Points of Wellness - Bibliography

Center for Mental Health

Center For Mental Health Services
An Annotated Bibliography on Refugee Mental Health

Introduction

The past decade has witnessed a number of ethnic and local conflicts worldwide with the result of alarming levels of forced migration in Africa, Asia and Europe in particular. As the international political context has been reshaping itself over the last two decades, the field of research on refugee mental health has also been able to open itself to new directions and perspectives. This edition of An Annotated Bibliography on Refugee Mental Health has for a primary objective to update the 1987 edition with significant research that has been conducted since that time.

This bibliography, like the previous one, contains primarily materials in the published scientific literature. When non-published material is cited, the website reference has also been included to facilitate access to the article. The authors have decided to exclude much of the non-published material, such as conference proceedings or pamphlets, as it is included later in the scientific literature. Additionally, the quality of most of the scientific literature is guaranteed by the peer review process.

Among the criteria used to determine which articles to include in this bibliography were: a) the originality of the study; b) a significant study sample; and c) the inclusion of a comprehensive bibliography that could serve as a valuable starting point for further references. As research on refugee mental health has opened its interests from Southeast Asian refugee groups, in recent years, to a broader range of ethnic groups, we have tried to include some of the most representative studies on refugee groups from Europe and Africa as well. Some difficulties, however, were encountered in trying to identify articles pertaining to clinical studies, particularly, treatment studies. It is widely recognized that this particular field of study within the broader area of refugee mental health still needs significant attention, as there are a very limited number of studies.

Three main sources of references were used. Computerized searches allowed us to obtain reference listings of the relevant literature on refugee mental health published between 1985 and 2002. Other bibliographies were also consulted. Finally, we made large use of suggestions from professionals involved in the field of refugee mental health both at local and international level. This latter method was particularly useful given the appropriateness and user friendliness of the materials suggested.

The sections included in the annotated bibliography are discussed further in the section User's Guide for the Bibliography.

**Note: The Authors Index will be revised for the final version of this document. The Index will indicate the section where each document written by the author listed is found (A â€“ F) and the number of the reference.

User's Guide for the Bibliography

The references in this bibliography are organized by content areas referring either to the nature of the study or to the object in analysis. When appropriate, chapters are divided into studies on adults, children, and/or adolescents. Studies were selected primarily on the basis of their original contribution to the field, the quality of scientific rigor, and the significance of the major findings of the studies. Although the previous edition of the Annotated Bibliography does not include studies prior to 1985, the authors have decided to include in this document a number of studies published before 1985 that were of special significance, have had a major impact in the field, and continue to be cited.

Despite our search for significant and important publications, some works have failed to be properly evaluated; therefore, they have not been included in this bibliography. The authors of this Annotated Bibliography would be pleased to receive from the readers major contributions that they deem necessary for inclusion in any subsequent revisions of this document.

The Table of Contents provides guidance to the reader in locating articles included in the bibliography. Each citation is followed by an abstract of the reference, including information on the aim of the study, the sample group, the instruments used, and the survey findings.

Sources for references included technical databases on clinical and epidemiological studies on refugee mental health, as listed below:

OVIDâ€”Medline: Medicine, Dentistry, and the Biomedical Sciences.
PubMed: Developed by the National Center for Biotechnology Information at the National Library of Medicine.
Pilots database: Index to literature on posttraumatic stress disorder and other mental-health consequences of exposure to traumatic events.

A. Epidemiological Studies on Refugee Mental Health

Adults

1. Allden K, Poole C, Chantanavich S, Ohmar K, Aung NN, Mollica RF (1996). Burmese Political Dissidents in Thailand: Trauma and Survival among Young Adults in Exile. American Journal of Public Health, 86(11), 1561-1569.

Refugee/Ethnic Group: Burmese

This study assessed the self-reported mental health, physical health, and social functioning conditions of 104 Burmese political exiles and related their psychiatric symptoms to their trauma and survival strategies. The interview schedule included sections on work, health, disability, survival strategies, and the Burmese versions of the Hopkins Symptom Checklist-25 and the Harvard Trauma Questionnaire. On the one hand, the survey indicated high levels of depressive symptoms (nearly 40-percent prevalence) in the sample studied, but a stronger association was not apparent between depressive symptoms and cumulative trauma. On the other hand, the criterion symptoms for posttraumatic stress disorder were quite strongly related to cumulative trauma.

2. Allodi F, Cowgill G (1982). Ethical and Psychiatric Aspects of Torture: A Canadian Study. Canadian Journal of Psychiatry, 27(2), 98-102.

Refugee/Ethnic Groups: Hispanic and Latin American

In the last two decades, widespread use of torture by totalitarian governments has been reported in over 60 countries. This situation concerns physicians who are sometimes called upon to see the victims. This paper reported the psychiatric findings in a group of 41 Latin American refugees who arrived in Canada from 1977 to 1979 and were alleged to have been subjected to political persecution and torture under the military rulers of their own countries. Most of them, young educated men, were apprehended violently and imprisoned under conditions below the minimum international standards. Systematic physical and psychological torture was the rule, including blindfolding, beatings, electrical shocks, sexual abuse, and threats of execution or sham executions. These experiences were followed by a cluster of psychiatric symptoms and physical evidence of trauma compatible with the history given. This pattern constitutes the torture syndrome included under categories 308 and 309 of the Diagnostic and Statistical Manual of Mental Disorders, Third Edition, and the International Statistical Classification of Diseases, and Related Health Problems, Ninth Revision. The paper also discussed the professional conduct of 19 doctors who saw 21 of these patients. It included a list of codes of medical ethics, intended to guide doctors confronted with this difficult problem.

3. Basoglu M, Paker M, Ozmen E, Tasdemir O, Sahin D (1994). Factors Related to Long-Term Traumatic Stress Responses in Survivors of Torture in Turkey. The Journal of the American Medical Association, 272(5), 357-363.

Refugee/Ethnic Group: Turkish

The aim of the study was to examine the factors related to long-term psychological functioning in political ex-detainees who had been subjected to systematic torture. The psychological status of 55 tortured political activists, 55 non-tortured political activists, and 55 subjects with no history of torture or political activism was assessed using the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Third Edition, for psychiatric assessment; the Semi-structured Interview for Survivors of Torture; and other self-rated measures of anxiety, depression, and posttraumatic stress disorder. Perceived severity of torture, secondary effects of captivity experience on various life areas, and general psychosocial stressors following captivity were identified as stressors related to different aspects of psychopathology in survivors of torture.

4. Beiser M (1997). Refugees' Time Perspective and Mental Health. American Journal of Psychiatry, 154(7), 996-1002.

Refugee/Ethnic Group: Southeast Asian

The author's goal was to investigate factors that protected the mental health of refugees, with a particular focus on time splitting and suppression of the past. Structured interviews covering premigration and postmigration stress, personal and social resources, and mental health were given to 1,348 Southeast Asian refugees resettled in Vancouver and to a comparison sample of 319 residents of Vancouver. Both groups also performed a task aimed at evaluating subjects' attitudes toward the past, present, and future. Compared with resident Canadians, refugees were more likely to exhibit an atomistic time perspective in which the past, present, and future are split. Temporal atomism and avoidance of nostalgia were associated with a lower risk of depression than other time perspectives were.

5. Candill W, De Vos G (1956). Achievement, Culture, and Personality: The Case of the Japanese-Americans. American Anthropologist, 58, 1102-1126.

Refugee/Ethnic Groups: Japanese and White

Between 1947 and 1950, an interdisciplinary team of anthropologists, sociologists, and psychologists from the University of Chicago extensively explored the achievement orientation of Japanese-Americans relocated in the Chicago area. Data were composed of (a) interview schedules obtained from a random sample of 342 Japanese-American families representing 1,022 persons; (b) employers' evaluation of Japanese-Americans in 79 firms; (c) summaries of all Japanese-American cases handled by Chicago social workers between 1942 and 1948; (d) an investigation of the child-rearing practices of 50 Nisei mothers; (e) the collection and study of 150 Rorschach and 100 TAT records; and (f) 53 psychiatric interviews with Issei and Nisei. Comprehensive demographic statistics including Japanese-American educational and occupational levels during the post-war period were presented in the analysis of remarkable socioeconomic accomplishment despite discrimination and alien values presumed to be maladaptive. Significant compatibility between the Japanese and American white middle-class value system was hypothesized, although the psychological motivation behind ostensibly similar behaviors was acknowledged to be possibly different. Cultural differences along other dimensions were discussed. The authors concluded that prediction of achievement for an ethnic group must focus on individual psychodynamic and genetic factors, overt and implicit cultural patterns, and interpersonal relations in both domestic and work settings.

6. Carlson EB, Rosser-Hogan R (1991). Trauma Experiences, Posttraumatic Stress, Dissociation, and Depression in Cambodian Refugees. The American Journal of Psychiatry, 148(11), 1548-1551.

Refugee/Ethnic Group: Cambodian

The authors analyzed the amount of trauma experienced by Cambodian refugees and subsequent symptoms of depression. Fifty randomly selected Cambodian adults were administered the Posttraumatic Inventory, and a Posttraumatic Stress Disorder (PTSD) Checklist based on Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised (DSM-III-R), diagnostic criteria was created ad hoc. Dissociation was measured through the Dissociative Experiences Scale, while depression and anxiety were assessed through the Hopkins Symptom Checklist-25. All subjects showed high levels of all symptoms measured. Forty-three (86 percent) met the DSM-III-R criteria for PTSD; 48 (96 percent) had high dissociation scores; and 40 (80 percent) were diagnosed with clinical depression. Moderate-to-large correlation between trauma scores and psychiatric symptoms was found.

7. Caspi Y, Poole C, Mollica R, Frankel M (1998). Relationship of Child Loss to Psychiatric and Functional Impairment in Resettled Cambodian Refugees. The Journal of Nervous and Mental Disease, 186(8), 484-491.

Refugee/Ethnic Group: Cambodian

One hundred sixty-eight Cambodian refugees resettled in Massachusetts were interviewed to assess the relationship of child loss to physical and emotional health and functioning. The Harvard Trauma Questionnaire was used to draw information on trauma events and related symptoms, while health problems were evaluated by self-perceived health status with items adapted from the Medical Outcomes Study Short Form General Health Survey. Loss of child and loss of spouse were determined in the demographic section of the interview. The findings of the study led to the conclusion that in Cambodian refugees child loss is not associated with conventional psychiatric symptoms as determined by Western diagnostic criteria for the presence of depression and PTSD. Child loss is more associated with culture-dependent symptoms and with a persistent perception of limited physical and social functioning.

8. de Jong JP, Scholte WF, Koeter MWJ, Hart AAM (2000). The Prevalence of Mental Health Problems in Rwandan and Burundese Refugee Camps. Acta Psychiatrica Scandinavica, 102(3), 171-177.

Refugee/Ethnic Groups: Rwandan and Burundese

The authors examined the prevalence of mental health disorders in Rwandan and Burundese refugees living under very poor and insecure conditions in four different camps in Tanzania. The population studied included a random sample of 854 refugees spread equally over the four camps and 23 clients of the M eacute;decins Sans Fronti egrave;res psychosocial program. It was decided that the General Health Questionnaire (GHQ) was the most appropriate screening instrument because of the political tension inside the camps. The prevalence of serious mental health problems was estimated at 50 percent (standard error was 12 percent), corresponding to a GHQ-28 score of at least 14.

9. de Jong JTVM, Komproe IH, Van Ommeren M, El Masri M, Araya M, Khaled N, van de Put W, Somasundaram D (2001). Lifetime Events and Posttraumatic Stress Disorder in 4 Postconflict Settings. The Journal of the American Medical Association, 286(5), 555-562.

Refugee/Ethnic Groups: Algerian, Cambodian, Ethiopian, and Palestinian

The study was an epidemiological survey conducted between 1997 and 1999 among survivors of war or mass violence, aged 16 years or older, to establish the prevalence rates of and risk factors for posttraumatic stress disorder (PTSD) in four post-conflict, low-income settings. Participants were randomly selected from community populations in Algeria (settled community), Cambodia (settled community), Ethiopia (refugee camps), and Gaza (temporary shelters). Prevalence rates of PTSD were assessed using the PTSD module of the Composite International Diagnostic Interview, Version 2.1, and were evaluated in relation to traumatic events assessed using an adapted version of the Life Events and Social History Questionnaire. The prevalence rate for assessed PTSD was 37.4 percent in Algeria, 28.4 percent in Cambodia, 15.8 percent in Ethiopia, and 17.8 percent in Gaza. Divergence of risk factors for PTSD was found, because conflict-related trauma after age 12 years was the only risk factor present in all four samples. Specific patterns of risk factors for each country above were reported.

10. Eitinger L (1960). The Symptomology of Mental Disease Among Refugees in Norway. Journal of Mental Sciences, 106, 947-966.

Refugee/Ethnic Group: European

The purpose of this study was to compare the symptoms presented by post-World War II psychotic European refugees in Norway with those presented by a matched control group of Norwegian patients. The sample consisted of 95 refugee patients who were treated in Psychiatric departments in Norway during the 10-year period from January 1, 1946, to December 31, 1955. The study found the following symptoms to be especially important: delusions of persecution, disturbances of consciousness, conversion symptoms, and ideas of jealousy.

11. Fox S, Tang S (2000). The Sierra Leonean Refugee Experience: Traumatic Events and Psychiatric Sequelae. The Journal of Nervous and Mental Disease, 188(8), 490-495.

Refugee/Ethnic Group: Sierra Leonean

The purpose of this study was to determine the prevalence of various traumatic events to which a sample of 55 Sierra Leonean refugees residing in a United Nations High Commissioner for Refugees-sponsored camp in Gambia, West Africa, has been exposed. Its purpose was also to determine psychological sequelae associated with the exposure. The Harvard Trauma Questionnaire (HTQ) and the Hopkins Symptom Checklist-25 (HSCL-25) served as survey instruments. Findings showed that almost half of the participants scored above the critical cut-off for posttraumatic stress disorder on the HTQ. They also showed that at least four-fifths scored above the critical cut-off point for both depression and anxiety on the HSCL-25.

12. Hauff E, Vaglum P (1995). Organised Violence and the Stress of Exile. Predictors of Mental Health in a Community Cohort of Vietnamese Refugees Three Years After Resettlement. The British Journal of Psychiatry, 166, 360-367.

Refugee/Ethnic Group: Vietnamese

This community cohort study analyzed the mental health course and outcome of 145 Vietnamese refugees, aged 15 years and older, during their first 3 years in Norway. The examination included the use of the Vietnamese version of the Symptom Checklist-90-Revised both upon the refugees' arrival and 3 years later (T2). It also included the use of the Present State Examination at T2 to assess psychiatric disorders and posttraumatic stress disorder. Questions included in the assessment ranged from the traumatic experiences before resettlement and life events after resettlement to social support and family separation. Almost one in four of the subjects had a psychiatric disorder 3 years after resettlement in Norway, because the level of emotional distress did not decrease during the first years after their arrival.

13. Hermansson A, Timpka T, Thyberg M (2002). The Mental Health of War-Wounded Refugees: An 8-Year Follow-Up. The Journal of Nervous and Mental Disease, 190(6), 374-380.

Refugee/Ethnic Groups: Iranian, Iraqi, Lebanese, Somali, Colombian, Salvadoran, Ethiopian, Angolan, and Bangladeshi

The authors analyzed the mental health status of war-wounded refugees after they were in exile for 8 years to explore the variables associated with their psychosocial scores. The present study was a follow-up conducted on 44 refugees living in Sweden and coming from nine different countries. The instruments used to assess the long-term mental health status of the study group were the Hopkins Symptom Checklist-25, the Posttraumatic Symptom Scale-10, and a self-rating scale on psychological well-being. Findings showed that the prevalence of posttraumatic stress disorder (PTSD) in the studied group was 50 percent and that subjects with a PTSD diagnosis were more likely to meet the criteria for anxiety and depression as well. No relationship between the degree of physical disability and mental health was found. However, a higher level of education was associated with a lower mental health status.

14. Hinton WL, Tiet Q, Tran CG, Chesney M (1997). Predictors of Depression Among Refugees From Vietnam: A Longitudinal Study of New Arrivals. The Journal of Nervous and Mental Disease, 185(1), 39-45.

Refugee/Ethnic Groups: Vietnamese and Chinese

This longitudinal study examined the impact of prearrival traumatic experiences and sociodemographic characteristics on future depression among 114 newly arrived Vietnamese and Chinese refugees. A structured interview and the Indochinese Hopkins Symptom Checklist to assess depression were administered to all subjects 6 months after arrival in the United States and 12 to 18 months later. Predictors of depression were identified in prearrival trauma (veteran status), baseline depression, and lower English-language proficiency. Age counted as a predictor only for the ethnic Vietnamese subpopulation.

15. Holman EA, Silver RC, Waitzkin H (2000). Traumatic Life Events in Primary Care Patients: A Study in an Ethnically Diverse Sample. Archives of Family Medicine, 9(9), 802-810.

Refugee/Ethnic Groups: Latino, Mexican, and Central American

The aim of this study was to determine the rates and types of traumatic events experienced, including interethnic differences, and the degree to which trauma is associated with psychiatric disorders, physical functioning, and the use of primary care services. A sample group of 1,456 patients agreed to participate and to complete the Composite International Diagnostic Interview and a modified version of the National Institute of Mental Health Diagnostic Interview Schedule section assessing traumatic experiences and posttraumatic stress disorder. Physical functioning was measured using the 10-item subscale of the Short Form Health Survey. Results showed that nearly 10 percent of participants had experienced traumatic events in the previous year and 57 percent during the course of their lives. The most common forms of traumatic experiences were interpersonal violence outside the family environment (21 percent of the entire sample), acute trauma (17 percent of the entire sample), and witnessing of death or violence (13 percent of the entire sample). Ethnicity was found to be the strongest predictor of lifetime trauma because Mexicans were less likely to report having experienced traumatic events than Central Americans. Traumatic experiences, female gender, and non-Latino ethnicity were associated with the presence of a psychiatric disorder. Lifetime psychiatric disorders were associated with poorer physical functioning and more frequent use of primary care services.

16. Holtz T (1998). Refugee Trauma Versus Torture Trauma: A Retrospective Controlled Cohort Study of Tibetan Refugees. The Journal of Nervous and Mental Disease, 186(1), 24-34.

Refugee/Ethnic Group: Tibetan

A retrospective study of 35 tortured Tibetan refugees and 35 non-tortured controls was conducted in India to test whether torture has long-term psychological effects independent of the psychosocial stressors inherent to the refugee experience; whether trauma experiences during escape, flight, and life in exile can cause elevated anxiety and depressive symptom scores; and whether survivors find resilience in religious and cultural resources. Subjects were administered the Hopkins Symptom Checklist-25, evaluating anxiety symptoms, affective disturbances, somatic complaints, and social impairment. The study did not include an assessment of posttraumatic stress disorder. The torture survivors had a statistically significant higher proportion of elevated anxiety scores compared to the non-tortured controls (54.3 percent versus 28.6 percent). The findings of the study suggested that the long-term effects of torture include elevated levels of anxiety independent of stressors related to escaping and living in a socially, culturally, and economically different environment; that psychological effects of the refugee experience and torture are mediated by political commitment, preparedness for arrest and torture, and social supports in exile; and that psycho-spiritual factors inherent to Tibetan Buddhism may explain an observed resilience among the torture survivors.

17. Lie B, Lavik NJ (2001). Traumatic Events and Psychological Symptoms in a Non-Clinical Refugee Population in Norway. Journal of Refugee Studies, 14(3), 276-294.

Refugee/Ethnic Groups: Bosnian and Kosovar-Albanian

The authors conducted a study to analyze the relationship between psychosocial distress and traumatic exposure in a non-clinical group of 462 newly settled refugees in Norway. A structured questionnaire translated into Albanian, Arabic, Bosnia/Serbo-Croatian, Somali, and Vietnamese was used as an interview guide. The Harvard Trauma Questionnaire with the Posttraumatic Symptom Scale-16, the Hopkins Symptom Checklist-25, and the Global Assessment Functioning Scale were also included. Results confirmed the high level of psychological distress of this refugee population, and women were found to have a higher degree of anxiety and depression than men. Findings related to ethnic background showed a significant difference between the Kosovar-Albanian group and the Bosnian group, the former expressing a higher degree of depression and anxiety.

18. Kinzie JD, Boehnlein JK, Riley C, Sparr L (2002). The Effects of September 11 on Traumatized Refugees: Reactivation of Posttraumatic Stress Disorder. The Journal of Nervous and Mental Disease, 190(7), 437-441.

Refugee/Ethnic Groups: Vietnamese, Cambodian, Lao, Bosnian, and Somali

The authors' objective was to study the effects of secondary traumatization on a group previously severely traumatized, many of whom suffered from a diagnosis of posttraumatic stress disorder (PTSD). A clinically oriented questionnaire was developed and administered to a clinic population in the Intercultural Psychiatric Program at Oregon Health & Science University. The questionnaire assessed traumatic symptoms and responses to the widely televised images from September 11 and differential responses among patients with PTSD, depression, and schizophrenia. The study found strongest responses among Bosnian and Somali patients with PTSD, and the Somalis had the greatest deterioration in their subjective sense of safety and security. Regardless of ethnic group, patients with PTSD reacted most intensely, but patients with schizophrenia the least. Although patients largely returned to their baseline clinical status after 2 to 3 months, this study showed that cross-cultural reactivation of trauma has a significant clinical impact. Clinicians must anticipate PTSD symptom reactivation among refugees when they are exposed to significant traumatic stimuli.

19. Lopes Cardozo B, Vergara A, Agani F, Gotway CA (2000). Mental Health, Social Functioning, and Attitudes of Kosovar Albanians Following the War in Kosovo. The Journal of the American Medical Association, 284(5), 569-577.

Refugee/Ethnic Group: Kosovar-Albanian

The aim of the study was to estimate the prevalence of psychiatric morbidity and to identify specific vulnerable populations among ethnic Albanians in Kosovo after the war. The authors conducted a cross-sectional cluster sample survey from August to October 1999. This survey was part of an agreement reached between the North Atlantic Treaty Organization and Serbia in June 1999, among 1,358 Kosovar-Albanians, aged 15 years or older, in 558 randomly selected households across Kosovo. Three screening tools used to assess mental health problems and social dysfunction were the General Health Questionnaire-28 for non-specific psychiatric morbidity, the Harvard Trauma Questionnaire for posttraumatic stress disorder (PTSD) symptoms, and the Medical Outcomes Study Short-Form 20 for social functioning. The authors also addressed additional questions specific to the Kosovar-Albanian population on feelings of hatred and revenge. Results demonstrated the severity of mental health problems among Kosovar-Albanians with a prevalence of non-specific psychiatric morbidity of 43 percent and an estimated prevalence of PTSD symptoms of 17.1 percent. Respondents also reported a high prevalence of traumatic events. Populations at increased risk for psychiatric morbidity were those aged 65 years or older, those with previous psychiatric illnesses or serious chronic health conditions, and those who had been internally displaced. Populations at risk for poorer social functioning were living in rural areas, were unemployed, or had a chronic illness. The vast majority of the respondents (89 percent of males and 90 percent of females) reported strong feelings of hatred against the Serbs, and 51 percent of men and 43 percent of women reported strong feelings of revenge.

20. Masuda M, Lin KM, Tazuma L (1980). Adaptation Problems of Vietnamese Refugees: II. Life Changes and Perception of Life Events. Archives of General Psychiatry, 37(4), 447-450.

Refugee/Ethnic Group: Vietnamese

Vietnamese refugees have encountered a multitude of acute psychological, social, cultural, economic, and political upheavals. This study documented Vietnamese refugees' perceptions of the life events that have occurred in the context of these upheavals. Questionnaires were administered in 1975 and 1976 as part of an ongoing study. The expected life change in the year of evacuation and substantial resettlement (1975) continued into the following year (1976). Financial, life-style, work, marital, and school problems continued to plague the refugees and increased in the second year. There was a positive correlation between life change and health status. The Vietnamese rank ordered the impact of life events in a manner similar to the Americans, but there were differences in magnitude estimations. Substantial reductions in magnitude estimations at the second administration of the Social Readjustment Rating Questionnaire indicated a change in the situational perception set with time.

21. McKelvey R, Webb J (1996). Premigratory Expectations and Postmigratory Mental Health Symptoms in Vietnamese Amerasians. Journal of the American Academy of Child & Adolescent Psychiatry, 35(2), 240-245.

Refugee/Ethnic Group: Vietnamese Amerasian

The aim of this report was to determine the relationship between premigratory expectations and postmigratory symptoms of anxiety and depression in a group of Vietnamese Amerasians. The original cohort of 161 respondents, aged 15 to 28 (mean age 20.4 years), was assessed before their departure from Vietnam to the United States using the Hopkins Symptom Checklist-25 (HSCL-25), the Vietnamese Depression Scale, and the Expectations Questionnaire. After migration, 25 respondents from the original cohort could be located and reassessed using the HSCL-25 and the Vietnamese Depression Scale. The results of the study showed that 20 percent of the U.S. sample scored in the clinical range for depression on the HSCL-25, while in Vietnam it was only 1.86 percent. Low support from the local Vietnamese community and high discrepancy between premigratory expectations and postmigratory reality were associated with higher scores on the HSCL-25.

22. Mollica RF (2000). Waging a New Kind of War. Invisible Wounds. Scientific American, 282(6), 54-57.

Refugee/Ethnic Groups: Bosnian, Cambodian, and Vietnamese

The present article was a review of the research work conducted by the Harvard Program in Refugee Trauma over the last 20 years. Epidemiological data were presented to support the six basic discoveries made during the course of this research activity: the sheer prevalence of major psychiatric disorders among civilian survivors of war, the measurability of war trauma, non-Western conceptions of mental health disorders, the accountability of particular trauma experiences to lead to posttraumatic stress disorder, the permanent organic change in the brain, and the connection between mental distress and social dysfunction.

23. Mollica RF, Donelan K, Tor S, Lavelle J, Elias C, Frankel M, Blendon RJ (1993). The Effect of Trauma and Confinement on Functional Health and Mental Health Status of Cambodians Living in Thailand-Cambodia Border Camps. The Journal of the American Medical Association, 270(5), 581-586.

Refugee/Ethnic Group: Cambodian

The study was designed to measure the extent of trauma and the health, mental health, and socioeconomic status of Cambodians living on the Thailand-Cambodia border. A total of 993 adults, aged 18 years and older, were interviewed on their trauma history and their mental health status through the Indochinese version of the Hopkins Symptom Checklist-25 and the Harvard Trauma Questionnaire. Health status, disability, and social functioning were partly drawn from the short form of the Medical Outcomes Study general health survey. More than 80 percent reported poor health, depression, and somatic complaints despite good access to health services, while 67.9 percent and 37.2 percent had symptom scores that correlate with Western criteria for depression and posttraumatic stress disorder, respectively. Despite reported high levels of trauma and symptoms, social and work functioning were well preserved in the majority of respondents.

