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 atte

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

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