Global Mental Health and Services for Migrants in Primary Care Settings in High-Income Countries: A Scoping Review

Migrants are at a higher risk for common mental health problems than the general population but are less likely to seek care. To improve access, the World Health Organization (WHO) recommends the integration of mental health services into primary care. This scoping review aims to provide an overview of the types and characteristics of mental health services provided to migrants in primary care following resettlement in high-income countries. We systematically searched MEDLINE, EMBASE, PsycInfo, Global Health, and other databases from 1 January 2000 to 15 April 2020. The inclusion criteria consisted of all studies published in English, reporting mental health services and practices for refugee, asylum seeker, or undocumented migrant populations, and were conducted in primary care following resettlement in high-income countries. The search identified 1627 citations and we included 19 studies. The majority of the included studies were conducted in North America. Two randomized controlled trials (RCTs) assessed technology-assisted mental health screening, and one assessed integrating intensive psychotherapy and case management in primary care. There was a paucity of studies considering gender, children, seniors, and in European settings. More equity-focused research is required to improve primary mental health care in the context of global mental health.


Introduction
Common mental disorders, including major depressive disorder, generalized anxiety disorder, posttraumatic stress disorder (PTSD), and substance-use disorders, have been found to affect one in five adults worldwide, and are becoming increasingly prevalent [1]. By 2030, depression is likely to be the second greatest burden of disease in the world and the single highest cause of disease burden in high-income countries-which has major implications for global mental health [2]. Refugees represent a global priority population with unique mental health promotion needs [3]. Around the world, there are over 28 million refugees and it is estimated that an additional 1.44 million people which medical and mental health needs are addressed concurrently [26,[33][34][35]. Although there have been some systematic reviews that supported the integration of mental health services into primary care for the general population, there has been a lack of systematic or scoping reviews summarizing the evidence on integrated services for migrant populations [36][37][38][39][40].
This scoping review aims to provide an overview of the characteristics and range of mental health services and practices provided to migrants in primary care following resettlement in high-income countries. In April 2020, we conducted a preliminary search for previous scoping and systematic reviews on the topic aligning to the same concept in the Joanna Briggs Institute (JBI) Database of Systematic Reviews and Implementation Reports and the Cochrane Database of Systematic Reviews and found no studies. For the purpose of this scoping review, we use 'mental health services' to represent behavior health services. We also use the term 'migrants' to refer to refugees, asylum seekers, and undocumented migrants. We recognize that these populations represent heterogeneous groups that face unique challenges in accessing mental health care following resettlement.

Protocol
We developed a protocol for this scoping review using the five-stage methodological framework proposed by Arksey and O'Malley [41], and further refined according to recommendations made by the JBI [42]. The final version of the protocol is available from the primary author upon request.
This scoping review included the following five key stages: (1) Identifying the research question; (2) identifying relevant studies; (3) study selection; (4) charting the data; and (5) collating, summarizing, and reporting the results. We report our findings according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Scoping Review (PRISMA-ScR) checklist [43] (See Additional file 1 in Supplementary Materials).

Research Question
The review was guided by the question, "What are the characteristics and range of mental health services and practices provided to migrants in primary care settings following resettlement to a high-income country?" This scoping review aimed to map and characterize the types of mental health services and practices provided to migrants in primary care following resettlement in high-income countries and to identify research gaps in the existing literature.

Data Sources and Search Strategy
We developed a search strategy in consultation with an expert librarian (LB). We systematically searched five electronic databases from 1 January 2000 to 15 April 2020: MEDLINE, EMBASE, PsycInfo, Global Health, and Cumulative Index to Nursing and Allied Health Literature (CINAHL). The search strategy consisted of terms such as refugee, asylum seeker, primary health care, community health services, family physician, general practitioner, nurse practitioner, family health team, shared care model, mental health, mental disorder, post-traumatic stress disorder, anxiety disorder, and depression, and were combined using Boolean operators (see Additional File 2 in Supplementary Materials for complete search strategy). The search query was tailored to the specific requirements of each database. We also scanned references of the included articles for any relevant studies. Companion reports were identified by matching the authors and mental health intervention and were used for Supplementary Materials only.

