I NTRODUCTION

8.1.1 Legal Basis for the Utilization of Medical and Psychotherapeutic Care by Asylum Seekers in Germany

Medical and psychotherapeutic care of asylum seekers in Germany is legally regulated in the Welfare Law for asylum seekers (Asylbewerberleistungsgesetz; AsylbLG) and the social security statutes (Sozialgesetzbuch; SGB).

According to § 264 SGB V and as of January 1^st 2004, asylum seekers who have lived in Germany for over 36 months, received benefits according to § 2 AsylbLG, and held at least limited residence permit or legal or humanitarian based prohibition of deportation for this time span, are entitled to receive health care through health insurance. In this case, the asylum seeker receives a chip card of the health insurance in charge with which he / she might consult the physician of choice. He / she receives the same benefits like any other insurant; this does not include travel or interpreter costs.

If an asylum seeker or refugee does not meet the prerequisites, the social welfare office covers the costs for health care (§§ 4 and 6 AsylbLG). In case of indisposition and need of in-tervention, the asylum seeker receives a certificate of illness from the administrator at the so-cial welfare office or the soso-cial worker at the actual reception center. It allows access to a lim-ited number of health care benefits. Health care through the social welfare office covers acute needs of intervention, painful illness, for the health maintenance indispensable interventions, and (unlimited) benefits in case of pregnancy and maternity, as well as preventive medical

checkups and inoculations. Benefits according to AsylbLG might cover more than health care according to SGB, e.g. travel costs to outpatient treatment, reimbursement of the personal con-tribution to prescription-free pharmaceuticals. According to current jurisdiction regarding the AsylbLG, the costs for an interpreter to conduct psychotherapy are also covered if no therapist with corresponding language knowledge is available (Classen, 2006). However, physicians have to cure with minimum-cost treatment. Accordingly, more often, medical treatment is granted by the social welfare office than psychotherapy (Flüchtlingsrat Berlin, Ärztekammer Berlin, & Pro Asyl, 1998; Kluwe-Schleberger, 2002).

8.1.2 Utilization of Medical and Psychotherapeutic Health Services by Asy-lum Seekers

In 2004, one million refugees were living in Germany and in 2005, 42,908 people from different countries applied for asylum (BAMF, 2006). As described above, many suffer from pre- as well as post-migration stressors and psychiatric symptoms besides medical problems.

As introduced in chapter 7.3 treatment guidelines and the clinical practice in the treatment of traumatized persons might differ to some extent. There is information available on research guidelines, but only scarce literature exists for actual clinical practice, let alone clinical practice with traumatized asylum seekers.

However, it has repeatedly been reported, that only a small number of asylum seekers ac-tually asks a physician or a psychotherapist for help (e.g., Schouler-Ocak, 2003). In an Afghan refugee sample in Pakistan with a PTSD prevalence of 80% only 13.7% had contacted health services due to their psychiatric illness (Naeem et al., 2005). A survey in Switzerland found low consultation rates of asylum seekers and refugees in the majority of the contacted medical practices (Blochliger et al., 1998). The diversity of the asylum seekers and refugees with re-spect to places of origin, education, and language proficiency appeared to be the major deter-minants of difficulties in providing adequate health care. However, the response rate of physi-cians in this survey was 31%. Surveys on resettled refugees in the UK and Australia found a high level of need but a low level of service use in comparison with the host-population (McCrone et al., 2005; Steel et al., 2005). Minas (2001) reports that immigrants receive more emergency aid but less outpatient psychotherapy as well as a lower quality of rehabilitation regimen than the general population.

Surveys on asylum seekers in Australia found that between 36.1% and 66.7% of the re-spondents had difficulties accessing medical services (Silove et al., 1997; Silove, Steel,

McGorry, & Drobny, 1999). Difficulties accessing medical and dental services consistently exceeded those reported by refugees and immigrants (Silove et al., 1999). One of the most im-portant reasons cited was not having a Medicare card; only up to 10% asylum seekers cited language difficulties or lack of information as impediments to accessing health care (Sinnerbrink, Silove, Manicavasagar, Steel, & Field, 1996). Even though language barriers were indicated as a minor problem, Eytan et al. (2002) report in the context of Kosovar asylum seekers that the use of trained interpreters improved the quality of communication, the detec-tion of severe symptoms and traumatic situadetec-tions, and facilitated the therapeutic orientadetec-tion in the context of traumatized asylum seekers.

