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GP role in handling psychological problems of asylum seekers

Dr Stefan Cembrowicz and

Dr Angela Burnett discuss the resources for

GPs to help this challenging group of patients

GPs who see asylum seekers are often faced with complicated scenarios that may seem far beyond the brief of the traditional 10-minute consultation. Language, culture, health beliefs and expectations of what the NHS can actually do may be quite different from your other patients. The trauma of the journey to this country alone is hard to imagine, let alone the experiences some have had in war zones at home, with torture or injury for some, and separation from, even violent loss of, family and friends.

Some asylum seekers present repeatedly with multiple unexplained medical symptoms; others may attend solely to request letters to improve social conditions and expedite housing. As time goes by and decisions about the right to stay are awaited, the monotony of existence on a tiny budget and the stress of temporary accommodation become all too apparent.

Major or minor psychological symptoms may be present, masked by culture, language difficulties or patient expectations. Doctors attuned to seeking the hidden agenda may have to try to elucidate these via the less sensitive medium of interpreter phonelines. Dedicated clinics for asylum seekers may exist in areas of high demand but may be many miles from your patient.

What is the best way to approach these patients and help them with their psychological problems in the perspective of the UK's hard-pressed, resource-limited primary care system? Are psychiatric labels or practical help of more importance?

Psychological distress is common among asylum seekers and refugees. They frequently experience sadness, depression, anxiety and panic attacks. Some are confused and disorientated, having problems with memory and concentration. Most have trouble sleeping.

These difficulties may result from:

lprevious experiences, including torture and multiple loss

ldisplacement and their situation in the UK

lsocial isolation, poverty, racism

lfear of being returned home

lmental illness (which may be longstanding or linked with their experiences).

Be cautious about rapid diagnosis: the situation is made more complex by different cultural expressions and norms. When making a psychological assessment include an assessment of suicide risk and issues of child protection.

Language and interpretation barriers

If you and the patient do not share a language it is advisable to use a professionally trained interpreter. Although patients may bring a friend or family member to translate, and this may be their preferred choice, be aware that they may interpret inaccurately. Additionally issues such as psychological problems, sexual violation, torture, domestic violence, child protection issues, family relationships or sexual health may be difficult to discuss openly through a family member or friend.

It is difficult to provide an interpreter for someone who consults in an emergency but you can arrange for follow-up with an interpreter. Telephone interpreting can be useful but is limiting when you are working with psychological issues and need non-verbal cues. Interpreters should be trained in mental health issues and be acceptable to their client.

For many patients, restoring their normal life as far as possible can be the most effective promoter of mental health. The factors outlined below have been shown to protect people in exile against mental illness:

lcontact with family/family reunion

lsocial support ­ links with community groups

lstrong religious or political ideology

lhaving a proactive problem-solving approach.

Although problems seem overwhelming, listening, dealing with a few issues at a time and directing the person to sources of assistance may make a huge difference. Follow-up appointments may prevent emergency attendances and keep the person engaged.

I was at the cash machine and a girl snatched my card. I grabbed her and shouted for help. When the police came they thought I was the robber and put me into handcuffs by mistake, so she got away

(Congolese woman)

It is a common assumption that asylum seekers are associated with criminal activity. In fact the police state that asylum seekers and refugees do not contribute to an increase in crime and are as likely, as in this case, to be a victim of crime. This patient may benefit from being put in touch with Victim Support (branches throughout the UK; 0845 303 0900).

Despair and depression may result in suicide and parasuicide, more commonly among young men. The risk has been noted to increase after refusal of an asylum application.

I don't want to go to the women's clinic for repair of circumcision if that interpreter is there. I know she'll tell other people

(Somali woman, 24)

People may fear the reaction of their community to contravening cultural norms. Many asylum seekers are survivors of sexual violence but in almost all cultures this is taboo and survivors may feel very uncomfortable discussing them.

If possible offer a choice of male and female health worker and interpreter. Interpreters may be viewed with suspicion. The principle of confidentiality needs to be clarified with the interpreter and explained to the patient.