Eligibility Criteria
We included articles that met the following criteria: (1) Included refugee, asylum seeker, or undocumented migrant populations; (2) described mental health services and practices; and (3) conducted in primary care settings following resettlement in high-income countries (see Table 1 for full inclusion criteria). Refugees, asylum seekers, and undocumented migrants were defined using the United Nations High Commissioner for Refugee's (UNHCR) definitions. Refugee is defined as "someone who is unable or unwilling to return to their country of origin owing to a well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group, or political opinion" [44]. Asylum seeker is defined as "someone whose request for sanctuary has yet to be processed" [45]. Undocumented migrants are defined as "persons who do not fulfil the requirements established by the country of destination to enter, stay, or exercise an economic activity" [46]. We included all refugees, asylum seekers, and undocumented migrants of any age and ethnicity, but immigrants, internally displaced persons, and all other populations were excluded from this scoping review. The primary care setting is defined as "the first level of care within the formal health system" [26] and is mostly led by family physicians, general practitioners, pediatricians, or nurse practitioners [47]. We excluded studies that focused on tertiary/specialist care. The essential mental health services at the primary care level include "early identification of mental disorders, treatment of common mental disorders, management of stable psychiatric patients, referral to other levels where required, attention to the mental health needs of people with physical health problems, and mental health promotion and prevention" [26]. Lastly, high-income countries were defined using the World Bank's definition of high-income economies for the 2020 fiscal year: "Those with a Gross National Income (GNI) per capita of $12,376 or more" [48]. We excluded studies that took place in low-and middle-income countries.

Inclusion Criteria Definition
Population Refugee "Someone who is unable or unwilling to return to their country of origin owing to a well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group, or political opinion" [44] Asylum seeker "Someone whose request for sanctuary has yet to be processed" [45] Undocumented migrant "Persons who do not fulfil the requirements established by the country of destination to enter, stay, or exercise an economic activity" [46] Concept Mental health services: "Early identification of mental disorders, treatment of common mental disorders, management of stable psychiatric patients, referral to other levels where required, attention to the mental health needs of people with physical health problems, and mental health promotion and prevention" [26] Context 1. Primary care setting: "The first level of care within the formal health system" [26] and is mostly led by family physicians, general practitioners, pediatricians, or nurse practitioners [47] 2. High-income countries: "Those with a Gross National Income (GNI) per capita of $12,376 or more" [48] Due to time and resource constraints, we applied date and language restrictions in order to select articles that were most relevant. We excluded studies that were published before 2000 and those published in languages other than English. Conference proceedings, articles without full text, book chapters, book reviews, vignette studies, commentaries, guidelines, study protocols, and editorials were also excluded. In addition, articles that only reported on health needs, barriers, and challenges to healthcare access among refugees without presenting specific interventions and practices were also excluded. Furthermore, articles that only included training or workshops aimed to improve the competencies of primary care providers were also excluded.

Study Selection Process
Search results were imported into COVIDENCE, an online systematic review software [49]. The inclusion criteria were also imported and were used for screening titles and abstracts during level 1 screening, and full-text articles during level 2 screening.
To ensure reliability between reviewers, a series of pilot tests was conducted before title and abstract screening. During each pilot test, 20 articles were used to evaluate inter-rater agreement. Once the percent agreement reached 70%, we proceeded to the next stage. If lower agreement was observed, the inclusion and exclusion criteria were clarified, and another pilot-test occurred. Two rounds of pilot tests were required for title and abstract screening on a random sample of 40 articles in total. Subsequently, two reviewers (JL and SJ) independently screened the title and abstract of each article for inclusion. Due to time constraints, titles for which an abstract was not available were excluded. Reviewers met throughout the screening process to resolve conflicts and discussed any uncertainties that arose during the study selection process.
All articles deemed relevant after title and abstract screening were included for full-text screening. For full-text screening, one round of pilot test was conducted on a random sample of 20 articles in total. Using the same process, groups of two reviewers (JL, JB, EA, SJ) subsequently screened the full text of potentially relevant articles to determine eligibility. Disagreements within each group were resolved through discussion between the two reviewers.

Data Extraction
A standardized data extraction template was developed with input from the entire review team. For all the articles included in the final analysis, data were extracted on the following variables: (1) Author and year of publication, (2) study setting and country, (3) study population (type, age, gender, country of origin, sample size), (4) study objective, (5) study design, (6) type of approach to care (categorized using Blount's framework [29]), (7) type of professional(s) involved, (8) type of mental health service(s) offered (and type of psychotherapeutic intervention(s), if any), (9) comparator (if any), and (10) impact measures.
Using a random sample of five included studies, the data extraction form was calibrated amongst the team. Subsequently, each included article was extracted by groups of two reviewers (JL, JB, EA, SJ). Disagreements within each group were resolved through discussion between the two reviewers.

