DEPRESSION AND SOMATIZATION IN BHUTANESE-NEPALI REFUGEES by Alexandra Ann ...

101 Pages·2016·1 MB·English

DEPRESSION AND SOMATIZATION IN BHUTANESE-NEPALI REFUGEES
by
Alexandra Ann Nowalk
B.A. Anthropology & B.A. Global Studies, University of North Carolina at Chapel Hill, 2013
Submitted to the Graduate Faculty of
the Graduate School of Public Health in partial fulfillment
of the requirements for the degree of
Master of Public Health
University of Pittsburgh
2016
UNIVERSITY OF PITTSBURGH
GRADUATE SCHOOL OF PUBLIC HEALTH

This thesis was presented

by
Alexandra Ann Nowalk

It was defended on
April 12, 2016
and approved by
Caroyln Ban, PhD, Professor, Graduate School of Public and International Affairs, University
of Pittsburgh

Joanne Russell, MPPM, Assistant Professor, Behavioral and Community Health Sciences,
Graduate School of Public Health, University of Pittsburgh

Thesis Director: Steven Albert, PhD, Professor and Chair, Behavioral and Community
Health Sciences, Graduate School of Public Health, University of Pittsburgh

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Copyright © by Alexandra Nowalk
2016
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Steven Albert, PhD
DEPRESSION AND SOMATIZATION IN BHUTANESE-NEPALI REFUGEES
Alexandra Nowalk, MPH
University of Pittsburgh, 2016
ABSTRACT

The number of Bhutanese-Nepali refugees entering Allegheny County has exceeded
4,500 over the last several years. Local physicians who work with this population have reported
patients exhibiting symptoms of various mental disorders. This phenomenon is of grave concern,
as various studies have found a suicide rate among Bhutanese-Nepali refugees that is
significantly higher than the suicide rates for the general US population and other refugee
groups. This research will determine if Bhutanese-Nepali cultural conceptualizations of mental
health correlate to mental disorders classified in the Diagnostic Statistical Manual of Mental
Disorders (DSM-V) through a series of individual interviews and a single focus group. By
determining and improving the correlations between Bhutanese-Nepali culturally specific disease
and western mental health diagnoses physicians will be able to provide informed, culturally-
appropriate healthcare for refugees. As a result, public health practitioners will be able to better
develop interventions that effectively address the mental health needs of Bhutanese-Nepali
refugees and the quality of mental healthcare refugees receive will improve.

