Journal of Immigrant and Minority Health

, Volume 17, Issue 5, pp 1444–1450 | Cite as

Does Integrated Care Affect Healthcare Utilization in Multi-problem Refugees?

  • Carol C. White
  • Craig A. Solid
  • James S. Hodges
  • Deborah H. Boehm
Original Paper


A history of trauma is common in refugee populations and appropriate treatment is frequently avoided. Using a convenience sample of 64 patients in a Somali primary care clinic, a culture and trauma specific intervention was developed to address retention into appropriate treatment. One goal of the intervention was to improve the rate of engagement in psychotherapy after a mental health referral and to test the effect of psychotherapy on health care utilization using a staged primary care clinical tool. Forty-eight percent of patients given a mental health referral engaged in psychotherapy. Patients engaging in psychotherapy had higher baseline utilization and over 12 months trended towards less emergency room use and more primary care. Our findings suggest that the intervention improved referral and retention in mental health therapy for East African refugee women.


Refugees Political trauma Integrated care Special populations Primary care 



Authors received Grant support from Minneapolis Medical Research Foundation.


  1. 1.
    Jaranson JM, Butcher J, Halcon L, et al. Somali and Oromo refugees: correlates of torture and trauma history. AJPH. 2004;94:591–8.CrossRefGoogle Scholar
  2. 2.
    Adams KM, Gardiner LD, Assefi N. Healthcare challenges from the developing world: post-immigration refugee medicine. BMJ. 2004;328(7455):1548–52.PubMedCentralCrossRefPubMedGoogle Scholar
  3. 3.
    Kirmayer LJ. Confusion of the senses: implications of ethnocultural variations in somatoform and dissociative disorders for PTSD. In: Marsella AJ, Friedman MJ, Gerrity ET, Scurfield RM, editors. Ethnocultural aspects of posttraumatic stress disorder: issues, research, and clinical applications. 3rd ed. Washington: American Psychological Association; 1996. p. 131–64.CrossRefGoogle Scholar
  4. 4.
    Eisenman DP, Keller AS, Kim G. Survivors of torture in a general medical setting: how often have patients been tortured, and how often is it missed? West J Med. 2000;172(5):301–4.PubMedCentralCrossRefPubMedGoogle Scholar
  5. 5.
    Lecrubier Y. Posttraumatic stress disorder in primary care: a hidden diagnosis. J Clin Psychiatry. 2004;65(Suppl 1):49–54.PubMedGoogle Scholar
  6. 6.
    Switzer GE, Dew MA, Thompson K, et al. Posttraumatic stress disorder and service utilization among urban mental health center clients. J Trauma Stress. 1999;12(1):25–39.CrossRefPubMedGoogle Scholar
  7. 7.
    Saechao F, Shamrock S, Recharger D, et al. Stressors and barriers to using mental health services among diverse groups of first-generation immigrants to the United States. Community Ment Hlt J. 2012;48:98–106.CrossRefGoogle Scholar
  8. 8.
    Hollifield M, Warner T, et al. Measuring trauma and health status in refugees: a critical review. JAMA. 2002;288(5):611–21.CrossRefPubMedGoogle Scholar
  9. 9.
    Moffic HS, Kinzie JD. The history and future of cross-cultural psychiatric services. Community Ment Hlt J. 1996;32(6):581–92.CrossRefGoogle Scholar
  10. 10.
    Shannon P, O’Dougherty M, Mehta E. Refugees’ perspectives on barriers to communication about trauma histories in primary care. Mental Health in Family Med. 2012;9:47–55.Google Scholar
  11. 11.
    Bradley R, Greene J, Russ E, Dutra L, Westen D. A multidimensional meta-analysis of psychotherapy for PTSD. Am J Psychiatry. 2005;162(2):214–27.CrossRefPubMedGoogle Scholar
  12. 12.
    Bisson JI. Pharmacological treatment to prevent and treat post-traumatic stress disorder. Torture. 2008;18:104–6.PubMedGoogle Scholar
  13. 13.
    Silber MH. Chronic insomnia. NEJM. 2005;353(8):803–10.CrossRefPubMedGoogle Scholar
  14. 14.
