Sharmila Shetty, MD
Immigrant, Refugee and Migrant Health Branch
Centers for Disease Control and Prevention
Curi Kim, MD
Office of Refugee Resettlement
An Investigation Into Suicides Among Bhutanese Refugees in the United States, 2009-2012
Background
Over 56,000 Bhutanese refugees resettled in U.S. since 2008
Since Feb 2009 reports of increasing number of suicides in Bhutanese refugees
By Feb 2012, 17 Bhutanese suicides in 10 states Handful of suicides also in Burmese,
Sudanese, Burundi
ORR requested CDC and RHTAC
to conduct epi investigation
Study Question
What are the risk factors that may be linked to suicidal ideation among Bhutanese refugees resettled to the
United States?
Study Design
1. Psychological Autopsies In-depth interviews with close contact of suicide victims
Describe epidemiology, and events around suicide
2. Cross-sectional survey of Bhutanese refugees in US Survey of randomly selected Bhutanese refugees in 4 states
Understand mental health picture of Bhutanese refugees in US
Identify risk factors for suicidal ideation
• Case-control study (Case=expressed suicidal ideation; control=no ideation)
PSYCHOLOGICAL AUTOPSIES
Bhutanese Suicide Events Feb 2009-Feb 2012
17 reports of suicide
1 car accident
16 confirmed
suicides
14 consented interview
Demographics of Completed Suicides
11 men, 5 women
Mean time since arrival= 6 mo (10 days- 2 years)
Mean age= 44 yo (range 19-81)
Age n (%)
18-25 3 (21)
26-39 4 (29)
40-59 4 (29)
> 60 3 (21)
Suicides among Bhutanese Refugees by Year, 2009-2012
Time Between Arrival in the US and Suicide among Bhutanese Refugees (n=15)
Median time male: 223 days (7.4 mo) Median time female: 33 days (1.1 mo)
Characteristics of Completed Suicides
All by hanging
Only 1 left a suicide note
10 suicides occurred in home
12 never previously talked about suicide
2 (14%) were employed
Characteristics of Completed Suicides
7 (50%) had friends/neighbors who attempted suicide
3 (21%) previously attempted suicide
3(21%) had a suicide in the family
2 (14%) reported mental health (MH) condition
Only 1 sought help from MH provider
Top 3 Post-migration Difficulties
n (%)
Language barriers 10 (77)
Worries about family back home
8 (61)
Difficulty maintaining cultural and religious traditions
6 (46)
“He was stressed about his new job, paying the bills, and being able to support his parents.”
“If all the family members could have been brought together, not fragmented, this could have been prevented.”
“His wife [acculturated] differently – did not like this, he felt blamed. He could not adapt. Hard to communicate.”
What might have contributed to the suicide?
“Include new families in social and education opportunities.”
“System navigator– someone to help with all the processes and changes.”
“We need trainings on how to address psychological distress on a community level.”
What might have prevented the suicide?
CROSS-SECTIONAL SURVEY
Methods
Representative, randomly selected sample of Bhutanese refugees from 4 states Georgia (Atlanta)
Arizona (Phoenix, Tucson)
New York (Buffalo, Syracuse)
Texas (Dallas/ Fort Worth, Houston)
Survey participants Age 18 and older
Resettled in U.S. between January 1, 2008 and Nov. 17, 2011
Target 579 refugees
Survey Questionnaire
Demographics
Previous mental health history
Hopkins Symptoms Checklist
Anxiety, distress, depression symptoms
Harvard Trauma Questionnaire
PTSD symptoms
Traumatic events experienced
Post migration experiences
Coping mechanisms
Methods
Face-to-face interview
Trained local Bhutanese refugees as interviewers Two day training in each city
32 page survey, approx 1.5 hr to administer
Results: Demographics
423 (73%) consented to be interviewed
52% men
Mean age 38 yrs (range 18-83)
Mean time in US 1.8 yrs
216 (52%) employed
Mental Health History
n (%)
Ever diagnosed with mental
health condition?
Yes 15 (4)
Ever seriously thought about
committing suicide?
Yes 13 (3)
Family history of mental illness? Yes 53 (13)
Symptoms of Mental Health Conditions
Total
n (%)
Men
n (%)
Women
n (%)
Anxiety* 79 (18) 33 (15) 46 (23)
Depression* 82 (21) 33 (16) 49 (26)
PTSD 14 (3) 3 (1) 11 (6)
*Chi-square p-value <0.05
Knowing Someone Who has Committed Suicide
n (%)
In the past 12 mos, have you known anyone personally that has taken their life?
