An Investigation Into Suicides Among Bhutanese Refugees in the United States,

Transcription

1 An Investigation Into Suicides Among Bhutanese Refugees in the United States, Sharmila Shetty, MD Immigrant, Refugee and Migrant Health Branch Centers for Disease Control and Prevention Curi Kim, MD Office of Refugee Resettlement

2 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

3 Study Question What are the risk factors that may be linked to suicidal ideation among Bhutanese refugees resettled to the United States?

4 1. Psychological Autopsies Study Design 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)

5 PSYCHOLOGICAL AUTOPSIES

6 Bhutanese Suicide Events Feb 2009-Feb reports of suicide 1 car accident 16 confirmed suicides 14 consented interview

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8 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 (%) (21) (29) (29) > 60 3 (21)

9 Suicides among Bhutanese Refugees by Year,

10 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)

11 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

12 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

13 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)

14 What might have contributed to the suicide? 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.

15 What might have prevented 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.

16 CROSS-SECTIONAL SURVEY

17 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

18 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

19 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

20 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

21 Mental Health History Ever diagnosed with mental health condition? n (%) Yes 15 (4) Ever seriously thought about committing suicide? Yes 13 (3) Family history of mental illness? Yes 53 (13)

22 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

23 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%)

24 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 (%) (30) (36) (34)

25 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)

26 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)

27 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

28 SUMMARY/CONCLUSIONS

29 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

30 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

31 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

32 In Nepal camps: Update on Suicides from : 67 completed and 64 attempted suicides In : 28 completed and 94 attempts In US: from : More than 20 completed suicides no formal reporting system

33 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

34 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

35 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

36 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 blast

37 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

38 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

39 Screening RHS-15 Recommendations ORR (continued) 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

40 QUESTIONS?

41 Acknowledgements ORR Arizona Eskinder Negash Ken Komatsu Marta Brenden Carrie Senseman Makda Belay Markay Adams Essey Workie Texas Curi Kim Jessica Montour RHTAC Georgia Heidi Ellis Monica Vargas Jennifer Cochran New York Paul Geltman Eric Cleghorn Charlot Lucien Cheryl Brown Students and Fellows Stephanie Anderton Cathy Baroang Jaya Kannan Karren Lamay Sonia Hegde Collin Basler Navit Robkin Ashley Hagaman Ugonna Ijeoma Local resettlement agencies in NY, AZ, TX, GA Bhutanese community leaders, members, and interviewers

42 EXTRA SLIDES

43 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

44 21 page questionnaire Demographics Mental health history Details of suicide Social networks Trauma events Post-migration stressors Open-ended questions Informed consent Psychological Autopsies

45 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) Intimate partner violence (7) 1 1 (7) No 11 (85) Don t know/missing 3 (15)

46 Employment Status of Completed Suicides Characteristic n (%) Employment Employed 2 (14) Unemployed 8 (57) Other (household 4 (28) duties/student/elderly) Problems at work Yes 2 (100)

47 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

48 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

49 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)

50 Previously Diagnosed Mental Health Conditions n (%) Ever diagnosed with mental Yes 15 (4) health condition? Name of condition Anxiety 7 (47) Depression 4 (27) Don t know 3 (20) Other 1(7)

51 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

52 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