24. Mollica RF, Henderson DC, Tor S (2002). The Psychiatric Effects of Traumatic Brain Injury Events in Cambodian Survivors of Mass Violence. The British Journal of Psychiatry, to be published.

Refugee/Ethnic Group: Cambodian

The aim of the study was to examine the association between traumatic brain injury events and the psychiatric symptoms of major depression and posttraumatic stress disorder (PTSD) in Cambodian survivors of mass violence. A multistage random sample of Cambodian refugees living in the Thai refugee camp known as Site 2 was interviewed. The main results analyzed the relationship between six categories of trauma events and psychiatric symptoms during two time periods. The symptoms of depression and PTSD were derived from the symptom scores of the Hopkins Symptom Checklist-25 and the Harvard Trauma Questionnaire, respectively. Findings showed that traumatic brain injury was most common in the highly educated and in individuals with the highest levels of cumulative trauma. Of all categories of trauma, traumatic brain injury revealed the strongest association with symptoms of depression and a weaker association with PTSD.

25. Mollica RF, McInnes K, Pham T, Smith Fawzi MC, Murphy E, Lin L (1998). The Dose-Effect Relationships Between Torture and Psychiatric Symptoms in Vietnamese Ex-Political Detainees and a Comparison Group. The Journal of Nervous and Mental Disease, 186(9), 543-553.

Refugee/Ethnic Group: Vietnamese

The purpose of this study was to establish the level of psychiatric morbidity in a population of Vietnamese torture survivors being resettled in the United States. The purpose was also to examine the dose-effect relationships between cumulative torture and the psychiatric symptoms of posttraumatic stress disorder (PTSD) and major depression in the population studied and in a comparison group. All 62 Vietnamese political ex-detainees and 43 Vietnamese men of the comparison group were administered the Vietnamese version of the Life Event and Social History Questionnaire to assess social and demographic information. The psychiatric symptoms of major depression and PTSD were evaluated using the Vietnamese versions of the Hopkins Symptom Checklist-25 and the Harvard Trauma Questionnaire. A Vietnamese version of the Structured Clinical Interview for the DSM-III-R was administered to the ex-political detainee group to determine a current psychiatric diagnosis for PTSD and major depressive disorders. Symptom differences were related to the following variables that defined the ex-political detainee group: time in reeducation camp, time in the United States, and cumulative torture. Regression analyses through the entire sample showed that significant dose-effect relationships exist between cumulative torture and the psychiatric symptoms of PTSD and depression.

26. Mollica RF, McInnes K, Tor S (1998). Dose-Effect Relationships of Trauma to Symptoms of Depression and Posttraumatic Stress Disorder Among Cambodian Survivors of Mass Violence. The British Journal of Psychiatry, 173, 482-489.

Refugee/Ethnic Group: Cambodian

The dose-effect relationships of cumulative trauma to the psychiatric symptoms of major depression and posttraumatic stress disorder (PTSD) in a community study of Cambodian survivors of mass violence were evaluated. In 1990, a survey of 1,000 households was conducted in a Thai refugee camp (Site 2) using a multistage random sampling design. Trauma history and psychiatric symptoms were assessed for two periods. This analysis used linear dose-response regression modeling. A total of 993 Cambodian adults reported a mean of 14 Pol Pot-era trauma events (1975 to 1979) and 1.3 trauma events during the past year (1989). Symptom categories of depression, PTSD, dissociation, and culturally dependent symptoms exhibited strong dose-effect responses except avoidance. All symptom categories, except avoidant symptoms, were highly correlated.

27. Mollica RF, McInnes K, Sarajlic N, Lavelle J, Sarajlic I, Massagli MP (1999). Disability Associated With Psychiatric Comorbidity and Health Status in Bosnian Refugees Living in Croatia. The Journal of the American Medical Association, 282(5), 433-439.

Refugee/Ethnic Group: Bosnian

The relationship between psychiatric symptoms and disability in refugee survivors of mass violence is not known. The aim of the study was to determine whether such risk factors as demographics, trauma, health status, and psychiatric illness are associated with disability in Bosnian refugees. A cross-sectional survey was conducted in 1996 on Bosnian refugee adults living in a camp established by the Croatian government near the city of Varazdin. One adult, aged 18 years or older, was randomly selected from each of 573 camp families; 534 (93 percent) agreed to participate (mean age 50 years; 41-percent male). Culturally validated measures for depression and posttraumatic stress disorder (PTSD), including the Hopkins Symptom Checklist-25 and the Harvard Trauma Questionnaire, were used. Disability measures included the Medical Outcomes Study Short-Form 20; a physical functioning scale based on World Health Organization criteria; and self-reports of socioeconomic activity, levels of physical energy, and perceived health status. Respondents reported a mean (standard deviation) of 6.5 (4.7) unduplicated trauma events; 18 percent (n=95) had experienced one or more torture events. While 55.2 percent reported no psychiatric symptoms, 39.2 percent and 26.3 percent reported symptoms that meet Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria for depression and PTSD, respectively; and 20.6 percent reported symptoms comorbid for both disorders. A total of 25.5 percent reported having a disability. Refugees who reported symptoms comorbid for both depression and PTSD were associated with an increased risk for disability compared with asymptomatic refugees (unadjusted odds ratio [OR], 5.02; 95-percent confidence interval [CI], 3.05 to 8.26; adjusted OR, 2.06; 95-percent CI, 1.10 to 3.86). Older age, cumulative trauma, and chronic medical illness were also associated with disability.

28. Mollica RF, Sarajlic N, Chernoff M, Lavelle J, Sarajlic Vukovic I, Massagli MP (2001). Longitudinal Study of Psychiatric Symptoms, Disability, Mortality, and Emigration Among Bosnian Refugees. The Journal of the American Medical Association, 286(5), 546-554.

Refugee/Ethnic Group: Bosnian

The aim of the study was to investigate whether previously observed associations among depression, posttraumatic stress disorder (PTSD), and disability in a Bosnian refugee cohort continue over time and are associated with mortality and emigration to another region. This report was a 3-year follow-up study conducted in 1999 on 534 adult Bosnian refugees originally living in a refugee camp in Croatia. Of the original respondents, those still living in the region and the families of the deceased were reinterviewed (77.7 percent of the original participants). Respondents' mental health status was assessed using the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), while depression and PTSD diagnoses were measured by the Hopkins Symptom Checklist-25 and the Harvard Trauma Questionnaire, respectively. Disability was measured using the Medical Outcomes Study Short-Form 20, while family interviews determined causes of death, confirmed with death certificates if available. In 1999, 45 percent of the original respondents who met the DSM-IV criteria for depression or PTSD, or both, continued to have these disorders, and 16 percent of those who were asymptomatic in 1996 developed one or both disorders. Log-linear analysis demonstrated that disability and psychiatric disorders were related at both times, because 46 percent of respondents who initially met disability criteria remained disabled.

29. Porter M, Haslam N (2001). Forced Displacement in Yugoslavia: A Meta-Analysis of Psychological Consequences and Their Moderators. Journal of Traumatic Stress, 14(4), 817-834.

Refugee/Ethnic Group: Yugoslav

The authors conducted a meta-analysis to synthesize what is known about the mental health consequences of displacement in the former Yugoslavia. They analyzed the differences between refugees and non-refugees. They also focused on the role that chronic stressors might play in moderating the size of these consequences. Results indicated that refugees suffer significantly more mental health impairment than non-refugees. The psychological consequences of forced displacement were found to vary significantly as a function of chronic stressors (e.g., locus of displacement and type of accommodation in exile) and were also associated with other factors (e.g., degree of war exposure in the non-displaced groups, participant age, and time of data collection as reflected in the year of publication).

30. Rumbaut RG (1985). Mental Health and the Refugee Experience: A Comparative Study of Southeast Asian Refugees. In T.C. Owan (Ed.), Southeast Asian Mental Health: Treatment, Prevention, Services, Training, and Research (pp. 433-486). Washington, DC: National Institute of Mental Health.

Refugee/Ethnic Group: Southeast Asian

The author reported findings from a 3-year longitudinal study conducted at the Indochinese Health and Adaptation Research Project of the University of California, San Diego, on the psychological adaptation of the five major Indochinese ethnic groups. They presented social and demographic characteristics of the sample group. Differences in levels of distress between the refugee population as a whole and the general population were documented, as well as significant differences between the five refugee groups. Some of the differences found between the five groups were unhappiness, depression, and life satisfaction. One instrument used to measure affective and cognitive psychological adaptation was the Psychological Well-Being Scale. An open-ended qualitative interview was also conducted with a subsample of respondents. A second measure was a comparative Satisfaction with Life Areas Scale, which focused on nine areas of everyday life: work, money, home life, children, neighborhood, social contacts, health, religion, and leisure. The two areas of highest dissatisfaction were those of work and money. Characteristics of refugees most at risk for mental health problems included lack of education, low English-language proficiency, welfare dependence, low income and unemployment, advanced age and widowhood, physical health problems, and traumatic migration history. The second year of residence in the United States appeared to be of significant importance in the onset of psychological problems.

31. Salama P, Spiegel P, Van Dyke M, Phelps L, Wilkinson C (2000). Mental Health and Nutritional Status Among the Adult Serbian Minority in Kosovo. The Journal of the American Medical Association, 284(5), 578-584.

Refugee/Ethnic Group: Kosovar-Serbian

The study aimed to determine the prevalence of undernutrition among Kosovar-Serbians, aged 60 years or older, and psychiatric morbidity among the adult Serbian population in Kosovo after the war in 1998 to 1999. A systematic random sample survey of 212 households was conducted between September 27 and October 2, 1999, in Pristina, the capital city, and in 10 towns in the rural municipality of Gnjilane in Kosovo. The General Health Questionnaire-28 (GHQ-28) was administered to determine non-specific psychiatric morbidity to any household member aged 15 years or older, and anthropometric measurements were obtained on each older adult in the household. Undernutrition was found in 11.2 percent of Serbian adults, aged 60 years or older. In a comparison with the GHQ-28 scores for Kosovar-Albanians in another survey, Kosovar-Serbians scored higher in the following GHQ-28 categories: total mean GHQ-28 score, social dysfunction, and severe depression.

32. Shrestha NM, Sharma B, Van Ommeren M, Regmi S, Makaju R, Komproe I, Shreshta GB, de Jong JTVM (1998). Impact of Torture on Refugees Displaced Within the Developing World: Symptomatology Among Bhutanese Refugees in Nepal. The Journal of the American Medical Association, 280(5), 443-448.

Refugee/Ethnic Group: Bhutanese

This case-control study was aimed at assessing the impact of torture on refugees displaced within the developing world. The study sample consisted of 526 tortured Bhutanese refugees and a control group of 526 non-tortured Bhutanese refugees matched for sex and age to account for sex-related and age-related responses to torture. Interviews were conducted by local physicians and included demographics, questions related to the torture experienced, a checklist of 40 medical complaints, and questions covering PTSD criteria from the Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised (DSM-III-R), and the Hopkins Symptom Checklist-25 translated into Nepali. The two groups were similar on most demographic variables. The tortured refugees suffered significantly more of each of the DSM-III-R posttraumatic stress disorder (PTSD) symptoms. A diagnosis of PTSD was significantly more common in the tortured group than in the non-tortured group, for which the only significant predictor was the total number of torture techniques experienced. The total number of torture techniques experienced was also a risk factor for depression. Female sex was a risk factor for anxiety, while the Buddhist religion was a protective factor for both depression and anxiety.

33. SÃ¶ndergaard HP, Ekblad S, Theorell T (2001). Self-Reported Life Event Patterns and Their Relation to Health Among Recently Resettled Iraqi and Kurdish Refugees in Sweden. The Journal of Nervous and Mental Disease, 189(12), 838-845.

Refugee/Ethnic Groups: Iraqi and Kurdish

This paper was a longitudinal study investigating the perception of life events and conditions of 86 recently resettled Iraqi and Kurdish refugees in Stockholm County and their relationship to health. A questionnaire in Arabic and Sorani measuring life events and ongoing difficulties was constructed for the study, while a number of self-rating instruments, for example, the General Health Questionnaire-28, the Harvard Trauma Questionnaire, and the Impact of Event Scale, were included. The main finding of the study was that the political situation in the home country or the situation in the country of resettlement, or both, affect recently resettled refugees.

34. Tang S, Fox S (2001). Traumatic Experiences and the Mental Health of Senegalese Refugees. The Journal of Nervous and Mental Disease, 189(8), 507-512.

Refugee/Ethnic Group: Senegalese

The purpose of the study was to conduct a preliminary investigation into the experiences and the mental health of 80 randomly selected Senegalese refugees living in two refugee camps in Gambia. A participant data form was used to gather information on the participants' sociodemographic background. The Harvard Trauma Questionnaire and the Hopkins Symptom Checklist-25 were used to determine the types of trauma suffered and to assess the refugees' mental health status. Participants reported suffering a large number of various trauma and high prevalence rates of anxiety (mean score of 1.75), depression (mean score of 1.92) and posttraumatic stress disorder (mean score of 1.96).

35. Van Ommeren M, de Jong JTVM, Sharma B, Komproe I, Thapa S, CardeÃ±a E (2001). Psychiatric Disorders Among Tortured Bhutanese Refugees in Nepal. Archives of General Psychiatry, 58(5), 475-482.

Refugee/Ethnic Group: Bhutanese

This study addressed three questions: whether a history of reporting torture is associated with specific demographic correlates, which psychiatric disorders are more likely to occur in this refugee population, and which demographic correlates of disorders are related to Bhutanese torture survivors. A population-based sample of 418 tortured and 392 non-tortured Bhutanese refugees living in a camp in Nepal was assessed with the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, for psychiatric disorders. Except for male sex, torture was not associated with demographics. Tortured refugees, compared with non-tortured refugees, were more likely to report 12-month posttraumatic stress disorder, persistent somatoform pain disorder, and dissociative (amnesia and conversion) disorders. Tortured women were more likely to report lifetime generalized anxiety disorder, persistent somatoform disorder, affective disorder, and dissociative disorders.

36. Van Ommeren M, Sharma B, Komproe I, Poudyal BN, Sharma GK, CardeÃ±a E, de Jong JTVM (2001). Trauma and Loss as Determinants of Medically Unexplained Epidemic Illness in a Bhutanese Refugee Camp. Psychological Medicine, 31(7), 1259-1267.

Refugee/Ethnic Group: Bhutanese

This case-control study involved 68 Bhutanese refugees who had at least one experience of medically unexplained fainting or dizziness and 66 controls to identify personal factors that placed people at risk during an epidemic of a medically unexplained illness in a Bhutanese refugee camp in Nepal. Instruments included the following sections of the Composite International Diagnostic Interview-2.1: affective, generalized anxiety, persistent pain, and posttraumatic stress and dissociative disorders as well as the Harvard Trauma Questionnaire section on traumatic events, which measured a number of childhood traumatic experiences. The Social Provision Scale was included to assess perceived social support. Trauma, early loss, and especially recent loss were identified as predictors of attacks during the medically unexplained epidemic illness.

37. Westermeyer J (1973). On the Epidemicity of Amok Violence. Archives of General Psychiatry, 28, 873-876.

Refugee/Ethnic Group: Lao

Traditionally, amok has been viewed as a bizarre culture-bound form of psychopathology. More recently, psychosocial aspects of this form of violence have been studied. This paper questioned the solely endemic nature of amok and suggested that it has certain epidemic characteristics. Data to support this argument came from work in Laos and from reports originating in Thailand, the Philippines, Malaysia, and Indonesia. Three specific variables were examined: change in incidence of amok over time, spread of amok from one ethnic group or nation to another, and use of a culturally prescribed weapon. Change in incidence of amok over time was related to certain historical correlates (especially politico-economic and cultural factors). Traditional hypotheses for amok violence were critiqued. A new psychosocial perspective was offered as a more inclusive and economic explanation for amok.

38. Westermeyer J, Neider J, Callies A (1989). Psychosocial Adjustment of Hmong Refugees During Their First Decade in the United States. The Journal of Nervous and Mental Disease, 177(3), 132-139.

Refugee/Ethnic Group: Hmong

This longitudinal study was aimed at clarifying demographic and social changes, acculturation skills, self-reported problems and treatment seeking, and self-rating scales with regard to refugee readjustment. The total sample consisted of 102 Hmong refugees, aged 16 years and older, living in Minnesota during the fall of 1977, studied on three occasions. An extensive questionnaire and two self-rating scales, the Zung Depression Scale and the 90-item Symptom Checklist translated into Hmong and Hmong-dialect Lao, were used to assess the respondents' performance on social adjustment and psychiatric symptoms. Results showed that many Hmong refugees have made a remarkable adjustment to the United States; however, unemployment, old age, poor education, social isolation, poor marital status, and non-English speaking were identified as main risk factors for an overall increase of depressive symptoms on the Zung Depression Scale.

Children and Adolescents

39. Allodi F (1980). The Psychiatric Effects in Children and Families of Victims of Political Persecution and Torture. Danish Medical Bulletin, 27(5), 229-232.

Refugee/Ethnic Groups: Chilean and Argentinean

This was a review article of three epidemiological studies conducted between 1973 and 1979 on exiled Chilean and Argentinean children. The studies focused on the effects of political repression including torture on families and children under 6 years of age. A comparison of the three studies showed that most of the children were subjected to traumatic experiences. The children reacted with a narrow repertoire of symptoms ranging from withdrawal, depression, sleep disturbances, and behavioral regression to developmental arrest.

40. Almqvist K, Broberg A (1999). Mental Health and Social Adjustment in Young Refugee Children 3Â½ Years After Their Arrival in Sweden. Journal of the American Academy of Child & Adolescent Psychiatry, 38(6), 723-730.

Refugee/Ethnic Group: Iranian

Thirty-nine Iranian refugee pre-school children were reevaluated in a follow-up study to investigate the relative importance of various risk and protective factors for mental health and social adjustment. The follow-up study was conducted 2Â½ years after an initial assessment in 1987 to 1988 of 47 Iranian refugee families with children between the ages of 4 and 8 years who had settled in Sweden. The effect of exposure to organized violence, age, gender, individual vulnerability, parental functioning, and peer relationships on the children's well-being and adjustment was investigated through parental interviews and child assessment using multiple and logistic regression analysis. Results revealed that increased vulnerability before the trauma appear to be an important risk factor for developing long-lasting posttraumatic stress symptomatology in children exposed to organized violence, especially boys (r=0.34, p lt; .05).

41. Clarke G, Sack WH, Goff B (1993). Three Forms of Stress in Cambodian Adolescent Refugees. Journal of Abnormal Child Psychology, 21(1), 65-77.

Refugee/Ethnic Group: Cambodian

The goal of this paper was to relate the stress suffered as a consequence of war, resettlement, and recent stressful life events to the posttraumatic stress disorder (PTSD) and depression psychopathology of 69 Cambodian adolescent refugees. The diagnostic interview consisted of the Children's Schedule for Affective Disorders and Schizophrenia with the PTSD section from the Diagnostic Interview for Children and Adolescents. Several stress and trauma scales were administered during the assessment phase. The respondents reported high levels of both war trauma and resettlement stress, which accounted for symptom variance (15.4 percent for war trauma and 11.7 percent for resettlement stress). Recent life event stressors did not significantly contribute to the prediction of PTSD symptoms.

42. Dyregrov A, Gupta L, Gjestad R, Mukanoheli E (2000). Trauma Exposure and Psychological Reactions to Genocide Among Rwandan Children. Journal of Traumatic Stress, 13(1), 3-21.

Refugee/Ethnic Group: Rwandan

A total of 3,030 Rwandan children, aged 8 to 19 years, were interviewed about their war experiences and reactions approximately 13 months after the genocide that began in April 1994. A quota sampling approach based on age, gender, living situation (unaccompanied center versus community), and residency was used to select the study sample. The survey questionnaire consisted of basic demographic information and questions about the nature of exposure to various war events, that is, a revised version of the Impact of Event Scale. Results showed that exposure was related to the degree of intrusive memories and thoughts. Children living in the community evidenced higher intrusion and arousal scores than those living at the unaccompanied centers where the United Nations Children's Fund had already launched a Trauma Recovery Program.

43. Hjern A, Angel B (2000). Organized Violence and Mental Health of Refugee Children in Exile: A Six-Year Follow-Up. Acta Paediatrica, 89(6), 722-727.

Refugee/Ethnic Groups: Chilean, Lebanese, Turkish, and Iranian

The study analyzed the effect of warfare and organized violence on the mental health of refugee children after their first period of adaptation and transition in Sweden. This follow-up study included 49 of the 63 children in the original study group coming from Chile, Turkey, Iran, and Lebanon. The respondents were assessed through direct interviews and through structured questions submitted to their parents and their teachers on the social situation of the family and the child's behavior. In the follow-up interview 6 to 7 years after the children's arrival in Sweden, only 22 percent (47 percent in the first study) were rated as having poor mental health as symptoms of posttraumatic stress disorder decreased markedly with time. Recent stress in the family sphere was identified as the most important determinant of poor mental health in the present study.

44. Kinzie JD, Sack WH, Angell RH, Manson S, Rath B (1986). The Psychiatric Effects of Massive Trauma on Cambodian Children: I. The Children. Journal of the American Academy of Child & Adolescent Psychiatry, 25(3), 370-376.

Refugee/Ethnic Group: Cambodian

Adolescent children who lived through the 4 years of the Pol Pot regime (1975 to 1979) in Cambodia were assessed regarding the psychiatric effects of massive trauma on children. The 40 students studied, ranging in age from 14 to 20 years, were compared to 6 Cambodian students who escaped internment. Semi-structured interviews were used including specific questions related to current life in the United States, health, school experience, life in Cambodia before and during Pol Pot, and the refugee camp experience. Specific questions on affective disorder, panic disorder, and anxiety were also drawn from the Schedule for Affective Disorders and Schizophrenia, while questions on posttraumatic stress disorder (PTSD) from the Diagnostic Interview Schedule led to a Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised, diagnosis of PTSD. At the time of the study (1983), 4 years after the end of the Pol Pot regime, half of the 40 students still experienced major symptoms considered as PTSD. Twenty-one students also had symptoms of an ongoing depressive disorder. Not living with a nuclear family member was a predictor for a major illness and lower global assessment scores. An interesting fact is that Cambodian cultural values played a major role in these children's coping with the brutality of Pol Pot, characterized by suppression of feelings and avoidant behavior.

45. Kinzie JD, Sack WH, Angell RH, Clarke G, Rath B (1989). A Three-Year Follow-Up of Cambodian Young People Traumatized as Children. Journal of the American Academy of Child & Adolescent Psychiatry, 28(4), 502-504.

Refugee/Ethnic Group: Cambodian

The present report described the psychiatric disorders and social adjustment in a follow-up of the previously reported Cambodian adolescents 3 years after the first study. Goals of the study were to relate the prevalence of psychiatric disorders to specific life events and to describe the course of the major disorders over time. Thirty of the original 46 students participated in this follow-up study. All participants were evaluated on the basis of the Global Adjustment Scale (GAS), the Social Adjustment Scale (SAS), the Beck Depression Inventory, and the Impact of Event Scale. Subjects with posttraumatic stress disorder (PTSD) tended to be more impaired than those without it, especially on the overall rating of the GAS and the SAS. Results showed that PTSD remains a major disorder over time, even if its course was variable for some subjects over time. Depressive and anxiety disorders, however, decreased with time, while antisocial behavior did not increase. Avoidant symptoms were high in the whole sample studied both in those with PTSD diagnosis and in those without it. Unlike the first study, living with a family member did not prevent a major diagnosis.

46. Melville MB, Lykes MB (1992). Guatemalan Indian Children and the Sociocultural Effects of Government-Sponsored Terrorism. Social Science & Medicine, 34(5), 533-548.

Refugee/Ethnic Group: Guatemalan Mayan Indian

The research settings were two orphanages and rural villages in Guatemala and two refugee camps and the urban environs of Mexico City in Mexico. Thirty-six children between the ages of 8 and 16 years were interviewed, during the summer of 1988, to underscore selected characteristics of the psychosocial trauma of civil war they had experienced in Guatemala. They were also interviewed to identify the factors from their Mayan Indian ethnic identity that helped them survive severe trauma and loss. Structured interviews with the children and less formal conversations with teachers, surviving parents, and caretakers were used along with taped children's trauma stories and several traditional psychological instruments. The prevalent feeling expressed by the children was fear, especially among those still living in Guatemalan villages, after having witnessed government-sponsored terrorism 5 to 7 years earlier. The children best able to verbalize their experiences were those living in Mexico; in Guatemala, the children living in orphanages were better able to verbalize their experiences than those living in rural villages. The children with the greatest occupational future, that is, with better opportunities to prepare for future occupations, were those living in the rural villages of Guatemala and in Mexico City. A project was developed to help all these children in many ways that include overcoming fear and maintaining their ethnic identity.

47. Miller KE (1996). The Effects of State Terrorism and Exile on Indigenous Guatemalan Refugee Children: A Mental Health Assessment and an Analysis of Children's Narratives. Child Development, 67(1), 89-106.

Refugee/Ethnic Group: Guatemalan Mayan Indian

Fifty-eight Guatemalan Mayan Indian children, between the ages of 7 and 16 years and living in two different refugee camps in Mexico, were assessed on their mental health and psychosocial development. All respondents were second-generation refugee children. The participants' mothers completed a 36-item version of the Child Behavior Checklist and the Women's Health Questionnaire. The aim of the instruments was to assess the level of psychological trauma present in the sample. The aim was also to find an association between children's score on the behavior problem checklist and the scores of their mothers in relation to their physical and psychological distress. The children's interview consisted of open-ended questions covering social functioning and the situation in Guatemala. Findings showed a low level of psychological trauma in this sample and a positive relationship between young girls' mental health and their mother's health status.

48. Mghir R, Freed W, Raskin A, Katon W (1995). Depression and Posttraumatic Stress Disorder Among a Community Sample of Adolescent and Young Adult Afghan Refugees. The Journal of Nervous and Mental Disease, 183(1), 24-30.