Methodological Quality Appraisal
We did not appraise the methodological quality or risk of bias of the included articles, which is consistent with guidance on scoping review conduct [42].

Data Summary and Synthesis
The data were compiled in a single spreadsheet and summarized quantitatively using Microsoft Excel. The frequencies were calculated for the following variables: Year of publication, study setting, study country, study design, type of participants, patient gender, patient age group, patient country of origin, type of approach to care, type of professional(s) involved, type of mental health service(s) offered, type of psychotherapeutic intervention(s) offered, and impact measure(s) reported in the intervention studies. Gaps in the literature were also identified.

Literature Search
A total of 1627 records were identified through database searching, and five additional records were identified through scanning the reference lists of included studies. After deduplication (removal of duplicate citations), 975 records were screened by title and abstract. After screening 117 potentially relevant full-text articles, 93 articles were excluded as they did not meet the inclusion and exclusion criteria. Most articles were excluded because they were not conducted in the primary care setting, did not include mental health services or interventions, were not written in English, or were editorials or abstract proceedings. Subsequently, 19 [24,. Five articles were used as companion reports [68][69][70][71][72]. The details of the search process are presented in Figure 1. Characteristics of included studies are summarized in Table 2.  [24,. Five articles were used as companion reports [68][69][70][71][72]. The details of the search process are presented in Figure 1. Characteristics of included studies are summarized in Table  2.  Trainees of mental health professionals were also included to assess and treat patients. Global health navigators assisted with interpreting, advocacy, and connecting with local groups and agencies. The same community health center before the implementation of the quality improvement project.    2 post-hoc groups (therapy adherents and therapy non-adherents) PCP = primary care physician; APRN = advanced practice registered nurse; RCT = Randomized controlled trial; CBT = cognitive behavioural therapy; NET = narrative exposure therapy.
As this scoping review aimed to map out the types and characteristics of mental health services and practices in the primary care setting, a variety of study designs were included. Four of the studies were qualitative studies that interviewed participants (study 4,8,9,11), three were randomized controlled trials (RCTs) (study 7,14,17), three were retrospective chart review studies (study 1, 2, 12), two were cohort studies (study 13 and 15), and two were case reports or case series (study 3 and 16). A cross-sectional study (study 5), a mixed-methods study (study 10), a quality improvement project (study 6), a feasibility study (study 18), and a quasi-experimental retrospective study (study 19) were also included.

Participant Characteristics
In the 19 included studies, one study included both refugees and asylum seekers (study 5), and two included refugees, asylum seekers, and undocumented migrants (study 7 and 10). On the other hand, eight studies specifically focused on refugees (study 3,[13][14][15][16][17][18][19], three on asylum seekers (study 1, 2, 12), and five studied professionals involved in providing health care to migrant populations (study 4,6,8,9,11). The number of participants in each study varied greatly; studies that included patients as participants ranged from 3 to 3511 while those that included health care professionals as participants ranged from 8 to 34. Of the studies that specified the age of migrant populations, most (n = 12) included adults (study 1-3, 5, 7, 12-15, 17-19). Three studies included seniors (study 3,5,19), three included children (study 3,12,16), and only one studied children as the target group (study 16). Most of the studies (n = 13) included both men and women (study 1-3, 5, 7, 10, 12-18), while one study included women exclusively (study 19). In addition, the majority of studies (n = 8) were non-targeted and included participants from multiple countries of origin (study 1-3, 5, 7, 10, 12, 15, 16). Five studies used country of origin to select participants; two studies only included migrant populations from East Asia and the Pacific (study 14 and 17), one only included migrants from Europe and Central Asia (study 18), and one only included migrants from Sub-Saharan Africa (study 19).

