Intensive psychotherapy and case management for Karen refugees with major depression in primary care: a pragmatic randomized control trial

Andrea K Northwood, Maria M Vukovich, Alison Beckman, Jeffrey P Walter, Novia Josiah, Leora Hudak, Kathleen O'Donnell Burrows, James P Letts, Christine C Danner, Andrea K Northwood, Maria M Vukovich, Alison Beckman, Jeffrey P Walter, Novia Josiah, Leora Hudak, Kathleen O'Donnell Burrows, James P Letts, Christine C Danner

Abstract

Background: Despite an unparalleled global refugee crisis, there are almost no studies in primary care addressing real-world conditions and longer courses of treatment that are typical when resettled refugees present to their physician with critical psychosocial needs and complex symptoms. We studied the effects of a year of psychotherapy and case management in a primary care setting on common symptoms and functioning for Karen refugees (a newly arrived population in St Paul, Minnesota) with depression.

Methods: A pragmatic parallel-group randomized control trial was conducted at two primary care clinics with large resettled Karen refugee patient populations, with simple random allocation to 1 year of either: (1) intensive psychotherapy and case management (IPCM), or (2) care-as-usual (CAU). Eligibility criteria included Major Depression diagnosis determined by structured diagnostic clinical interview, Karen refugee, ages 18-65. IPCM (n = 112) received a year of psychotherapy and case management coordinated onsite between the case manager, psychotherapist, and primary care providers; CAU (n = 102) received care-as-usual from their primary care clinic, including behavioral health referrals and/or brief onsite interventions. Blinded assessors collected outcomes of mean changes in depression and anxiety symptoms (measured by Hopkins Symptom Checklist-25), PTSD symptoms (Posttraumatic Diagnostic Scale), pain (internally developed 5-item Pain Scale), and social functioning (internally developed 37-item instrument standardized on refugees) at baseline, 3, 6 and 12 months. After propensity score matching, data were analyzed with the intention-to-treat principle using repeated measures ANOVA with partial eta-squared estimates of effect size.

Results: Of 214 participants, 193 completed a baseline and follow up assessment (90.2%). IPCM patients showed significant improvements in depression, PTSD, anxiety, and pain symptoms and in social functioning at all time points, with magnitude of improvement increasing over time. CAU patients did not show significant improvements. The largest mean differences observed between groups were in depression (difference, 5.5, 95% CI, 3.9 to 7.1, P < .001) and basic needs/safety (difference, 5.4, 95% CI, 3.8 to 7.0, P < .001).

Conclusions: Adult Karen refugees with depression benefited from intensive psychotherapy and case management coordinated and delivered under usual conditions in primary care. Intervention effects strengthened at each interval, suggesting robust recovery is possible.

Trial registration: clinicaltrials.gov Identifier: NCT03788408. Registered 20 Dec 2018. Retrospectively registered.

Keywords: Basic needs; Case management; Depression; PTSD; Primary care; Refugees.

Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Consort flow chart of Karen refugee patients through the RCT. Patients referred to the study and enrolled in the intervention or care-as-usual groups from eligibility determination through baseline, 3, 6, and 12 months follow up
Fig. 2
Fig. 2
Change in depression and PTSD over time. Mean scores of patient symptom frequency using Hopkins Symptom Checklist-25 for depression (15 items) and Posttraumatic Diagnostic Scale PTSD symptoms (17 items) for Intensive Psychotherapy & Case Management and Care-As-Usual groups at baseline, 3, 6, and 12 months
Fig. 3
Fig. 3
Change in meeting social needs over time. Mean scores of how often social needs are met on CVT Social Circumstances and Functioning Inventory subscales of Safety, Employment, and Social Support for Intensive Psychotherapy & Case Management and Care-As-Usual groups at baseline, 3, 6, and 12 months

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