Refugee/Ethnic Group: Afghan

This study examined the prevalence of posttraumatic stress disorder (PTSD) and other psychiatric disorders among a community sample of 38 young Afghan refugees, ranging in age from 12 to 24 years and living in the United States. Conventional assessment instruments were used to gather phenomenological data from the respondents and their parents on possible correlation of current psychiatric disorders with the number of traumatic events experienced and parental acculturation and distress. Instruments included the Harvard Trauma Questionnaire for trauma symptoms; the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised (DSM-III-R), to diagnose major depression, generalized anxiety disorder, and panic disorder; the Clinician-Administered PTSD Scale to measure the DSM-III-R diagnosis of PTSD; and the Beck Depression Inventory to screen for depression. Parents were also interviewed using the Hopkins Symptom Checklist-25 to assess scores for anxiety and depression. Five subjects met DSM-III-R criteria for PTSD; 11 subjects met the criteria for major depression; and 13 had either PTSD or major depression, or both. Positive correlations were found between the respondents' psychiatric diagnoses and their parents' level of psychological distress.

49. Mollica RF, Poole C, Son L, Murray CC, Tor S (1997). Effects of War Trauma on Cambodian Refugee Adolescents' Functional Health and Mental Health Status. Journal of the American Academy of Child & Adolescent Psychiatry, 36(8), 1098-1106.

Refugee/Ethnic Group: Cambodian

The aim of the study was to measure the impact of war trauma on the functional health and mental health of Cambodian refugee adolescents living in a refugee camp (Site 2) on the Thai-Cambodian border. The principal instruments used to assess the mental health of 182 adolescents, aged 12 and 13 years, were the Cambodian versions of the Child Behavior Checklist (CBCL), administered to the parents, and the Youth Self-Report (YSR), administered directly to the adolescents. Both parents and adolescents reported having experienced such cumulative trauma as lack of food, water, or shelter, or any of these. Total Problem scores differed consistently according to respondents (53.8 percent in the clinical range by parents' report on the CBCL and 26.4 percent in the clinical range by adolescents' report on the YSR). The dose-effect relationship between cumulative trauma and symptoms was strong for parent reporting on the CBCL and on both the CBCL and the YSR for the Anxious/Depressed subscale and the Aggressive Behavior subscale.

50. Montgomery E, Foldspang A (2001). Traumatic Experience and Sleep Disturbance in Refugee Children From the Middle East. European Journal of Public Health, 11(1), 18-22.

Refugee/Ethnic Groups: Lebanese, Iraqi, Iranian, Syrian, Palestinian, and Turkish

This study described the specific trauma risk indicators and modifying factors for sleep disturbance among 311 recently arrived refugee children from the Middle East. The study sample comprised 160 boys and 151 girls between the ages of 3 and 15 years who arrived in Denmark between February 1992 and April 1993. Parents were asked questions about their children's health and eventual exposure to war trauma and human rights violations, living conditions before arrival in Denmark, loss of and separation from parents, and symptoms of sleep disturbance. The most important predictors for sleep disturbance were a family history of violence and an unsafe or unpleasant family situation at the time of the interview. Being in Denmark with both parents was a modifying factor because parental behavior mediated the effect of traumatic experiences on children's sleep disturbance.

51. Paardekooper B, de Jong JTVM, Hermanns JMA (1999). The Psychological Impact of War and the Refugee Situation on South Sudanese Children in Refugee Camps in Northern Uganda: An Exploratory Study. Journal of Child Psychology and Psychiatry, 40(4), 529-536.

Refugee/Ethnic Group: Sudanese

The aim of this paper was to study the psychosocial effects of war and subsequent flight on a group of South Sudanese children. The study sample consisted of 193 Sudanese refugee children, ranging in age from 7 to 12 years, who were compared with a group of 80 Ugandan children who had not experienced war and flight. In addition to a questionnaire for sociodemographic variables, the Trauma Event Scale (a subscale of the Harvard Trauma Questionnaire), the Daily Stressors Inventory to measure daily problems, and the KidCope on coping reactions were used. Findings showed that Sudanese children had experienced more traumatic events than the Ugandan control group. In addition, the Sudanese children reported more complaints and depressive symptoms similar to posttraumatic stress disorder.

52. Rousseau C, Drapeau A (1998). Parent-Child Agreement on Refugee Children's Psychiatric Symptoms: A Transcultural Perspective. Journal of the American Academy of Child & Adolescent Psychiatry, 37(6), 629-636.

Refugee/Ethnic Groups: Cambodian, Guatemalan, Honduran, and Salvadoran

The types and rates of psychiatric symptoms of young Central American and Cambodian refugees were compared, and the parent-child agreement in the reporting of symptoms was examined. One hundred and twenty-three children, aged 8 to 12 years, and 158 adolescents, aged 12 to 16 years, were assessed on psychiatric symptoms through using the Dominic (a scale made up of drawings) and the Youth Self-Report, respectively. Parents also were interviewed using the Child Behavior Checklist (CBCL). Cambodian parents reported fewer symptoms on the CBCL than their Central American counterparts, while Cambodian children reported fewer symptoms than Central Americans. No major differences were found with regard to adolescents' symptom reports from both ethnic backgrounds. Results showed that parent-child agreement did not increase with age and that agreement differed slightly on the basis of ethnicity.

53. Sack WH, Clarke GN, Gregory N, Seeley J (1995). Posttraumatic Stress Disorder Across Two Generations of Cambodian Refugees. Journal of the American Academy of Child & Adolescent Psychiatry, 34(9), 1160-1166.

Refugee/Ethnic Group: Cambodian

The present study investigated the possibility of intergenerational risk factors for posttraumatic stress disorder (PTSD) and major depressive disorder (MDD) in relation to particular environmental variables in two generations of Cambodian refugees. A probability sample of 209 Khmer adolescents, aged 13 to 25, as well as one of their parents, was interviewed using sections of the Diagnostic Interview for Children and Adolescents and the Schedule for Affective Disorders and Schizophrenia. All psychiatric diagnoses were based on the Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised, criteria. PTSD, but not MDD, was found to be significantly related across parent-child generations. No evidence was shown on the relationship between PTSD and environmental variables. Parents reported an earlier onset of PTSD symptoms.

54. Sack WH, Clarke GN, Seeley J (1996). Multiple Forms of Stress in Cambodian Adolescent Refugees. Child Development, 67(1), 107-116.

Refugee/Ethnic Group: Cambodian

The goal of this study was to relate three forms of stress experienced by a sample of Cambodian adolescent refugees to their posttraumatic stress disorder (PTSD) and depression psychopathology. The sample consisted of 170 Khmer youth and 80 of their mothers. Both groups were interviewed regarding Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised, diagnoses of PTSD through using the Diagnostic Instrument for Children and Adolescents and the Kiddie-Schedule for Affective Disorders and Schizophrenia for School-Aged Childrenâ€”Epidemiologic Version. The three forms of stress analyzed were war trauma, resettlement, and recent life events. A consistent relationship was found between war trauma, resettlement, and PTSD symptomatology. Recent stressful life events were found to be a strong predictor of depressive symptoms.

55. Savin D, Sack WH, Clarke GN, Meas N, Richart I (1996). The Khmer Adolescent Project: III. A Study of Trauma From Thailand's Site II Refugee Camp. Journal of the American Academy of Child & Adolescent Psychiatry, 35(3), 384-391.

Refugee/Ethnic Group: Cambodian

The present study analyzed the prevalence of posttraumatic stress disorder (PTSD) and depression in a sample of 99 Cambodian youth living in the Site II refugee camp and compared them with data collected from a similar sample of Cambodian refugees living in the United States. The diagnosis of PTSD was based on the adolescent version of the Diagnostic Interview for Children and Adolescents, while major depression rates were assessed through the Schedule for Affective Disorders and Schizophrenia for School-Aged Childrenâ€”Epidemiologic Version. The Beck Depression Inventory and the Impact of Events Scale were used as self-report measures. Overall rates of PTSD and depressive disorders were found to be very high in Site II. In addition, the intensity of PTSD was much greater for the Site II sample than for the Cambodian refugees relocated in the United States.

56. Servan-Schreiber D, Lin BRN, Birmaher B (1998). Prevalence of Posttraumatic Stress Disorder and Major Depressive Disorder in Tibetan Refugee Children. Journal of the American Academy of Child & Adolescent Psychiatry, 37(8), 874-879.

Refugee/Ethnic Group: Tibetan

The medical and mental health needs of Tibetan refugees in Indian settlements were determined. Posttraumatic stress disorder (PTSD) and major depressive disorder (MDD) rates were assessed in two different samples of Tibetan refugee children. The first sample consisted of 27 children, aged 8 to 17 years; 61 children in the same age range composed the second sample. A screening form was developed through a single group session with the first sample of children. PTSD rates were found to be higher in children who had arrived in the previous 18 months than in those who had been in the refugee camp for a longer period of time. The prevalence of PTSD identified was 11.5 percent to 30 percent and that of MDD was 11.5 percent to 25 percent.

57. Smith P, Perrin S, Yule W, Rabe-Hesketh S (2001). War Exposure and Maternal Reactions in the Psychological Adjustment of Children From Bosnia-Hercegovina. The Journal of Child Psychology and Psychiatry, 42(3), 395-404.

Refugee/Ethnic Group: Bosnian

The authors examined multiple risk and moderating factors in children's psychological reactions to war. Data were collected from a representative sample of 339 children, aged 9 to 14 years, their mothers, and their teachers. Different self-report instruments were used both for children and for their mothers. Instruments included the War Trauma Questionnaire, the Revised Impact of Event Scale, the Revised Children's Manifest Anxiety Scale, the Beck Depression Inventory, and the General Health Questionnaire-28. Data from both children and their mothers revealed high levels of posttraumatic stress disorder symptoms and grief reactions but normal levels of depression and anxiety. Child distress was related to their exposure to war trauma and to maternal reactions.

58. Stein B, Comer D, Gardner W, Kelleher K (1999). Prospective Study of Displaced Children's Symptoms in Wartime Bosnia. Social Psychiatry and Psychiatric Epidemiology, 34(9), 464-469.

Refugee/Ethnic Group: Bosnian

This prospective cohort study assessed Bosnian children's reported symptoms of anxiety, depression, and posttraumatic stress disorder over time. The hypotheses were that girls would report higher symptom rates than boys, that younger children would report higher symptom levels than older children, and that symptoms would decrease over time. A representative sample of 147 children, aged 7 to 12 years, was screened in 1994 and again 8 months after the first interview. The instrument used was a cartoon-based interview of children's distress symptoms. No evidence was found that symptoms decreased over time and that younger children would report more symptoms than the older respondents. Findings, however, showed that boys and girls subject to war trauma may have a different symptomatic course.

59. Tousignant M, Habimana E, Biron C, Malo C, Sidoli-LeBlanc E, Bendris N (1999). The Quebec Adolescent Refugee Project: Psychopathology and Family Variables in a Sample From 35 Nations. Journal of the American Academy of Child & Adolescent Psychiatry, 38(11), 1426-1432.

Refugee/Ethnic Groups: Southeast Asian and Central American

The aim of the present study was to analyze the impact of the cultural area of origin on the prevalence of psychopathology in refugee children in Canada. Other questions were whether the rates of morbidity were higher in a metropolitan than in a non-metropolitan area and what family variables were associated with psychopathology after arrival. Two hundred and three adolescents, aged 13 to 19 years, coming from 35 different countries, were interviewed using the Diagnostic Interview Schedule for Children, Version 2.25, and the Children's Global Assessment Scale. Findings showed that the differences between cultural regions are minimal and that the area of residence has no major influence on the rates of morbidity. Father's long-term unemployment was associated with psychopathology in the whole sample, while family structure was related to boys only.

B. Clinical Studies on Refugee Mental Health

Adults

a. Treatment

60. Boehnlein JK (1987). Clinical Relevance of Grief and Mourning Among Cambodian Refugees. Social Science & Medicine, 25(7), 765-772.

Refugee/Ethnic Group: Cambodian

The paper analyzed general aspects of grief and mourning under an ethnographical and medical anthropological point of view. The paper also took a further step in considering the clinical relevance of these concepts in the diagnosis and treatment of posttraumatic stress disorder (PTSD) in Cambodian patients. A more relevant insight is given to the identification of the cross-cultural factors that could play a major role in the doctor-patient relationship and could affect patients' subjective experience of specific PTSD symptoms. Finally, the paper attempted to answer how various therapeutic interventions can effectively address all the different cultural factors.

61. Boehnlein JK (1987). Culture and Society in Posttraumatic Stress Disorder: Implications for Psychotherapy. American Journal of Psychotherapy, 41(4), 519-529.

Refugee/Ethnic Group: General

The author analyzed the interpretation of the cross-cultural phenomenology of posttraumatic stress disorder (PTSD) and its implications on the therapist's formulation and treatment design. The importance of cultural belief systems, both secular and religious, and the effects of traditional family and social roles on the patient's self-identity and adjustment were stressed. In the cross-cultural psychotherapy of PTSD, recognizing both the values that patients bring to therapy and those inherent to the Western medical tradition can bridge cultural differences. Two clinical cases of Cambodian refugee women who survived internment in concentration camps in Cambodia during the late 1970s were presented.

62. De Martino R, Mollica RF, Wilk V (1995). Monoamine Oxidase Inhibitors in Posttraumatic Stress Disorder. Promise and Problems in Indochinese Survivors of Trauma. The Journal of Nervous and Mental Disease, 183(8), 510-515.

Refugee/Ethnic Group: Southeast Asian

A review of the literature on monoamine oxidase inhibitors (MAOI) in treating posttraumatic stress disorder (PTSD) was presented. Existing evidence is contradictory, suggesting that the efficacy of MAOI may or may not be independent of the response of symptoms of major depression. However, the authors reported evidence on how avoidance symptoms of PTSD respond less reliably to chemotherapy. MAOI were found to be an effective choice of treatment for those patients who did not respond to tricyclic antidepressants but showed more serious complications with dietary non-compliance than with other antidepressants. Five clinical cases from the Indochinese Psychiatry Clinic in Boston were presented to provide evidence. In all cases, patients were diagnosed with major depression and PTSD using criteria from the Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised, through the Cambodian and Laotian version of the Hopkins Symptom Checklist-25.

63. Drozdek B (1997). Follow-up Study of Concentration Camp Survivors from Bosnia-Herzegovina: Three Years Later. The Journal of Nervous and Mental Disease, 185(11), 690-694.

Refugee/Ethnic Group: Bosnian

The goal of this study was to evaluate the short- and long-term effects of early short-term therapy on posttraumatic stress disorder (PTSD). The study also examined the role of psychosocial factors on PTSD. A group of 120 concentration camp survivors from Bosnia-Herzegovina was first screened with the Watson Questionnaire for PTSD at their arrival in the Netherlands. Fifty survivors randomly selected from the original sample were screened again 6 months after entering therapy and 3 years later when a structured interview was specifically designed to obtain information on psychosocial status. The 120 survivors were assigned to six different groups and treated with group psychotherapy or drug therapy, or a combination of the two. Results showed that early short-term treatment is effective, in some cases also improving long-term functioning.

64. Fischman Y, Ross J (1990). Group Treatment of Exiled Survivors of Torture. American Journal of Orthopsychiatry, 60(1), 135-142.

Refugee/Ethnic Groups: Central and South American

A model for time-limited group treatment of exiled survivors of torture was examined; advantages and disadvantages of the model were illustrated through the case of a group of Central and South American refugees. Evaluation of the group treatment showed that patients were able to develop a new perspective on their torture experience by reassessing and placing their symptoms in a social and psychological context. By sharing common values and beliefs, the group allowed its participants to have a psychological recovery.

65. Gorman W (2001). Refugee Survivors of Torture: Trauma and Treatment. Professional Psychology: Research and Practice, 32(5), 443-451.

Refugee/Ethnic Group: General

The present paper addressed the impact of torture on refugees and the different possible approaches to treatment. A review of the literature on diagnosing and treating refugee survivors of torture was presented. A number of examples on therapeutic interventions were examined showing the importance of the trauma story within the rehabilitative process of torture survivors. Herman's model of stages in diverse forms of trauma recovery was suggested as a valuable instrument in the multicultural care of tortured refugees.

66. Hiegel JP (1983). Collaboration With Traditional Healers: Experience in Refugees' Mental Care. International Journal of Mental Health, 12, 30-43.

Refugee/Ethnic Group: Southeast Asian

The author described his experiences in promoting cooperation between modern and traditional medicine in refugee camps in Thailand. The author also emphasized the importance of involving traditional caregivers in the medical and psychological aspects of mental health care.

67. Kinzie JD, Boehnlein JK (1993). Psychotherapy of the Victims of Massive Violence: Countertransference and Ethical Issues. American Journal of Psychotherapy, 47(1), 90-102.

Refugee/Ethnic Group: Cambodian

The aim of this article was to present some common countertransference reactions in treating posttraumatic stress disorder and to suggest biomedical ethical principles applicable to psychotherapy. Psychotherapy was illustrated as a process in which all the different stages are characterized by guiding principles developing over time, such as fidelity, beneficence, justice, non-maleficence, and autonomy. Therapists will refer to these six ethical principles as therapy proceeds to its end. Clinical cases of Cambodian refugee women were discussed as examples of psychotherapeutic treatment involving feelings of countertransference and the ethical principles mentioned above.

68. Kinzie JD, Boehnlein JK, Leung PK, Moore LJ, Riley C, Smith D (1990). The Prevalence of Posttraumatic Stress Disorder and Its Clinical Significance Among Southeast Asian Refugees. The American Journal of Psychiatry, 147(7), 913-917.

Refugee/Ethnic Group: Southeast Asian

The aim of the study was to assess the prevalence of posttraumatic stress disorder (PTSD) in a clinic population of 322 Southeast Asian refugees attending a psychiatric clinic. Previous clinical studies on Indochinese refugees had shown different diagnoses according to the different ethnic groups. For example, among the Hmong from Laos, there was a high rate of undiagnosable psychiatric disorders, and no PTSD symptoms were reported. All patients were reinterviewed using a checklist from the Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised. The checklist allowed a current or past diagnosis of PTSD and its distribution among the different ethnic groups. A high rate of PTSD was found among all Indochinese patients in the clinic. The authors analyzed the reasons for misdiagnosis.

69. Kinzie JD, Leung P (1989). Clonidine in Cambodian Patients With Posttraumatic Stress Disorder. The Journal of Nervous and Mental Disease, 177(9), 546-550.

Refugee/Ethnic Group: Cambodian

In previous research studies, parallels have been noted between hyperactivity in posttraumatic stress disorder (PTSD) and the symptoms of opiate withdrawal. The goal of this paper was to assess the success of clonidine-imipramine therapy, as noticed in opiate withdrawal, in the treatment of refugee patients with PTSD. The goal was also to describe the results of a 1-year prospective study with nine severely traumatized Cambodian patients using clonidine-tricyclic antidepressant (TCA) combination therapy. The study sample was followed in therapy for 12 to 19 months. All participants were screened for PTSD and depression using the Hamilton Rating Scale for Depression and criteria from the Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised (DSM-III-R), and blood tests were regularly performed. Results showed that the combination therapy was useful in treating both depression and PTSD symptoms because TCA alone helped only the depressive symptoms. When clonidine was added, however, there was a reduction in intrusive PTSD symptoms as well. PTSD global symptoms improved in six patients and in two to the point where DSM-III-R criteria were no longer met; symptoms of depression improved in six patients and in five to the point where DSM-III-R diagnoses were no longer met.

70. Kinzie JD, Leung P, Boehnlein JK, Fleck J (1987). Antidepressant Blood Levels in Southeast Asians. Clinical and Cultural Implications. The Journal of Nervous and Mental Disease, 175(8), 480-485.

Refugee/Ethnic Groups: Cambodian, Mien, and Vietnamese

The aim of the study was to describe the results of the clinical monitoring of blood tricyclic antidepressant (TCA) levels in Southeast Asian refugees and to compare the compliance rates among the three different ethnic groups. Forty-one patients who had been diagnosed with major depressive disorders were administered TCA, usually imipramine. The TCA blood levels were determined by high-pressure liquid chromatography. Results showed that 25 (61 percent) patients had no detectable level and were therefore declared noncompliant with TCA treatment. Only six (15 percent) had a therapeutic level. After the results were shown to this clinic population, compliance improved among the Vietnamese and the Cambodians, but not among the Mien. A cultural approach was attempted to explain Southeast Asian patients' attitude toward compliance.

71. Kinzie JD, Tran KA, Breckenridge A (1980). An Indochinese Refugee Psychiatric Clinic: Culturally Accepted Treatment Approach. The American Journal of Psychiatry, 137(11), 1429-1432.

Refugee/Ethnic Groups: Cambodian, Vietnamese, and Lao

The study described the treatment approaches used on a clinical population of Southeast Asian refugees referred to the Indochinese Refugee Psychiatric Clinic in Portland, Oregon, during a 20-month period. The study sample consisted of 50 patients, predominantly Vietnamese, aged 15 to 59 years. Most patients received psychotropic medications for psychotic disorders or depressive symptoms. At follow-up (4 to 26 months), two different groups were identified: those with a psychotic diagnosis and long-term contact with the clinic and those with a non-psychotic diagnosis and short-term involvement with the clinic. Case studies were presented to show the effectiveness of the therapies used.

72. Miller KE (1999). Rethinking a Familiar Model: Psychotherapy and the Mental Health of Refugees (1999). Journal of Contemporary Psychotherapy, 29(3), 183-306.

The objective of the study was to explore the notion that conventional (i.e., Western) mental health services, and psychotherapy, in particular, represent an adequate response by the mental health professions to the psychological needs of refugee communities. The author posited that because exile-related variables lie largely outside the scope of conventional mental health services, including psychotherapy, complementing clinical treatments with a variety of community-level interventions tailored specifically to helping people adapt to and master the numerous challenges of life in exile would be most effective. The author pointed to factors that limit the utility of clinic-based mental health treatment, including psychotherapy, with refugees. Examples of community-based approaches to refugee mental health were described, and suggestions were offered for community-level strategies that might be explored. The paper concluded by emphasizing the complementary nature of clinical and community-based programs. It also concluded by suggesting that psychotherapy might best be conceptualized as one component of a more comprehensive approach to addressing the mental health needs of refugee communities.

73. Mollica RF, Wyshak G, Lavelle J (1987). The Psychosocial Impact of War Trauma and Torture on Southeast Asian Refugees. The American Journal of Psychiatry, 144(12), 1567-1572.

Refugee/Ethnic Group: Southeast Asian

More than 700,000 refugees from Southeast Asia have settled in the United States since 1975. Although many have suffered serious trauma, including torture, few clinical reports have described their trauma-related symptoms and psychosocial problems. The authors conducted a treatment study of 52 patients in a clinic for Indochinese. They found that these patients were a highly traumatized group; each had experienced a mean of 10 traumatic events and 2 torture experiences. Many of the patients had concurrent diagnoses of major affective disorder and posttraumatic stress disorder as well as medical and social disabilities associated with their history of trauma. The authors also found that Cambodian women without spouses demonstrated more serious psychiatric and social impairments than all other Indochinese patient groups.

74. Mollica RF, Wyshak G, Lavelle J, Truong T, Tor S, Yang T (1990). Assessing Symptom Change in Southeast Asian Refugee Survivors of Mass Violence and Torture. The American Journal of Psychiatry, 147(1), 83-88.

Refugee/Ethnic Groups: Cambodian, Hmong/Lao, and Vietnamese

The aim of the study was to observe the symptom response of highly traumatized Southeast Asian refugee patients to psychiatric intervention over a 6-month treatment period. Changes in symptoms and levels of distress were evaluated in 21 Cambodians, 13 Hmong/Laotians, and 18 Vietnamese attending the Indochinese Psychiatry Clinic in Brighton, Massachusetts. Symptom change was measured by using the Indochinese versions of the Hopkins Symptom Checklist-25. Cambodian and Hmong/Lao patients had higher scores on both anxiety and depression than Vietnamese patients. After the treatment, Cambodians showed the greatest reduction in depressive symptoms, and the Hmong/Laotians showed the least. Results also showed that in a culturally sensitive setting depressive symptoms were more responsive than somatic symptoms and that a high correlation existed between self-report of improvement in level of illness and symptom reduction.

75. Moore LJ, Boehnlein JK (1991). Treating Psychiatric Disorders Among Mien Refugees From Highland Laos. Social Science & Medicine, 32(9), 1029-1036.

Refugee/Ethnic Group: Mien

The authors gave a brief historical and ethnological overview of the Mien as an introductory understanding of their responses to therapy. They reported on clinical experience with Mien refugees in the Indochinese Psychiatric Program of the Oregon Health & Sciences University. They also introduced a number of Mien cultural beliefs as an example of how Mien cultural background can influence the doctor-patient relationship and the secure development of treatment. Major depression and posttraumatic stress disorder were found to be the most common psychiatric diagnoses among this ethnic group, usually revealed through somatic symptoms. Pharmacotherapy was found to be minimally effective in treating Mien refugees, so a group-oriented treatment process was started as an alternative therapeutic approach. Clinical studies from the group sessions illustrate that traditional and Western healing approaches can operate simultaneously in the care of these patients.

76. Morris P, Silove D, Manicavasagar V, Bowles R, Cunningham M, Tarn R (1993). Variations in Therapeutic Interventions for Cambodian and Chilean Refugee Survivors of Torture and Trauma: A Pilot Study. Australian and New Zealand Journal of Psychiatry, 27(3), 429-435.

Refugee/Ethnic Groups: Cambodian and Chilean

A selective review of the literature introduced the issue of culture and its influence on the treatment of torture survivors. The paper focused primarily on two specific ethnic groups and their cultural backgrounds: Cambodians and Chileans. Therapists working with both groups were asked whether they noticed differences in emphasis in refugees' trauma stories. The clinical study group, comprising 32 patients, aged 20 to 73 years, was surveyed on its refugee experience and on its exposure to violent trauma. Fifteen were Cambodian and 17 were Chilean. Therapists reported the trauma story as being a more central step in the process of recovery for Chilean refugees than for Cambodians. The paper presented social and cultural explanations to address the results of this pilot study.

77. Paunovic N, Ost L (2001). Cognitive-Behavior Therapy vs. Exposure Therapy in the Treatment of PTSD in Refugees. Behaviour Research and Therapy, 39(10), 1183-1197.

Refugee/Ethnic Group: General

The present paper described the results of a treatment outcome study with a clinical refugee population by comparing the effects of both cognitive-behavior therapy and exposure therapy on posttraumatic stress disorder (PTSD). It was hypothesized that both treatments would significantly reduce symptoms of anxiety and depression and that cognitive-behavior therapy would be more effective on symptoms of depression. The study sample included 20 refugee patients diagnosed with PTSD according to criteria from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Patients were randomly assigned to the two different treatments and were assessed before and after treatment and at follow-up after the end of the treatment. Instruments used were the Clinician-Administered PTSD Scale and the Anxiety Disorders Interview Schedule-IV along with self-report scales. Results of this study showed that both treatments equally reduced the patients' PTSD symptoms (48-percent reduction with cognitive-behavior therapy and 53 percent with exposure therapy), general anxiety (49 percent and 50 percent), and depression (54 percent and 57 percent).

