Mental Health Screening: Domestic Refugee Health Screening Guidance - Minnesota Dept. of Health

Domestic Refugee Health Screening Guidance
Mental Health Screening

Last updated: July 2022

On this page:
Minnesota mental health screening recommendations
     Adult mental health screening tool
     Microlearning series: Mental health and emotional wellbeing
     Response to needs
     Best practices
Background and epidemiology
Additional provider training webinars
Resources

Minnesota mental health screening recommendations

  • Review overseas records for documentation of type and severity of any trauma/abuse, physical and mental disorders with associated harmful behaviors, and/or substance-related disorders.
  • All refugee arrivals should be assessed for mental health needs.
    • For adults ages 18 and older, providers should use the brief WE-Check (Minnesota Well-being and Emotions Check) tool. Refer to Adult mental health screening tool for eligibility, items, and scoring. Responses for each item, as well as the screening outcome (positive or negative) should be recorded on the screening results form.
    • For those under age 18, there is currently no “gold standard” for pediatric mental health screening. Certain mental health screening tools, such as the Refugee Health Screener-15 (RHS-15), have been validated for those age 15 and up. Another emerging best practice for the mental health status examination is a structured or semi-structured assessment that is integrated into the overall health assessment. Learn more at CDC: Mental Health Status Examination and Screening–Pediatrics (<18 years).
    • Ask directly about symptomology, functionality, and suicidal ideation as part of an integrated history and physical examination, helping to minimize stigmatization.
  • Those with an existing diagnosis or newly identified needs should receive appropriate follow-up that is accessible and acceptable to them and appropriate to the severity of symptoms. Warm hand-offs are important to optimize connection to care.

Adult mental health screening tool

Eligibility

  • Age 18 and older (refer to recommendations above for assessment of those under 18)
  • No prior mental health diagnosis. If there is documentation of a prior diagnosis, assess for medication supply (if applicable), acute needs, and care plan.
  • Physically and cognitively able to answer questions (consider specific barriers and integrate a structured or semi-structured well-being assessment as feasible)

Introduce the screening with a brief, clear description. Example script: “Now I’d like to ask you five questions about common reactions and feelings that people might have when they have experienced things like war, loss, or political violence. Your answers will help us to better understand your situation. Your answers will not impact your immigration status, benefits, or resettlement services. I’d like you to answer the questions with yes or no.”

Screening tool

WE-Check: Minnesota Well-being and Emotions Check (PDF)
12/30/21

In the past month…

  • Have you felt too sad?
  • Have you been worrying or thinking too much?
  • Have you had thoughts about the past that kept you from doing things or spending time with others?
  • Have you had sleep problems?
  • Have you had memory problems?

If any of the above answers were yes, then ask:

  • Did any of the above stop you from doing things you need to do every day?

Scoring

If patient answers yes to two or more of the above questions, and/or if clinical judgment supports mental health follow-up, the screening is considered “positive.” Develop an action plan with associated management and/or referral.

Pilot project

Minnesota Refugee Mental Health Screening Tool Final Report (PDF)
Methods, results, and recommendations from a pilot project with four clinics from 2016 to 2019. Learn more under background and epidemiology.
12/30/21

Webinar recording

Refugee Mental Health Screening: Guidance and Implementation (YouTube)
Recorded on Jan. 6, 2022

Microlearning series: Mental health and emotional wellbeing

This video (under 5 minutes) is meant to serve as a summary of mental health and emotional wellbeing screening guidance and resources for providers completing the refugee health screening and all those serving new arrivals.

Refugee Health Microlearning Series: Mental Health and Emotional Wellbeing Transcript (PDF)

Responses to needs

Mental health screening serves to identify likely mental health needs. Ethically, screening is appropriate when identified needs are met. The critical final step in the screening process is to identify a plan to address needs. Providers should assess the severity of symptoms and ability to function in daily life. Based on that assessment, a refugee may need immediate intervention in unusual situation: this response should be informed by established clinic workflows for mental health emergencies. More commonly, a refugee may benefit from follow-up in mental health or primary care settings. If the screening provider will not be directly providing the follow-up care, it is then very important to provide a warm hand-off and to discuss the utility of the care in practical terms connected to the symptoms endorsed. Some refugees may also benefit from additional referrals to strengthen social connections or support activities of daily living. Professional connections between clinics and potential referral organizations can create a smoother pathway for refugees. MDH's Directories for Organizations Serving Diverse Communities may offer ideas of possible referral partners.

