Forcibly displaced persons (FDPs), including refugees, asylum seekers, and other displaced persons, numbered over 110 million people globally in 2023.¹ The United States (US) has accepted 10,000 to 100,000 refugees annually over the last few decades, of which many were resettled in Pennsylvania.² Refugees undergo a domestic medical examination within the first 90 days after arriving in the United States. Per the Centers of Disease Control and Prevention guidelines, much of this initial examination focuses on screening and treatment of communicable infections.³ Evaluation for infectious diseases exceeds 90% in these domestic medical visits; but assessment of other conditions, such as mental health conditions, is much lower.⁴ This is an unmet need as FDPs could greatly benefit from mental health care, as they frequently experience traumatic events and migration-related stressors.⁵ Furthermore, neurological disease is the leading cause of life lost to disability worldwide.⁶ Despite their global prevalence and studies that highlighted how common neurologic and psychiatric conditions are in refugees,^{7, 8} these are not typically assessed during the domestic medical examination. For example, at our institution the bulk of screening questions revolve around infectious etiologies (Table 1). However, we have also attempted to broaden this by including mental health screening and measuring vitamin B12 in Nepalese/Bhutanese refugees, because this is often low in this population and can lead to anemia and neuropathy.⁹ Given refugees face several barriers to accessing acute medical care,¹⁰ better understanding their conditions is essential for improved screening and treatment options at this initial visit. We, therefore, sought to characterize neuropsychiatric diseases that affect refugees at a single academic center in Philadelphia, Pennsylvania, with consideration to sex, age, and geography.

Methods

This is a retrospective cross-sectional study looking at neuropsychiatric diagnoses of adult patients (age ≥18 years) who presented for their initial domestic medical examination at the Refugee Clinic at Penn Center for Primary Care at the Hospital of the University of Pennsylvania between January 2018 and September 2024. This study was approved by the University of Pennsylvania Institutional Review Board. Given the sensitivity of this population the data is not publicly available. The STROBE checklist was used for formulating this study. These patients were referred to the clinic from one of city's resettlement agencies that helped coordinate transportation to the clinic and any subsequent work-up. Pennsylvania Medicaid funded this clinic. Neuropsychiatric diagnosis was based on self-reported history or if the examining physician made a diagnosis. For neurologic diagnoses, the conditions were divided into the following groups: traumatic brain injury (TBI)/head trauma, sleep disorder (including insomnia and obstructive sleep apnea), headache (including migraines and tension type headaches)/facial pain, peripheral nerve disorder (such as radiculopathies and neuropathies), epilepsy, stroke/vascular neurological condition, movement disorder, hearing impairment, vision impairment (excluding myopia/hyperopia/presbyopia), dizziness/vertigo, meningitis/encephalitis, post-infectious sequela (such as polio myelitis), sequela of neonatal encephalopathy (like cerebral palsy), demyelinating conditions, dementia/neurodegenerative disease, and nervous system tumor. The main purpose of the clinic's psychiatric review of systems is to screen for referral to psychiatric resources. This was not detailed enough to consistently differentiate between psychiatric conditions including anxiety, depression, unspecified mood disorders, post-traumatic stress disorder (PTSD) and other psychiatric conditions; therefore, all psychiatric conditions were grouped together.

After initial descriptive analysis, we evaluated for association of specific diagnoses based on sex, age (grouped by decade), or continent of origin using either independent samples two tailed t tests or χ² tests for categorical variables, with a p-value of <0.05 for statistical significance. P-values were not calculated when samples sizes were under five. Countries and continents of origin were noted. For continents we used the regional definitions as per the US Department of Homeland Security's Office of Homeland Security Statistics,¹¹ except that we combined Central and North American regions within the North American continent, and the transcontinental country of Georgia was included within Europe. For the number of countries in which a person resided, countries they traveled through for under 1 month were not counted. Data analysis was performed by GraphPad Prism v9.5.

Results

A total of 407 patients were examined at the clinic from 2018 to 2024 (Table 2). They were overall young, with a median age of 33 years old (range, 18–75 years), and nearly evenly split by gender (46% female [n = 187], 54% male [n = 220]). Geographically, people came from 33 countries around the world spanning five continents (62% from Asia [n = 251], 17% from Africa [n = 72], 14% from Europe [n = 57], 5% from North America [n = 20], and 2% from South America [n = 7]). The most frequent countries of origin were Afghanistan, Syria, Myanmar, Ukraine, and Democratic Republic of Congo. These are the same most common countries of origin for US-resettled refugees on a national level between 2018 and 2024.¹² Most patients, 72%, had lived in at least one other country aside from their country of origin before coming to the United States (range, 0–5 countries).