78. Pope KS, Garcia-Peltoniemi RE (1991). Responding to Victims of Torture: Clinical Issues, Professional Responsibilities, and Useful Resources. Professional Psychology, Research and Practice, 22(4), 269-276.

Refugee/Ethnic Group: General

The present study attempted to identify common reactions among clinicians in treating torture survivors and to explore different ways of responding to torture victims from ethnically diverse backgrounds. The study listed important clinical issues significant to all clinicians who attempt to provide services to this population. Trust and trustworthiness were defined as essential in the doctor-patient relationship involving torture victims as well as cultural factors that might influence how victims perceive torture trauma. Such issues as medical and dental needs and posttraumatic stress disorder were also considered. The study also included a list of resources for additional useful information and documents.

79. Smajkic A, Weine S, Djuric-Bijedic Z, Boskailo E, Lewis J, Pavkovic I (2001). Sertraline, Paroxetine, and Venlafaxine in Refugee Posttraumatic Stress Disorder With Depression Symptoms. Journal of Traumatic Stress, 14(3), 445-452.

Refugee/Ethnic Group: Bosnian

The goal of this pilot study was to assess the effectiveness of sertraline, paroxetine, and venlafaxine in the treatment of posttraumatic stress disorder (PTSD) and symptoms of depression in 32 Bosnian refugees who had survived ethnic cleansing. All participants were screened using translated versions of the PTSD Symptoms Scale, the Beck Depression Inventory (BDI), and the Global Assessment of Functioning (GAF). All three medications produced consistent improvements, but while sertraline and paroxetine had significant positive effects on all PTSD symptoms, the BDI, and the GAF, venlafaxine did not cause improvements in the BDI. All patients, however, continued to test positive for PTSD at the 6-week follow-up.

80. Somnier FE, Genefke IK (1986). Psychotherapy for Victims of Torture. The British Journal of Psychiatry, 149, 323-329.

Refugee/Ethnic Group: General

The study was based on an analysis of three groups of torture victims to formulate a general guideline for the psychotherapy of this population. The first group comprised 200 case reports from Amnesty International medical groups of torture victims mainly coming from Latin America, Europe, and Africa. Structured interviews were conducted to collect data on the psychological methods of torture. The second group consisted of 24 Latin American torture survivors who were examined at the Department of Neurology, Rigshospitalet, in Copenaghen. Long-term neuropsychological complaints were examined as the basis for a follow-up comparison. The victims from group 2 plus four Europeans and two African victims formed the third group. Physical and psychological sequelae of torture were analyzed in this last sample with the aim of establishing rehabilitation programs. Torture techniques and long-term neuropsychological effects of torture were subsequently identified, and an example of psychotherapy was suggested.

81. Yamamoto J (1978). Therapy for Asian Americans. Journal of the National Medical Association, 70(4), 267-270.

Refugee/Ethnic Groups: Asian American and Pacific Islander

This paper asserted that Asian Americans and Pacific Islanders underutilize mental health services because of a combination of the attitudes or culture, or both, brought from their homeland and their prejudice against the mentally ill and mental health services. Others' findings suggested that Asians tend to seek help from mental health services only when they are seriously disturbed. It is recommended that the object of therapy be on how to learn to cope with family support, rather than on individualism. In this context, the patient's family could be seen frequently. The therapist, preferably bicultural, should explore role conflicts and understand close family ties and healthy mutual interdependency. The therapist also needs to be aware of the fact that he or she is viewed as an authority figure.

b. Clinical Description

82. Adler SR. Refugee Stress and Folk Belief: Hmong Sudden Deaths (1995). Social Science & Medicine, 40(12), 1623-1629.

Refugee/Ethnic Group: Hmong

Since 1977, more than 100 Southeast Asians, of which all but 1 were male, in the United States have died from the mysterious disorder known as the Sudden Unexpected Nocturnal Death Syndrome (SUNDS). Because the author posited that biomedicine provided no adequate answer to the question of what causes SUNDS, the study aimed to determine whether the supranormal nocturnal experience traditionally known as the nightmare and familiar to the Hmong acts as a trigger for the sudden nocturnal deaths. The study interviewed 118 Hmong men and women in Stockton, California, regarding their awareness of and personal experience with a traditional nocturnal spirit encounter. The author, on the basis of this research and data analysis, concluded that the power of traditional belief in the nightmare among the Hmong refugeesâ€”compounded with such factors as the trauma of war, migration, rapid acculturation, and the inability to practice traditional healing and ritualsâ€”causes cataclysmic psychological stress that can result in the deaths of male Hmong refugees from SUNDS.

83. Boehnlein JK, Kinzie JD, Ben R, Fleck J (1985). One-Year Follow-Up Study of Posttraumatic Stress Disorder Among Survivors of Cambodian Concentration Camps. The American Journal of Psychiatry, 142(8), 956-959.

Refugee/Ethnic Group: Cambodian

The authors analyzed individual symptoms of 12 Cambodian refugees who had survived concentration camps 1 year after the original diagnosis of posttraumatic stress disorder (PTSD) was made. They presented the clinical status of each patient at follow-up. Five patients no longer met the Diagnostic and Statistical Manual of Mental Disorders, Third Edition, criteria for PTSD, and 10 had reduction or almost complete cessation of nightmares. Patients were administered four different groups of psychoactive medications. Some were treated only with one medication, while others used medications in sequence. Tricyclics were found to be more effective on both PTSD and depressive symptomatology. However, despite the symptom reduction, the respondents remained impaired 1 year after the first screening, because they were usually unemployed and unable to take English classes.

84. Ekblad S, Roth G (1997). Diagnosing Posttraumatic Stress Disorder in Multicultural Patients in a Stockholm Psychiatric Clinic. The Journal of Nervous and Mental Disease, 185(2), 102-107.

Refugee/Ethnic Group: General

The question arising in the present study was whether it is possible to assess posttraumatic stress disorder (PTSD) and associated symptoms in a multicultural refugee population. The study sample comprised a multicultural refugee and immigrant population attending a psychiatric outpatient clinic in Stockholm. All participants were screened with the Harvard Trauma Questionnaire and the Hopkins Symptom Checklist-25 and were assessed by the Structured Clinical Interview for the DSM-III-R. Of the 63 patients who wanted to participate, 42 were interviewed at the 1-year follow-up. Results showed that the experience of trauma affected the health outcome. Findings indicated that a multidisciplinary approach and validated cross-cultural psychometric instruments were sensitive and accurate diagnostic tools in the assessment of a group of multicultural psychiatric patients.

85. Farias PJ (1991). Emotional Distress and Its Socio-political Correlates in Salvadoran Refugees: Analysis of a Clinical Sample. Culture, Medicine and Psychiatry, 15(2), 167-192.

Refugee/Ethnic Group: Salvadoran

This study described the patterns of emotional distress in a clinical sample of 71 Salvadoran refugees attending a community health center in the United States between 1986 and 1987. Case stories were presented to illustrate patterns of trauma, distress, and associated life problems. Sociocultural factors were also examined to support the theory that distress patterns reflect the particular sociocultural conditions faced by the patients. The analysis was conducted to overcome the reductionism of psychiatric categories by focusing on the psychosocial trauma experienced by the Salvadoran refugees.

86. Favaro A, Maiorani M, Colombo G, Santonastaso P (1999). Traumatic Experiences, Posttraumatic Stress Disorder, and Dissociative Symptoms in a Group of Refugees From Former Yugoslavia. The Journal of Nervous and Mental Disease, 187(5), 306-308.

Refugee/Ethnic Groups: Bosnian, Croatian, Serbian, and Kosovar-Albanian

The aim of the study was to examine the psychiatric sequelae in a group of 40 refugees from the Former Yugoslavia living in a refugee camp in Northern Italy. A semi-structured interview investigated the presence of traumatic experiences during and after the war in Bosnia. The presence of posttraumatic stress disorder (PTSD) was assessed through the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, and all participants were also asked to complete the Hopkins Symptom Checklist-25. Twenty subjects met the criteria for PTSD and 14 for major depressive disorder. This specific study sample appeared to present a particular PTSD symptom profile, and the sample's dissociative symptoms were not closely related to the presence of PTSD and the number of different traumatic experiences.

87. Goldfeld AE, Mollica RF, Pesavento BH, Faraone SV (1988). The Physical and Psychological Sequelae of Torture. Symptomatology and Diagnosis. The Journal of the American Medical Association, 259(18), 2725-2729.

Refugee/Ethnic Group: General

This review of the literature was intended to be a source of information on the physical and psychological sequelae of torture and to make current medical providers' experience easily accessible to the entire medical community. Effective diagnostic approaches to clinically discussed significant symptoms were also discussed. The use of standardized diagnostic criteria to evaluate torture survivors was suggested as a way to facilitate both patients' care and the documentation of human rights violations. Particular attention should be given to the physical and psychological sequelae deriving from the common occurrence of sexual violence during the torture of women and to the neuropsychiatric consequences of the highly frequent rate of head injury.

88. Hinton D, Chau H, Nguyen L, Nguyen M, Pham T, Quinn S, Tran M (2001). Panic Disorder Among Vietnamese Refugees Attending a Psychiatric Clinic: Prevalence and Subtypes. General Hospital Psychiatry, 23(6), 337-344.

Refugee/Ethnic Group: Vietnamese

The aim of the study was to determine the rate of panic disorder (PD) among a group of Vietnamese refugees as a consequence of trauma and to investigate panic attack subtypes. One hundred patients attending two psychiatric clinics were administered a culturally valid adaptation of the Panic Disorder Module of the Structured Clinical Interview for the DSM-III-R (the Vietnamese Panic Disorder Survey). Findings indicated that 50 percent of the patients suffered from PD. Among the 50 patients suffering from PD, the most common subtypes were orthostatic dizziness (74 percent), headache (50 percent), and out-of the-blue palpitations (24 percent). A review of the literature on PD attacks and mechanisms accounting for the specific profile of the subtypes was presented.

89. Jensen SB, Schaumburg E, Leroy B, Larsen O, Thorup M (1989). Psychiatric Care of Refugees Exposed to Organized Violence. A Comparative Study of Refugees and Immigrants in Frederiksborg County, Denmark. Acta Psychiatrica Scandinavica, 80(2), 125-131.

Refugee/Ethnic Groups: Middle Eastern and Asian

The present study aimed at describing symptoms, clinical situations, and courses of treatment among refugees attending the Psychiatric Department in Frederiksborg County, Denmark. It also aimed at comparing the data of the refugees with those of the immigrants using the same service. The study group consisted of 49 refugees and 44 immigrants. Results revealed marked differences between the two groups in terms of social situation, symptomatology, and exposure to organized violence. Both groups had brief courses of treatment whether deriving either from their decision or from the psychiatric staff's advice. Specific treatment programs for refugees were suggested.

90. Kinzie JD, Fredrickson RH, Ben R, Fleck J, Karls W (1984). Posttraumatic Stress Disorder Among Survivors of Cambodian Concentration Camps. The American Journal of Psychiatry, 141(5), 645-650.

Refugee/Ethnic Group: Cambodian

The present study was a report of the symptomatology of 13 Cambodian refugees who had survived 2 to 4 years of concentration camps and were attending the Indochinese refugee clinic sponsored by the Oregon Health & Science University. All 13 patients, previously diagnosed with major depression, were administered the Diagnostic Interview Schedule. The most common symptoms observed were avoidance, hyperactive startle reactions, emotional numbness, intrusive thoughts, and nightmares. A summary of all 13 cases was presented along with typical case histories.

91. Lin EH, Ihle LJ, Tazuma L (1985). Depression Among Vietnamese Refugees in a Primary Care Clinic. The American Journal of Medicine, 78(1), 41-44.

Refugee/Ethnic Group: Vietnamese

Refugees are at high risk for mental disorders and manifest cultural influences in their health behavior. The Vietnamese Depression Scale was administered to Vietnamese patients at a community clinic to assess the underlying prevalence of depression. The rate of accurate diagnosis and the manifestations of depression were also examined. A high prevalence of depression (52 percent) and a high level of underdiagnosis (56 percent) by primary care physicians were found. Ninety-five percent of these patients presented with physical symptoms. Compared with patients who had negative depression scores, those who had positive depression scores were more likely to be older and sought care at the clinic more frequently. These findings underscored the importance of depression as an urgent health problem among Vietnamese refugees in primary care. Accuracy in diagnosis can be improved by using the Vietnamese Depression Scale and constitutes the first step toward effective treatment.

92. Mollica RF, Wyshak G, Lavelle J (1987). The Psychosocial Impact of War Trauma and Torture on Southeast Asian Refugees. The American Journal of Psychiatry, 144(12), 1567-1572.

Refugee/Ethnic Group: Southeast Asian

This paper reported clinical information about Indochinese refugee patients, focusing on refugee trauma and associated psychiatric and social impairments. Important implications of these findings for diagnosis and treatment were reviewed, giving particular attention to those major patient subgroups, such as Cambodian widows, who were revealed to have greater psychosocial problems than other Indochinese patients. Data were drawn from a sample of 52 refugee patients in treatment at the Indochinese Psychiatric Clinic, who were given the Life Events and Social History Questionnaire and the National Institute of Mental Health Diagnostic Interview Schedule. Each respondent had experienced a mean of 10 traumatic events and 2 torture experiences, and a high percentage of them suffered from major affective disorder and posttraumatic stress disorder.

93. Tyhurst L (1951). Displacement and Migration: A Study in Social Psychiatry. The American The Journal of Psychiatry, 107, 561-568.

Refugee/Ethnic Group: General

This paper reported on clinical findings in the psychiatric study and treatment of 48 displaced persons. It outlined two phases of their psychological reactions following arrival. The first phase lasted about 2 months after arrival and was characterized by (a) a subjective sense of well-being, (b) an increased psychomotor activity, (c) an interest in the new environment focusing on fulfillment of immediate and basic needs, and (d) a sense that no one can understand his or her war experiences. The second phase was marked by (a) an increasing awareness of the present social situation and its implications for the future; (b) a retrospective idealization of the distant past and childhood; and (c) psychiatric reactions, which tend to become obvious and reach their peak at about 6 months after arrival. Common reactions followed three main trends: (1) suspiciousness and paranoid trends, (2) anxiety and depression, and (3) somatic complaints. These findings were briefly discussed with an emphasis on the psychosocial dynamics of mobility. The paper also outlined differences between the displaced person and the ordinary pre-war immigrant.

94. Tyhurst L (1977). Psychosocial First Aid for Refugees: An Essay in Social Psychiatry. Mental Health & Society, 4(5-6), 319-343.

Refugee/Ethnic Group: General

This study outlined an operational definition of the structure and natural history of the social situation of resettlement with reference to the working hypotheses of the Social Displacement Syndrome and the Psychosocial First Aid for Refugees Project. These hypotheses were derived from clinical and field studies of four successive refugee groups in Canada over 27 years, with emphasis on the social dynamics of the situation from immediately upon resettlement to 1 year after. In the early phase, the coexistence of personal and social disequilibrium in the refugees and among those who represent the institutions responsible for their management created specific conditions; that is, some enhanced recovery or "repair" and others reinforced the disposition for lasting "social breakdown." Some generalizations concerning practical and theoretical work in social psychiatry were made.

95. Weine S, Becker DF, McGlashan TH, Laub D, Lazrove S, Vojvoda D, Hyman L (1995). Psychiatric Consequences of "Ethnic Cleansing": Clinical Assessments and Trauma Testimonies of Newly Resettled Refugees. The American Journal of Psychiatry, 152(4), 536-542.

Refugee/Ethnic Group: Bosnian

The present report described the traumatic events associated with ethnic cleansing; the characteristics of the participants' syndromes of posttraumatic stress disorder (PTSD) and depression; and the relationships among diagnosis, symptoms, trauma exposure, and age. Twenty Bosnian refugees were interviewed a few months after they had resettled in the United States using the PTSD Symptom Scale and the Global Assessment of Functioning Scale (Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised). All subjects had experienced organized violence, which led to a diagnosis of PTSD and depressive disorders in 65 percent and 35 percent of the refugees, respectively. Increased age was associated with exposure to higher numbers of types of traumatic events. Traumatic stress symptom profiles were presented.

Children and Adolescents

96. Miller KE, Billings DL (1994). Playing to Grow: A Primary Mental Health Intervention With Guatemalan Refugee Children. American Journal of Orthopsychiatry, 64(3), 346-356.

Refugee/Ethnic Group: Guatemalan

Adaptation and implementation of a primary mental health project based on work with children affected by political repression in Guatemala and Argentina were described, focusing on their mental health and psychosocial development. The Playing to Grow intervention used a variety of expressive art techniques to assist children in creatively exploring salient issues related to the unique experience of growing up in exile. The primary goals of the intervention, as implemented in the refugee camps, such as creating a safe and supportive context in which children could examine positive aspects of their homeland and culture, were listed. In each of the two Guatemalan refugee camps in Chiapas, approximately 20 children, aged 7 through 15 years, participated in 5-week workshops. The main activities constituting the Playing to Grow project were also described. The model emphasized training community members in the theory and methods of the intervention, as a way to incorporate the community's indigenous understanding of mental health and psychological development.

97. Rousseau C, Corin E, Renaud C (1989). Conflit Arm eacute; et Trauma: Une Eacute;tude Clinique chez des Enfants R eacute;fugi eacute;s Latino-Am eacute;ricains. [Armed Conflict and Trauma: A Clinical Study of Latin-American Refugee Children]. Revue Canadienne de Psychiatrie, 34(5), 376-385. [French]

Refugee/Ethnic Groups: Chilean, Guatemalan, Salvadoran, Nicaraguan, Bolivian, and Honduran

The aim of the study was to observe the consequences of war trauma in a group of Latin American refugee children and to assess its influence on patients' symptomatology. The study group comprised 30 children, aged 8 to 12 years, resettled in Canada for no more than a few months. Two different types of survey instruments were used: scales for clinical evaluation (Achenbach and Dominique) and symptom assessment and the Thematic Apperception Test (TAT) to analyze psychosocial data. Findings showed a significant correlation between the intensity of trauma experienced and the symptoms evaluated through the Achenbach scale. Analysis of TAT scores highlighted the prevalence of violent themes in children's stories.

98. Sourander A (1998). Behavior Problems and Traumatic Events of Unaccompanied Refugee Minors. Child Abuse & Neglect, 22(7), 719-727.

Refugee/Ethnic Group: General

The present study aimed at analyzing the emotional and behavioral problems of 46 unaccompanied refugee minors, aged 6 to 17 years. Events connected to the specific refugee experience were also examined. Children were assessed using the Child Behavior Checklist (CBCL), and all relevant clinical information was collected. About half of the refugee children had behavior symptoms in clinical or borderline range as scored on the CBCL. The most common symptoms were related to posttraumatic stress disorder (PTSD), depression, and anxiety. However, a complete PTSD diagnosis could not be formulated given the non-specific nature of the CBCL.

C. Methodological Issues

Screening Instruments

99. Ayuso-Mateos JL, Lasa L, Vazquez-Barquero JL, Oviedo A, Diez-Manrique JF (1999). Measuring Health Status in Psychiatric Community Surveys: Internal and External Validity of the Spanish Version of the SF-36. Acta Psychiatrica Scandinavica, 99(1), 26-32.

Refugee/Ethnic Group: General

The acceptability and the internal and external validity of the Spanish version of the Short Form-36 were tested for its use in mental health research on the general population. A stratified random sample of 1,250 subjects between the ages of 18 and 64 years comprised the study group. A two-stage procedure was adopted: use of mental health screening instruments (the Spanish version of the General Health Questionnaire and the SF-36) and assessment of concurrent validity between the two instruments used. Construct validity was determined by studying the extent to which scores on different variables reflected the expected distribution of health status for and between certain groups. Overall, the Spanish version of the SF-36 was demonstrated to be a reliable survey instrument to be used as part of a community mental health survey.

100. Beiser M, Fleming JA (1986). Measuring Psychiatric Disorder Among Southeast Asian Refugees. Psychological Medicine, 16(3), 627-639.

Refugee/Ethnic Groups: Chinese, Lao, and Vietnamese

The authors analyzed four mental health scales (Panic, Depression, Somatization, and Well-Being), developed for use on a Southeast Asian population, in relation to their development and their psychometric properties. The study sample, comprising 1,348 Southeast Asian refugees, was drawn from the three major ethnic groups resettled in British Columbia, Canada. A specific interview schedule derived from a number of screening instruments (the Senegal Health Scales, the Self-Report Questionnaire, and the Diagnostic Interview Schedule) was designed and translated into Cantonese, Vietnamese, and Laotian. Factor analysis of 52 mental health variables produced the four scales, which proved satisfactory to excellent reliability, using Cronbach's coefficient alpha. Three of the scales also demonstrated criterion validity. The study suggested that well-being be identified as a different dimension apart from psychopathology.

101. Bhui K, Bhugra D, Goldberg D (2000). Cross-Cultural Validity of the Amritsar Depression Inventory and the General Health Questionnaire Amongst English and Punjabi Primary Care Attenders. Social Psychiatry and Psychiatric Epidemiology, 35, 248-254.

Refugee/Ethnic Group: Punjabi

The cross-cultural validity of the General Health Questionnaire-12 (GHQ-12) and the Amritsar Depression Inventory (ADI), developed in India, was assessed. The criterion measure used on 209 Punjabis and 185 English primary care attenders was the Clinical Interview Schedule-Revised. Validity coefficients and optimal thresholds were calculated to compare cross-cultural performance. Findings showed that the GHQ-12 performed well in both cultural groups, while the development of the ADI was not so rigorous. Change in the expression of distress due to acculturation was suggested as an explanation.

102. Bolton P (2001). Cross-Cultural Validity and Reliability Testing of a Standard Psychiatric Assessment Instrument Without a Gold Standard. The Journal of Nervous and Mental Disease, 189(4), 238-242.

Refugee/Ethnic Group: Rwandan

This paper described the cross-cultural validity and reliability testing of a standard instrument to measure depression, the Depression section of the Hopkins Symptom Checklist (DHSCL). No "gold standards" represented by another instrument or a professional diagnosis were used in this case. Blind interviews using the adapted DHSCL were conducted on 81 respondents who had reported suffering from "agahinda gakabije," a locally described grief syndrome. To assess criterion validity, interviews where respondent and informant agreed on the presence or absence of agahinda gakabije were compared with depression diagnosis using the DHSCL. Construct validity, internal reliability, and test-retest reliability were also tested. Test-retest reliability of a DHSCL-based scale was found to be less adequate in comparison with results from construct validity and internal reliability.

103. De Figueiredo JM (1980). Some Methodological Remarks on Transcultural Interviewing on Psychopathology. International Journal of Social Psychiatry, 26, 280-292.

Refugee/Ethnic Group: Hindu

This paper discussed transcultural interviewing methods and the problems involved with their use in the collection of data on psychopathology. Methods to make measurement both valid and reliable in a transcultural setting were exemplified in a study conducted in Goa, India, to examine symptom prevalence in two groups, Christians and Hindus. Description of the design of interview instruments was reviewed, taking into account such steps as translation, pretests before actual use of the survey, and its reliability and validity. Questions on social characteristics, general health status, and symptoms as defined within the culture were included in the survey instrument thus obtained. Two forms, one in Portuguese and the other in Konkani, were made equivalent in meaning by a translation and back-translation. The Langner scale was used for questions on symptoms. Other steps involved wording questions carefully, using redundancy and decentering, providing context, warning translators against biases and supervising their work, approaching subjects in local ways and through local leaders, and having the instrument administered by a bilingual physician.

104. Devins G, Beiser M, Dion R, Pelletier L, Edwards RG (1997). Cross-Cultural Measurements of Psychological Well-Being: The Psychometric Equivalence of Cantonese, Vietnamese and Laotian Translations of the Affect Balance Scale. American Journal of Public Health, 87(5), 794-799.

Refugee/Ethnic Groups: Cantonese, Lao, and Vietnamese

The aim of the study was to describe the process of translating the Affect Balance Scale (ABS) into Cantonese, Laotian, and Vietnamese and to evaluate the cultural equivalence of the translated versions with the original English-language version. The authors reported on the psychometric properties of the positive and negative affect subscales of the ABS. A study sample of 399 Vietnamese, 193 Lao, 756 Cantonese, and 319 English speakers who participated in the Clarke Institute-University of Toronto Refugee Resettlement Project completed the scale. A two-factor solution best accounted for item variance in the ABS as indicated by confirmatory factor analyses. Examination for item bias suggested some cross-group differences. Highly similar reliability coefficients were observed across subscales and language groups.

105. Eisenbruch M (1990). The Cultural Bereavement Interview: A New Clinical Research Approach for Refugees. Psychiatric Clinics of North America, 13(4), 715-735.

Refugee/Ethnic Group: General

Cultural bereavement is a culturally valid measure of key constructs used in the study of refugee populations and adopted as a category complementary to posttraumatic stress disorder. The cultural bereavement interview was derived from a schedule that was initially employed as a research tool to explore and measure refugee's grief and bereavement and was developed to improve the validity of the clinical encounter with the refugee patient. The present article described the structure and the construction of this diagnostic instrument providing documented examples for each item approached in the interview. The author presented the theory of cultural bereavement as the key to the refugee experience and as a valid framework for the clinical interview.

106. Flaherty JA, Gaviria FM, Pathak D, Mitchell T, Wintrob R, Richman JA, Birz S (1988). Developing Instruments for Cross-Cultural Psychiatric Research. The Journal of Nervous and Mental Disease, 176(5), 257-263.

Refugee/Ethnic Group: General

Suggestions for a valid methodology in the selection, adaptation, and validation of instruments designed in one culture for use in another culture were presented. The case of investigations in a single country with culturally different populations was also analyzed. The topics approached included instrument selection and validation for cross-cultural equivalence. Five major dimensions of cross-cultural equivalence were proposed: content, semantic, technical, criterion, and conceptual equivalence. The concepts presented were supported by examples from the authors' experience in research on internal migrants in Peru.

107. Geisenger KF (1994). Cross-Cultural Normative Assessment: Translation and Adaptation Issues Influencing the Normative Interpretation of Assessment Instruments. Psychological Assessment, 6(4), 304-312.

