Mental Health Screening for Newly Arrived Refugees: CDC Guidance

This guidance is for state health departments and clinicians in the United States who do refugees' initial medical screening, usually 30–90 days after arrival. It aims to promote refugee health, prevent disease, and introduce refugees to the U.S. health care system.

Scope

The mental health screening finds refugees who need mental health support and refers them for diagnosis and care. It is not a diagnosis. Timely referral can help refugees live healthier, more productive lives after resettlement.

• Most common diagnoses: major depressive disorder, PTSD, anxiety and adjustment disorders, and substance abuse.
• Emergencies are rare at this visit, but urgent concerns — such as suicidal or homicidal thoughts — follow clinic protocol, up to immediate evaluation and inpatient psychiatric care.

Five steps

1. Review overseas records for the type and severity of trauma or abuse, disorders with harmful behavior, and substance-related disorders.
2. Ask directly about symptoms, functioning and suicidal thoughts, within the overall history and physical — which lessens stigma. Note insomnia, appetite changes, nightmares, muscle tension, headaches and unexplained body pain.
3. Screen — adults (≥ 18) with standardized tools; children and adolescents (< 18) with a structured or semi-structured assessment.
4. Screen for substance use, explain possible legal consequences in the U.S., and refer or connect to community resources if the person wants it.
5. Make an impairment-related action plan, with management or referral, for anyone who needs support.

Background

Refugees often face extreme hardship at home and in displacement, transit and resettlement. How a person responds depends on:

• how directly, how long and how intensely they were exposed to trauma;
• their disposition and resilience;
• their sense of economic and physical security after resettlement;
• their coping skills and support — family and community;
• access to education.

Youth, older people and women may face more trauma. Older refugees risk abuse and isolation. Children, though often resilient, share their families' trauma and lose homes, relatives and schooling. Women and children are disproportionately targeted in armed conflict, and sexual violence is often systematic; survivors may face discrimination and little support. Most refugees go on to healthy lives, but many have symptoms that screening and treatment can ease.

In the examination

• Overseas exam: its mental health part looks for physical and mental disorders (including alcohol), associated harmful behavior, drug use, and remission or recurrence risk — see the Technical Instructions for Panel Physicians. A clean overseas exam doesn't rule out needs.
• Use the records so the patient needn't retell traumatic memories.
• Respond without judgment, as to a physical injury. Symptoms may appear months or years later.
• Warning signs: visible distress or crying; being withdrawn or slow to respond; uncontrolled laughter or making light of tragedy; a heightened startle reflex; disorganized thoughts; signs of psychosis such as hallucinations.
• Ask about suicide calmly and directly, for example: "With everything people have had to endure in their home country, then being uprooted to come to the US and facing challenging circumstances here, some people have thoughts about suicide or hurting themselves. Do you have those thoughts?"

Screening adults (≥ 18)

Some refugees are pre-literate in their first language or need help with rating scales, and a tool validated in one group may not transfer to another. Use one of two approaches:

• A single broad tool, such as the RHS-15; or
• A combination that must cover PTSD, anxiety and depression — for example PHQ-2 first, then PHQ-9 for those in significant distress.

Select tools (as of April 2019):

The RHS-15 has been validated with adolescents ≥ 14; PHQ-2 from age 13 and PHQ-9 as young as 12.

Screening children and adolescents (< 18)

There is no gold standard; best practice is a structured or semi-structured assessment within the overall exam, watching development and how the child and parents engage.

• Ages 0–5: the mental status exam, including development and engagement — which cultures read differently.
• Ages 6–13: most can be interviewed. Ask about symptoms and functioning; build rapport first; take care with school, which may be a sensitive or traumatic subject.
• 14 and older: the RHS-15 (or sample questions), the mental status exam and parents' observations; PHQ-2 and PHQ-9 may help. Be sensitive about sexual history, substance use and corporal punishment, and explain the limits of confidentiality.

Sample questions (not a validated tool):

There is no cut-off: if symptoms interfere with school or family life, refer.

Substance use

Ask about drugs, alcohol and tobacco, and learn culturally specific substances and their local names. Two examples:

• Betel nut, chewed or smoked across Southeast Asia (including Bhutan, Nepal, Burma, Malaysia, Taiwan and Thailand): not a controlled substance in the U.S.; a mild stimulant, addictive, often started in early adolescence; linked to tooth decay, oral cancer and milk-alkali syndrome.
• Khat, chewed in East Africa, the Horn of Africa and the Arabian Peninsula: controlled in the U.S.; a mild stimulant linked to fast heart rate, high blood pressure and possibly oral cancer.

If use is significant: explain that it can be a way to cope with trauma or to self-medicate; ask specific questions ("How much do you drink?"); explain legal consequences, and those of violence, neglect or impaired driving; refer to community services — or a community or religious leader — and consider dual diagnoses.

The action plan

Build it from overseas records, physical signs seen in the exam, information from family or social workers, and screening tools (including CAGE if substance use is reported). Then place the person in one of four groups:

Referrals

Most conditions can be managed in primary care, but some need a specialist. Barriers include stigma, unfamiliarity with mental health care, transport, scheduling and interpretation, visits only during work hours, overwhelmed families, and few culturally informed or pediatric services.

Good practice:

• agree on referral procedures with local services in advance;
• make sure providers have cultural and language skills or interpreters — otherwise work with community leaders, resettlement agencies or the state Refugee Health Program;
• book the appointment with the refugee present, with a release of information so agencies can help with transport;
• send reminder calls in the patient's language one week and one day before;
• treat the refugee as a partner in the plan and confirm they intend to attend.

Sources

Based on "Mental Health," Refugee Health Domestic Guidance, Centers for Disease Control and Prevention; a work of the United States government in the public domain. Tool details, validation studies and languages are condensed.