    Mollica R. Medical best practices for the treatment of torture survivors. Torture. 2011;21(1):8–17.PubMedGoogle Scholar
  15. 15.
    Neuner F, Catani C, Ruf M, et al. Narrative exposure therapy for the treatment of traumatized children and adolescents: from neurocognitive theory to field intervention. Child Adolesc Psychiatr Clin N Am. 2008;17(3):641–64.CrossRefPubMedGoogle Scholar
  16. 16.
    Bass J, Annan J, Murray SM, et al. Controlled trial of psychotherapy for Congolese survivors of sexual violence. N Engl J Med. 2013;368:2182–91.CrossRefPubMedGoogle Scholar
  17. 17.
    Kayzen D, Lindgren K, Zangana GA, et al. Adaptation of cognitive processing therapy for treatment of torture victims: experience in Kurdistan, Iraq. Psychol Trauma Theory Res Pract Policy. 2013;5(2):184–92.CrossRefGoogle Scholar
  18. 18.
    Barsky AJ, Orav EJ, Bates DW. Somatization increases medical utilization and costs independent of psychiatric and medical co-morbidity. Arch Gen Psychiatry. 2005;62(8):903–10.CrossRefPubMedGoogle Scholar
  19. 19.
    Holman EA, Silver RC, Waitzkin H. Traumatic life events in primary care patients: a study in an ethnically diverse sample. Arch Fam Med. 2000;9(9):802–10.Google Scholar
  20. 20.
    Elkin I, Falconnier L, Smith Y, et al. Therapist responsiveness and patient engagement in therapy. Psychother Res. 2014;24(1):52–66.CrossRefPubMedGoogle Scholar
  21. 21.
    Elkin I, Yamaguchi J, Arnkoff D, et al. Patient-treatment fit and early engagement in therapy. Psychother Res. 1999;9(4):437–51.Google Scholar
  22. 22.
    Surgeon general: mental health: culture, race and ethnicity (executive summary). 2001; Rockville, MD: US Department of Health and Human Services, Public Health Service.Google Scholar
  23. 23.
    Manderscheid R, Kathol R. Fostering sustainable, integrated medical and behavioral health services in medical settings. Ann Intern Med. 2014;160:61–5.CrossRefPubMedGoogle Scholar
  24. 24.
    Bartels SJ, Stephen J, Coakley EH, et al. Improving access to geriatric mental health services: a randomized trial comparing treatment engagement with integrated versus enhanced referral care for depression, anxiety, and at-risk alcohol use. Am J Psychiatry. 2004;161:1445–62. doi: 10.1176/appi.ajp.161.8.1455.CrossRefGoogle Scholar
  25. 25.
    Ayalon L, Arean PA, Linkins K, et al. Integration of mental health services into primary care overcomes ethnic disparities in access to mental health services between black and white elderly. Am J Geriatr Psychiatry. 2007;15(10):906–12. doi: 10.1097/JGP.0b013e318135113e.CrossRefPubMedGoogle Scholar
  26. 26.
    Szymanski B, et al. Integrated care: treatment initiation following positive depression screens. J Gen Intern Med. 2013;28(3):346–52.PubMedCentralCrossRefPubMedGoogle Scholar
  27. 27.
    Isakson B, Jurkovic G. Healing after torture: the role of moving on. Qual Health Res. 2013;23(6):749–61.CrossRefPubMedGoogle Scholar
  28. 28.
    Neuner F, Schauer M, Klaschik C, et al. A Comparison of narrative exposure therapy, supportive counseling, and psychoeducation for treating posttraumatic stress disorder in an African refugee resettlement. JCCP. 2004;72(4):579–87.Google Scholar
  29. 29.
    Otto MW, Hinton D, Korbly NB, et al. Treatment of pharmacotherapy-refractory posttraumatic stress disorder among Cambodian refugees: a pilot study of combination treatment with cognitive-behavior therapy vs sertraline alone. Behav Res Ther. 2003;41(11):1271–6.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2014

Authors and Affiliations

  • Carol C. White
    • 1
  • Craig A. Solid
    • 2
  • James S. Hodges
    • 3
  • Deborah H. Boehm
    • 4
  1. 1.Center for Victims of TortureSt. PaulUSA
  2. 2.Minneapolis Medical Research FoundationMinneapolisUSA
  3. 3.Division of BiostatisticsUniversity of MinnesotaMinneapolisUSA
  4. 4.Division of General Internal MedicineHennepin County Medical CenterMinneapolisUSA

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