Refugee/Ethnic Group: General

The present article described how a measure from one language and culture should be adapted to another language and culture. It addressed steps to ensure that the test continued to measure the same psychological characteristics and presented the same content as before. Psychometric procedures available to study adapted measures to determine whether they were assessing the same construct in the adapted form and whether the scores might be used with equivalent validity were presented. Steps included translation techniques, pilot tests, score standardization, and validation research. Such issues as fairness and norms were also addressed.

108. Hollifield M, Warner TD, Lian N, Krakow B, Jenkins JH, Kesler J, Stevenson J, Westermeyer J (2002). Measuring Trauma and Health Status in Refugees. A Critical Review. The Journal of the American Medical Association, 288(5), 611-621.

Refugee/Ethnic Group: General

The present article was a review of the literature on refugee trauma and health. Instruments used to measure trauma and health status in refugees were identified and evaluated. Primary sources for articles were online databases (MEDLINE, PsychInfo, Health and Psychosocial Instruments, CINAHL, and Cochrane Systematic Reviews) and the New Mexico Refugee Project database. The instruments collected, divided into instruments developed in refugee research and instruments adapted for and tested in refugees, were then evaluated using five criteria: purpose, construct definition, design, developmental process, and reliability and validity. None of the 12 instruments pertaining to the first category fully met all the criteria, 3 (the Harvard Trauma Questionnaire, the Vietnamese Depression Scale, and a scale developed by Bolton) met four criteria and 5 met only one criterion. Of the eight instruments adapted for research in refugee populations, two instruments (the Hopkins Symptom Checklist and the Beck Depression Inventory) met all five criteria and six met four criteria.

109. Jeon W, Yoshioka M, Mollica RF, Phillips D, Conley TM, Leff HS (Eds.) (2001). Science of Refugee Mental Health: New Concepts and Methods. Evaluation Center@HSRI and Center for Mental Health Services. U.S. Substance Abuse and Mental Health Services Administration (SAMHSA). Conference documents.

This compilation was developed and produced after the 1992 conference, "Science of Refugee Mental Health," through a collaborative partnership between the Center for Mental Health Services, the Harvard Program in Refugee Trauma, and the Multicultural Issues in Evaluation Program of the Evaluation Center@HRSI. The objective of this compilation was to provide material that would be useful to mental health researchers and care providers worldwide working with survivors of mass violence and torture. The compilation included the following sections: The Magnitude of the Refugee Mental Health Problem: A Worldwide Survey, The Relationship between the Refugee Experience (Migration and Trauma) and Outcomes, The Unique Nature of the Refugee Experience, Developing Culturally Valid Concepts and Measures, The Health and Psychological Impact of Torture, Research on Services to Refugee Populations, and Summary and Future Directions.

110. Kinzie JD, Spero MM, Do TV, Nguyen TT, Bui A, Than NP (1982). Development and Validation of a Vietnamese-Language Depression Rating Scale. The American Journal of Psychiatry, 139(10), 1276-1281.

Refugee/Ethnic Group: Vietnamese

The present paper described the development and specific items of a Vietnamese-language depression scale and reported the results of the validation of this scale. Implications for further clinical research and cross-cultural study of depression were also analyzed. The Vietnamese Depression Scale was derived and readapted to specific Vietnamese culture-related issues from a translated version of the Beck Depression Inventory. The original scale was validated by a comparison of the test results of two groups: a psychiatric clinic index group of 21 patients attending the Oregon Health & Science University's Indochinese Psychiatric Clinic and a community sample of 44 refugees recruited from the Vietnamese community in the greater Portland, Oregon, area. Fifteen items accounted for 96 percent of the variance between the two groups and were used as the final form of the Vietnamese Depression Scale.

111. Kleijn WC, Hovens JE, Rodenburg JJ (2001). Posttraumatic Stress Symptoms in Refugees: Assessments With the Harvard Trauma Questionnaire and the Hopkins Symptom Checklist-25 in Different Languages. Psychological Reports, 88, 527-532.

Refugee/Ethnic Groups: Arabic, Farsi, Serbo-Croatian, and Russian

This report examined some of the psychosometric properties of data from the Harvard Trauma Questionnaire and the Hopkins Symptom Checklist-25 in Englishâ€“Arabic, Englishâ€“Farsi, Dutchâ€“Serbo-Croatian, Dutchâ€“Russian, and Dutchâ€“English bilingual adaptations. The data in these bilingual adaptations were used in the diagnostic research with 353 refugee patients referred to a Dutch treatment center for psychiatric help. It was concluded that the psychosometric properties of both tests were adequate across those different cultures and were, in general, applicable to measure symptoms of depression, anxiety, and posttraumatic stress disorder. The Dutchâ€“English version of the questionnaires was answered by a heterogeneous group of patients who were sufficiently fluent in English but came from 24 different non-English-speaking countries. However, the psychosometric properties of this version were also really good, suggesting that for English speakers from different countries, the questionnaires provided reasonable results.

112. Mollica RF, Wyshak G, de Marneffe D, Khuon F, Lavelle J (1987). Indochinese Versions of the Hopkins Symptom Checklist-25: A Screening Instrument for the Psychiatric Care of Refugees. The American Journal of Psychiatry, 144(4), 497-500.

Refugee/Ethnic Groups: Cambodian, Lao, and Vietnamese

The present report presented a general overview of the validation and development of the three Indochinese versions (Cambodian, Laotian, and Vietnamese) of the Hopkins Symptom Checklist-25 (HSCL-25). The HSCL-25 was first translated into the three different languages and back-translated into English. Validation included all three translated versions of the HSCL-25 because the sample was not large enough for the analysis of each language group alone. A total of 65 patients newly admitted to the Indochinese Psychiatry Clinic composed the study group. The HSCL-25 translations were also assessed for test-retest and interrater reliability. The HSCL-25 proved to be a short, non-provocative reliable instrument offering an effective method for screening the psychiatric symptoms of anxiety and depression and for evaluating trauma victims.

113. Mollica RF, Caspi-Yavin Y, Bollini P, Truong T, Tor S, Lavelle J (1992). The Harvard Trauma Questionnaire. Validating a Cross-Cultural Instrument for Measuring Torture, Trauma, and Posttraumatic Stress Disorder in Indochinese Refugees. The Journal of Nervous and Mental Disease, 180(2), 111-116.

Refugee/Ethnic Groups: Cambodian, Lao, and Vietnamese

The authors presented the development and validation of three Indochinese versions (Cambodian, Laotian, and Vietnamese) of the Harvard Trauma Questionnaire (HTQ). The HTQ, a self-report scale consisting of three sections, was developed by the Indochinese Psychiatry Clinic over a 4-year period. Its aim was to obtain information about the actual trauma events experienced by Indochinese refugees and to assess both Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised, symptoms and culture-specific symptoms associated with posttraumatic stress disorder (PTSD). The study sample consisted of 91 subjects who received the HTQ within 8 weeks of their initial visit to the clinic. Interrater reliability and test-retest were assessed on 30 patients (10 from each language group). Internal consistency was also determined. The HTQ proved to be more accurate than the Hopkins Symptom Checklist-25 in identifying PTSD symptoms. Test-retest reliability for the HTQ revealed a higher consistency over a 1-week period for such personal trauma items as torture than for more general items.

114. Noh S, Avison WR, Kaspar V (1992). Depressive Symptoms Among Korean Immigrants: Assessment of a Translation of the Center for Epidemiologic Studies-Depression Scale. Psychological Assessment, 4(1), 84-91.

Refugee/Ethnic Group: Korean

This article reported on the utility of the Center for Epidemiologic Studies-Depression Scale (CES-D) for identifying symptoms of depression among the Korean population. Content validity of the Korean version of the CES-D was examined by comparing back-translations of each item in the translated version with those of the original one. Construct validity was also assessed by examining the factor structure of the Center for Epidemiologic Studies-Depression-Korean version (CES-D-K) and its correlations with other constructs. Cultural validity was finally evaluated by comparing the Korean sample's responses with those of a large community sample of Americans. Findings showed that the CES-D-K was an adequate and valid measure of depressive symptoms that could be easily administered to large samples of Korean respondents. The authors suggested that the CES-D-K be used in both cross-cultural and intranational investigations involving Korean populations.

115. Rait G, Burns A, Baldwin R, Morley M, Chew-Graham C, St Leger AS (2000). Validating Screening Instruments for Cognitive Impairment in Older South Asians in the United Kingdom. International Journal of Geriatric Psychiatry, 15, 54-62.

Refugee/Ethnic Groups: Bangladeshi, Gujarati, and Pakistani

The modified versions of two screening instruments for cognitive impairment, the Mini-Mental State Examination (MMSE) and the Abbreviated Mental Test (AMT), were compared with a computerized diagnostic interview, the Geriatric Mental State (GMS), and AGECAT (a computerized diagnostic system used with the GMS) in this two-stage study. The MMSE and the AMT were translated into five South Asian languages (Bangladeshi, Gujarati, Hindi, Punjabi, and Urdu) and used in a pilot study. The study group comprised 120 subjects, aged 60 years and older, who were administered the survey instruments. Modified versions of the MMSE and AMT have been shown to be acceptable and may have a high sensitivity and assist with the recognition of cognitive impairment if an appropriate cut-off is used.

116. Scott KM, Sarfati D, Tobias MI, Haslett SJ (2000). A Challenge to the Cross-Cultural Validity of the SF-36 Health Survey: Factor Structure in Maori, Pacific and New Zealand European Ethnic Groups. Social Science & Medicine, 51(11), 1655-1664.

Refugee/Ethnic Groups: Maori, Pacific, and New Zealand European

The goal of the study was to assess whether the two-dimensional structure of the Short Form-36 (SF-36) health status questionnaire might be applicable to Maori and Pacific populations. The sample size for each ethnic group was 5,647 New Zealand European; 1,321 Maori; and 645 Pacific. All survey participants completed the SF-36 themselves after sociodemographic and risk-related behavior information had been collected. Results showed that, in terms of the construct validity of the measure, among Western European and Neo-European populations the questionnaire is aimed at assessing largely independent dimensions of physical and mental health, while for other ethnic groups some of the component factor coefficients may not appear valid for use. Similar factor structure was found for New Zealand Europeans and younger Maori ( lt;45), while for the Pacific population and the older Maori the factor structure did not clearly differentiate physical and mental health components. Implications were discussed both specifically to the SF-36 and generally for the cross-cultural validity of self-reported survey instruments.

117. Smith Fawzi MC, Murphy E, Pham T, Lin L, Poole C, Mollica RF (1997). The Validity of Screening for Posttraumatic Stress Disorder and Major Depression Among Vietnamese Former Political Prisoners. Acta Psychiatrica Scandinavica, 95(2), 87-93.

Refugee/Ethnic Group: Vietnamese

The aim of this study was to investigate the validity of the Harvard Trauma Questionnaire (HTQ) and the depression subscale of the Hopkins Symptom Checklist-25 (HSCL-25) in screening for posttraumatic stress disorder (PTSD) and major depressive disorder (MDD) among Vietnamese former political prisoners of war (POWs). The study population included Vietnamese POWs (n=51) who migrated to the Boston metropolitan area between January 1990 and July 1992 under the Special Released Reeducation Center Detainees Resettlement Program. The criterion validity of the HTQ in assessing PTSD and of the depression subscale of the HSCL-25 in assessing MDD was supported by the results. Consideration of an appropriate cut-off score should include examination of the utility of a given screening instrument for PTSD or MDD within different settings, such as refugee camps versus countries of third asylum.

118. Willis G, Gonzalez A (1998). Methodological Issues in the Use of Survey Questionnaires to Assess the Health Effects of Torture. The Journal of Nervous and Mental Disease, 186(5), 283-289.

Refugee/Ethnic Group: General

A review of the recent literature on refugee health, on the measurement and treatment of trauma, and on survey methodology and cognitive psychology was presented to verify the effectiveness of survey questionnaires in assessing the health effects of torture. A definition of torture and the measurement of torture versus generalized trauma experiences were regarded as prerequisites for a survey-based assessment of torture-related health effects. Recommendations were advanced on the choice of valid survey procedures and on the steps referring to the survey practice (from the explanation for data collection to the appreciation of cultural values). A review of the most critical pitfalls to be avoided when conducting assessment of torture survivors through the use of survey questionnaires was proposed.

Cross-Cultural Research

119. Bolton P (2001). Local Perceptions of the Mental Health Effects of the Rwandan Genocide. The Journal of Nervous and Mental Disease, 189(4), 243-248.

Refugee/Ethnic Group: Rwandan

The study described the methods used to explore a rural Rwandan community's perceptions of mental illness and how these perceptions differ from the established descriptions of these illnesses as a result of the genocide in 1994. Three ethnographic methods in interviewing respondents from two rural communes in Rwanda were chosen: first, a list of common mental symptoms and disorders; second, key informant interviews with more detailed information about the diagnostic symptoms; and finally, pile sort exercises to test the significance of local depressive symptoms with any major disorder in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). Findings showed that the population studied experienced depression as a result of the genocide in 1994 and that the effects of trauma were not classified into the same categories of depression and posttraumatic stress disorder symptoms that appear in the DSM-IV. It was suggested that existing depression assessment instruments might be used in this population with specific adaptations. This study represented a mini-ethnographic study, part of a field trial of rapid methods to assess mental health in other cultures.

120. Bracken P, Giller JE, Summerfield D (1997). Rethinking Mental Health Work with Survivors of Wartime Violence and Refugees. Journal of Refugee Studies, 10(4), 431-442.

Refugee/Ethnic Group: General

The paper addressed the issue of ethical concern in the mental health care of refugees and victims of wartime violence in both Western and non-Western countries. The challenge in working with refugees and other victims of violence was to establish ways to support people through times of suffering by listening to their different voices. An analysis of postmodern ethics was provided to answer the need for questioning the assumptions in which Western health care providers are engaged.

121. Bracken P, Giller JE, Summerfield D (1995). Psychological Responses to War and Atrocity: The Limitations of Current Concepts. Social Science & Medicine, 40(8), 1073-1082.

Refugee/Ethnic Group: General

This paper analyzed some of the cultural assumptions involved in the discourse of posttraumatic stress disorder (PTSD) and questioned its relevance to communities in the non-Western world. The authors' main argument was that the limitations of the concepts of PTSD and related syndromes be recognized and that the use of these concepts in non-Western situations be approached with caution. They also suggested that recovery over time is intrinsically linked to reconstruction of social and economic networks, cultural institutions, and respect for human rights. Recognizing these dynamics will assist the health care professionals in understanding why some victims become psychological casualties and why the large majority do not.

122. Chung RC, Singer MK (1995). Interpretation of Symptom Presentation and Distress. A Southeast Asian Refugee Example. The Journal of Nervous and Mental Disease, 183(10), 639-648.

Refugee/Ethnic Groups: Cambodian, Chinese-Vietnamese, Lao, and Vietnamese

The study analyzed consistency between psychological distress expressed by Southeast Asian refugees and patterns required by Western diagnostic criteria. It also addressed the question of the validity of applying measures developed using Western samples on Southeast Asian populations. The study sample comprised 2,471 Southeast Asian refugees between the ages of 18 and 68 years residing in California. The Health Opinion Survey was used as the screening tool for the original study, and specific subscales were drawn for depression, anxiety, and psychosocial dysfunction. Results showed that the four ethnic groups did not present three different forms of distress but just a single robust factor, which consisted of all depression, anxiety, psychosocial dysfunction, and somatic symptoms, consistent with Asian nosology. The findings were then tested through three sets of factor analysis (acculturation, English proficiency, and education level) to assess their pertinence to cultural influence on symptom expression. Intergroup differences in the distress levels among the four ethnic groups were also found.

123. Eisenbruch M (1983). "Wind Illness" or Somatic Depression? A Case Study in Psychiatric Anthropology. The British Journal of Psychiatry, 143, 323-326.

Refugee/Ethnic Group: Chinese

This study illustrated the case of a 46-year-old Chinese mother with a history of chronic headaches and a clinical diagnosis of depression. The study also described the characteristic features of "wind illness," a term referring to any combination of organic pathology, psychosomatic disturbance, and spirit possession. The case underlined the importance for every clinician of understanding the patient's cultural system of reference and its impact on his or her own understanding of the symptomatology described. Understanding the patient's own point of view of the illness can lead to a more effective intervention and a correct diagnosis. The case also emphasized the value of distinguishing between the disease, the pathological process and the illness, and the personal and cultural construction of the disease.

124. Eisenbruch M (1984). Cross-Cultural Aspects of Bereavement. I: A Conceptual Framework for Comparative Analysis. Culture, Medicine and Psychiatry, 8(3), 283-309.

Refugee/Ethnic Group: General

This paper reviewed some key conceptual questions in the study of cross-cultural aspects of bereavement. The six questions reviewed in a cross-cultural perspective were as follows: (1) Do individuals in all societies share the same private experience and public expression of grief? (2) Do the stages of grief occur in the same sequence and at the same rate in all cultures? (3) What is the nature of the relationship between the individual's private grief and his or her public mourning? (4) What are the reactions of children to death, and what are the reactions of adults to the death of children? (5) What is the role of religious belief? and (6) What is the possibility that an ethnic group can experience collective grief in response to uprooting.

125. Eisenbruch M (1984). Cross-Cultural Aspects of Bereavement. II: Ethnic and Cultural Variations in the Development of Bereavement Practices. Culture, Medicine and Psychiatry, 8(4), 315-347.

Refugee/Ethnic Group: General

Despite a growing interest in bereavement in a cross-cultural perspective, few reports have described a comparative analysis of bereavement. When the social contexts in the transformations of Western bereavement practices are examined, structures common to bereavement in a range of cultures can be identified. The paper compared the contemporary bereavement practices of several ethnic and cultural groups in North America: Blacks, ethnic Chinese, Southeast Asian refugees, Haitians, Italians, Greeks, and Spanish-speaking groups. The state of widowhood in different cultural systems was considered. The impact of modernization among traditional societies demonstrated that even though Western technologies were incorporated into the procedures followed by these modernizing societies, the deep cultural code remained intact. Five questions required further clarification: (1) Is bereavement an illness, or a rite of passage and a normal life event? (2) How widespread and useful are protective factors, such as group support, that facilitate successful resolution of grief? (3) How effective are mourning practices of various ethnic groups in preventing "bad grief," and might some of these practices be beneficial if taken up by other ethnic groups? (4) How can the Western health practitioner know that a bereaved person from an unfamiliar cultural group is suffering "bad grief"? and (5) How acceptable is Western grief counseling to non-Western clients?

126. Eisenbruch M (1991). From Post-Traumatic Stress Disorder to Cultural Bereavement: Diagnosis of Southeast Asian Refugees. Social Science & Medicine, 33(6), 673-680.

Refugee/Ethnic Group: Cambodian

The aim of the study was to promote the use of cultural bereavement as a valid instrument to improve the diagnosis and management of refugees and to refine such psychiatric diagnoses as posttraumatic stress disorder. A brief overview of the classification of mental disorders was presented from "nostalgic fixation" to Diagnostic and Statistical Manual taxonomy. Case studies drawn from an empirical study conducted by the author on Cambodian refugees were illustrated. The benefits implied in using cultural bereavement were identified to help clinicians separate signs of pathology from signs of a culturally normal relationship between a person's past and present. They were also identified to give a culturally accepted meaning to the distress suffered by refugees.

127. Hultkrantz A (1985). The Shaman and the Medicine Man. Social Science & Medicine, 20(5), 511-515.

Refugee/Ethnic Group: Southeast Asian

The present article discussed the terms medicine man and shaman as used by scholars and scientists, and attempted to arrive at a possible distinction between them. Obviously, the two terms not only overlap but also cause confusion, even among shamanologists. The terms have consequently been used interchangeably by many scholars. By recourse to the North American ethnographic material in particular (which once was the source of this confusion), the author reaches the conclusion that the only way of separating the terms from each other is to approach the whole problem structurally as a two-leveled issue. It is then possible to differentiate between the shaman as primarily the mediator between the supernatural powers and man, and the medicine man as primarily the curer of diseases through traditional techniques. The shaman may also be medically active when his expert knowledge of the supernatural disease agents is called for. Therefore, some shamans are medicine men. Conversely, some medicine men are shamans.

128. Jacobs U, Evans FB, Patsalides B (2001). Principles of Documenting Psychological Evidence of Torture (Part I). Torture, 11(3), 85-89.

Refugee/Ethnic Group: General

The aim of this paper was to provide specific guidelines within the framework of forensic psychological practice on how to collect psychological evidence of torture for the legal setting. The article continued by defining the role of the forensic examiner through informed consent and by distinguishing between clinical and forensic roles. It is stated that the clinician's job is to suspend a preoccupation with facts and to discuss only as much of a person's trauma history as is in the best interest of the treatment. This paper also provided guidelines on how to take a detailed history of the patient's trauma and issues of credibility and the assessment of malingering and deception.

129. Jacobs U, Evans FB, Patsalides B (2001). Principles of Documenting Psychological Evidence of Torture (Part II). Torture, 11(4), 100-102.

Refugee/Ethnic Group: General

This paper described the techniques used to conduct psychological assessment of individuals who present with torture claims. It outlined clinicians' desirable characteristics and reliable screening instruments. A further step was identified in the assessment of causation: Once it had been found that the history taken was detailed and internally and externally consistent, that the psychological findings were suggestive of trauma, and that there was no evidence of malingering or deception, it had to be answered whether other causes might account for the psychological findings.

130. Kirmayer LJ, Young A (1998). Culture and Somatization: Clinical, Epidemiological, and Ethnographic Perspectives. Psychosomatic Medicine, 60(4), 420-430.

Refugee/Ethnic Group: General

This review of recent research literature and findings of an epidemiological survey and ethnographic study focused on the cultural prevalence of somatization. This review also addressed the limitations of current nosology and psychiatric theory for interpreting cultural variations in somatization. The potential meaning of somatic symptoms from physiological, psychological, and sociocultural perspectives was also considered. Examples were provided by a community study of somatization among ethnocultural groups in Montreal, Canada. A random sample of 2,246 residents was asked to complete a structured interview with a 12-item version of the General Health Questionnaire that showed a high correlation between somatic and emotional distress in all ethnocultural groups. No clinical explanations were provided for differences in the rates and form of somatization among different cultural groups.

131. Kleinman A (1975). The Symbolic Context of Chinese Medicine: A Comparative Approach to the Study of Traditional Medical and Psychiatric Forms of Care in Chinese Culture. American Journal of Chinese Medicine, 3(2), 103-124.

Refugee/Ethnic Group: Chinese

This article explored a distinctly different aspect of Chinese medicine, and of health care in Chinese culture, from that receiving the most attention and serious study at present in this country. It examined the symbolic structure and significance of illness and care in the Chinese context by (a) applying concepts developed in anthropology and the cross-cultural study of medicine and psychiatry; (b) examining recent studies of folk and popular forms of health care in contemporary Chinese communities; and (c) raising questions about the cognitive structure, cultural background, and bio-social significance of traditional Chinese healing beliefs and practices. An attempt was made to place this analysis in a comparative framework, so that Chinese cases could be related to health care systems in other cultural settings.

132. Okazaki S, Sue S (1995). Methodological Issues in Assessment Research With Ethnic Minorities. Psychological Assessment, 7(3), 367-375.

Refugee/Ethnic Group: General

This study addressed the multiple methodological and conceptual challenges encountered during assessment research on ethnic minorities. It specifically referenced the difficulty of defining ethnicity as a variable in psychological research. The study also examined common methodological problems in relation to the salient issues of design, sampling, measure selection and equivalence, method of assessment, and interpretation of data. Guidelines regarding the most common mistakes made while conducting research on ethnic minorities were provided: Assumptions underlying the use of ethnicity as a variable should be made explicit, while individual studies should consider using multiple measures and multiple methods of assessment.

133. Phan T, Silove D (1997). The Influence of Culture on Psychiatric Assessment: The Vietnamese Refugee. Psychiatric Services, 48, 86-90.

Refugee/Ethnic Group: Vietnamese

In transcultural psychiatry, ethnocentric biases play a major role in influencing the diagnostic accuracy of the assessment procedures used. Both the "emic" and the "etic" approach, however, are inadequate if applied in contextual isolation. The present article focused on the specific Vietnamese cultural subgroup by examining the limitations of the "etic" approach in developing diagnostic assessment procedures for Asian populations resettled in Western countries. It also focused on the limitations of the tendency to generalize Asian population behaviors. Such culture-specific factors as semantic, context-specific, concept-specific, and politico-historical factors in the Vietnamese refugee population were analyzed. An approach that could harmonize both an "emic" and an "etic" perspective on mental illness was advised as a way to help clinicians gain valuable insights into their own illness-related view. This approach was also advised as a way to determine the extent to which Non-Western patients might benefit from Western-based medicine.

134. Stevens CA (2001). Perspectives on the Meanings of Symptoms Among Cambodian Refugees. Journal of Sociology, 37(1), 81-98.

Refugee/Ethnic Group: Cambodian

Because the perception of symptoms as disease or illness might differ according to different cultures, this study analyzed a number of selected physical states and symptoms commonly presented by Cambodian refugees to better understand their meaning. Two main approaches were used in the analysis: providing an external view of the patient by examining social, demographic, and health correlates and reviewing the explanations Cambodians give to the symptoms they present. The study sample comprised 150 randomly selected Cambodian refugees between the ages of 20 and 75 years residing in South Australia. The interview schedule used did not constitute a diagnostic instrument and included some but not all symptoms defined by the Diagnostic and Statistical Manual of Mental Disorders. An in-depth analysis of both Cambodian theories of causation and explanations of symptom causes was provided with particular attention to sociocultural and religious factors.

135. Sue S, Zane N (1987). The Role of Culture and Cultural Techniques in Psychotherapy. A Critique and Reformulation. American Psychologist, 42(1), 37-45.

Refugee/Ethnic Group: General

The present article described the principles and the culture-specific techniques underlying psychotherapeutic treatment of ethnic-minority groups. Starting from a review of the research and clinical literature on the delivery of mental health services to ethnic-minority populations, the author analyzed a number of recommendations for a culturally sensitive approach to psychotherapy. Current practices often fail to consider within-group heterogeneity among ethnic clients and are developed regardless of their appropriateness for a specific cultural group. The authors' suggestion was to reformulate these recommendations on the basis of two major concepts: credibility, referring to the client's perception of the therapist as an effective helper, and giving, the client's perception that something was received during the therapeutic encounter.

136. Terheggen MA, Stroebe MS, Kleber RJ (2001). Western Conceptualizations and Eastern Experience: A Cross-Cultural Study of Traumatic Stress Reactions Among Tibetan Refugees in India. Journal of Traumatic Stress, 14(2), 391-403.