Approach to Care
Several distinct approaches to care were utilized by health care professionals to work with migrants in the primary care setting. In all of the studies, health care professionals practiced cross-cultural care and communication, such as working with interpreters or culture brokers when communicating with patients and/or recognizing the influence of culture on the perception of mental disorders and their treatment. In four of the studies, health care professionals also reported to recognize the pervasive impact of trauma on migrant health and practiced trauma-informed care (study 3,9,17,19). In terms of the level of integration, four studies were conducted in primary care settings with coordinated care (study 9,10,15,18), in which primary care providers referred patients to mental health specialists. For example, the study by Jensen et al. described a primary care clinic in which the primary care physicians diagnosed, prescribed medications, provided psychotherapy, and referred patients to community mental health services as needed (study 9). Five studies were conducted in clinics with co-located care (study 2,5,14,16,19), in which medical services and mental health services are located in the same facility but the organizational structures are not merged. For example, the study by Northwood et al. described two urban primary care clinics in which primary care physicians, psychotherapists, and case managers provided care at the same site (study 14). While most of the organizational structure remains not merged, patients are able to take advantage of the proximity of medical, mental health, and social services (study 14). Seven studies were conducted in integrated care clinics (study 1,3,4,6,7,13,17), and teams of primary care providers and mental health specialists worked together to deliver medical and behavioral health components within one treatment plan. For example, the study by Dalgaard et al. described a treatment center in which social workers, physiotherapists, psychologists, and primary care physicians worked in a team to provide treatment to every family (study 4). After the initial assessment, professionals in the team work together to develop a comprehensive case formulation and treatment plan for each family (study 4).

Interventions and Impact Characteristics
Of the 19 studies, eight were intervention studies, which include three RCTs, two cohort studies, a quasi-experimental retrospective study, a quality improvement project, and a feasibility study. The evaluated interventions varied considerably between studies. Four studies evaluated the implementation of written or technology-assisted mental health screening tools, often in combination with other interventions (study 6,7,15,17). The studies reported on the impact of the intervention on screening rates (n = 2) (study 6 and 15), diagnosis rates (n = 4) (study 6,7,15,17), and access to community mental health treatment (n = 4) (study 6,7,15,17). In addition, two studies reported its impact on clinical outcomes for patients (study 6 and 17), one on the discussion of mental health issues during primary care consultation (study 7), and one on patient adherence to treatment regime (study 6). Three studies evaluated the implementation of collaborative care management, in which primary care providers worked with mental health professionals in the same facility to provide mental health care to patients (study 13,14,19). Reported impact measures differed between the studies, and included diagnosis rates (study 14), access and/or utilization of community mental health treatment (study 13), patient adherence to treatment regime (study 19), clinical outcomes for patients (study 14), healthcare utilization (study 19), social functioning outcomes (study 14), and feasibility of the model (study 13). Lastly, one study evaluated a multi-family support group intervention (study 18), and reported its impact on psychiatric service utilization, perception of social supports, and mental health knowledge.