Best practices

  • Discussions of mental health should avoid jargon and potentially stigmatizing language (including the phrase “mental health” if possible). Instead, focus on concrete symptoms in a patient-centered approach.
  • Asking about “stress” rather than mental problems and prefacing questions with a context of stress reactions can be helpful (e.g., “When people lose so much and have to start their lives over in a new country, it is common for them to have difficulty with…”).
  • Clear discussion of confidentiality, including its limits, should accompany screening. Refugees may be particularly concerned of potential consequences related to immigration or child custody and should be reassured on these points.
  • As with all patients, mental health symptoms may appear or stabilize over time. The mental health screening is an opportunity to screen for current needs and to provide normalization and psychoeducation should needs change over the resettlement process. Consider ways to integrate mental health screening or discussion into on-going care as well.
  • Referrals and follow-up plans are sometimes an iterative process. Engaging with the refugee, and/or parents for children, is important to identify symptoms and establish a safe and respectful environment to discuss needs.

Background and epidemiology

Expand All   Contract All

Overview of patient-centered mental health engagement

Directly addressing and supporting mental health needs can lead to improved patient outcomes across a range of metrics. Unmet mental health needs can interfere with a range of activities of daily living, necessary tasks of resettlement, and the understanding and management of other medical conditions.

Trauma and mental health distress

Assessment for mental health distress is distinct from trying to assess trauma exposure. Refugees often experience extremely difficult situations in their home country, as well as during displacement, transit, and resettlement. While these difficult experiences are risk factors for mental health problems, an individual’s mental and emotional response to these circumstances varies based on unique factors such as:

  • Level of direct exposure to or participation in traumatic events and/or abuse
  • Duration and intensity of prior traumatic experiences
  • Individual disposition and psychological resilience
  • Perceived economic and physical security post-resettlement
  • Ability to identify and utilize coping mechanisms and support networks, including family and community groups
  • Access to education

Many groups, including youth, the elderly, and women, may be more likely to be exposed to traumatic events that can trigger or exacerbate mental health conditions.

Diverse ways of discussing mental health

Many refugees come from cultures with specific stigmas or interpretations of mental well-being and mental illness. Depending on the refugee’s exposure to diverse concepts and belief systems within the home country, discussion of mental health issues may need to be adapted to accommodate the refugee’s frame of reference (e.g., people from urban environments may have a different approach than those who lived a rural or nomadic life). A refugee may describe or express mental distress in physical or spiritual or religious terms (e.g., “I have pain in my heart,” “The devil is busy with me,” “My head feels heavy”) or as a general, nonspecific sense of ill-health that encompasses physical and mental well-being (e.g., “I feel weak,” “I am not fine at all,” or “I no longer have the will”). It is very common for torture survivors to have chronic pain, often in areas of the body that were tortured or bear symbolic meaning in relation to psychological effects of the torture. Somatic expression of emotional difficulties is also more culturally acceptable than having mental health problems in many societies. When screening for mental health, providers need to take into account that for many people, personal and family problems are discussed only within the family, within the community social structure, or with religious/spiritual leaders or traditional healers.

Importance of social supports and opportunities

A range of social factors may impact a refugee’s mental health and well-being, so it is important to conduct a broad and open assessment. It is helpful for providers to inquire and acknowledge the value of these support to gain relevant information on mental health. Inquire about basic activities that contribute to one’s mental well-being (appetite, sleep quality, employment, language acquisition, social contact, cultural connections, neighborhood safety, opportunities to contribute or help others) and levels of energy or fatigue. Connecting the person with local community resources if available may be helpful to support their well-being long term.

