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

Research output: Contribution to journalArticlepeer-review

1 Scopus citations


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.

Original languageEnglish (US)
Article number17
JournalBMC Family Practice
Issue number1
StatePublished - Jan 28 2020

Bibliographical note

Funding Information:
The study was funded by the following: The Saint Paul Foundation, The F.R. Bigelow Foundation, Kresge Foundation, The Jacob and Valerie Langeloth Foundation, UCare Foundation, Medica Foundation, Greater Twin Cities United Way, Kinney Family Foundation, State of Minnesota Office of Justice Programs, The John and Ruth Huss Fund of the Saint Paul Foundation, Boston Scientific. The study was also conducted in partnership with HealthEast Care, University of Minnesota Physicians, and the Minnesota Department of Human Services. Study funders/supporters had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Publisher Copyright:
© 2020 The Author(s).


  • Basic needs
  • Case management
  • Depression
  • PTSD
  • Primary care
  • Refugees

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