Refugee/Ethnic Group: Tibetan

This study investigated the impact of traumatic experiences on a group of Tibetan refugees in India and analyzed the extent to which the concept of posttraumatic stress disorder might be applied to this population. The study sample of 76 Tibetan refugees between the ages of 18 and 29 years was drawn from a group of students of an adult school in a refugee camp in northern India. Participants were asked to complete the Posttraumatic Inventory (PTI), four additional questions to assess intrusion and avoidance symptomatology, and the Asian version of the Hopkins Symptom Checklist-25 (HSCL-25). Scores on the PTI indicated the number and nature of the trauma experienced, while the HSCL-25 provided information on correlations between the number of traumatic experiences and depression or somatic complaints. A significant difference was found on distress scores between those who suffered from intrusive-avoidant symptomatology and those who did not. The most traumatic experiences recalled by this Tibetan population were all connected with religion and not personal danger as in Western populations. Suggestions for the use of culture-sensitive instruments in the assessment of trauma events and distress were advanced.

137. Weinstein CS, Fucetola R, Mollica R (2001). Neuropsychological Issues in the Assessment of Refugees and Victims of Mass Violence. Neuropsychology Review, 11(3), 131-141.

Refugee/Ethnic Group: General

This paper reviewed current knowledge of neurological, psychiatric, and neuropsychological data on victims of violence as overlapping symptoms associated with traumatic brain injury, depression, stress, and posttraumatic stress disorder that might lead to a misdiagnosis. It considered issues related to cultural sensitivity in the assessment stage. The paper also considered the occurrence of starvation, torture, beatings, imprisonment, and head injuries experienced by refugee and prisoner of war populations to assess the presence of chronic and persistent neuropsychiatric morbidity. The authors proposed models for the neuropsychologist to understand and described symptom production both in the neuropsychological screening and assessment stage and in the therapeutic approach.

138. Westermeyer J (1979). Folk Concepts of Mental Disorder Among the Lao: Continuities With Similar Concepts in Other Cultures and in Psychiatry. Culture, Medicine and Psychiatry, 3(3), 301-317.

Refugee/Ethnic Group: Lao

Folk concepts for mental disorder were studied among rural Lao people. Although predominantly inferring etiology (e.g., spirit-caused disorder), certain terms also emphasized particular descriptive psychopathology or behavioral abnormality. Preventive strategies were stressed for insanity due to "excessive worry" or "broken taboo." These broad folk categories of disorder bore considerable similarity to some psychiatric and neurologic categories within medicine. These categories included psychosis, mania, neurosis, organic brain syndrome, mental retardation, cerebral palsy, epilepsy, and childhood autism. Lao folk terms for mental disorder also closely resembled those of other southern Asian cultures, although illiterate tribal peoples appeared to have fewer terms than literate peasant peoples. Folk terms from more distant regions had broad similarity to those of Southeast Asia, but lacked the specificity found within the region.

139. Westermeyer J, Wintrob R (1979). "Folk" Criteria for the Diagnosis of Mental Illness in Rural Laos: On Being Insane in Sane Places. The American Journal of Psychiatry, 136(6), 755-761.

Refugee/Ethnic Group: Lao

"Folk" criteria for identifying the mentally ill, as distinguished from folk theories about the causes of mental illness, have been comparatively neglected in cultural psychiatry. The authors described the criteria by which villagers in Laos labeled 35 subjects as baa (insane). Unprovoked assaultive or destructive behavior, social isolation, self-endangerment due to neglect of personal needs, non-violent but socially disruptive or inappropriate behavior, and inability to perform productive work were found to be important folk criteria. The authors emphasized that folk criteria for mental illness are determined primarily by the persistence of socially dysfunctional behavior rather than by disturbances in thought and affect.

140. Westermeyer J (1987). Clinical Considerations in Cross-Cultural Diagnosis. Hospital and Community Psychiatry, 38(2), 160-165.

Refugee/Ethnic Group: General

Understanding the sociocultural background of the patient is crucial in assessing psychopathology and coping behaviors, especially in a cross-cultural doctor-patient relationship. In a clinical setting, a number of decisions need to be made and a number of issues need to be considered in relation to the choice of a language or the use of a translator, the interviewing techniques, and the doctor-patient relationship. Basic clinical methods might be enhanced by special techniques and knowledge about behavioral, attitudinal, and cognitive norms in the patient's culture.

Trauma Story

141. Banks-Wallace J (1998). Emancipatory Potential of Storytelling in a Group. Image Journal of Nursing Scholarship, 30(1), 17-21.

Refugee/Ethnic Group: African

The present article described a project entitled "Sisters in Session (SIS): Focus Groups as a Research Tool and Intervention for Working with Women of African Descent." The purposes of the SIS were to increase awareness of barriers to women participating in or conducting research, to examine research priorities with people of African descent, and to explore the therapeutic potential of participating in focus groups. A total of 28 women residing in the Seattle-Tacoma region of the United States participated in the study. Six major functions of storytelling in the group were identified: (1) to provide contextual grounding, (2) to provide a means of bonding with other participants, (3) to provide a means of validating and affirming women's experiences, (4) to provide a means of catharsis, (5) to provide a means for resisting oppression, and (6) to provide a vehicle for educating other participants. All these functions were thoroughly analyzed.

142. Cienfuegos AJ, Monelli C (1983). The Testimony of Political Repression as a Therapeutic Instrument. American Journal of Orthopsychiatry, 53(1), 43-51.

Refugee/Ethnic Group: Chilean

This paper discussed a therapeutic approach based on the belief that for the victims of political repression and torture the process of healing requires restoration of the individual's capacity to resume the course of his or her life. Testimony has proven to be therapeutic in restoring the necessary ego force required for dynamic psychotherapy. Examples were drawn from the work conducted with 39 individuals who sought treatment at a mental health center established in Chile after the coup in 1973. Their predominant symptomatology included helplessness, anxiety, sleeplessness, feelings of disintegration, inability to concentrate, impaired memory, and social withdrawal. To illustrate characteristics and experiences typical of these patients, all 39 cases were briefly presented. The categories used to evaluate the effectiveness of testimony as a therapeutic instrument were success, partial success, and failure. The highest rate of success was reached with those patients whose traumas were due to torture.

143. Gee JP (1985). The Narrativization of Experience in the Oral Style. Journal of Education, 167(1), 9-35.

Refugee/Ethnic Group: General

The focus of this paper was the oral style, which was analyzed in detail from a linguistic-stylistic point of view using a 7-year-old black child's "sharing time" narrative. "Sharing time" is a school exercise that is meant to develop a literate style of communication. Oral style often appears incoherent to the teacher and ends up being given less instructional time and quality than the literate style of communication. The stylistic analysis given here sought to explicate how the child makes sense of the experience through narrative. The author stressed how narrative is a way of organizing experience that often appeals to pervasive, culturally pervasive, and unquestioned myths.

144. Gilbert KR (2002). Taking a Narrative Approach to Grief Research: Finding Meaning in Stories. Death Studies, 26, 223-239.

Refugee/Ethnic Group: General

The present article described the meaning of narrative and the use of a narrative approach. The article also addressed its specific implications for grief research, issues related to the researcher and the participants in a project, and some details on using a narrative approach to qualitative research. The need to create stories to make order of disorder and find meaning in the meaningless was analyzed. When the process of conducting a narrative study was looked at, questions about what could be analyzed and how it might be presented were considered. Cautions were also necessary with the narrative approach to death, loss, and grief studies because the intimate details of the stories of the individual's experience brought up critical research and ethical issues.

145. Howard GS (1991). Culture Tales. A Narrative Approach to Thinking, Cross-Cultural Psychology, and Psychotherapy. American Psychologist, 46(3), 187-197.

Refugee/Ethnic Group: General

The aim of this paper was to demonstrate that cultural differences might be rooted in the preferred stories habitually entertained by ethnic, class, racial, and cultural groups. The paper presented an epistemological background on objectivism and constructivism as the analysis proceeded to describe different sets of selective criteria through which the adequacy of non-scientific forms of storytelling was determined. The hypothesis advanced was that if thinking can be considered as instances of storytelling and if cross-cultural differences are rooted in certain groups' entertaining differing stories and roles within stories, then examples of psychotherapy as interesting cross-cultural experiences in story repair can be seen.

146. Mishler EG (1990). Validation in Inquiry-Guided Research: The Role of Exemplars in Narrative Studies. Harvard Educational Review, 60(4), 415-442.

Refugee/Ethnic Group: General

The author reformulated validation as the social construction of knowledge, a process through which a community of researchers evaluates the trustworthiness of a particular study as the basis for their own work. The author reported on recent historical and sociological studies of scientific practice to ground this perspective. It was also suggested that this reformulation is compatible with a growing recognition among mainstream validity theorists of the centrality of interpretation in validation, which poses problems for the standard model. The author also examined several instances of how validity claims are made and may be assessed in inquiry-guided, interpretive studies.

147. Mollica RF (2001). Assessment of Trauma in Primary Care. The Journal of the American Medical Association, 285(9), 1213.

Refugee/Ethnic Group: General

Because the clinical assessment of trauma in primary care medicine has become a central issue, the need for a new scientific method for assessing the clinical impact of traumatic life experiences must be explored. This short essay focused on the patient's trauma story as an important stage of the clinical assessment. It was suggested that in the case of refugees and survivors of mass violence the psychosocial history, especially bereavement and the traumatic loss or disability of family members, especially spouses and children, should be given particular attention.

148. Mollica RF (1988). The Trauma Story: The Psychiatric Care of Refugee Survivors of Violence and Torture. In FM Ochberg (Ed.), Post-Traumatic Therapy and Victims of Violence (pp. 295-314). New York: Brunner/Mazel.

Refugee/Ethnic Group: Southeast Asian

This chapter reflected clinical experience of the Indochinese Psychiatric Clinic in treating refugee survivors of violence and torture. As part of the psychiatric examination, the trauma story was considered as the centerpiece of therapy. Every refugee patient had at least one traumatic experience that figured as an essential aspect of his or her life history and that could be totally understood only if the different cultural meanings of trauma were analyzed. Three trauma stories were presented as an example of the uniqueness of each refugee's traumatic experiences.

149. Mollica RF (2001). The Trauma Story: A Phenomenological Approach to the Traumatic Life Experiences of Refugee Survivors. Psychiatry, 64(1), 60-63.

Refugee/Ethnic Group: General

The author commented on Cecil Rousseau et al.'s "Trauma and Extended Separation from Family among Latin American and African Refugees in Montreal." The use of life stories to study the impact of premigration trauma and family separation on refugee resettlement and adaptation was analyzed. Examples were drawn from the Cambodian Women's Oral History project to illustrate methodological issues relevant to the article by Rousseau and colleagues. Relevant issues included the possibility that refugee storytellers may be severely affected by their clinical status, that mental health workers suffer from burn-out, and that life histories follow a basic phenomenological pattern. The dominant features of the trauma story can be found in medical examination, in psychological evaluation, and in all levels of family, community, and society.

150. Silove D, Chang R, Manivacasagar V (1995). Impact of Recounting Trauma Stories on the Emotional State of Cambodian Refugees. Psychiatric Services, 46(12), 1287-1288.

Refugee/Ethnic Group: Cambodian

This pilot study explored the extent of the help provided by disclosing trauma stories in allaying psychological symptoms. Twenty Cambodian refugees with premigration histories of trauma received an average of 16 sessions of individual therapy from a Cambodian bicultural counselor at a trauma treatment center in Australia. Subjects participated in a semi-structured interview and completed the Cambodian version of the Harvard Trauma Questionnaire and the Hopkins Symptom Checklist. Nineteen of the 20 patients reported that during treatment they had been willing to talk about their trauma histories. However, self-disclosing therapy alone did not appear to benefit Southeast Asian patients. Only four patients found talking about their trauma story directly helpful in improving their emotional state.

151. Uehara ES, Farris M, Morelli PT, Ishisaka A (2001). "Eloquent Chaos" in the Oral Discourse of Killing Fields Survivors: An Exploration of Atrocity and Narrativization. Culture, Medicine and Psychiatry, 25, 29-61.

Refugee/Ethnic Group: Cambodian

The aim of this paper was to explore the meaning of the Cambodian killing fields for survivors, by examining the struggle of Seattle-area survivors to describe the past and the "meaning" of the killing fields. The analysis was drawn from two transcribed interviews with survivors and was situated within a narrative framework. Basic assumptions about the links among experience, discourse, meaning making, and healing, and the ways in which these assumptions change when the subject of narrativization is atrocity, were provided as a context for the present analysis. The paper suggested that anti-narratives articulate each person's recollections of childhood experience under the Khmer Rouge, salient forms of contemporary suffering, and specific patterns of narrative chaos in a manner that is manifestly logical and highly evocative.

152. Waitzkin H, MagaÃ±a H (1997). The Black Box in Somatization: Unexplained Physical Symptoms, Culture, and Narratives of Trauma. Social Science & Medicine, 45(6), 811-825.

Refugee/Ethnic Group: Central American

This article addressed a theoretical black box in understanding somatization, that is, how culture mediates severe stress to produce symptoms that cannot be explained by the presence of physical illness. Such "somatoform" symptoms seemed quite common, especially among refugees who had experienced psychosocial traumas before leaving their countries of origin, during relocation to other countries, during the process of migration to the United States, and after their resettlement there. Data were drawn from a research project focused on immigrants and refugees from Central America, especially those who had experienced extreme stress. The Composite International Diagnostic Interview, a clinical assessment, and several measures of utilization and costs in comparing three Latino ethnic groups (Central Americans, Mexicans, and Chicanos) were used. Narrative was operationally defined as attempts at storytelling that portray the interrelationships among physical symptoms and the psychological, social, or cultural context of these symptoms. Regarding somatization and trauma, particular attention was given to the ways that narrative integrates the cultural context with traumatic life events. In an explanation of the black box, it was postulated that extreme stress is processed psychologically as a terrible, largely incoherent narrative of events too painful to hold in consciousness.

153. Weine SM, Kulenovic AD, Pavkovic I, Gibbons R (1998). Testimony Psychotherapy in Bosnian Refugees: A Pilot Study. The American Journal of Psychiatry, 155(12), 1720-1726.

Refugee/Ethnic Group: Bosnian

This pilot study described the impact of the testimony method of psychotherapy on posttraumatic stress disorder (PTSD) and depression in individual survivors. It also discussed the use of testimony psychotherapy as a treatment intervention and factors that may account for its efficacy. The study sample comprised 20 Bosnian refugee survivors of ethnic cleansing, resettled in Chicago. All subjects received a standardized evaluation for traumatic stress, depression, psychosocial functioning, and screening for prior psychiatric history using the Beck Depression Inventory, the Global Assessment of Functioning Scale, and the Structured Clinical Interview for DSM-III-R. Results provided preliminary evidence that testimony psychotherapy may lead to improvements in PTSD and depressive symptoms, as well as to improvement of functioning, in survivors of state-sponsored violence.

D. Mental Health Services

Delivery and Use of Mental Health Services

154. Boehnlein JK (1987). A Review of Mental Health Services for Refugees Between 1975 and 1985 and a Proposal for Future Services. Hospital and Community Psychiatry, 38(7), 764-768.

Refugee/Ethnic Group: Southeast Asian

A review of the American policy on mental health services for refugees over a decade, this article proposed a separate system of mental health services for refugees. The most striking gaps identified within the Federal policy on refugee mental health relate to planning and to an effective communication system among agencies. Ideally, the services would be responsive to the refugees' political, social, economic, and cultural needs and would be provided within existing medical institutions. Medical psychiatrists and social service personnel should be assisted by culturally sensitive translators. The role of government in funding and evaluating mental health services for refugees was considered.

155. Chow JC, Jaffee KD, Choi DY (1999). Use of Public Mental Health Services by Russian Refugees. Psychiatric Services, 50(7), 936-940.

Refugee/Ethnic Group: Russian

The aim of this study was to identify the demographic characteristics and the patterns of mental health service use among Russian refugees in New York State. The data used were taken from a survey conducted on clients served by the New York State mental health systems during the fall of 1995. Three groups of clients were identified: Russian refugees (N=2,142), non-Russian refugees (N=2,697), and non-refugees (N=146,169). Data collected were analyzed using chi-square statistics and logistic regression. Findings suggested the emergence of a distinct group of Russian refugees who are users of mental health services. Russian refugees were twice as likely to be diagnosed as having an affective disorder and eight times less likely to suffer from schizophrenia. At the same time, Russian refugees were more likely to use outpatient services and to receive individual rather than group or crisis counseling.

156. Downs K, Bernstein J, Marchese T (1997). Providing Culturally Competent Primary Care for Immigrant and Refugee Women. A Cambodian Case Study. Journal of Nurse-Midwifery, 42(6), 499-508.

Refugee/Ethnic Group: Cambodian

A 1991 survey of certified nurse-midwives indicated that 51 percent of the respondents serve immigrant women. The present article was aimed at providing the midwife with some of the intellectual tools and communication skills necessary to provide culturally competent primary care to refugee and immigrant women. A brief description of the key components of culturally competent primary care was presented as an introduction to a case study approach. This description illustrated the barriers to health experienced by foreign-born women and the efficacy provided by cultural competence in decreasing the gap between needs and services. Four operative recommendations were singled out as examples for primary care practitioners to use to provide an effective service: (1) The health care system should be accessible and provide an efficient use of resources; (2) there should be a sustained partnership between the individual provider and the client, recognizing the patient's traditional beliefs; (3) primary care should be provided within the client's family structure to provide better outcomes; and (4) primary care must be provided within the context of the communities where the clients live.

157. Gong-Guy E, Cravens RB, Patterson TE (1991). Clinical Issues in Mental Health Service Delivery to Refugees. American Psychologist, 46(6), 642-648.

Refugee/Ethnic Group: General

As the refugee experience reveals itself as potentially devastating, it is imperative to deliver mental health services in the refugee camps, even though evidence shows serious limitations in delivery throughout the whole resettlement process. The authors analyzed the basics of mental health services in refugee camps, then focused on the specific situation of refugee populations resettled in the United States. New barriers there arose, such as frequent misdiagnosis, inappropriate use of interpreters and paraprofessionals, and culturally inappropriate treatment methods. Suggestions for improving mental health services for refugee populations emphasized modifying diagnostic assumptions and treatment approaches; recognizing potential problems associated with the use of interpreters; and examining the role of consultation, prevention, and outreach services in addressing refugee mental health concerns.

158. Gustafson MB (1989). Western Voodoo: Providing Mental Health Care to Haitian Refugees. Journal of Psychosocial Nursing, 27(12), 22-25.

Refugee/Ethnic Group: Haitian

Findings from research studies related to black Americans cannot be generalized to Haitian refugees in the United States, who reflect influences from West Africa. The purpose of this article was to explore Haitian cultural beliefs about health and illness, their traditional healing practices and practitioners, and the impact of voodoo on society. The authors analyzed the meaning of voodoo through a brief review of the literature followed by a careful analysis of the Haitian refugees' experience in the United States. They focused on the problem of communication between the patient and the health care worker with a closer look at issues specific to Haitians and at coping methods outside the mainstream medical system. Suggestions for health care providers for a better and more efficient service delivery were provided.

159. Howard M, Hodes M (2000). Psychopathology, Adversity, and Service Utilization of Young Refugees. Journal of the American Academy of Child & Adolescent Psychiatry, 39(3), 368-377.

Refugee/Ethnic Group: General

The aim of the study was to investigate the psychopathology, social impairment, adversities, and service utilization of refugee families and their children seeking help at a child and adolescent psychiatric clinic in London. Three hypotheses were tested: (1) children of refugee parents would be more likely to suffer from a psychosocial disorder and have greater social impairment compared with controls; (2) refugee families would be more socially disadvantaged and isolated; and (3) refugee families would be more likely to drop out of treatment prematurely. The study sample comprised 30 refugee children and their families individually matched with non-refugee immigrant and British families. Diagnoses were made with criteria from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, and social impairment was measured with the Children's Global Assessment Scale. Service utilization was assessed during the 3 months after the first interview. Refugee children tended to have disorders with a psychosocial etiology rather than neurobiological disorders. Different referral pathways emerged from the study with no implication for patients' dissatisfaction with services or service underutilization. The ability of community agencies to refer families who could use treatment was found to have relevant resource implications.

160. Jones D, Gill P (1998). Refugees and Primary Care: Tackling the Inequalities. British Medical Journal, 317(7170), 1444-1446.

Refugee/Ethnic Group: General

The aim of this brief article was to address the problem of the deficiencies of primary care as observed in the United Kingdom. The refugee experience was summarized, and a brief description of the health problems most commonly found in this specific population was provided. General guidelines for the improvement of the primary care of refugees were presented.

161. Keefe SE, Casas JM (1980). Mexican Americans and Mental Health: A Selected Review and Recommendations for Mental Health Service Delivery. American Journal of Community Psychology, 8(3), 303-326.

Refugee/Ethnic Group: Mexican American

The paper was a review of the literature on the prevalence of mental illness among Mexican Americans, their use of ethnic community support systems, and the relationship between the use of mental health services and Mexican American subculture. Evidence was organized around eight working assumptions about Mexican Americans, mental illness, and mental health services. Particular attention was given to the statistical evidence for each assumption and the differences within this specific ethnic group and with other ethnic populations. Three assumptions were considered as explanations for cases of mental health service underutilization: (1) Mexican Americans are unfamiliar with the services provided; (2) mental health services are inappropriate; or (3) Mexican American clients are discouraged from receiving services. Education about mental health services and changes in service delivery were then considered as logical actions to undertake.

162. Leong FTL, Lau ASL (2001). Barriers to Providing Effective Mental Health Services to Asian Americans. Mental Health Services Research, 3(4), 201-214.

Refugee/Ethnic Group: Asian American

Asian Americans as an ethnic group are quite heterogeneous with over 20 subgroups associated with a variety of differences in mental health service needs, utilization, and outcome. The present paper discussed the culture-related barriers to providing effective mental health services to Asian Americans, using a five-stage integrated sequential model proposed by Rogler, Malgady, and Rodriguez (1989). Special attention was given to stages 2, 3, and 4, namely (a) help-seeking behavior or mental health service utilization, (b) diagnosis and evaluation of mental health problems, and (c) psychotherapeutic services. In each section related to these three stages, research and methodological problems were discussed along with the barriers to the delivery of effective mental health services.

163. McMiller WP, Weisz JR (1996). Help-Seeking Preceding Mental Health Clinic Intake Among African American, Latino and Caucasian Youths. Journal of the American Academy of Child & Adolescent Psychiatry, 35(8), 1086-1094.

Refugee/Ethnic Groups: African American, Latino, and Caucasian

The hypothesis tested was that African American and Latino families are less likely than Caucasian families to seek help from agencies and professionals and more likely to refer to family and community resources. Potential determinants of help-seeking behavior such as socioeconomic status, child gender, and age were also investigated. Data were collected from a study focused on families of children who had been admitted to a community mental health clinic. The sample included 192 children between the ages of 7 and 17 years pertaining to one of the three ethnic groups under consideration. As predicted, African American and Latino families sought help from professionals and agencies much less often also on the basis of such variables as income, gender, and age.

164. Nguyen SD (1984). Mental Health Services for Refugees and Immigrants. The Psychiatric Journal of the University of Ottawa, 9(2), 85-91.

Refugee/Ethnic Group: Southeast Asian

This paper discussed issues in the delivery of mental health services for refugees and immigrants as shown by clinical data collected on a group of 118 Southeast Asian refugees resettled in Canada. The underutilization of mental health services by Southeast Asian populations was due in part to the sociocultural background of this specific population. The stigma of mental illness and the use of family and extended kinship may be explanatory factors. Other factors may be issues related to the availability of alternative resources, such as the heavy use of medical practitioners instead of mental health professionals and the use of traditional Sino-Vietnamese medicine and folk-healing practices. An important factor preventing the proper use of mental health services was the lack of culturally appropriate services. Five objectives, including the training of bilingual, bicultural mental health workers and the provision of educational programs, were drawn as steps to provide culturally effective mental health services to refugees and immigrants.

165. Phan T. Investigating the Use of Services for Vietnamese with Mental Illness. Journal of Community Health, 25(5), 411-425.

Refugee/Ethnic Group: Vietnamese

The aim of the study was to investigate and explore experiences in the use of mainstream ethnospecific services for the identification, intervention, and care of Vietnamese-speaking adults with mental illnessâ€”binh tam thanâ€”focusing on types of services, concerns or difficulties, or both, associated with utilization, and preferences for services. An ethnographic-based interview was conducted with 324 Vietnamese-speaking adult caregivers living in the New South Wales state of Australia. Almost one in two interviewees had used such services during the previous 12 months, including those provided by local Vietnamese-speaking doctors (100 percent), Asian naturalists, spiritual healers, witchcraft doctors, herbalists, and folk healers (more than 50 percent) as well as mainstream psychiatric hospital facilities (50 percent) and community services (more than 30 percent). Difficulties and recommendations were put forth in four domains, including accessibility, acceptability, accommodation, and affordability. These domains explained patterns of caregivers' help-seeking behaviors and their choices of services.

166. Pickwell S (1989). The Incorporation of Family Primary Care for Southeast Asian Refugees in a Community-Based Mental Health Facility. Archives of Psychiatric Nursing, 3(3), 173-177.

Refugee/Ethnic Group: Southeast Asian

This report reviewed the literature that documents the incidence of mental health disturbance among Southeast Asian populations and describes some of the treatment approaches carried out at health centers throughout the United States. A Family Nurse Practitioner's clinical experience with a Cambodian woman was presented to provide empirical insights on nurses' dilemmas in integrating the techniques of modern clinical psychiatry with culturally diverse people. A list of persistent themes identified over the years of work with Southeast Asian refugees and causes for concern was highlighted. Examples were the multiplicity and fragmentation of services, which results in duplication of services and increased costs; cultural beliefs pertaining to every refugee's cultural sphere; and referral to traditional healers and practices.

167. Portes A, Kyle D, Eaton WW (1992). Mental Illness and Help-Seeking Behavior Among Mariel Cuban and Haitian Refugees in South Florida. Journal of Health and Social Behavior, 33, 283-298.

Refugee/Ethnic Groups: Haitian and Mariel Cuban

The two groups who are the subject of this analysis present unique characteristics that differentiate them from other ethnic groups. The study focused on the attempts of the mental health system in Florida to cope with their presence and examine the differences that emerged over the years between these two groups. A review of the literature examined the differences in psychopathology and use of the mental health system by recent refugee groups. Data were collected from a sample of 452 Mariel Cubans and 500 Haitian refugees selected at random in their principal areas of concentration. Results showed that Haitian refugees arriving in South Florida during the early 1980s had relatively small needs for mental health care that were, however, largely unattended. Mariel Cubans, on the contrary, had far more urgent needs that were mostly met, because of their familiarity with service facilities and because of their incorporation into a favorable social environment.

