Mental Health in Bhutanese Refugee Populations

Imagine that you‘ve been driven from your home, deprived of your possessions, made dependent on others, and forced to flee to a foreign country not once, not twice, but three times over the course of your life. You feel isolated and lost without a sense of citizenship or permanent community. Lhotshampas (“People of the South”) are Bhutanese of Nepali origin who have lived in Bhutan and maintained their distinct cultural and religious traditions since the 19th century. Starting in the early 1990s, confronted with increased cultural and religious persecution by the Bhutanese government, more than 100,000 Lhotshampas fled to refugee camps in neighboring Nepal. In these camps, the Lhotshampas faced host country labor and movement restrictions.

Beginning in 2008, Bhutanese refugees began resettling in the United States, and to date, more than 57,000 have resettled into communities across the country. Even though this may seem like a happy ending, we now see that the years of persecution and loss of citizenship have taken their toll on the mental health of the Bhutanese refugee population. From February 2009 to February 2012, the US Department of Health and Human Services’ Office of Refugee Resettlement (ORR) reported 16 suicides among Bhutanese refugees in the United States. This number far surpasses the number of suicides reported to ORR among any other refugee community in the United States, yielding a suicide rate that is twice as high as that in the general United States population. These statistics, along with a recommendation by the International Organization of Migration (IOM), prompted us to begin one of the first systematic investigations of mental health and suicide in this population.

We used a combination of psychological autopsies and cross-sectional surveys to gather our data. A psychological autopsy is a standard procedure used to investigate a death by interviewing a person who was close to the deceased to reconstruct his/her mental state and actions before death. These autopsies were conducted for 15 of the 16 suicide decedents across the country. We then conducted a survey of randomly selected Bhutanese refugees in 4 states (Georgia, Arizona, Texas, and New York) in order to gain a better overall understanding of the mental health status, including suicidal thoughts, of the Bhutanese refugee population in the United States. These surveys were conducted by trained members of the local Bhutanese community. Because suicide is a sensitive subject, especially within this particular culture, we took pains to ensure that those who conducted the interviews were trusted members of the community in order to increase the comfort and confidentiality of respondents.

The results of the psychological autopsies indicate that 40% of suicide decedents had reported symptoms suggestive of anxiety. Statelessness was found to be a common traumatic event experienced by the deceased, with language barriers being reported as one of the most common post-migration difficulties. In the overall refugee community, we found that about 21% of respondents reported symptoms of a mental health condition, much higher than the national average of 6.7%. More than half of the respondents had experienced traumatic events such as lack of nationality, having to flee suddenly, and lack of food, water, or safety.

Many of the Bhutanese in the United States reside in apartment complexes assigned to them by resettlement agencies. They live modestly, with large families often sharing one or two bedrooms. Neighbors come and go from each other’s homes in a sort of open-door policy. I felt welcomed by this tightknit group, having come with a community leader who served as my bridge during my site visits. But the mood was also somber. It was apparent that people wanted to help us, but a balance was required between getting information we needed and being respectful of a culture that values privacy.

We do know that there is a problem; there is a significant, yet undiagnosed, burden of mental health conditions in this population of refugees. Our report offers recommendations, including enhanced screening for mental health when refugees first arrive in the United States, establishing more culturally appropriate mental health resources in the community, and creating a centralized database to keep better track of reported suicides in all refugee communities. We hope that this survey and our accompanying recommendations can help increase awareness of mental health issues as a whole in order to build stronger communities, not only for Bhutanese refugees but for any groups facing resettlement challenges in the future.

For more information, read the Morbidity and Mortality Weekly Report (MMWR) article on this topic titled, Suicide and Suicidal Ideation Among Bhutanese Refugees — United States, 2009–2012.