Developing and evaluating an integrated care model for unemployed trauma-affected refugees with PTSD: An important step towards cross-sectoral collaborative treatment

Abstract

Introduction: Trauma-affected refugees are at high risk of developing mental health problems such as PTSD and depression. Within the PTSD treatment community, it is now widely recognized that for refugees a combination of pre-migration and post-migration factors determines the rates and course of PTSD. Unemployment, along with insecure residency status and poor finances, is one of the prominent post-migration stressors. In the Nordic countries, 64% of refugees with PTSD are unemployed and there seems to be a codependent link between symptoms of trauma, unemployment, and well-being. This highlights that today's PTSD treatment, consisting primarily of psychotherapy, might be greatly improved if attention to post-migration stressors, e.g. unemployment, is actively and systematically included as part of the PTSD treatment in an integrated and collaborative manner. In Denmark, management of social matters such as unemployment is under the responsibility of the municipality sector, and mental health treatment is a regional function. This separation of sectors serves as a severe challenge for integrating a focus on post-migration stressors into the psychiatric PTSD treatment. Aim: Thus, we aimed to engage in a development process involving both municipal and psychiatric stakeholders as well as the patient perspective with the vision of revising PTSD treatment and providing the necessary training for managing the new revised treatment. Furthermore, to evaluate the effectiveness and experience of taking part in the revised treatment. Methods: Stakeholders from four municipalities and one PTSD clinic, all from the Capital Region of Denmark, participated in six workshops through the course of one year. Five of the workshops included 1) a presentation of one stakeholder's approach and possibilities when encountering trauma-affected refugees and 2) presentation of a case and subsequent group work. The sixth workshop focused on clarifying the important points of attention and ensuring consistent expectations and agreement on the content of the revised PTSD treatment. Subsequently, a pilot study tested the feasibility and acceptability of the core component of the revised PTSD treatment, which are cross-sectoral collaborative meetings with a focus on formulating joint care plans. Additionally, nine cross-sectoral collaborative meetings were observed, and each participant was interviewed to gather information from both the patient and professional perspective on what went well and what could be improved during the meetings. As a result, we developed an educational course for PTSD-clinicians. The course provides knowledge and practical skills-training aimed at meeting the needs of both patients and municipal case counsellors and ensuring effective and meaningful collaborative meetings during PTSD treatment. Expected results/Conclusion: The developed and revised PTSD treatment is currently being tested in a randomized controlled trial comparing it to treatment as usual. The primary outcome is level of functioning measured using WHODAS 2.0. However, PTSD, well-being and depressive symptoms are also measure as well as perceived post-migration stressors. Inclusion was started in March 2020. Additionally, a qualitative study explores the application and expectation of the collaborative meetings from the perspectives of patients, PTSD clinicians and municipal case counsellors. Preliminary results will be available in May 2022.".