Yes 131 (31%)
Has anyone close, like a friend or neighbor committed suicide?
Yes 83 (20%)
Has anyone in your family committed suicide?
Yes 22 (5%)
Trauma Events Experienced in Nepal/Bhutan
Trauma Event n (%)
Lack of nationality or citizenship 381 (91)
Having to flee suddenly 229 (54)
Lack of adequate food/water/clothing 216 (51)
Total # of trauma events experienced n (%)
0-3 125 (30)
4-7 153 (36)
8+ 145 (34)
Post-migration Difficulties
n (%)
Language barriers 260 (62)
Lack of choice over future 195 (46)
Worries about family back home
163 (39)
Being unable to find work 156 (37)
Poor access to healthcare
126 (30)
Difficulty maintaining cultural and
religious traditions
92 (22)
What would you do to seek help if you were
thinking of killing yourself?
N (%)
Talk to friend/relative 106 (26)
Talk to doctor 87 (21)
Talk to mental health prof. 65 (16)
Don’t know 60 (15)
Cope by self 37 (9)
Talk to clergy 10 (2)
Call crisis hotline 9 (2)
Significant Risk Factors Associated with Suicidal Ideation
Not being provider of family
Depression, PTSD
Being unable to find work
Increased family conflict
Wished that people would just leave you alone
SUMMARY/CONCLUSIONS
Psychological Autopsies Summary
Most suicide decedents
were unemployed
faced language barriers
high exposure to suicides (50% friends/neighbors attempted suicide)
Only 2/14 had previously diagnosed MH condition
Only 1 sought help from MH provider
Cross Sectional Survey Summary
About half employed (vs. 14% in suicide victims)
High percentage exposed to multiple trauma events
Only 4% with previously diagnosed MH condition But by screening, high rates of depression and anxiety, especially
among women
Significant association between suicidal ideation and: Not being a provider/unemployment
Depression/PTSD
Increased family conflict
Conclusions
Suicide rate in this population 20.3/100,000 US rate 12.4
Nepal camps rate 20.7
Mental health conditions, especially depression, likely under-diagnosed
Highlights importance of mental health screening
Need for community-based, culturally appropriate suicide prevention strategies
Need to target high risk groups
Update on Suicides
In Nepal camps: from 2004-2010 : 67 completed and 64 attempted suicides
In 2011-2013: 28 completed and 94 attempts
In US: from 2009 – 2013: More than 20 completed suicides
no formal reporting system
Interventions in Refugee Camps in Nepal
Developed intervention guidelines for cases of completed/attempted/threatened suicide
Trained counselors, IOM doctors and resettlement staff on in-depth identification and treatment of suicidal cases and recognition of psychosocial problems
Increased visits to camp by psychiatrist (weekly)
Classroom/community-based psychosocial intervention classes for kids 8-15yo to provide emotional support
Suicide Prevention Groups work with CPSWs to raise awareness and ID/assist at-risk cases
Interventions in US RHTAC
In fall 2010, RHTAC adapted core QPR training to be more culturally appropriate to Bhutanese refugees
10 Bhutanese refugees certified as QPR trainers
Created Refugee Suicide Prevention Training Toolkit
http://refugeehealthta.org
Recommendations Resettlement Network
1. Wrap-around support for families/communities of recent suicides
2. Standard reporting of suicides
3. Conduct QPR trainings
4. Familiarize with local MH services and use cultural brokers
5. Minimize contagion effect
Recommendations ORR
Coordinate collection of psychological autopsy info Protocol for refugee suicide surveillance system developed, but
implementation pending PRA and SORN approval
Strengthen community structures and implement community-based suicide prevention activities Training for resettlement network
Funded RHTAC: QPR, refugee suicide prevention toolkit
Webinars:
When Helping Hurts: Self-Care Strategies for Refugee Community Leaders & Service webinar (6/13)
Tips on Mitigating Suicide Clusters webinar (8/8)
Exploring Pathways to Wellness Community Adjustment Support Groups
Mental Health First aid email blast
Recommendations ORR (continued)
Strengthen community structures and implement community-based suicide prevention activities Suicide prevention in grant programs
Preferred Communities – intensive case management
Preventive Health – medical/mental screening
Continue to support vocational training
TAG FOA included social adjustment barriers
Enhance community’s psychosocial supports
Linking Survivors of Torture grantees with resettlement network
Support development of social media tools to promote suicide prevention messages
Recommendations ORR (continued)
Explore partnerships with NGOs serving refugees to leverage resources and educate re refugee suicide risk Bhutanese directory of ECBOs
Ethiopian and Eritrean NGO
Outreach to psychological/psychiatric organizations
Further explore problem of mental health and suicides in this community Held a series of consultation calls with Bhutanese community
leaders and subject matter experts
Engage SAMHSA about adding refugees to high priority group list Continuing collaboration with SAMHSA – informal working group
on refugee suicide prevention; joined National Suicide Prevention Workgroup; met with SAMHSA Regional Administrators
Recommendations ORR (continued)
Screening – RHS-15 ORR leadership met with Pathways to Wellness
PhD fellow to explore screening tools
Hired Mental Health Specialist to focus on suicide prevention and emotional wellness
QUESTIONS?
