What's the best approach to mental health treatment for refugees with posttraumatic symptoms? One clinic with extensive experience in managing traumatized refugees recommends a medical approach combining psychoactive medications, long-term psychotherapy, and screening and treatment for associated health issues, according to a paper in the Journal of Psychiatric Practice, published by Wolters Kluwer.

J. David Kinzie, MD, of the Intercultural Psychiatric Program at Oregon Health & Science University, Portland, shares his center's approach to the evaluation and treatment of refugee psychiatric patients, based on over 35 years of experience. He writes, "Refugees are a highly traumatized and culturally diverse group of patients who present many clinical challenges and who have a high prevalence of traumas from torture, ethnic cleansing, and the effects of long civil wars."

Management Recommendations from the Intercultural Psychiatric Program

The Intercultural Psychiatric Program has followed the same treatment model since its initiation in 1978. Each patient is followed by a single faculty psychiatrist, while 14 counselors from various ethnic groups play multiple roles in patient care. If at all possible, no changes are made in the patient's counselor or psychiatrist--the clinic's motto is "One patient, one counselor, one psychiatrist forever."

The clinic currently has 1,300 patients and can work with 18 different language groups. Part of the Oregon Mental Health System, the Intercultural Psychiatric Program is largely funded by Medicare and Medicaid payers, with additional funding from the federal Office of Refugee Resettlement and the United Nations.

The clinic's medical model is more patient- than disorder-oriented, focusing on symptom reduction. The most common diagnosis in traumatized refugees is posttraumatic stress disorder (PTSD), sometimes with accompanying depression. For PTSD, the suggested treatment approach involves long-term supportive psychotherapy, combined with medications to reduce the most disruptive symptoms.

Specifically, Dr. Kinzie recommends a sedating tricyclic antidepressant, an alpha-2 adrenergic blocker such as clonidine or prazosin, and an antipsychotic medication. This combination provides rapid relief of major PTSD symptoms, enabling patients to sleep while reducing nightmares, irritability, and psychotic symptoms, if present. "This relief from suffering is very much appreciated by patients and their families," Dr. Kinzie notes.

Studies have also found high rates of diabetes and hypertension among traumatized refugees. These associations strongly suggest a causal relationship with PTSD, possibly involving a role of inflammation. Dr. Kinzie recommends a thorough medical evaluation, including measurement of blood pressure, testing for diabetes, and prescription of appropriate treatment.

Numbers of refugees have greatly increased worldwide, with ever-larger numbers of displaced individuals coming to the United States. Since 1975, the United States has admitted 3 million refugees; in 2013, it admitted nearly 17,000. Although refugees come from diverse cultures, the vast majority have undergone severe and multiple traumas.

"The main value of this approach is that it meets patients' expectations, provides symptomatic relief, usually quickly, and supports a long-term doctor-patient relationship," Dr. Kinzie adds. Refugees are generally accepting of psychiatric treatment and can obtain relief from symptoms associated with massive trauma and losses.

There have been no placebo-controlled trials of the clinic's medical approach to traumatized refugees--nor are any likely to be performed because of the challenges of conducting such research and the lack of financial incentives for doing so. A previous one-year, prospective study found good improvement in 20 of 22 patients treated with the program.

"Our work with traumatized refugees suggests that attending to major symptoms, providing long-term supportive psychotherapy, and ensuring the treatment of associated medical conditions result in good patient acceptance and good clinical outcomes," Dr. Kinzie concludes. He also believes that the medical approach provides a "safety net" for the fluctuating course of PTSD, helping to prevent more serious mental and physical illness.