He's had a psychiatric report for his immigration appeal. It says he has post-traumatic stress disorder (PTSD) and needs to go on medication

Common expressions of psychological and emotional distress do not necessarily mean the same in different cultural and social settings. Diagnoses such as PTSD and depression should be used cautiously. They may not address the complex way in which historical, social and political factors interact and impact on the experience of communities. No psychiatric illness is specific to trauma or torture and PTSD is not in itself a marker for past trauma. However the description of psychological state is formulated, care is paramount. Using an approach wider than a biomedical base may offer more appropriate treatment models. This man may indeed gain benefit from medication, but assistance with his social situation is also important.

The government soldiers tied me up and beat me ­ they published a picture of me being tortured in the local paper

(former politician from Zimbabwe)

Torture is used by repressive regimes to terrorise communities as well as to obtain information. Sequelae are due to the effects of physical violence, detention and the psychological consequences of being tortured yourself or witnessing the torture of another. Although some people may require referral, many will be cared for in primary care services. The essentials are time, empathic listening, and developing trust. Many women and some men held in detention have been raped, which is often extremely hard for them to disclose.

I need a letter to get my mother over here ­ I need it tomorrow

(17-year-old from Iraq)

Close family are entitled to join a person who has refugee status, but otherwise such a letter is unlikely to be successful. It is best to co-ordinate with the lawyer.

Access to good legal advice is very important for all asylum seekers. The Immigration Law Practitioners Association can provide advice on suitable lawyers (0207 251 8383). Asylum seekers and refugees are entitled to legal aid and most work is carried out under this scheme. The Red Cross may be able to trace relatives whose whereabouts are unknown.

I was in a house with eight people. They hit us with cannon fire. Six were killed. My little boy was dead. I picked up his body in pieces this big. I put them into plastic bags. After that happened I've been like this in my mind

(Farmer from Afghanistan)

Some people experience atrocities without developing any psychological symptoms beyond a natural increase in anxiety and some nightmares. Others show more marked signs of anxiety, depression, guilt and shame. For many people the most valuable inputs are supportive listening, support to grieve and practical assistance to rebuild their lives as far as possible. Many people have been unable to follow proper funeral rites for those who have died, and may find it helpful to arrange this, even a long time after the death. Be cautious of pathologising, but antidepressants should be considered for depressive illness.

He can't sleep, there are bad people in his bed and breakfast, they make noise all night, he wants a letter for the housing department

(17-year-old from Kosovo, with six attendances this year with multiple physical symptoms)

Unaccompanied children aged 15 and under are usually looked after by social services. Those aged 16 or 17 usually receive services under section 17 of the Children Act. Accommodation in a hostel or bed and breakfast is often unsuitable, they have no allocated social worker and they may be vulnerable.

The Refugee Council provides specialist advice to unaccompanied refugee children. It offers support for under-18s and those between 18 and 21 who are the main carers for brothers or sisters.

People living in stressful circumstances often present with headaches, abdominal, neck or back pain, with no apparent physical basis. Young men are often bored and frustrated and have little to fill their day (asylum seekers no longer have the right to work). People may have unrealistic expectations of what can be achieved with a letter from a GP.

Asylum seekers in temporary accommodation may have little in common with other residents, and this may lead to tensions. There is significant stigma around drug use in refugee communities, which also face risk factors for drug use such as poor housing, poverty, and less access to education.

Organisations and resources

Refugee Council

www.refugeecouncil.org.uk

Tel: 0207 820 3000

Panel of Advisers for Unaccompanied Refugee Children

Tel: 020 7582 4947

The Medical Foundation for the Care of Victims of Torture www.torturecare.org.uk

Tel: 0207 813 7777

Health for Asylum seekers and Refugees Portal

www.harpweb.org

www.mentalhealth.harpweb.org.uk

Department of Health Asylum Seeker Co-ordination Team

Tel: 0113 254 6605

E-mail: Justine.Osbourne @doh.gsi.gov.uk

Save the Children

www.savethechildren.org.uk

International Welfare Department, British Red Cross, 020 7793 3360

Further reading

Meeting the Health Needs of Refugees and Asylum Seekers in the UK.

An information and resource pack for health workers 2002. Available online at www.london.nhs.uk/newsmedia/publications/Asylum_Refugee.pdf

Caring for Dispersed Asylum Seekers: A Resource Pack www.doh.gov.uk/asylumseekers/resourcepack.pdf

Harris K, Maxwell C A. Needs Assessment in a Refugee Mental Health Project in north-east London. Medicine, Conflict and Survival 2000;16:201-215

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