Trauma

It is useful to remember that trauma-informed care and an intentional assessment of potential mental health distress is an important component of clinical care for many patients. Trauma exposure is not unique to new arrivals with refugee status: more than half of Minnesotans reported having experienced at least one Adverse Childhood Experience (ACE).

Mental health distress

Among 1,991 eligible adult refugees who arrived in Minnesota from 2016-2019 and who were screened at one of the four participating pilot clinics, 1,705 (86%) were screened through the pilot of the MN Mental Health Screening Tool, which was the predecessor of WE-Check. Approximately thirteen percent screened positive for mental health distress, with significant differences related to country of origin and increasing age. A review of relevant mental health distress among refugees found in literature revealed prevalence broadly similar to or above the positive screening rates in this pilot. Of note, no formal meta-analysis was performed, and studies frequently measured diagnoses of anxiety, depression, and PTSD. According to data from the National Institute of Mental Health: Mental Illness, this is lower than the prevalence of mental illness among U.S. adults.

Minnesota Mental Health Screening Tool Pilot Results, 2016-2019

Country of Origin Eligible for Mental Health Screening* Screened for Mental Health** Positive Screen***
Burma 649 562 (87%) 75 (12%)
Somalia 556 488 (84%) 37 (8%)
Ethiopia 188 156 (83%) 20 (13%)
DR Congo 169 136 (80%) 26 (19%)
Bhutan 98 76 (78%) 11 (14%)
Iraq 66 59 (89%) 18 (31%)
Ukraine 56 52 (93%) 4 (8%)
Eritrea 55 49 (89%) 6 (12%)
Afghanistan 51 41 (80%) 10 (24%)
Other 103 86 (83%) 10 (12%)
Total 1,991 1,705 (86%) 217 (13%)

Age at U.S. Arrival (years) Eligible for Mental Health Screening* Screened for Mental Health** Positive Screen***
18-29 825 703 (86%) 62 (9%)
30-44 704 621 (88%) 77 (12%)
45-64 344 290 (84%) 59 (20%)
65+ 118 91 (77%) 19 (21%)
Total 1,991 1,705 (86%) 217 (13%)

Sex Eligible for Mental Health Screening* Screened for Mental Health** Positive Screen***
Male 934 801 (86%) 85 (11%)
Female 1,057 904 (86%) 132 (15%)
Total 1,991 1,705 (86%) 217 (13%)

*Eligibility requirements for MN Mental Health Screening Tool: 18 years or older at the time of U.S. arrival, screened at one of the four participating pilot clinics, no previous mental health diagnosis, and cognitively able to answer questions.
**Screened using MN Mental Health Screening Tool.
***A positive screen constitutes two or more “Yes” answers or positive based on clinical judgment.

Among 2,013 refugee arrivals from 2016-2019 who were 18 years of age or older upon U.S. arrival and screened at one of four pilot clinics, 1,991 (99%) were eligible for mental screening using the Minnesota Mental Health Screening Tool. Those ineligible for mental health screening included those with a pre-existing mental health diagnosis (N=16) or who were cognitively unable to answer questions (N=6).

Among those eligible, 1,705 (86%) were screened for mental health using the Minnesota Mental Health Screening Tool pilot questions. Among those not screened for mental health using the pilot questions, the reasons included a failed follow-up appointment (N=30), not offered by provider (N=108), a different screening tool was used (N=25), or unknown/other (N=123).

Among the 1,705 screened using the pilot questions, 217 (13%) had a positive screen, which represented either 2+ “Yes” answers or a positive based on the provider’s judgment. The prevalence of a positive screen varied by country of origin, with refugees from Iraq and Afghanistan having the highest prevalence of a positive screen (31% and 24%, respectively). Older arrivals were also more likely to screen positive compared to younger arrivals, and women were more likely than men to screen positive.

Among the 217 who screened positive, 109 (50%) were referred for mental health services. The most common reasons for no referral included patient refusal or low clinical concern.

Additional provider training webinars

Webinar recordings, slides, and Q&A summaries.

Resources


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Updated Friday, 22-Jul-2022 14:46:18 CDT