Evidence-based clinical guidelines for immigrants and refugees

Abstract

Background: Exposure to premigratory traumatic events is common in refugees and non-refugee immigrants who have left their countries to escape socio-political turmoil.We conducted an evidence review to determine the burden of post traumatic stress disorder (PTSD) within immigrant and refugee populations, to evaluate the effectiveness of screening and treatment and to identify barriers for primary care.Methods: Using the GRADE approach, we systematically assessed evidence on PTSD screening and treatments and reviewed evidence for clinical considerations and implementation issues for newly arriving immigrants and refugees to Canada.Results: The prevalence of PTSD in refugees is approximately 9%, and, although comorbidity with depression is high, it generally has a favourable prognosis.Routine administration of brief screening tools for PTSD has yet to demonstrate clear benefits and could be harmful.The presence of unexplained somatic symptoms, sleep disorders, or of mental health disorders like depression or panic disorder however, should alert the practitioner to the possibility of PTSD.Culturally adapted psychological treatments appear promising for PTSD in refugees, but more research is needed.Pharmacotherapy is not recommended as a first line treatment although it may be helpful for severe sleep problems or co-morbid depression.In the case of asylum seekers a phased approach is recommended: interventions should focus on practical family and social supports, until safety has been objectively established.Subsequent treatment should address patient priorities including treatment of PTSD symptoms and support for social integration.Interpretation: Primary care practitioners need to be aware that exposure to traumatic events is likely in newly arrived immigrants and refugees.Empathy, reassurance and advocacy are key elements to establish an alliance and provide a sense of safety.Partnership with community organisations help to reduce isolation and support social integration.A system of clinical and institutional support for the practitioners is needed to prevent compassion fatigue.