High rates of PTSD and depression continue to plague refugees decades
after they fled brutality in their homeland for a new life in the United
It turns out that time does not heal all wounds, as evidenced in a recent
study of the mental health of Cambodian refugees who came to the United States
more than 20 years ago. All of the nearly 500 study participants had been
exposed to trauma prior to immigrating to the United States, and 62 percent of
them are suffering from posttraumatic stress disorder (PTSD) two decades
Depression rates were also alarmingly high, with 51 percent showing
symptoms warranting a depression diagnosis. These rates for the two disorders“
are extremely elevated” compared with the general U.S.
population's rates, said the researchers.
The results of the study are published in the August 3 JAMA.
Researchers at RAND Corp. and California State University at Long Beach
enrolled a stratified random sample of Cambodian refugees living in Long
Beach, Calif., which has the largest population of Cambodians in the United
States. Participants were between the ages of 35 and 75 and had lived in
Cambodia during the brutal Khmer Rouge regime in the middle and late 1970s,
when about 2 million of their countrymen were killed by the Khmer Rouge.
Trauma prior to arriving in the United States was assessed with the 17-item
Cambodian-language version of the Harvard Trauma Questionnaire. Almost all of
the participants had endured multiple traumas, with at least 90 percent
reporting nearly dying from starvation, being in combat, having family or
friends murdered, and witnessing killings or beatings; 54 percent had been
tortured. The mean number of reported traumas per individual was 15.
Subjects also completed the Survey of Exposure to Community Violence, which
was used to determine whether they were victims of violence after coming to
the United States, and the Composite International Diagnostic Interview (CIDI)
version 2.1, which was used to evaluate them for PTSD and depression. The CIDI
reflects DSM-IV diagnoses, the researchers noted. In addition,
subjects were screened for alcoholism with the Alcohol Use Disorders
All interviews were conducted in Khmer, the subjects' native language,
since only a minority were fluent in English.
The research team, headed by Grant Marshall, Ph.D., of RAND noted as well
that their study population was generally of “low socioeconomic status,
with low levels of education, English-speaking proficiency, and
employment.” Nearly 70 percent had household incomes below the federal
While the Cambodian immigrants showed very high levels of both PTSD and
depression, only 4 percent had symptoms of an alcohol-use disorder.
Alcohol-use disorders were “significantly associated only with exposure
to trauma after immigration to the United States,” not with having PTSD
or depression, the researchers reported.
The data on participants' exposure to trauma once they had come to the
United States indicated that 34 percent had seen a dead body in their
neighborhood, 28 percent had been robbed, and 17 percent had been threatened
by a weapon. Overall, this group had been exposed to a mean of 1.7 types of
trauma out of a list of 11 such events.
The data led the researchers to conclude that “members of refugee
communities can have substantial need for mental health services even years
removed from their tribulations.” They noted that many refugee studies
have focused on PTSD, but “the relationship of trauma to depression has
perhaps not been as widely appreciated.”
Of particular interest, the researchers noted, is that women in this
population were no more likely to develop PTSD or depression than were men, a
finding that runs counter to other studies of these disorders. “One
possible explanation,” they wrote, “is that the frequency or
severity of the traumas differed for men and women in ways not captured by our
trauma measures.” They urged additional research on this topic.
Marshall and his colleagues noted that while previous data have
demonstrated a high level of psychiatric disability in refugee populations,
theirs is an important contribution to this literature because of the
population studied. Most previous data come from individuals who had sought
health or social services, which may have led to the overestimation of mental
health problems, or from studies of asylum seekers, “who may be
motivated to overreport psychiatric symptoms.” They pointed out that
using a general population of refugees is likely to give more accurate data on
their health status, “guiding health-policy decision makers to the
needed services for this refugee community.”
An abstract of “Mental Health of Cambodian Refugees 2 Decades
After Resettlement in the United States” is posted at<http://jama.ama-assn.org/cgi/content/abstract/294/5/571>.▪