The United Nations reports there were approximately 19.2 million refugees, internally displaced persons, and asylum seekers worldwide in 2004, according to background information in the article. Researchers studying these populations have found high levels of violence exposure, often involving multiple traumas, as well as significant mental health problems. Previous investigations generally conclude that depression and posttraumatic stress disorder (PTSD) constitute the most common psychiatric disorders in refugee populations. Little is known about the long-term mental health of trauma-exposed refugees years after permanent resettlement in resource-rich countries like the United States.
Cambodians constitute one of the largest refugee groups in the United States, with approximately 150,000 refugees admitted since 1975. After a coup in 1970, a civil war began that led to a Khmer Rouge takeover from 1975 to 1979. Of an estimated population of 7.1 million in 1975, as many as 2 million Cambodians were killed during the 4-year Khmer Rouge reign. Approximately 1 million more were killed in the civil wars before and after this period.
Grant N. Marshall, Ph.D., of RAND, Santa Monica, Calif., and colleagues assessed the population prevalence, related illnesses and correlates of psychiatric disorders in the U.S. Cambodian refugee community 25 years after the Khmer Rouge era. The study included face-to-face interviews, conducted in Khmer language, with a random sample of households from the Cambodian community in Long Beach, Calif., the largest such community in the United States. The interviews, conducted between October 2003 and February 2005, included a total of 490 adults aged 35 to 75 years who lived in Cambodia during the Khmer Rouge reign and immigrated to the United States prior to 1993.
All participants had been exposed to trauma before immigration. Ninety-nine percent (n = 483) experienced near-death due to starvation and 90 percent (n = 437) had a family member or friend murdered. Seventy percent (n = 338) also reported exposure to violence after settlement in the United States. High rates of PTSD (62 percent) and major depression (51 percent) were found. PTSD and major depression often existed simultaneously in this population (n=209; 42 percent) and each showed a strong dose-response relationship with measures of traumatic exposure. In further analyses, PTSD and major depression were associated with premigration and postmigration trauma exposure and older age.
"We found evidence of pronounced mental health problems in previously traumatized refugees. Indeed, only approximately 30 percent of the sample was free of any of the 3 disorders [PTSD, major depression, alcohol use disorder] assessed. These results indicate that members of refugee communities can have substantial need for mental health services even years removed from their tribulations," the authors write.
"The pervasiveness of these disorders raises questions about the adequacy of existing mental health resources in this community. Addressing this high level of need may require additional research to identify barriers to seeking services as well as efforts at improving treatment for this population," the researchers conclude.
(JAMA. 2005; 294:571–579. Available pre-embargo to the media at www.jamamedia.org.)
Editor's Note: This study was supported by grants from the National Institute of Mental Health and from the National Institute on Alcohol Abuse and Alcoholism.
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JAMA