Over one-third of the patients, (33%, n = 136) had at least one neuropsychiatric diagnosis. Of these 29% (n = 116) had at least one neurologic condition, 10% (n = 41) had a psychiatric condition, 5% (n = 21) had both a neurologic and psychiatric condition, and 4% (n = 14) had at least two neurologic conditions. The most common neurological diagnoses were headache/craniofacial pain (n = 50, 12%), peripheral nerve disorders like radiculopathy and neuropathy (n = 34, 8%), TBI/head trauma (n = 13, 3%), and dizziness/vertigo (n = 11, 3%). No patients were diagnosed with dementia, demyelinating conditions, or nervous system tumors. Although there were no diagnoses that were statistically significant by continent of origin nor age group, and dizziness/vertigo was significantly more common in women than in men (p = 0.0293) (Table 3).

Discussion

Approximately 43% of people worldwide are estimated to have at least one neurological condition, with life lost from neurological disease as the leading cause of disability adjusted life years (DALYs).⁶ Globally, the primary neurologic contributors to DALYs were stroke, neonatal encephalopathy, migraine, and dementia. Similarly, across the United States, nearly one-third of the population has a neurological disorder. Tension-type headaches, migraines, stroke, and dementia were most prevalent, whereas stroke, dementia, and migraines were the most burdensome diseases by DALYs.¹³ Despite the high prevalence of and burden from neurological disease, there is a dearth of studies investigating neurologic disease in refugees and other FDPs. In the only other study we are aware of that specifically studied neuropsychiatric diseases in US-resettled refugees, at a community health center in Northeast Massachusetts, the authors noted approximately 37% of refugees had at least one neurologic condition with headaches, sleep disorders, cognitive impairment/dementia, and head trauma as most common.⁷ Although both Parvez and colleagues'⁷ study and our study shows a similar prevalence of neurologic disease compared to global and national averages, the neurologic profile is strikingly different from the global and national profile with both stroke and dementia less common (likely because of the younger age distribution of refugees), and TBI/head trauma far more common.

The high prevalence of TBI in FDPs, ranging from 9 to 78%, often results from traumatic experiences like interpersonal violence and militarized violence and torture.^{7, 14, 15} Although the inciting episode for TBI was not established in many of our patients, some people who did share their experiences recalled episodes ranging from electrocution to beatings. This is quite different from the leading causes of TBI in the United States, which are usually falls, being struck by an object, or motor vehicle collisions.¹⁶ As TBI is associated with increased rates of other conditions, from headaches, seizures, and dementia to psychiatric conditions and even death,¹⁷ the increased prevalence in FDPs underscores the importance of screening for head trauma, close monitoring, and treatment.

Regarding psychiatric conditions, mental health questionnaires and surveys of FDPs across different countries and continents show 20 to 50% of FDPs experience mental health concerns,^{5, 18-20} especially PTSD and depression. As fewer patients from our clinic had at least one active psychiatric condition (10%), it is highly possibly that this is being under-screened with our current parameters. Therefore, although the current domestic medical exam primarily screens for infectious risk and immunization status,⁴ our study highlights the need to screen for both neurologic and psychiatric conditions to help better assess and treat the unique challenges suffered by this population.

Finally, our study is limited by several factors. First, the majority of these diagnoses are self-reported or based on the physician's diagnosis after a one-time visit, leading to likely an under-reporting of these conditions. This underestimation is also likely given general internists are less experienced with nuances of certain neurologic conditions compared to specialists. Therefore, diagnoses like demyelinating conditions and neuromuscular disease that often need brain/spine imaging, lumbar puncture, nerve conduction studies etc., were also uncommon in our population. This is especially true for psychiatric diagnoses where stigma and limited ability to distinguish between different psychiatric conditions in the initial domestic visit leads to under diagnosis. However, many patients were able to be referred for additional mental health care based on screening questions. We are also limited by small sample sizes for some stratifications that precluded analysis, as noted above. Finally, although we had patients from a diverse panel of countries, our findings cannot be extrapolated to other FDPs such as asylum seekers or special visa holders, or those from other countries who often face different challenges.

Author Contributions

N.S., U.G., and A.B. contributed to the conception and design of the manuscript; N.S. and A.B. contributed to the interpretation of studies included in the manuscript; N.S. and A.B. contributed to drafting the text and preparing the figures.

Potential Conflicts of Interest

Nothing to report.