Domestic Refugee Health Screening Guidance
Mental Health Screening

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

*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.