168. Reid JC, Strong T (1988). Rehabilitation of Refugee Victims of Torture and Trauma: Principles and Service Provision in New South Wales. The Medical Journal of Australia, 148, 340-346.

Refugee/Ethnic Group: General

In 1987, the Western Metropolitan Health Region of the New South Wales Department of Health commissioned a study on the extent of the problems of torture and trauma among recently arrived refugees, on service availability and refugee needs, and on the resources required to train health workers to recognize and effectively assist affected individuals. Case materials from this study were illustrated here. An interesting overview of treatment and rehabilitation centers all around the world for victims of trauma and torture was offered. The focus was then shifted to the particular situation in Australia where the therapeutic needs of victims are, in several important aspects, unique because of the nature of refugee and migrant communities present. Recommendations for an efficient health care system included the organization of a network structure that consists of a treatment center whose specialty is psychotherapy and whose administrative control is independent of government and ethnic community organizations to preserve the integrity of the service.

170. Sharma VK, Wilkinson G, Dowrick C, Church E, White S (2001). Developing Mental Health Services in a Primary Care Setting: Liverpool Primary Care Mental Health Project. International Journal of Social Psychiatry, 47(4), 16-29.

Refugee/Ethnic Group: General

This article described the Primary Care Mental Health Project (PCMHP) started in Liverpool in 1996 to provide mental health services in a primary care setting. It also provided a detailed analysis of the impact of a working model of a multidisciplinary team in close relationship with five Liverpool practices. Data were collected on 642 patients who came into contact with the project over a 3-year period and then were compared with the data available for the five neighboring teams on waiting time between referral and assessment. The PCMHP is a demonstration that a specialist mental health team can be established in General Practice that is beneficial to both patients and General Practitioners. The present model could serve as a working example for the development of future specialized mental health services for the care of such specific subgroups as refugee populations.

171. Silove D, Manicavasagar V, Beltran R, Le G, Nguyen H, Phan T, Blaszczynski A (1997). Satisfaction of Vietnamese Patients and Their Families With Refugee and Mainstream Mental Health Services. Psychiatric Services, 48(8), 1064-1069.

Refugee/Ethnic Group: Vietnamese

Treating ethnic minorities within mainstream services avoids the risk of discrimination and makes economic and logistic sense, but at the same time mainstream services may not be sensitive enough to cultural issues. The study examined the levels of satisfaction with both mainstream mental health services and specialized mental health services for refugees among Vietnamese psychiatric patients and their families. The study sample comprised 86 Vietnamese patients identified from case notes of mainstream inpatient services (N=31), mainstream community services (N=7), and a specialized refugee treatment unit (N=48). Patients completed the Vietnamese version of the Hopkins Symptom Checklist-25, the Harvard Trauma Questionnaire, and an eight-item measure on service satisfaction. On average, patients and relatives were satisfied with treatment. Patients expressed greater satisfaction with the specialized refugee treatment unit than with mainstream services. They based their feelings on such variables as the extent of the information provided and the ease of negotiating treatment. Patients' fluency in English and their relatives' level of education were inversely associated with satisfaction scores.

172. Somasundaram DJ, van de Put WACM, Eisenbruch M, de Jong JTVM (1999). Starting Mental Health Services in Cambodia. Social Science & Medicine, 48, 1029-1046.

Refugee/Ethnic Group: Cambodian

This paper described an attempt to introduce mental health services into Cambodia within the health system. It focused on the establishment of mental health clinics at the district and provincial levels for the first time in Cambodia. Community mental health interventions and research into the social context and traditional sector were reported on separately. A program to implement the community mental health approach of the Transcultural Psychosocial Organization based in Amsterdam was started in 1995. A core group of 12 Cambodians was trained in the theory and practice of mental health by an expatriate multidisciplinary team with relevant experience in Cambodia. The paper presented basic statistics from the clinics in the context of the historical and traditional setting and described the effort to maintain a culturally informed approach. The contrasting results in the clinics were analyzed in relation to factors intrinsic to the health care system and those related to the local population. These results highlighted the issues involved in establishing future mental health services, both locally in other provinces and in situations similar to those in Cambodia. The efficacy of introducing low-cost, basic mental health care was shown and related to the need to find solutions for prevailing psychosocial problems.

173. Sue S (1977). Community Mental Health Services to Minority Groups: Some Optimism, Some Pessimism. American Psychologist, 32(8), 616-624.

Refugee/Ethnic Groups: Asian American, Chicano, Black, Native American, and Caucasian

For many years, researchers and practitioners have found that minority-group clients who seek psychotherapeutic services receive discriminatory treatment from white therapists. Underlying this finding is the implicit assumption that the mental health delivery service should strive to provide equal and non-discriminatory services for all clients. An analysis of the services received by minority clients in 17 community mental health facilities suggested that blacks received differential treatment and poorer outcomes than whites. However, Asian American, Chicano, and Native American clients who tended to receive treatment equal to that of white clients also had poorer outcomes as measured by premature termination rates. It was suggested that a time may well come when minority clients receive equal but ineffective services. It was also suggested that primary attention be put on the delivery of effective services rather than on the demonstration of inequities.

174. Sue S, Fujino DC, Hu L, Takeuchi DT (1991). Community Mental Health Services for Ethnic Minority Groups: A Test of the Cultural Responsiveness Hypothesis. Journal of Consulting and Clinical Psychology, 59(4), 533-540.

Refugee/Ethnic Groups: African American, Asian American, Mexican American, and Caucasian

This study intended to examine the relationship between therapist-client match according to ethnicity, language, and gender and such variables as premature termination rates, number of sessions, and treatment outcomes for four ethnic groups. Services received, length of treatments, and outcomes of Asian American, African American, Mexican American, and Caucasian clients using outpatient services in the Los Angeles County mental health system were examined. Results indicated that Asian Americans and Mexican Americans underutilized services, whereas African Americans overutilized them. African Americans also showed less positive treatment outcomes. Among clients who did not speak English as a primary language, ethnic and language match was related to length and outcome of treatment.

175. Watters C (2001). Emerging Paradigms in the Mental Health Care of Refugees. Social Science & Medicine, 52, 1709-1718.

Refugee/Ethnic Group: General

The paper examined the role of psychiatric diagnosis in relation to refugees' own perception of their needs and within the context of general health and social care provision. A review of the literature critiqued the way in which Western psychiatric categories have been ascribed to refugee populations with scarce consideration of the important role of sociopolitical and economic factors. The paper presented emerging paradigms in mental health service provision by focusing on a three-dimensional model of interaction between services and refugees. This model provided a framework for examining the provision of mental health services. The framework examined the interrelationship between such macro-level factors as the institutional context in which decisions are made regarding the funding and organization of services and, at a micro level, the local organization of services and the provision of treatment to individual refugees.

176. WHO. Traditional Medicine. Regional Committee. 52nd Session, Brunei, Darussalam, 10-14 September 2001. Provisional agenda item 13. WPR/RC52/7. 6 August 2001.

The paper put forth a regional strategy for traditional medicine for the Western Pacific Region to ensure the safe and effective practice of traditional medicine. The document addressed a number of key issues, including the cultural and philosophical background of traditional medicine, the use and range of traditional medicine practices in the region, and the economic value of traditional medicine. It discussed a number of issues that require attention, including the need for political support, the establishment of appropriate standards, the need for an evidence-based approach, and the protection and conservation of indigenous health resources. It stated strategic objectives and described actions to be taken to ensure that the aforementioned objectives are met.

Interpreters and Bilingual Workers

177. Egli EA (1991). Bilingual Workers. In J Westermeyer, CL Williams, & AN Nguyen (Eds.). Mental Health Services for Refugees (pp. 90-110). Washington, DC: U.S. Government Printing Office.

Refugee/Ethnic Group: General

This chapter described the role of bilingual workers who lack formal mental health training in the provision of mental health services to refugees. This focus on the non-professional worker reflected the lack of professionally trained mental health workers in many refugee groups. Roles and functions of bilingual workers were analyzed with a focus on five main areas of intervention: translation, interpretation, culture brokerage, outreach and community education, and mental health counseling and cotherapy. The main problems related to the role of the bilingual workers stemmed from the complex interplay of interpersonal dynamics in the triad patient-interpreter-clinician and from the lack of training that most workers experience. The possibility of burn-out among bilingual workers was also presented, connected to a number of such risk factors as high case loads, high percentages of chronic or seriously ill patients, inability to emotionally escape from the demands of the job, and low levels of support from the coworkers.

178. Eytan A, Bischoff AM, Loutan L (1999). Use of Interpreters in Switzerland's Psychiatric Services. The Journal of Nervous and Mental Disease, 187(3), 190-192.

Refugee/Ethnic Group: General

The aim of the study was to record the different approaches adopted in various care centers and psychiatric facilities in Switzerland when staff are faced with patients who do not speak one of Switzerland's official languages. A total of 78 questionnaires were collected from psychiatric hospitals and public psychiatric services all over the country. Seventy-three departments (94 percent) considered that difficulties exist in communicating with patients who do not speak the local language or speak it poorly. Care providers never used interpreters in 5 (6.5 percent) departments, rarely in 31 (40 percent), and often in 39 (50 percent). Most services felt the need for access to trained interpreters, but only 10 of them expressed the intention of organizing such a network.

179. Musser-Granski J, Carrillo DF (1997). The Use of Bilingual, Bicultural Paraprofessionals in Mental Health Services: Issues for Hiring, Training and Supervision. Community Mental Health Journal, 33(1), 51-60.

Refugee/Ethnic Group: General

The aim of this article was to present the situation of bilingual, bicultural professionals hired by mental health agencies to work primarily with their own cultural community. Its aim was also to examine the issues relevant to the hiring, training, and supervision of these professionals. Bilingual, bicultural professionals' role is to bridge language and cultural barriers between mental health professionals and client and to educate communities regarding mental health services. Both the challenging tasks of community outreach and clinical interpretation, and the role of mental health professionals in working with and through bicultural workers, were reviewed.

180. Westermeyer J (1990). Working With an Interpreter in Psychiatric Assessment and Treatment. The Journal of Nervous and Mental Disease, 178(12), 745-749.

Refugee/Ethnic Group: General

The process of selecting a language in the assessment and treatment stage can be complex, involving the decision to use or not use the services of an interpreter. Advantages and disadvantages for both outcomes were presented, and the process of selecting, training, and assigning the translator-interpreter was described. Three conceptual models of psychiatric translation were analyzed: (1) the triangle model, in which the triangle clinician-interpreter-patient involves three relationships; (2) the black box model, in which the interpreter is merely seen as taking messages from one person and passing them on to another; and (3) the bilingual worker model, in which the interpreter gains the status of "junior clinicians." Special subtypes of psychiatric translation such as emergency translation and forensic evaluation were also taken into account and provided a few working guidelines.

E. Selected Subgroups of Refugees

Women

181. Allodi F, Stiasny S (1990). Women as Torture Victims. Canadian Journal of Psychiatry, 35(2), 144-148.

Refugee/Ethnic Group: Latin American

Little attention has been given to women as torture victims over the past decades. This paper represented an effort to give evidence of the trauma suffered by women victims of torture. It analyzed the relationship between sex and torture in the context of political persecution. In this context, sex is the main independent variable, affecting the occurrence of the trauma, its nature, severity, and outcome, in terms of psychological and behavioral reactions. Evidence was extrapolated from the case records of 28 persecuted or tortured women from Central and South America, resettled in Canada. The authors constructed the trauma scales used to score the reported abuses and deprivations. Results supported the hypothesis that the frequency and effects of torture in women differ from those found in men. In female victims, the severity of torture was related to the grade of political involvement and happened to be more frequently sexual, affecting the women's sexual adaptation.

182. Catolico O (1997). Psychological Well-Being of Cambodian Women in Resettlement. Advances in Nursing Science, 19(4), 75-84.

Refugee/Ethnic Group: Cambodian

The experience of traumatic pain and multiple losses, coupled with the struggle for adjustment in a foreign community, places refugee women at risk for diminished health and psychological well-being. The present study delineated the situational and cultural context relevant to the migration experience of Cambodian women, examined the value assumptions of psychological well-being from micro (affect, ability, and personal perception of life satisfaction and integration) and macro (interaction and cultural change) perspectives and their relevance to Cambodian immigrant women, and reviewed and critiqued related literature.

183. Chung RC, Bemak F, Kagawa-Singer M (1998). Gender Differences in Psychological Distress Among Southeast Asian Refugees. The Journal of Nervous and Mental Disease, 186(2), 112-119.

Refugee/Ethnic Group: Southeast Asian

The aim of this study was to examine gender differences in levels and predictors of psychological distress in a community sample of Southeast Asian refugees. Data used in this study were from the California Southeast Asian Mental Health Needs Assessment study conducted for the State of California, Department of Mental Health. The study sample comprised 959 women and 1,221 men between the ages of 18 and 68. The questionnaire used was translated into Vietnamese, Khmer, and Lao and tested depression, anxiety, and psychosocial dysfunction symptoms. The results showed that even after premigration and postmigration differences, ethnicity, and other confounding variables were controlled for, refugee women in this study reported significantly higher levels of distress than their male counterparts. Significant distress predictors for women were no formal education in their home country and fewer years in the United States.

184. Hynes M, Lopes Cardozo B (2000). Sexual Violence Against Refugee Women. Journal of Women's Health & Gender-Based Medicine, 9(8), 819-823.

Refugee/Ethnic Group: General

The focus of this article was sexual violence, its prevalence in refugee settings, and its health consequences. It also discussed measures that health professionals working with refugee populations should take. A brief presentation of a CDC population-based survey of 1,358 Kosovar-Albanians who had been internally displaced or who had recently returned to Kosovo was presented. As part of a larger study of mental health and trauma events, women were asked about their experiences with rape. Suggestions about prevention or response to sexual violence were drawn as a result of the study, which also addressed research solutions in refugee settings.

185. Kozaric-Kovacic D, Folnegovic-Smalc V, Skrinjaric J, Szainberg NM, Marusic A (1995). Rape, Torture, and Traumatization of Bosnian and Croatian Women: Psychological Sequelae. American Journal of Orthopsychiatry, 65(3), 428-433.

Refugee/Ethnic Groups: Bosnian and Croatian

This study reported on the assessment and diagnosis of 25 Bosnian and Croatian women refugees admitted to the Zagreb Obstetrics and Gynaecological Clinic or its associated regional psychiatric centers. Three case examples were presented to illustrate the extent of the traumatic reactions and psychological difficulties encountered by the women.

186. Fornazzari X, Freire M (1990). Women as Victims of Torture. Acta Psychiatrica Scandinavica, 82, 257-260.

Refugee/Ethnic Group: Latin American

The aim of this retrospective study was to describe demographic data, psychological sequelae of torture, and recovery rates of a group of refugee women, comparing victims of physical and psychological torture with victims of only psychological torture. A total of 36 cases of women exiled from Latin America to Toronto were reviewed. Recovery rates were measured by looking at the patient's level of functioning and adaptation to the new society. The symptoms presented were mainly anxiety and affective-type symptoms, plus symptoms that match current diagnostic criteria for posttraumatic stress disorder. Findings showed that women who did not suffer direct types of torture had the highest frequency of good recovery rates.

187. Lipson JG, Miller S (1994). Changing Roles of Afghan Refugee Women in The United States. Health Care for Women International, 15, 171-180.

Refugee/Ethnic Group: Afghan

The authors reported on cultural, familial, and role conflicts faced by Afghan women in Northern California from the perspective of three generations. Data were collected from an ongoing ethnographic study, begun in 1986, in which participant observation and structured and informal interviews were used to determine the health and adjustment of 32 Afghan women between the ages of 21 and 75 years. Although similar issues were expressed by most Afghan women, generation influenced the experiences faced by the respondents and consequently the implications for health care. The elderly suffer from social isolation and lack of respect; the middle generation bears the triple role of housewife, employee, and mediator between children and spouse; and young and single women face culture conflicts and the lack of appropriate mates.

188. Mollica RF, Son L (1989). Cultural Dimensions in the Evaluation and Treatment of Sexual Trauma. Psychiatric Clinics of North America, 12(2), 363-379.

Refugee/Ethnic Group: General

The present article focused on describing the cultural issues relevant to treating patients who have been sexually traumatized, using clinical descriptions and patients' testimonies as a clinical guide for evaluation and treatment. An attempt to define sexual trauma was provided with an analysis of its prevalence both in the general population and in refugee populations. Two factors were considered fundamental in understanding the sexual trauma experienced by each woman: the historical context and their language and culture. These factors provided insight into how cultural definitions of rape and sexual trauma can affect individual responses. Clinical vignettes also revealed a range of clinical problems associated with sexual violence.

189. Mattson S (1993). Mental Health of Southeast Asian Refugee Women: An Overview. Health Care for Women International, 14, 155-165.

Refugee/Ethnic Group: Southeast Asian

This paper described manifestations of mental health disorders among Southeast Asian refugees, focusing on the responses displayed by women who had suffered under the Pol Pot regime, during the flight from Cambodia, and while in the refugee camps. A review of the literature was presented to support the evidence shown. Intervention strategies based on reports commissioned by the U.S. Office of Refugee Resettlement in 1983 were suggested. The main failures in providing effective mental health services were due to cultural beliefs regarding mental health problems and emotions among Southeast Asians and due to the lack of a professional who spoke their language. Interview settings and pace of the clinical interview, respect for values and coping strategies, and use of bilingual professionals and community workers were stressed.

190. Rojnik B, Andolsek-Jeras L, Obersnel-Kveder D (1995). Women in Difficult Circumstances: War Victims and Refugees. International Journal of Gynecology & Obstetrics, 48, 311-315.

Refugee/Ethnic Group: General

The present paper focused on health and reproductive rights. It also concentrated on war victims and refugee women as those who need more than an average "reproductive health package." A definition of reproductive health by the World Health Organization was the starting point of a discussion that led to assertions about the traumatic consequences of rape in a war context and on refugee women. The role of medical professionals, including gynecologists and obstetricians, was stressed.

191. Rozee PD, Van Boemel G (1989). The Psychological Effects of War Trauma and Abuse on Older Cambodian Refugee Women. Women & Therapy, 8(4), 23-49.

Refugee/Ethnic Group: Cambodian

The aim of this study was to provide the clinician with information about the extent of multiple traumas experienced by Cambodian refugee women. These traumas form the basis of their psychological symptomology. This study presented a brief history of the political situation during the 1970s leading up to the overthrow of Cambodia and the decimation of Cambodian culture. Interview data collected from 30 Cambodian women between the ages of 40 and 69 years demonstrated the superiority of environmental stress theories over psychodynamic theories in explaining non-organic blindness among this population. Subjective visual acuity was significantly related to years of internment in communist camps during and after the fall of Cambodia in 1975. Onset of visual loss following these traumas, preceded by healthy pre-trauma functioning, suggested environmental rather than intrapsychic etiology. Suggestions for culturally relevant interventions with Cambodian refugees were discussed.

192. Shanks L, Schull MJ (2000). Rape in War: The Humanitarian Response. Canadian Medical Association Journal, 163(9), 1152-1156.

Refugee/Ethnic Group: General

In this article, a review of the recent experiences of non-governmental organizations and United Nations agencies was presented stressing their efforts to prevent sexual violence and to treat victims in conflict areas. Examples were drawn from the experience of M eacute;decins Sans Fronti egrave;res/Doctors Without Borders in Rwanda and Zaire in 1994 and that of the International Rescue Committee in Burundi. Specific guidelines addressed to medical professionals were provided for the care of victims of sexual violence in complex emergencies. For example, a comprehensive protocol should attempt to address the medical, psychological, and legal consequences of rape. However, many barriers exist for the proper implementation of such a protocol. Ensuring a sufficient number of female health care workers and training health care workers in treatment protocols are just two of the ways proposed to reduce those barriers. Particular attention was also given to ways of preventing sexual violence in camps for refugees and internally displaced people.

193. Thompson JL (1991). Exploring Gender and Culture With Khmer Refugee Women: Reflections on Participatory Feminist Research. Advances in Nursing Science, 13(3), 30-48.

Refugee/Ethnic Group: Cambodian

The purpose of the research was to explore psychosocial adjustment among refugee women, focusing especially on the cultural or symbolic traditions that refugee women bring with them from the United States. Cultural definitions of gender, historical narratives of women in Cambodian culture, and religious or cultural symbols that may influence women's adjustment and their responses to trauma and assault were analyzed. The research presented here was influenced by descriptions of a feminist participatory research paradigm and its application in community health nursing. The sample consisted of 12 to 16 Khmer women who were invited to participate in the study through referrals made by physicians and community health nurses. Life history and trauma history interviews, discussion of dream narratives and Cambodian myths, and participant observation were used as survey instruments with most of the women. Findings included four recurring themes identified in the women's stories: persistent violence, communication with the spirits of relatives or with helping spirits, ubiquitous messages regarding good or bad luck, and sexuality or their relationship with men, or both.

Family and Kinship

194. Boehnlein JK, Tran HD, Riley C, Vu K, Tan S, Leung PK (1995). A Comparative Study of Family Functioning Among Vietnamese and Cambodian Refugees. The Journal of Nervous and Mental Disease, 183(12), 768-773.

Refugee/Ethnic Groups: Cambodian and Vietnamese

The aim of this study was to explore the nature and severity of family problems among a clinic population of Cambodian and Vietnamese refugees and to identify similarities and differences between the two ethnic groups. A sample of 107 patients with adolescent children was interviewed using a semi-structured questionnaire. The types of problems with children reported by the two groups were classified into five dimensions: communication, personal behavior, school performance, social behavior, and antisocial behavior. Significantly, Vietnamese parents reported more problems with their children and more dissatisfaction with the life in the United States than Cambodians. For both groups, parents' relationship with their adolescent children was a major source of concern and had a major impact on parents' perception of their own health. Yet, there were important differences between the two groups in how patients perceived their problems: Vietnamese would report their inability to use force to discipline their children as a major problem, while Cambodians would describe lack of respect from their children as the primary problem.

195. Fox PG, Cowell J, Johnson MM (1995). Effects of Family Disruption on Southeast Asian Refugee Women. International Nursing Review, 42(1), 27-30.

Refugee/Ethnic Group: Southeast Asian

A woman's identity in Southeast Asia is attached to her family role and to a number of family norms and values. Hence, resettlement is seen as an extremely emotionally stressful experience for those women who have lost or have been separated from other family members. Data were collected on home visits with 75 Southeast Asian refugee women who had arrived in the United States since 1983 from resettlement camps. The structured interview was designed to identify premigration and postmigration socioeconomic factors including residence, education, occupation, religion, marital status, and number of children. All women were evaluated for emotional distress using the Hopkins Symptom Checklist-25. The most compelling identified theme was that of broken family ties and the ensuing grief. Findings showed the significant role of family and the incidence of problems associated with separation from family leading to the design of specific intervention programs that encourage social support networks.

196. Frye BA, D'Avanzo C (1994). Themes in Managing Culturally Defined Illness in the Cambodian Refugee Family. Journal of Community Health Nursing, 11(2), 89-98.

Refugee/Ethnic Group: Cambodian

This follow-up study from prior research that examined cultural themes in health care decision making among Khmer women was designed to identify the main cultural themes used by Cambodian families to manage culture-bound syndromes. Data were collected from 120 Cambodian refugee women in Long Beach, California, and in Lowell, Massachusetts, where the Khmer refugee population in America had primarily relocated. Koucharang, described as "thinking too much," was identified by informants as a culture-bound syndrome in response to the violence experienced in Cambodia. This syndrome was characterized by behavioral changes and somatic complaints. Two main cultural themes used by Cambodian families to cope with this disabling condition were identified: withdrawal or suppression of bad thoughts, and sheltering or protective behavior toward the family member suffering from or exposed to koucharang. Nursing strategies for using the identified cultural themes to intervene with the Cambodian family were presented. It was important that the community health nurse recognize the strength and tenacity of the cultural forces framing the Cambodian response to the stress of illness.

197. Kuss T (1997). Family Planning Experiences of Vietnamese Women. Journal of Community Health Nursing, 14(3), 155-168.

Refugee/Ethnic Group: Vietnamese

The purpose of this study was to examine the complex sociocultural beliefs of Vietnamese women in the United States and the ways in which these beliefs may influence their family-planning practices. A sample of 15 Vietnamese women, aged 23 to 51 years, was identified. The interview schedule included closed-ended demographic questions and an unstructured interview guide, which contained questions pertaining to sociocultural factors influencing family-planning practices. Findings revealed that the stresses associated with starting over in a new land, such as concern with finances and learning English, influenced younger Vietnamese women to use family-planning methods that would limit the number of future pregnancies. The meaning of children and the importance of their educational future were also influential in determining the number of children desired. Cultural and religious beliefs nonetheless played an important role.

198. Rousseau C, Mekki-Berrada A, Moreau S (2001). Trauma and Extended Separation from Family Among Latin American and African Refugees in Montreal. Psychiatry, 64(1), 40-59.

Refugee/Ethnic Groups: South American and African

This paper described the relationship between separation from family and trauma. It focused on the interaction between premigration personal and family trauma and extended separation from the family and its impact on refugees' degree of emotional distress. Personal and family mechanisms that might explain the interaction between separation and trauma in refugee groups coming from contrasting contextual and cultural backgrounds were analyzed. The basis for the survey was the original hypothesis that refugees who had experienced premigration trauma would be more affected by prolonged separation because of the prolonged vulnerability induced by the trauma and because of the possible cumulative effects of those stresses. The sample consisted of 113 refugees from Latin America and Africa, who were evaluated using the latest version of the Symptom Checklist-90R. Case studies from Salvadoran and Congolese families were presented. Findings revealed that separation from family and its impact were common to most refugee populations. For the Latin and African refugees in the sample, the relationship between personal trauma and psychological distress was reversed when subjects were with all or part of their families. Quantitative data also suggested that family trauma was extremely important to African subjects, much more than personal trauma, probably in association with the sacredness of the family to these communities.

199. Spasojevic J, Heffer RW, Snyder DK (2000). Effects of Posttraumatic Stress and Acculturation on Marital Functioning in Bosnian Refugee Couples. Journal of Traumatic Stress, 13(2), 205-217.

