Many refugees can’t flee mental ailments

Serious psychiatric disorders now plague many of the more than 100,000 people who in the past decade have fled government persecution in the Asian nation of Bhutan. Refugees who had been tortured have fared particularly poorly, according to a new study of this displaced population.

The only previous mental-health investigation among non-Western refugees, published in 1993, found high levels of anxiety, depression, and post-traumatic stress disorder (PTSD) among Cambodians who fled to Thailand.

The Bhutanese refugees, who fled to camps in neighboring Nepal, did no better overall. In the May Archives of General Psychiatry, Mark Van Ommeren of the Center for Victims of Torture in Kathmandu, Nepal, and his colleagues report a survey of 418 tortured and 392 nontortured Bhutanese refugees, ages 21 to 85. Trained interviewers probed for psychiatric symptoms, and physicians conducted medical exams.

Five of every six refugees who survived torture in Bhutan reported having mental ailments at some time, in most cases after becoming refugees. Most of them cited at least one disorder in the year before the 1997 survey.

Nearly half of the nontortured refugees had suffered from a mental disorder, usually after leaving Nepal.

The results indicate the need for increased attention to the mental health of refugees, Van Ommeren remarks. This is a massive problem, he adds. The United Nations tallied more than 12 million refugees worldwide last year.

The Cambodian and Bhutanese data indicate that stress responses vary from one region to another, Van Ommeren proposes. For instance, tortured Bhutanese refugees exhibited particularly high rates of several psychiatric disorders. Only one of these, PTSD, commonly affected the Cambodian refugees. It consists of symptoms that result from intense fear, helplessness, and physiological arousal after extreme traumas.

Tortured Bhutanese refugees also reported high rates of persistent physical pain with no apparent medical cause, as well as certain dissociative disorders. The latter conditions include amnesia about personal history and trances with wild bodily contortions.

Overall, Bhutanese refugees exhibited less depression and anxiety than do Cambodian refugees and Western survivors of rape and other traumas.

Although a larger proportion of men than women had been tortured, women reported higher rates of all the psychiatric disorders than men did.

The new study could help counter international health organizations longstanding resistance to confronting refugees mental-health problems, comments psychiatrist Joseph J. Westermeyer of the Veterans Affairs Medical Center in Minneapolis. These organizations have worried that a focus on psychological ills would stigmatize refugee groups and discourage host countries from letting them in, says Westermeyer, who treats refugees living in the Minneapolis area.

The tide now seems to be turning in favor of addressing mental-health issues among refugees, he notes.

Effective treatment hinges on whether refugees remain in crowded, dangerous camps or relocate to safe locales, Westermeyer contends. Symptoms of PTSD, depression, and dissociation often help people cope with the hazards of their lives as refugees. After leaving those hazards behind, however, these coping mechanisms become liabilities that often require treatment.