As evidenced by our patients, PTSD and MDD usually run a chronic course, and treatment is of long duration. Therapy generally affords a rapid reduction in the most obvious symptoms (such as nightmares and startle reaction); nevertheless, patients remain highly vulnerable to stress.3 Stress secondary to news of renewed fighting in their homeland and worry about relatives left behind typically exacerbates symptoms in almost all patients. Many refugees were greatly disturbed by the events of 9/11. Like many Americans, these patients believed they were safe in the United States; after the attacks, they felt that the horror they had experienced had followed them here.4

There is a high rate of hypertension (44%) and diabetes (15%) among all the refugee populations who attend our clinic. This finding does not seem to be related to trauma as much as to obesity.5 In addition, the high incidence of these disorders is not related to ethnicity (rates are the same across all ethnic and racial groups). Because combined medical and psychiatric care is necessary, we have started to screen for these 2 disorders and have a primary care physician available in our clinic to attend to immediate problems.

Treatment approaches
Treatment of refugees who have survived violence and torture is complicated and not formula-bound (Table). Therapy must address the interface of psychiatric disorders related to trauma with an understanding of cross-cultural needs. Cultural sensitivity and awareness of the effects of massive trauma are crucial. One of the most important aspects of our approach has been the consistent relationship of the counselor, psychiatrist, and patient over the long period needed for treatment. Stress reduction is also essential and is achieved by ensuring that patients have housing, a social network, and adequate food, and by providing continuity of care in the community and alleviating symptoms with medication.

Psychotherapy is of a supportive-dynamic type: the clinicians listen to the patient’s story and stay with the patient through the difficult process of coming to terms with the trauma and adjusting to life in the United States. Educational reframing (ie, defining the symptoms as the body’s response to massive trauma) provides a cognitive frame of reference to all patient groups. However, highly specific techniques, such as cognitive-behavioral therapy or exposure therapy, may be culturally inappropriate, or may seem like “tricks” to those who have suffered severe interpersonal losses or existential crises.

Clearly, many of the problems can­not be fixed. Family members cannot be brought back; cultures will never be the same; and (for some) status, position, and income will be forever lost. There is no easy solution, but relieving the symptoms and staying with the patients through the ups and downs of their lives has been very valuable. Many patients have never had a chance to tell their story before, nor have they had someone listen with compassion.6

Group therapy of a socialization type has been very helpful. Sessions are used to educate the patient about the symptoms associated with the disorder; to promote the patient’s culture and holidays; and to bring together people of different cultures for American celebrations, such as Thanksgiving. Group sessions also give patients the opportunity to share their experiences and challenges in adjusting to life in this country. (Many of our middle-aged parents are having difficulty in raising their children in the United States.) More than half of our patients attend socialization groups.7

Medicines have been particularly helpful. Antidepressant medicines, both SSRIs and tricyclics, are very useful for the depressive symptoms. The tricyclics, such as imipramine and doxepin, help with insomnia— a common problem among this patient population. There is strong evidence that prazosin and clonidine help reduce nightmares and, to some extent, startle reactions.8 Occasionally, when aggressive behavior must be addressed, risperidone has been useful.

The usual antipsychotic medications, both first- and second-generation, have been useful for patients with chronic mental illness. Because adherence has been a problem, most of our patients with schizophrenia are treated with long-acting injectable medicines, such as fluphenazine, haloperidol, or risperidone.

Outcomes
We believe our program is a successful one, but we have not yet statistically evaluated patient outcomes. Perhaps unique for a minority mental health clinic, 90% of our patients keep their appointments for physician visits. We have, however, followed responses to treatment with the Sheehan Disability Scale, which indicates diminished impairment in social functioning and family/home life. With a sample of 70 Somali, Ethiopian, and Kurdish patients over 1 year, the Sheehan Social Disruption scale average went from 8.0 to 5.8 (x2 < .0001) and Family Disruption went from 7.6 to 5.8 (x2 < .001). Nevertheless, some of our severely traumatized patients have symptoms even after 25 years of treatment.

We are beginning a project to determine the effects of treatment on quality of life, the effects of social and family impairment, as well as the effects of symptoms reduction in a prospective manner to evaluate this very traumatized group.

Conclusions
Those of us who treat this population find some of the countertransference issues difficult. It can be challenging to maintain the right therapeutic balance between over-involvement and emotional distance. Treatment is difficult and takes a toll on providers. Our medical staff and counselors find peer interaction and support necessary to maintain our emotional balance.

Despite the difficulties in treating survivors of violence and tragedy, the work is ultimately rewarding and fulfilling. Physicians cannot stop all the violence in the world, but we can comfort the suffering survivors and be compassionate witnesses to their pain.
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