Language difficulties have been considered as one reason, why only 5% to 15.6% of refu-gees and migrants, respectively, were fully compliant with all prescribed medications (Kroll et al., 1990; Lee, Buchwald, & Hooton, 1993; Schmeling-Kludas, Froschlin, & Boll-Klatt, 2003).

One study evaluated knowledge of 96 South East Asian refugees about prescribed medica-tions and compliance with taking those medicamedica-tions in a primary care clinic in Washington, USA (Lee et al., 1993). Medication was given due to physical as well as psychological condi-tions. Although 97% of the medications were either named or described correctly, the correct rationale for taking the medication was known to only 79% of the refugees and the correct dos-age regimen to only 63%. Thirty-two (33%) were not taking one or more of their prescribed medications, 17 (18%) were taking one or more medications not prescribed, 5 (5%) were tak-ing duplicate forms of the same medication that had been discontinued by the clinic provider.

Seventy-five percent of the patients were taking one or more medications at an incorrect dose.

These data indicate knowledge about and compliance with medications as a major problem among the examined refugees.

Brucks and Wahl (2003) report for people with migration background in Germany defi-ciencies in preventative measures, health education and health promotion, and overprovision of not indicated or overdosed medication. The authors further state that the access to health care might be too difficult, which fosters chronification. This is supported by Schmeling-Kludas et al. (2003), who report about 184 Turkish migrants in psychosomatic rehabilitation. The pa-tients took an average of 3 pharmaceuticals (SD = 2.3) at admission and 2 at discharge 2.3 (SD

= 1.8). General practitioners and psychiatrists conducted pretreatment in 98% and 77% of the cases, respectively. Despite the high number of outpatient treatment providers, the inpatient diagnostic procedure uncovered previously unknown somatic diseases in 16% of the patients.

Minas (2001) states that misdiagnosis and lack of other more appropriate service options lead

to an increased rate of health care utilization in migrants. However, comparable findings con-cerning diagnosis and treatment options in the general practice have been reported for the gen-eral population. Of patients with a mental disorder and a physical illness, more than 93% con-sulted a physician in the previous year and on several occasions (Ohayon & Lader, 2002).

MacKenzie (2005) states that because of a limited access to mental health services, general internists must treat psychiatric illnesses outside their area of expertise. The prevalence rate of psychogenic disorders in primary care in Germany is estimated between 30% and 40%, but only half of these are identified by the physician (Tress, Kruse, Heckrath, Schmitz, & Alberti, 1997). The majority of the patients with psychogenic problems in primary care named gastroin-testinal problems, mainly stomach pain, and only 3.5% declared mental health as reason for consultation. Of these patients, 43.7% received medication and only 8.4% a referral to psycho-therapy. Even in case the patient demonstrates psychological distress, only 31.0% receive a psycho-educative introduction and 9.5% a referral to psychotherapy. Prescription rates of chotropic drugs in the general population in primary care increase with the prominence of psy-chological complaints, severity of mental disorder, severity of social disability, female gender, age older than 40 years, lower education, unemployment, and marital separation (Linden, Le-crubier, Bellantuono, Benkert, Kisely, & Simon, 1999).

In conclusion, access to health care might not necessarily be the primary problem for asy-lum seekers but the patient-physician-interaction concerning diagnosis, treatment options, psy-cho-education, prescription patterns and compliance.

The following chapter provides descriptive information on the pharmaceutical and psycho-therapeutic supply, health care utilization and drug intake patterns in relation to mental health status as reported by asylum seekers at the Psychotrauma Research- and Outpatient Clinic for Refugees of the University of Konstanz. Since the Outpatient Clinic is a research institution, it is not part of the German health care system. Therefore evaluations as well as psychotherapeu-tic treatments are only offered as part of treatment studies. Accordingly, the asylum seekers have their individual structure of physicians and treatment providers outside the Outpatient Clinic, which is collected at evaluation.