Refugee/Ethnic Group: Bosnian

In this study, levels of posttraumatic stress disorder (PTSD) and acculturation were used to predict participants' level of marital functioning. Based on previous research, a significant positive correlation between the level of PTSD and the level of marital distress was hypothesized to emerge for both genders. A significant positive relation was also hypothesized to exist between spousal difference in the level of acculturation and the level of marital distress. Forty Bosnian refugee couples, who had been a couple since before the war in Bosnia and who had resided in the United States for 1 to 5 years, participated in the study. The PTSD Symptom Scale-Self Report was used to measure PTSD symptomatology, while the Behavioral Acculturation Scale was used to measure the acculturation to the American culture and the Marital Satisfaction Inventory-Revised, the marital functioning. PTSD symptomatology was the best predictor of marital functioning and was related negatively to acculturation. After PTSD was controlled for, acculturation did not predict marital functioning. On the one hand, wives' marital satisfaction was best predicted by husbands' PTSD, acculturation, and their own PTSD. On the other hand, husbands' marital satisfaction was not predicted satisfactorily by any of these variables.

200. Tran TV (1991). Family Living Arrangement and Social Adjustment Among Three Ethnic Groups of Elderly Indochinese Refugees. International Journal of Aging and Human Development, 32(2), 91-102.

Refugee/Ethnic Groups: Lao and Vietnamese

This study examined family living arrangement and social adjustment in a sample of 258 elderly refugees from Laos and Vietnam, aged 55 years and older. Social adjustment was defined in terms of the refugees' sense of satisfaction with life and their living environment in American society. Family living arrangement was chosen as the major predictor of social adjustment because for many refugees the family is the main source of social support in a host society. Findings revealed that living with one's family tended to facilitate the social adjustment of elderly Indochinese refugees into American society, while living outside the family context tended to result in a poorer sense of adjustment. Moreover, elderly refugees who lived in a household that had children under 16 years of age had a lower sense of adjustment than those who lived in a house without children.

Asylum Seekers

201. Harris MF, Telfer BL (2001). The Health Needs of Asylum Seekers Living in the Community. Medical Journal of Australia, 175(3), 589-592.

Refugee/Ethnic Group: General

This article analyzed the situation of asylum seekers living in the Australian community and awaiting the outcome of applications for protection visas. Their access to health care in Australia was presented in comparison with the situation in the United Kingdom and Europe. A guide to the care of refugee patients in general practice was also presented. The major aims in managing refugee patients who may have experienced torture or other trauma associated with refugee status were as follows: to identify patients who may have experienced torture, to understand the context in which torture may have occurred, to assess the physical and mental health problems of torture and trauma survivors, and to be aware of and confident in referring patients to appropriate services.

202. Lynch MA, Cuninghame C (2000). Understanding the Needs of Young Asylum Seekers. Archives of Disease in Childhood, 83(5), 384-387.

Refugee/Ethnic Group: General

The aim of this paper was to provide background information on young asylum seekers for those who provide care to refugee children and their families. It presented the recognition process for refugee status in the United Kingdom (UK) and numbers and extent of the phenomenon. All entitlements received by asylum seekers in the UK were singularly considered, from subsistence and housing to health and education. Particular attention was given to the role of health professionals in advocating for local services that meet the needs of asylum-seeking children in ways that are culturally accepted and not stigmatizing.

203. Peel MR (1996). Effects on Asylum Seekers of Ill Treatment in Zaire. British Medical Journal, 312(7026), 293-294.

Refugee/Ethnic Group: Zairean

A retrospective study was performed to describe the health effects of the political system in Zaire on asylum seekers seen at the Medical Foundation for the Care of Victims of Torture. The study sample comprised 92 asylum seekers from Zaire who were seen for medical reports at the medical foundation in 1993 and 1994. Eighty-one had been imprisoned; the others had been severely ill treated at home by the security services. Sixty-six had been detained for up to 1 year. Prison conditions were invariably unsanitary, and food was of poor quality when provided. These findings showed the damaging effects of imprisonment and torture on asylum seekers' health and mental health.

204. Silove D, Curtis J, Mason C, Becker R (1996). Ethical Considerations in the Management of Asylum Seekers on Hunger Strike. The Journal of the American Medical Association, 276(5), 410-415.

Refugee/Ethnic Group: Cambodian

Hunger strikes have posed complex ethical dilemmas for the physician throughout history. The observations made in this article were based on the experience collected by the Australian Service for the Treatment and Rehabilitation of Torture and Trauma Survivors (STARTTS) on three Cambodian asylum seekers in October 1992. Several factors confounded the task of assessment and decision making, including language and cultural barriers, the patient's past exposure to persecution by authorities, and the complexity of the legal procedures being pursued. Recommendations for the management of asylum seekers on hunger strike were illustrated, including the appointment of an external physician of confidence and the writing of a confidential directive specifying the hunger striker's wishes about resuscitation in the event of collapse. The advantages and disadvantages of these proposals were analyzed.

205. Silove D, McIntosh P, Becker R (1993). Risk of Retraumatisation of Asylum Seekers in Australia. Australian and New Zealand Journal of Psychiatry, 27, 606-612.

Refugee/Ethnic Group: General

This paper aimed to outline the psychological problems experienced by asylum seekers and the risks they face of being retraumatized while pursuing their claims for refugee status in Australia. The risk of such retraumatization arises directly out of shifts in policy toward asylum seekers, that is, changes that have their roots in local, regional, and international political agendas. Therefore, having a wider understanding of the potential impact, often unintentional, of such policy changes on the already fragile mental health of asylum seekers is crucial. Reasons accounting for the psychosocial status of asylum seekers, such as processing claims, access to services, and emphasis on detention, were individually presented and commented on. Solutions giving particular attention to the role mental health professionals may play in providing a deeper understanding of the fears and motivations of asylum seekers were provided.

206. Silove D, Steel Z, McGorry P, Mohan P (1998). Trauma Exposure, Postmigration Stressors, and Symptoms of Anxiety, Depression and Posttraumatic Stress in Tamil Asylum Seekers: Comparison With Refugees and Immigrants. Acta Psychiatrica Scandinavica, 97, 175-181.

Refugee/Ethnic Group: Tamil

Large numbers of the Tamil community, many as unauthorized asylum seekers, have fled to Western countries. The present paper aimed to determine whether their trauma-related symptoms persisted in the postmigration period. For the purposes of this study, asylum seekers were defined as those individuals, entering Australia on temporary visas, who subsequently applied for refugee status. The study sample comprised 62 Tamil asylum seekers who were given the Harvard Trauma Questionnaire and the Hopkins Symptom Checklist-25. They returned statistically significantly higher scores than immigrants (N=104) on measures of past trauma; symptoms of anxiety, depression, and posttraumatic stress disorder; and all dimensions of postmigration difficulties. Asylum seekers did not differ from refugees (N=30) on measures of past trauma or psychiatric symptoms, but they scored higher on selective components of postmigration stress.

207. Silove D, Steel Z, Watters C (2000). Policies of Deterrence and the Mental Health of Asylum Seekers. The Journal of the American Medical Association, 284(5), 604-611.

Refugee/Ethnic Group: General

Several key concerns have been raised across a number of countries about the status of asylum seekers. The present study examined the effect of evolving policies of deterrence on the health and psychosocial well-being of asylum seekers, drawing data not only from empirical studies but also on human rights reports. In several countries, asylum seekers living in the community face restricted access to work, education, housing, welfare and, in some situations, to basic health care services. Allegations of abuse and cases of hunger strikes and outbreaks of violence among asylum seekers in detention centers have been reported. Growing evidence has shown that salient postmigration stress adds to the effect of previous trauma in creating the risk of ongoing posttraumatic stress disorder and other psychiatric symptoms. The study suggested that the medical profession have a legitimate role in commenting on the general and mental health risks of imposing restrictive and discriminatory measures on asylum seekers.

208. Silove D, Steel Z, McGorry P, Miles V, Drobny J (2002). The Impact of Torture on Posttraumatic Stress Symptoms in War-Affected Tamil Refugees and Immigrants. Comprehensive Psychiatry, 43(1), 49-55.

Refugee/Ethnic Group: Tamil

The study examined the effects of torture in generating posttraumatic stress disorder (PTSD) symptoms by comparing its impact with that of other traumas suffered by a war-affected sample of Tamil living in Australia. Specifically, traumatic predictors of PTSD were examined among a subsample of 107 Tamil refugees, asylum seekers, and immigrants. All respondents were assessed through the Harvard Trauma Questionnaire (HTQ) and had endorsed at least one trauma category of the HTQ. The present study provided additional support for the identification of torture as a particularly traumatic event with a unique impact. Its impact is evident even in the context of widespread civil war where exposure to other traumas is common.

209. Silove D, Sinnerbrink I, Field A, Manicavasagar V, Steel Z (1997). Anxiety, Depression and PTSD in Asylum Seekers: Associations With Pre-Migration Trauma and Post-Migration Stressors. The British Journal of Psychiatry, 170, 351-357.

Refugee/Ethnic Group: General

The aim of this study was to examine possible relationships between past trauma and the ongoing stressors experienced by asylum seekers and symptoms of depression, anxiety, and posttraumatic stress. It was postulated that there might be a compounding of stress in those with histories of past trauma; therefore, subjects with posttraumatic stress disorder (PTSD) would be more vulnerable to the stress posed by the process of seeking asylum. Forty consecutive asylum seekers attending a community resource center in Sydney, Australia, were interviewed using the Hopkins Symptom Checklist-25 and the Harvard Trauma Questionnaire. Anxiety scores were associated with female gender, poverty, and conflict with immigration officials, while loneliness and boredom were associated with both anxiety and depression. A diagnosis of PTSD was associated with greater exposure to premigration trauma, delays in processing refugee applications, difficulties in dealing with immigration officials, obstacles to employment, racial discrimination, and loneliness and boredom.

210. Sinnerbrink I, Silove D, Manicavasagar V, Steel Z, Field A (1996). Asylum Seekers: General Health Status and Problems With Access to Health Care. Medical Journal of Australia, 165(2), 634-637.

Refugee/Ethnic Group: General

The aim of this article was to examine asylum seekers' general health status and their access to mental and dental services during a period before government-funded assistance was available. Forty asylum seekers from 21 countries attending English-language classes in a community-based asylum seeker center in Sydney, Australia, were assessed through the Harvard Trauma Questionnaire, a postmigratory problem checklist, the COOP Functional Health Assessment Charts, the Dukeâ€“University of North Carolina Health Profile, and a structured interview to discover difficulties in accessing health care in Australia. More than 30 of the 40 participants reported exposure to past trauma. Asylum seekers were more impaired in their emotional health than a normative group of patients. Twenty-seven respondents reported major difficulties in accessing dental services and in obtaining general medical care.

211. Sultan A, O'Sullivan K (2001). Psychological Disturbances in Asylum Seekers Held in Long Term Detention: A Participant-Observer Account. Medical Journal of Australia, 175(3), 593-596.

Refugee/Ethnic Group: General

The present paper described the impact of detention on asylum seekers' psychological state. The psychological reaction patterns of detainees whose claims for asylum are unsuccessful are characterized by stages of increasing depression, punctuated by periods of protest, as feelings of injustice overwhelm them. These reactions have a marked secondary impact on their children in detention. To support the participant-observer accounts, a survey was conducted on detainees who had been held for over 9 months. The sample comprised 33 participants who were assessed through a semi-structured interview based on previous observations. All but one of the detained asylum seekers displayed symptoms of psychological distress at some time.

F. Human Rights and Mental Health

Articles

212. Amowitz LL, Reis C, Hare Lyons K, Vann B, Mansaray B, Akinsulure-Smith AM, Taylor L, Iacopino V (2002). Prevalence of War-Related Sexual Violence and Other Human Rights Abuses Among Internally Displaced Persons in Sierra Leone. The Journal of the American Medical Association, 287(4), 513-521.

Refugee/Ethnic Group: Sierra Leonean

The present paper reported a population-based assessment of the prevalence and impact of sexual violence and other human rights abuses among internally displaced persons (IDPs) in Sierra Leone. A total of 991 women, living in three IDP camps and one town, were selected for the study. The survey contained 49 questions pertaining to demographics, physical and mental health perception, personal experiences of war-related sexual assaults, experiences of war-related human rights abuses among household members, opinions regarding punishment and justice for perpetrators, and attitudes on women's human rights and their role in society. Overall, 13 percent (1,157) of household members reported incidents of war-related human rights abuses in the last 10 years. Ninety-four (9 percent) of 991 respondents reported war-related sexual assaults. The lifetime prevalence of non-war-related sexual assault committed by a family member, friends, or civilians among these respondents was 9 percent.

213. Apfel RJ, Geltman D, Simon B, Sims A (2000). Human Rights and Psychiatry: Report on a Teaching Model. Harvard Review of Psychiatry, 7, 355-360.

Refugee/Ethnic Group: General

The present article was a report of the seminar "Human Rights and Psychiatry" held at Cambridge Hospital, starting in 1996. The primary activity of the seminar has been to conduct mentored psychiatric evaluations of refugees applying for political asylum in the United States and to discuss the dilemmas and situations presented by these evaluations. The process of psychiatric evaluation of refugees was analyzed along with four case examples, which led to issues of general importance to psychiatric learning and teaching. Examples were the potential conflict between advocacy and professionalism and the benefits that psychiatric assessment can bring to survivors. Beyond refugee evaluations, the article focused on multiculturalism as being different from merely respecting diversity and on pressing political issues related to refugees.

214. de Jong K, Mulhern M, Ford N, van der Kam S, Kleber R (2000). The Trauma of War in Sierra Leone. The Lancet, 355, 2068-2069.

Refugee/Ethnic Group: Sierra Leonean

The extent of psychosocial problems that result from mass exposure to traumatic events may threaten the prospects for long-term stability in society. The present paper presented the main findings of an assessment of traumatic stress by M eacute;decins Sans Fronti egrave;res in Freetown, Sierra Leone, after a period of intense violence in January 1999. The sample consisted of 30 clusters of 8 respondents, covering almost all areas of Freetown. Structured interviews were based on a questionnaire consisting of four sections: demographic factors, exposure to traumatic events, consequences of traumatic events, and non-specific health complaints. The survey results showed that almost everyone was exposed to conflict.

215. de Jong K, Ford N, Kleber R (1999). Mental Health Care for Refugees From Kosovo: The Experience of M eacute;decins Sans Fronti egrave;res. The Lancet, 353, 1616-1617.

Refugee/Ethnic Group: Kosovar-Albanian

The authors examined the need for mental health support in the emergency refugee crisis in the Balkans. One example, the M eacute;decins Sans Fronti egrave;res mental health care program in Bosnia, was analyzed, pointing out its main characteristics, such as the establishment of accessible counseling centers, the in-depth training of local counselors and supervisors, and the provision of specific short-term interventions. These current features were readapted in Kosovo in 1998. Focus was on the needs of Kosovar-Albanians and on the concerns about advocacy referring to basic needs and to the levels of assistance and protection given to refugees or deportees by the United Nation High Commissioner for Refugees.

216. Geiger HJ, Cook-Deegan RM (1993). The Role of Physicians in Conflicts and Humanitarian Crises: Case Studies From the Field Missions of Physicians for Human Rights, 1988 to 1993. The Journal of the American Medical Association, 270(5), 616-620.

Refugee/Ethnic Group: General

This article presented case studies from the field missions of Physicians for Human Rights to illustrate the investigation and documentation of violations of medical neutrality, refugee health crises, the use of indiscriminate weapons, torture, deliberate injury and rape, and mass executions. The development of such organizations as Physicians for Human Rights was mainly stimulated by the recognition that many human rights violations like those cited above have significant health consequences and that the skills of physicians, other health workers, and medical and forensic scientists are uniquely valuable in human rights investigation and documentation.

217. Iacopino V, Frank M, Bauer HM, Keller AS, Fink SL, Ford D, Pallin DJ, Waldman R (2001). A Population-Based Assessment of Human Rights Abuses Committed Against Ethnic Albanian Refugees From Kosovo. American Journal of Public Health, 91(12), 2013-2018.

Refugee/Ethnic Group: Kosovar-Albanian

The purpose of this study was to document patterns of forced displacement and human rights abuses among Kosovar refugees living in Macedonia and Albania. A sample of 1,180 ethnic Albanian refugees living in 31 refugee camps and collective centers in Macedonia and Albania was interviewed. The questionnaire contained 50 questions that assessed patterns of forced migration among the individuals interviewed and their household members and human rights abuses both witnessed and experienced. This study documented numerous reports of Serbian forces' destroying property owned by Albanians throughout Kosovo (68 percent of participants reported that their families were directly expelled from their homes) and widespread abuses of human rights.

218. Rasek Z, Bauer HM, Manos MM, Iacopino V (1998). Women's Health and Human Rights in Afghanistan. The Journal of the American Medical Association, 280(5), 449-455.

Refugee/Ethnic Group: Afghan

The aim of the study was to assess the health and human rights concerns and conditions of women living in Kabul under the Taliban regime. A total of 160 women participated in a cross-sectional survey, including 80 women currently living in Kabul and 80 Afghan women who had recently migrated to Pakistan. The survey questionnaire contained 101 questions focusing on physical and mental health status, access to health care, war-related experiences, human rights abuses, land mine injury and awareness education, and attitudes toward women's human rights. Posttraumatic stress disorder (PTSD) was assessed using the 17 Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, symptoms for PTSD, while the Hopkins Symptom Checklist-25 was used to assess symptoms of depression and anxiety. The majority of the respondents reported that access to and quality of health care were inadequate. Based on self-reported symptoms, there was a high prevalence of poor mental health among study participants. Nearly all the women surveyed supported women's human rights.

219. Shenson D (1996). A Primary Care Clinic for the Documentation and Treatment of Human Rights Abuses. Journal of General Internal Medicine, 11(9), 533-538.

Refugee/Ethnic Group: General

The present paper provided an account of the background and services offered at the Human Rights Clinic established at a public hospital in the Bronx. Besides clinical services, the clinic has considered the treatment and documentation needs of patients as equally important and emphasizes the humanitarian nature of medicine's response to survivors of torture. Discussion focused on the documentation of human rights abuses as prevention and on the clinical care and the important role of continuing medical education in the clinic's agenda. Case studies were provided as examples of cases handled by the clinic in the course of its clinical and documentation experience.

220. Silove D (1999). Health and Human Rights of East Timorese. The Lancet, 353, 2067.

Refugee/Ethnic Group: East Timorese

As a brief account of the humanitarian crisis, which affected East Timor in 1998 and 1999, the present article provided a general idea of the political situation behind the widespread occurrence of human rights violations. The role of health professionals in East Timor was analyzed as a key to planning for the future health needs of the population.

Covenants

221. Universal Declaration of Human Rights. G.A. res. 217A (III), U.N. Doc A/810 at 71. (December 10, 1948).

Because representatives at the United Nations (UN) Convention in 1945 wrestled with reconciling their various conceptions of human rights, the clauses relating to human rights that were finally included in the UN Charter were very ambiguous. The UN assigned a commission to clarify the Charter's references to human rights. The result was a statement of universal goals concerning human rights and freedoms, which was adopted by the UN General Assembly in 1948. The Declaration is not binding, but its contents have been incorporated into many national constitutions, and it has become a standard measure of human rights.

222. Convention Relating to the Status of Refugees. 189 U.N.T.S. 150. (July 28, 1951).

One main aim of the Convention Relating to the Status of Refugees was to ensure that individuals having fled their homeland were not further discriminated against. Written to revise and consolidate numerous prior international agreements and "to assure refugees the widest of possible exercise of fundamental human rights and freedom" the Convention is all encompassing. The rights protected by this document include the ability to have gainful employment, receiving at least minimal social services, providing identification documents, etcâ€¦. All the ideas set forth by this human rights instrument are applied only in degrees according to each country's own commitment to fundamental rights. And all these provisions shall be fulfilled "without discrimination as to race, religion, or country of origin."

223. Protocol Relating to the Status of Refugees. 606 U.N.T.S. 267. (October 4, 1967).

The Protocol was adopted within the framework of the United Nations. It is applicable to persons who are refugees as therein defined. The assessment of who is a refugee, that is, the determination of refugee status under the 1951 Convention and the 1967 Protocol, is incumbent upon the Contracting State in whose territory the refugee applies for recognition of refugee status. It provides for cooperation between the Contracting States and the Office of the United Nations High Commissioner for Refugees. This cooperation extends to the determination of refugee status, according to arrangements made in various Contracting States.

224. OAU Convention Governing Specific Aspects of Refugee Problems in Africa. (September 10, 1969).

(www.unhcr.bg/bglaw/en/convention_governing_specific_aspects_Africa_en.pdf)

The Organisation for African Unity (OAU) Convention was prepared, in part, to take into account the unique situation of refugees in Africa. Article One of the OAU Convention's definition of refugee presents a specific reference to the African continent, which reads as follows: "The term refugee shall also apply to every person who, owing to external aggression, occupation, foreign domination or events seriously disturbing public order in either part or the whole of his country of origin or nationality, is compelled to leave his place of habitual residence in order to seek refuge in another place outside his country of origin or nationality." No distinction is made between internally displaced people, considered de facto refugees, and de jure refugees.

225. Cartagena Declaration on Refugees. (November 19â€“22, 1984).

(www.asylumlaw.org/docs/international/CentralAmerica.PDF)

In 1984, 10 Latin American states, at a colloquium entitled "Coloquio Sobre la Protecc iacute;on Internacional de los Refugiados en Am eacute;rican Central, M eacute;xico y Panam aacute;: Problemas Jur iacute;dicos y Humanitarios" in Cartagena, Colombia, adopted the Cartagena Declaration on Refugees, which contained an extension of the refugee definition contained in the 1951 convention on refugees. The refugee definition of the Cartagena Declaration builds upon the OAU (Organisation for African Unity) definition, adding to it the threat of generalized violence, internal aggression, and massive violation of human rights as requirements.

226. San Jose Declaration on Refugees and Displaced Persons Under the Auspices of the Costa Rican Government. (December 5â€“7, 1994).

(www.lnf.org.lb/migrationnetwork/unn13.html)

"A Colloquium to commemorate the tenth anniversary of tile Cartagena Declaration on Refugees was held in San Jos eacute;, Costa Rica, from 5 to 7 December 1994. The Colloquium was co-organized by UNHCR and the Inter-American Institute of Human Rights, under the auspices of the Government of Costa Rica. Government Officials and experts from more than 20 American and Caribbean countries attended the Colloquium. As a result, participants in the Colloquium adopted the â€˜San Jos eacute; Declaration on Refugees and Displaced Persons,' which in addition to reiterating the validity of the principles embodied in the Cartagena Declaration, deals with the current situation of refugees and other populations affected by violence, and proposes guidelines for the search of solutions to their plight."

227. Declaration on the Protection of Refugees and Displaced Persons in the Arab World. (November 16â€“19, 1992).

(www.lnf.org.lb/migrationnetwork/unn12.html)

A group of Arab Experts, meeting in Cairo, Arab Republic of Egypt, from 16 to 19 November 1992 at the Fourth Arab Seminar on "Asylum and Refugee Law in the Arab World," under the sponsorship of the United Nations High Commissioner for Refugees, adopted the present declaration. Specificity of this covenant is the reference to the "humanitarian principles of asylum in Islamic law and Arab values."

228. Declaration of the Rights of the Child. G.A. res. 1386 (XIV), 14 U.N. GAOR Supp. (No. 16) at 19, U.N. Doc. A/4354. (November 20, 1959).

This document expanded and amplified the theme of the special rights of the child first enunciated in the Universal Declaration of Human Rights. This Resolution recognizes that children "by reason of [their] physical and mental immaturity, [need] special safeguards and care, including appropriate legal protection, before as well as after birth." This document is a non-binding resolution of the U.N. General Assembly.

229. Convention Against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment. G.A. res. 39/46, annex, 39 U.N. GAOR Supp. (No. 51) at 197, U.N. Doc. A/39/51. (December 10, 1984).

The Convention against Torture contains detailed steps that state parties must take in carrying out their obligation to prohibit and prevent torture. It also establishes the Committee against Torture, consisting of 10 independent experts, to monitor state parties' compliance with their obligations under the Convention. The Committee carries out its mandate by reviewing state party periodic reports, by deciding on individual complaints, and by carrying out confidential inquiries.

230. Petevi M, Mollica R, Mikus Kos A, Perren-Klinger G, Groenenberg M, DeMartino R (1995). Utrecht Guidelines. Draft Guidelines for the Evaluation and Care of Victims of Trauma and Violence. Geneva, Switzerland: United Nations High Commissioner for Refugees.

(http://www.hprt-cambridge.org/Layer3.asp?page_id=23)

The guidelines that grew out of a consultation held in Utrecht, the Netherlands, in 1993, are intended to emphasize the need of psychosocial assistance to refugees and victims of trauma and violence. They are also intended to provide proven and accepted measures of addressing the mental health needs of refugees and displaced persons, aiming at some universality but recognizing at the same time that the specific context of each situation will influence the relevance of any component of the guidelines.

231. Mollica RF, Ross ME, Kikuchi Y (1997). Tokyo Guidelines for Trauma and Reconstruction. Cambridge: Harvard Program in Refugee Trauma.

(http://www.hprt-cambridge.org/Layer3.asp?page_id=22)

Taking place in May 1995 in Tokyo, Japan, the symposium held at the Institute for Asia-Pacific Studies at Waseda University brought together international experts to address the issues of economic and social recovery of communities extensively devastated by human and natural disaster. The focus was particularly "on the impact of violence and natural disaster on personal, social, and community development"; "on the role of the medical and mental health system in recovery and reconstruction of traumatized populations"; and on "new policies for economic and social reconstruction of societies affected by mass violence and natural disaster."

List of Contributors

Alastair Ager, Queen Margaret University College
James K. Boehnlein, MD
Eugene B. Brody, MD
Solvig Ekblad, PhD
Arancha Garcia del Soto, PhD, Solomon Asch Center for Study of Ethnopolitical Conflict, University of Pennsylvania
Kaz de Jong, MD
J. David Kinzie, MD, Oregon Health & Science University
Derrick Silove, MB ChB CapeT, FRANZCP, University of New South Wales
Ed K. S. Wang, Department of Mental Health, Office of Multicultural Affairs
Joseph Westermeyer, MD, MPH, PhD, University of Minnesota

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Center For Mental Health Services An Annotated Bibliography on Refugee Mental Health

Contents

Introduction

User's Guide for the Bibliography

List of Contributors

Introduction

User's Guide for the Bibliography

A. Epidemiological Studies on Refugee Mental Health

Adults

B. Clinical Studies on Refugee Mental Health

Children and Adolescents

C. Methodological Issues

D. Mental Health Services

E. Selected Subgroups of Refugees

F. Human Rights and Mental Health

List of Contributors

Center For Mental Health Services
An Annotated Bibliography on Refugee Mental Health