Importance: Asylum seekers experience a high burden of physical and psychological trauma, yet there is a scarcity of literature regarding the epidemiology and sequelae of head injury (HI) in asylum seekers.

Objective: To examine head injury prevalence and related neuropsychiatric comorbidities in asylum seekers.

Methods: A retrospective cross-sectional study through review of 139 medical affidavits from an affidavit database was performed. Affidavits written from 2010 – 2018 were included. Demographic and case-related data were collected and classified based on the presence of head injury. Primary study outcome measurement was prevalence of head injury and headache. Secondary outcomes included the neuropsychiatric sequelae of head injury including depression, PTSD, anxiety, memory/concentration deficits, and the prevalence of abusive and traumatic history. Hypothesis and outcome measures were determined before data extraction.

Results: One hundred and thirty-nine medical affidavits of asylum seekers were included in the study. The mean age was 27.4±12.1, 56.8% identified as female, 28.1% were <18 years. Almost half (42.5%) explicitly self-reported history of head injury. Compared to clients who did not report head injury, clients with head injury were older (31.4 vs 24.4, 7.0 year difference; 95%CI [2.9, 10.9 years]) and more likely to report a history of headache (62.7% vs 28.8%, 33.9% difference; 95%CI [20.0, 47.8%], p<.001), physical abuse (91.5% vs 65.0%, 26.5% difference; 95%CI [12.8, 38.5%];), physical trauma (96.6% vs 66.3%, 30.4% difference; 95%CI [17.9, 41.5%]), concussion (22.0% vs 0.0%, 22% difference; 95%CI [12.2, 34.1%]), and loss of consciousness (27.1% vs 0.0%, 27.1% difference; 95%CI [16.4, 39.6%]). Moreover, clients with head injuries were more likely to suffer neuropsychological sequelae such as memory/concentration deficits (45.8% vs 28.8%, 17.0% difference; 95%CI [0.8, 33.2%]), and depression (83.1% vs 65%, 18.1% difference; 95%CI [3.0, 33.2%]).

Human Rights Clinic

            The Human Rights Clinic of Miami (HRCM) provides pro bono clinical evaluations and medical affidavits for individuals seeking asylum in the United States. Medical affidavits are physician-generated, legal documents utilized in immigration court to provide objective clinical corroboration of a client’s narrative. Clients applying for asylum are connected to the HRCM through pro bono legal representatives and are interviewed for 2-3 hours by a physician and medical interpreter. To remain an objective entity, the organization does not provide medical care.

Data collection

In this study, consecutive medical affidavits written by physicians at the HRCM from January 1^st, 2010 to April 31^st, 2018 were independently reviewed by two investigators to extract relevant demographics and case information. Medical affidavits contained the results of PTSD (Primary Care PTSD Screen, DSM IV, and PCL-4), depression (HAMD, PHQ-9, and DSM IV criteria), and anxiety (GAD-7) screens.  Variables were marked as present only if they were explicitly reported in the affidavit and were experienced for a significant period.

Statistical analysis

Clients were classified into two groups based on the presence or absence of HI. Summary statistics and comparative analyses were performed using JMP-Pro version 14.0.0 (SAS Institute Inc., Cary, NC). Continuous variables were analyzed using a t test and categorical variables were analyzed using a Pearson’s chi-squared test. All tests were two-tailed, and a P value of <0.05 was considered statistically significant.

Standard Protocol Approvals, Registrations, and Patient Consents

            All clients provided informed consent and were de-identified for research purposes. The University of Miami Institutional Review Board approved this investigation.