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TABLE OF CONTENTS
1.0 INTRODUCTION............................................................................................................. 1
2.0 BACKGROUND ............................................................................................................... 3
3.0 LITERATURE REVIEW ................................................................................................ 6
3.1 STAGES OF MIGRATION & MENTAL HEALTH RISK FACTORS ........ 6
3.1.1 Pre-Migration Stage ........................................................................................ 6
3.1.2 Migration Stage................................................................................................ 7
3.1.3 Post-Migration Stage ....................................................................................... 7
3.2 RISK FACTORS UNIQUE TO REFUGEES ................................................... 9
3.3 MENTAL HEALTH OUTCOMES IN MIGRANTS & REFUGEES .......... 10
3.3.1 Mental Health Outcomes in Migrants ......................................................... 10
3.3.2 Mental Health Outcomes in Refugees .......................................................... 11
3.4 CULTURAL AND POLITICAL HISTORY OF THE BHUTANESE-
NEPALI ........................................................................................................................... 12
3.4.1 The Lhotshampas and Early Settlement of Bhutan ................................... 12
3.4.2 Political and Cultural Equality .................................................................... 13
3.4.2 Rise of Bhutanese Cultural Nationalism ..................................................... 14
3.4.4 Political Dissent and Conflict........................................................................ 17
3.4.5 Flight from Bhutan ........................................................................................ 19
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3.5 MENTAL HEALTH IN BHUTANESE-NEPALI REFUGEES ................... 20
3.5.1 Prevalence of Mental Disorders ................................................................... 20
3.5.2 Depression in Bhutanese-Nepali Refugees .................................................. 21
3.5.3 Prevalence of Suicide & Associated Risk Factors ....................................... 27
3.5.4 Risk Factors for Mental Disorders ............................................................... 28
3.6 CLASSIFICATION OF MENTAL DISORDERS IN THE DSM-V ............ 29
3.6.1 Depressive Disorders ..................................................................................... 29
3.6.2 Somatic Symptom and Related Disorders ................................................... 30
3.7 IDIOMS OF DISTRESS ................................................................................... 31
4.0 MATERIALS AND METHODS ................................................................................... 33
4.1 STUDY DESIGN ............................................................................................... 33
4.2 PARTICIPANTS ............................................................................................... 34
4.2.1 Interviews ....................................................................................................... 34
4.2.1.1 Eligibility .............................................................................................. 34
4.2.1.2 Recruitment ......................................................................................... 35
4.2.2 Focus Groups ................................................................................................. 36
4.2.2.1 Eligibility .............................................................................................. 36
4.2.2.2 Recruitment ......................................................................................... 36
4.3 INSTRUMENTS ................................................................................................ 37
4.3.1 Interviews ....................................................................................................... 37
4.3.1.1 Patient Health Questionnaires ........................................................... 37
4.3.1.2 Cultural Formulation Interviews ...................................................... 38
4.3.2 Focus Group ................................................................................................... 39
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4.4 DATA COLLECTION ...................................................................................... 39
4.4.1 Interviews ....................................................................................................... 39
4.4.2 Focus Group ................................................................................................... 40
4.5 DATA ANALYSIS ............................................................................................. 41
5.0 RESULTS ........................................................................................................................ 43
5.1 INTERVIEWS ................................................................................................... 43
5.1.1 Patient Demographics ................................................................................... 43
5.1.2 Personal Health Questionnaires ................................................................... 44
5.1.2.1 Prevalence of Somatic Symptoms ...................................................... 44
5.1.2.2 Prevalence of Depressive Symptoms ................................................. 46
5.2 FOCUS GROUP ................................................................................................ 48
5.2.1 Focus Group Demographics ......................................................................... 48
5.2.2 Common Themes ........................................................................................... 48
5.2.2.1 Manifestation of Depression ............................................................... 48
5.2.2.2 Causes of Depression .......................................................................... 50
5.2.2.3 Effects of Depression on Daily Life ................................................... 51
5.2.2.4 Experiences with Healthcare in the United States ........................... 52
5.2.2.5 Mental Health in Nepal....................................................................... 53
5.2.2.6 Treatment for Depression .................................................................. 55
5.2.2.7 The Refugee Experience ..................................................................... 57
6.0 DISCUSSION .................................................................................................................. 58
6.1 ROLE OF MIND BODY DIVISIONS ............................................................. 59
6.2 ROLE OF IDIOMS OF DISTRESS ................................................................ 60
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6.3 IMPLICATIONS OR MENTAL HEALTH PROFESSIONALS ................. 61
6.4 LIMITATIONS .................................................................................................. 65
7.0 FUTURE DIRECTIONS ................................................................................................ 66
APPENDIX A :IRB APPROVAL.............................................................................................. 67
APPENDIX B : RECRUITMENT LETTER........................................................................... 70
APPENDIX C : INFORMED CONSENT................................................................................ 74
APPENDIX D : SOMATIC SYMPTOMS (PHQ-15).............................................................. 81
APPENDIX E: DEPRESSIVE SYMPTOMS (PHQ-9)........................................................... 83
APPENDIX F: FOCUS GROUP GUIDE... ............................................................................. 85
BIBLIOGRAPHY ....................................................................................................................... 88
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LIST OF TABLES
Table 1 - Raw Scores for Somatic Symptoms (PHQ-15) ............................................................. 45
Table 2 - Raw Scores for Depressive Symptoms (PHQ-9) .......................................................... 47
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LIST OF FIGURES
Figure 1 - Nepali Mind-Body Divisions & Treatment-Seeking Behavior .................................... 26
Figure 2 - Components of Nepali Ethnopsychology in Therapy Modalities ................................ 64
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