Mental health of refugees: report of a successful case in Brazil

Refugees have a substantially higher risk of developing a variety of mental disorders.¹,² Between 2000 and 2010, Brazil saw an 87% increase in the number of immigrants,³ a major portion of whom are refugees. However, there is little research and training focused on this subject, and it is given little importance.

Recognition and proper treatment of mental health problems in this population are challenging due to differences in language and culture, in addition to the specific stressors associated with migration and resettlement.⁴

We present a case that exemplifies successful multidisciplinary treatment of a refugee that addressed the specific problems of this population.

A 23-year-old black male born in the Democratic Republic of the Congo, the country with the world's worst quality of life,⁵ arrived in Brazil after a series of traumatic events. He witnessed the kidnapping and murder of two friends and the violent execution of his parents, and was himself kidnapped and physically and sexually abused. He came to Brazil by ship, as a stowaway, in a precarious and clandestine journey. All the information given was corroborated by documentary evidence and by an investigation by the Federal Police.

The patient was admitted to the Outpatient Transcultural Psychiatry Unit of Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo with posttraumatic stress disorder (PTSD) and a major depressive episode, meeting both DSM-IV-TR and DSM-V criteria. Personal and family neuropsychiatric history, blood tests, and brain magnetic resonance imaging were normal.

During the first 3 months, treatment was essentially pharmacological. Two classes of antidepressants were trialed, at appropriate doses and for appropriate lengths of time; however, the patient experienced progressive worsening of symptoms.

The patient also lacked psychosocial support, with no significant relational bonds, housing, income, legal recognition, employment, or familiarity with the Portuguese language. This is a common situation in the refugee population.

With the help of Caritas Arquidiocesana, a Roman Catholic relief organization that provides support to refugees, and volunteers, we then pursued a multidisciplinary and comprehensive approach that included: case discussion in the hospital's grand round for therapeutic planning; psychiatric follow-up; support psychotherapy for 6 months, followed by shorter cycles for management of exacerbations; legal aid to help the patient gain refugee status and obtain documents; an intensive Portuguese language course; educational support (including scholarships for a pre-college examination, free vocational training, and English classes); specialized accommodation for 12 months, followed by aid for housing transition; a financial subsidy for basic expenses for 6 months; and general medical follow-up.

Before treatment, the patient exhibited several factors that increased the severity of his depression and PTSD and hindered their treatment, indicating a poor prognosis. Nonetheless, he achieved remission of mental disorders and a significant improvement in quality of life, as shown in Figure 1.

Figure 1
Progression of symptoms and quality of life of a refugee patient. PTSD = posttraumatic stress disorder.

Broader investigations and new initiatives that address the mental health of refugees in Brazil are required. Given the potentially negative consequences of failing to treat this population (long-term overburdening of health services,⁶ crime, low productivity, etc.), specific policies for this area would probably be cost-effective.

References

• ¹
  Lindert J, Ehrenstein OS, Priebe S, Mielck A, Brahler E. Depression and anxiety in labor migrants and refugees: a systematic review and meta-analysis. Soc Sci Med. 2009;69:246-57.
• ²
  Fazel M, Wheeler J, Danesh J. Prevalence of serious mental disorder in 7000 refugees resettled in western countries: a systematic review. Lancet. 2005;365:1309-14.
• ³
  Instituto Brasileiro de Geografia e Estatística (IBGE). Censo demográfico [Internet]. [cited 2014 Mar 17]. 2010. http://www.ibge.gov.br/home/estatistica/populacao/censo2010/
  » http://www.ibge.gov.br/home/estatistica/populacao/censo2010/
• ⁴
  Kirmayer LJ, Narasiah L, Munoz M, Rashid M, Ryder AG, Guzder J, et al. Common mental health problems in immigrants and refugees: general approach in primary care. CMAJ. 2011;183:E959-67.
• ⁵
  Human Development Index (HDI) and its Components [Internet]. United Nations Development Programme. [cited 2014 Mar 17]. 2012. http://data.un.org/DocumentData.aspx?id=324
  » http://data.un.org/DocumentData.aspx?id=324
• ⁶
  Crosby SS. Primary care management of non-English-speaking refugees who have experienced trauma: a clinical review. JAMA. 2013;310:519-28.

Publication Dates

• Publication in this collection
  Jul-Sep 2014

History

• Received
  1 Jan 2014
• Accepted
  22 Feb 2014