Acknowledgements
ORR
Eskinder Negash
Marta Brenden
Makda Belay
Essey Workie
Curi Kim
RHTAC
Heidi Ellis
Jennifer Cochran
Paul Geltman
Charlot Lucien
Students and Fellows Cathy Baroang
Jaya Kannan
Karren Lamay
Sonia Hegde
Collin Basler
Navit Robkin
Ashley Hagaman
Ugonna Ijeoma
Arizona
Ken Komatsu
Carrie Senseman
Markay Adams
Texas
Jessica Montour
Georgia
Monica Vargas
New York
Eric Cleghorn
Cheryl Brown
Stephanie Anderton
Local resettlement agencies in NY, AZ, TX, GA
Bhutanese community leaders, members, and interviewers
EXTRA SLIDES
Psychological Autopsies
“A procedure for investigating a person's death by reconstructing what the person thought, felt, and did before death” based on information gathered from variety of sources
Face-to-face interview with families, friends, etc. who had contact with the person before the death
Interview conducted by EISO or state Refugee Health Program staff with interpreter
Psychological Autopsies
21 page questionnaire Demographics
Mental health history
Details of suicide
Social networks
Trauma events
Post-migration stressors
Open-ended questions
Informed consent
Social Network and Relationships of Suicide Decedents
n (%)
Relationship with family Not difficult 11 (85)
Moderately difficult 1 (7)
Very difficult 1 (7)
Number of friends 4 or more 10 (76)
2-3 1 (7)
1 1 (7)
Intimate partner
violence
No 11 (85)
Don’t know/missing 3 (15)
Employment Status of Completed Suicides
Characteristic n (%)
Employment Employed 2 (14)
Unemployed 8 (57)
Other (household
duties/student/elderly)
4 (28)
Problems at work Yes 2 (100)
Cross-sectional Survey: Methods
Structured questions on Demographics
Mental health history
Trauma events
Symptoms of Depression, Anxiety, PTSD
Post-migration stressors
Coping mechanisms
Informed consent
Participation Rates
Status Number (%)
Consented 423 (73)
Outmigration 85 (15)
Refused 39 (7)
Unable to contact 12 (2)
Did not meet requirement 11 (2)
Other 9 (2)
Total 579
Demographics
Characteristic N (%)
Education
None 148 (35)
Primary/Secondary 219 (52)
University/Graduate 54 (13)
Currently employed Yes 216 (52)
Provider of Family Yes 205 (49)
Previously Diagnosed Mental Health Conditions
n (%)
Ever diagnosed with mental
health condition?
Yes 15 (4)
Name of condition Anxiety 7 (47)
Depression 4 (27)
Don’t know 3 (20)
Other 1(7)
Demographic Characteristics (N=423)
Characteristics
Men
n (%)
(n=221)
Women
n (%)
(n=202)
Total
N(%)
Education* None 57 (26) 91 (45) <0.01
Primary 32 (15) 24 (12)
Secondary 92 (49) 71 (35)
University/Graduate 39 (18) 15 (8)
Currently employed* Yes 146 (67) 70 (35) <0.01
No 73 (33) 129 (65)
General health* Excellent/Very Good/Good 105 (48) 63 (31) 0.03
Fair/Poor 116 (53) 139 (69)
Chi-square p-value <0.05
Limitations
Likely under-reporting of suicide attempts and symptoms of mental illness
Responses to psychological autopsies may be less reliable because second hand info
Not able to quantify attempts
