To characterise the IFMC patients who recently went on to access mental health services within our integrated care clinic, we first identified all patients who had a mental health diagnosis listed as their primary diagnosis from a primary care provider (family medicine MD or NP) visit between 1 January 2016 and 31 December 2021. Out of the 966 patients seen in the IFMC during this time frame, 111 (11.5%) had a primary mental health diagnosis identified during their visit. The most common mental health diagnosis listed in the primary care providers’ notes was depression (49.5%), followed by anxiety (27%), and mixed anxiety/depression (6.3%). Of the 111 patients identified, 82 (73.87%) went on to attend at least one appointment with either FSC or psychiatry, suggesting that our integrated care model helped redirect at least 8.5% of our refugee patients to specialised mental health services during a 5-year span. See box 1 for three case studies that illustrate various referral pathways that refugee patients attending a primary care visit with a chief mental health complaint might take after subsequently being redirected to mental health services.
Box 1Case studies
Jita, a young adult refugee from a South Asian Country
Jita presented to her IFMC initial visit reporting a complex medical history, significant trauma history, depressed and anxious mood, restricted eating and low body weight. During her IFMC visit, Jita’s provider paged FSC and a doctoral student then joined the end of the visit, introduced themselves and FSC’s services, and scheduled an initial behavioural health appointment with Jita for the next day. Jita completed two behavioural health appointments, which focused on helping her establish care with the Teen and Young Adult Health Centre for eating disorder management, before transitioning to ongoing psychotherapy at FSC. Weekly FSC sessions focused on safety management, identity formation, processing traumatic experiences and reducing anxiety and depressive symptoms. Jita’s FSC therapist also engaged in care coordination with the Teen and Young Adult Centre, the International Rescue Committee, Jita’s high school counsellors and her primary care team. After 6 months of treatment with FSC, Jita decided to establish care with psychiatry for medication management alongside continued psychotherapy with FSC.
Deeba, an adult refugee from a Middle Eastern Country
Deeba presented to FSC for a behavioural health appointment at the request of her cousin. Her cousin was concerned about Deeba’s anxiety and health in the context of Deeba’s eldest daughter not yet being able to escape Afghanistan. Deeba reported significant physical symptoms (eg, tingling in her hands, headaches, muscle aches). She also described low energy, tearfulness, difficulty eating and trouble connecting with her younger children. Deeba completed three behavioural health appointments, which provided supportive therapy and helped Deeba identify coping strategies that brought her relief (eg, prayer, playing with her younger children, diaphragmatic breathing). Deeba also informed her FSC provider that she was confused about the various medications that had been prescribed to her, which allowed the FSC provider to help Deeba communicate this confusion to her primary care team and ultimately feel more confident in her physical health treatment. Deeba then decided to establish care with psychiatry for antidepressant medication management throughout her high-risk pregnancy.
Rayan, a teenage refugee from a Southwest Asian Country
Rayan endorsed suicidal ideation when completing a depression symptom screener during an IFMC visit. His primary care provider consulted FSC, who then joined the visit to complete a risk assessment and develop a safety plan with Rayan. FSC was reconsulted a few weeks later when Rayan reported at a follow-up IFMC visit that his suicidal ideation had increased in intensity and frequency. FSC again engaged Rayan and Rayan’s mother in safety planning and helped initiate a bed search for inpatient treatment. Following inpatient treatment, Rayan established care with psychiatry for antidepressant medication management and psychotherapy.
Patients who followed up with our mental health services tended to be somewhat younger (M=37.28 years old) than patients who declined to do so (M=41.97 years old), which is consistent with previous work showing that older adults are less likely to perceive a need to seek mental health help than younger adults.24 However, this difference in age between those who did and did not follow up with a mental health provider was not statistically significant (t=−1.18, p=0.256). Further, men tended to be more likely to follow up with our mental health services compared with women (80% vs 71.6%, respectively, although this difference was not statistically significant, χ2=0.42, p=0.515). Although this pattern runs counter to US trends,25 it may be that lack of childcare more frequently acts as a barrier to women in our patient population. That said, we try to reduce this barrier by inviting parents to bring their children into visits, as needed, which often happens. See online supplemental table S1 for additional diagnostic and demographic information regarding IFMC patients who received a primary mental health diagnosis at their primary care visit.
Of the 82 patients who followed up with a mental health provider, it was most common to do so only with FSC (46.34%), whereas 15.85% were seen only by psychiatry and 37.80% were seen by both FSC and psychiatry. Diagnoses per the mental health visit tended to more often account for the trauma-related and stressor-related nature of the mental health concern’s origin compared with those given by the primary care provider: Whereas only one patient was given a PTSD diagnosis by their primary care provider, close to two-thirds (63.41%) of the patients who followed up with FSC and/or psychiatry were subsequently diagnosed with either adjustment disorder or PTSD. These follow-up diagnoses may have offered patients greater self-understanding and validation, along with opportunities for more tailored treatment (eg, cognitive processing therapy, prolonged exposure). Other common diagnoses following a mental health visit included major depression and anxiety disorders.
Patients diagnosed with a trauma-related or stressor-related disorder during their mental health visit were more often seen by FSC or FSC/psychiatry (80.77%) than psychiatry alone (19.23%). No additional patterns in the relative likelihood for any diagnosis to be seen by FSC versus psychiatry emerged, suggesting that patient preference might guide referral pathways. For example, patients who were only seen by psychiatry tended to be older, on average (M=44.69 years old), than patients who were seen by FSC (M=35.42 years old for patients seen by FSC alone and M=36.45 years old for patients seen by both FSC and psychiatry, although neither of these differences were statistically significant, ps>0.087). See online supplemental table S2 for additional descriptive information regarding those who followed up with mental health treatment, including the average number of visits attended per patient.