Discussion
This scoping review identified 19 studies that systematically report on the type and characteristics of mental health services and practices provided to migrants in primary care in high-income countries.
Our analysis of these studies shows promising programs and also identifies research gaps in the existing literature. There is a paucity of intervention studies on the topic, especially considering the growing nature of forcibly displaced migrants [6]. This paucity may be due to the ethical, methodological, and resource-related challenges of conducting experimental research with migrant populations [73,74]. As a result of these challenges, research studies in the field often have small sample sizes, a lack of control groups, and lack of randomization [73,74]. Based on our analysis of the existing evidence base, we have identified a number of research gaps that require further investigation.
The majority of studies were conducted in the US. Although the US hosts a sizable population of forcibly displaced migrants, this significantly underrepresents countries that host significantly more forcibly displaced migrants. For example, Germany resettled almost 1.5 million refugees and asylum seekers, the third largest number in 2019 [6]. More research is needed on mental health services for refugees in primary care outside of the US. In addition, this scoping review was limited to studies in high-income countries, thus excluding studies conducted in countries such as Turkey, Colombia, and Pakistan. Considering that 85% of forcibly displaced migrants are hosted in developing countries, more research is needed on low-and middle-income countries [6]. Certainly, mental health services in primary care may be different and predominantly delivered by nurses or trained lay workers in lowand middle-income countries [26].
Most studies included adult patients, while few focused specifically on children and seniors. In addition, for migrant status, most studies included refugees, while none of the studies specifically focused on undocumented migrants and unaccompanied minors. By comparison, 40% of forcibly displaced persons were children below 18 years of age in 2019, and around 400,000 unaccompanied and separated children sought asylum between 2010 and 2019 [6]. Taking all these characteristics into account, future studies should better reflect the demographic profiles of migrant populations, particularly children and unaccompanied minors.
All studies reported that cross-cultural care and communication were practiced by health care providers. By comparison, trauma-informed care was reported to be practiced by providers in only four studies. Trauma-informed care is an approach that recognizes the pervasive impact of trauma [75], and has been identified as best practice for the care of migrant youth by both the American Academy of Pediatrics and the Budapest Declaration on the Rights, Health, and Well-Being of Children and Youth on the Move [76,77]. However, many primary care providers do not discuss trauma histories with patients or feel unprepared to do so [78,79]. Future studies should assess trauma-informed care for primary care providers [65,80]. For vulnerable populations, socioeconomic stressors are closely connected to their mental health and can prevent them from benefiting from mental health treatment [54]. The study by Dalgaard et al. [54] found that it was important to help parents determine the most immediate problems in order to stabilize the family and help them benefit from therapy; we identified two studies that offered social services and case management to patients [54,60].
We identified only three RCTs; two on technology-assisted mental health screening and one on integrating intensive psychotherapy and case management (IPCM) into primary care. In the study by Ahmad et al. [50], an interactive computer-assisted client assessment survey (iCCAS) tool improved mental health consultations compared to usual care. Similarly, the study by Sorkin et al. [65] found that a multicomponent health information technology mental health screening intervention helped primary care providers with diagnosing and providing evidence-informed care to Cambodian refugees. In terms of integrating mental health care into primary care, the study by Northwood et al. [60] conducted a pragmatic RCT on adult Karen refugees in two primary care clinics. Compared to baseline, IPCM patients showed significant improvements in depression, PTSD, anxiety, and pain symptoms and in social functioning at 3, 6, and 12 months. By comparison, care-as-usual patients did not show significant improvements. More experiments using good between-group design is required to empirically validate the intervention [81]. Future studies are required with more heterogeneous groups of migrants to examine the effectiveness of the intervention more broadly. Furthermore, cost effectiveness analyses are needed to demonstrate the benefit of co-located and integrated care to the healthcare system.
A range of the psychotherapeutic interventions were offered in the studies, including CBT, family and couple therapy, support groups, and NET. Although psychotherapeutic interventions were offered, none of the studies evaluated the effectiveness of psychotherapeutic interventions for migrants in primary care.
Due to the lack of studies, the effectiveness of mental health interventions in primary care has not been established with migrant populations. Although the primary care mental health interventions that have been validated for the general population may be valid for migrant populations, as scientists, we cannot with certainty assume this indirect evidence will apply to refugees [81]. Furthermore, these studies may further validate the importance of considering cultural factors in treatment.

Strengths and Limitations of this Scoping Review
A strength of this scoping review is that we conducted this review using a predefined protocol that followed Arksey and O'Malley's framework and the JBI guidance [41,42]. In addition, the studies were carefully selected based on a set of predefined eligibility criteria and have yielded potentially useful information regarding the type of mental health interventions that have been evaluated for migrants in primary care. However, there are several limitations in this review that need to be considered.
Due to the scoping approach of this review, we did not appraise the quality of the evidence and should be cautious in reporting the impact of each intervention. The scoping review was also limited to published peer-reviewed studies and studies published in English. As such, it is likely that other relevant information was not captured, for example, books, grey literature, and publications from non-English-speaking countries. A further limitation is the variation in locations included as 'primary care' and the broad concept of integrated care. Many studies lacked details of the study setting and did not specify the relationship between mental health and medical providers.

Conclusions
This scoping review has highlighted the current evidence on mental health interventions in primary care targeted at migrant populations in high-income countries and identified research gaps in the existing literature. However, the studies are not globally representative, and thus, approaches and interventions may not be generalizable. Future research should include evidence from lowand middle-income countries. More research is also needed to validate the integrated primary and mental health care model for migrant populations, disentangle elements that make integrated care effective for the population, and evaluate the cost-effectiveness of the integrated care model for the population. Future research teams should consider applying systematic review methods to determine the effectiveness of different care practices on clinical and health system outcomes. In addition, future research studies should consider PROGRESS equity factors and pediatric populations to evaluate the equity effectiveness of psychotherapeutic interventions in primary care for migrant populations. PROGRESS equity factors include place of residence, race/ethnicity/language, occupation, gender/sex, religion, education, socioeconomic status, and social capital [82]. Better reporting of the study setting and the relationship between mental health and medical providers should also be encouraged in future studies.